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Ask the Diabetes Nurse Specialist

Frequently Asked Questions

In our facility we use many different amounts and types of food to treat hypoglycemia for our residents taking insulin. What should we be using?

Diabetes organizations recommend approximately 15gms of fast acting oral carbohydrate for glucoses 70 mg/dL or less. So what does that mean? The amount does not have to be exact since each individual responds slightly differently. Among your elderly clientele you want to choose something easily swallowed, easily broken down by the stomach and easily absorbed for a rapid rise in blood sugar. Examples are 4 ounces of juice, 4 ounces of non diet soda, 4 ounces of fruit sauce or more recently 3-4 glucose tablets or glucose gel that contains 15gms carbohydrate. The last is helpful since it eliminates guesswork and may be easier to swallow than other treatments. A good response should be visible within 15 minutes or less. Remember to analyze the cause of the hypoglycemia and initiate changes to avoid future episodes.

We see many different targets for glucose control used in long term care facilities, what should they be?

Different levels may be appropriate given the patient's prognoses or comorbidities. However The limits for which to contact the doctor are described by the American Medical Directors Guidelines. These recommend physicians be notified immediately when patients have multiple blood glucose results of 70 mg or are ever once unresponsive. They should be informed as soon as possible when two or more values are greater than 250 mg/dL if a treatment change has not been initiated to counter this and at 300mg/dl whenever it occurs. The American Diabetes Association recommends day to day goals for adults be used for the elderly as well: an A1c of < 7%, a preprandial (premeal) glucose of 70-130 mg/dl and a post prandial (<180 mg/dl). Prolonged hyperglycemia places patients at risk for dehydration, infection, altered mental status. Nurses should examine glucose patterns to detect impending crises.

What are the latest ways to confirm a diagnosis of diabetes?

The criteria for diagnosis of diabetes are straightforward and can be done in several ways.

  • Laboratory tests (not bedside glucose meter results):
  • Fasting plasma glucose result of > 126 mg OR
  • Classic symptoms of hyperglycemia and a random glucose of > 200 mg. OR
  • Two hour post glucose intake of > 200 mg (during a glucose tolerance test)
  • And new in 2010, an A1c (glycosylated hemoglobin) > 6.5% can also be used.

There is no definitive evidence that older adults normally have higher glucose results than anyone else

What should be included in a Diabetic foot exam?

American Diabetes Association tells us that all individuals with diabetes should receive an annual foot examination more frequently for high-risk patients. This means its more then just looking at the feet. The examination should include: Assessment of protective sensation, Foot structure, Vascular status, Skin integrity, Semmes Weinstein Monofilament Test.

Why is it that people with diabetes have so many lower extremity ulcers?

The most common cause of amputation among ambulatory people with diabetes is actually neuropathic ulceration. Many people today avoid major vascular disease with good long term control though they may still have small vessel disease (microvascular). They are at a higher risk for poor healing. Some have a loss of protective sensation primarily (neuropathy) in the lower extremities. As a result, they may develop foot deformities (internal high pressure areas) that predispose to tissue breakdown with walking. Sometimes they may experience painless trauma. Any ulcer is harder to heal if there are multiple kinds of pathology, poor nutrition or inadequate glucose control. Each patient with diabetes should be considered high risk for skin breakdown and ulceration and their specific pathology assessed with targeted appropriate prevention measures in place.

Susan Pohl
RN



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