Key points

Practice nurses are playing an increasingly important role in diabetes care.
Well established collaboration and referral procedures among health services and health service providers is essential.
Community, practice and home care nurses are in an ideal position to deliver preventative health care education.

Introduction

Community care enables technical and professional care to be provided to acutely and chronically ill patients at home. The provision of specific services will be influenced by the home environment, the person’s condition and capabilities, and available home support services. A nursing care plan should be prepared to complement the medical management plan.

Supporting people to enable them to remain at home is an important consideration of diabetic management. Practice nurses and community and home-care nurses play an important role in this respect.

These nurses also play and important role in supporting carers and identifying carer distress. A recent Australian study showed carers have lowest well being of any large societal group (Australian Unity 2008). Significantly, well being decreases as the number of hours spent providing care increases and women carers have lower levels of well being than male carers. The Australian Unity survey showed unpaid, largely family, carers provide ∼$30.5 billion worth of care per year. Many carers have high levels of worry about their financial situations and their personal health that often results in depression. They often make significant lifestyle, family and work sacrifices in order to provide care. Many do not receive care for their own health issues, which include depression, chronic pain, injuries attributable to caring and many are overweight, which increases their risk of obesity-related diseases.

Diabetes-related care in the home includes:

Preparing insulin doses.
Administering insulin.
Performing blood glucose tests.
Assessing the general condition of the patient.
Supporting the continuing education of the patient and of family/carers.
Attending to wound dressings.
Attending to personal hygiene.
Assisting with medication management.
Detecting deteriorating metabolic control, and functional and cognitive ability.

Making clinical decisions about the patient in the home situation without advice and support can be stressful and difficult. In addition, the home situation must be carefully assessed to ascertain how to obtain access to the home, and the correct address and telephone number. The safety of the nurse is an important consideration and issues such as the surrounding environment and household members should be assessed beforehand, if possible. The service base should have some idea of the route the nurse is likely to take. Other information (e.g. presence of dogs) should also be noted.

This chapter outlines the important diabetes-related information needed to gauge whether medical assessment is necessary.

How to obtain advice

It is important for home care and domiciliary nursing bodies to establish open communication links with the referring agency or practitioner.

The referring agency should be the first point of contact for advice.

General points

(1) Ensure diabetes teaching is consistent with that of the diabetes educator.

(2) Before recommending equipment, for example, meters, insulin delivery systems, ensure the person will be able to use it, can afford it and can obtain further supplies. This is particularly important if the person is visiting from another country or is travelling overseas where some brands of equipment may not be available. Assess:

vision
manual dexterity
comprehension.

There may be costs associated with purchasing diabetes equipment and medications in some countries. It is important that the person understands the costs and any government initiatives to reduce/eliminate those costs.

(3) Ensure the patient is enrolled in the National Diabetes Services Scheme so that they can obtain syringes, lancets and test strips at the subsidised price (relevant only in Australia).

Diabetic problems commonly encountered in the home

(1) Finding an elevated blood glucose level.

(2) Hypoglycaemia.

(3) The patient has not taken their insulin/diabetes tablets.

(4) The patient does not follow the diabetes management plan.

(5) Management of wounds such as surgical wounds, trauma, and foot ulcers.

(6) Disposal of sharps (needles and lancets) in the home situation.

(7) How and where to obtain help/advice about specific patient problems.

Nursing actions

(1) Assess general clinical state (see Chapters 2 and 3).

(2) If the patient appears unwell, record:

temperature
pulse
respiration and presence of respiratory distress
blood pressure
colour.

(3) Assess presence, location, duration and severity of any pain and whether it is increasing or resolving.

(4) Note nausea, diarrhoea, and/or vomiting.

(5) Note presence of any symptoms of urinary tract infection but be aware there are often few, if any symptoms:

frequency
burning
scalding
itching.

(6) Assess state of hydration.

(7) Note time and dose of last diabetic medication.

(8) Note time and amount of last meal.

(9) Measure blood glucose level.

Interpreting the blood glucose level

To assess the diabetic status one must first ascertain whether the patient is in danger because of the blood glucose level. Ascertain:

The present level.
The usual blood glucose range.
Why the blood glucose is outside the usual range. Whether the patient has suffered any illness, committed a dietary indiscretion, commenced on a new medication, missed a medication dose, or is using a complementary or self-prescribed medication.
Whether it is likely to go up or down.

When ascertaining the blood glucose level check whether:

The test was performed correctly.
There was enough blood on the strip; if using a meter that the meter was calibrated and used correctly.
The strips have exceeded the expiry date (see Chapter 4, Monitoring 1: blood glucose).
The patient has commenced any new medication that could alter the blood glucose level (see Chapter 3).

The patient may require attention if the blood glucose level is:

Low – hypoglycaemia <3 mmol/L.
High – hyperglycaemia >17 mmol/L for a significant number of tests.

Hypoglycaemia

For more detailed information see Chapter 8.

(1) Treat according to the severity and time of occurrence of hypoglycaemia.

(2) Avoid over treatment.

(3) Give rapidly absorbed high GI glucose, if symptomatic, for example,:

glucose gel
orange juice
tea/coffee with sugar
jelly beans.

(4) Give more slowly absorbed low GI glucose, if the hypoglycaemia is asymptomatic and there is some time before the next meal is due.

(5) Suggest they have their meal if it is due in half an hour.

(6) Ensure patient has recovered before leaving the home. Check the blood glucose. Wash the person’s hands before testing the blood glucose if they have been handling glucose to treat the hypoglycaemia.

(7) Record incident.

If severe follow the procedure for managing unconscious hypoglycaemia ( Chapter 8). IM glucagon can be administered if it is available. If not, manage the airway and seek medical or ambulance assistance.

Practice point

The next dose of medication is not usually withheld.

Discuss recognition and treatment of hypoglycaemia with patient and family. Ensure that the person and/or their family and carers know how to manage hypoglycaemia, that there is appropriate food/fluids to manage hypoglycaemia and they know who to call in an emergency.

Hyperglycaemia

For more detailed information, see Chapter 7. Ascertain:

How long the blood glucose level has been elevated.
Whether the patient is unwell.
Whether there are any symptoms of hyperglycaemia, for example, polyuria, polydipsia, thirst or lethargy.
Whether there are ketones present in the urine.

If moderate/heavy ketones are detected seek medical advice (this usually only occurs in Type 1 people).

Check for any obvious source of infection:

Urinary
Foot ulcer wound
Cold or flu.

Practice point

Infection can be present without any overt signs and symptoms.

Counsel the patient about managing at home when unwell. (Patient information guidelines are shown in Chapter 5.) The important points are that the patient should: