Blood Glucose - How to test

Transcription

1 Blood Glucose - How to test no nurse should use blood glucose monitoring equipment without complete training the ward manager is responsible for ensuring staff are trained in Blood Glucose testing Calibration The meter must be calibrated for every new box of test strips. Insert calibrator into meter. Once calibration is complete, remove calibrator LOT = OK Perform Quality Control regularly Quality Control must be performed:- Daily use if used infrequently With a new pack of test strips After changing batteries After unexpected results If a new meter is used. LOT = Meter will display LOT number Store calibrator in box with test strips and retain leaflets _ Appointed personnel only Blood Glucose Testing using a calibrated BGM device Wash hands with soap and dry (Nurse and Patient) + Insert new testing strip into meter Prick patient s finger with sterile lancet to draw blood drop LOT = Put on surgical gloves Check LOT Number and expiry date are okay Vary test sites and avoid thumb and forefingers. Touch the drop of blood to the tip or top of the strip _ Test will start automatically Countdown to result will begin Countdown to result 5.6 After countdown result will show Record result immediately on patient s chart BLOOD GLUCOSE TEST RESULT 5.6 Abnormalities should be reported Remove test strip from meter _ Wipe meter clean between patients Dispose of sharps and test strip Follow NHS guidelines on sharps disposal All staff must ensure: Only one pack of Blood Glucose test strips is open at any one time. The pack of test strips is stored with the meter for which it has been calibrated. The meter is recalibrated each time a new pack of strips is used. Quality Control is carried out by an accredited person to ensure the practitioner is carrying out the test correctly and that the meter is functioning properly. External Quality Control is carried out once every three months. Patients using their own meter must have result checked/recorded against ward meter. if in any doubt as to the clinical validity of a result, an urgent blood glucose sample must be sent to the clinical chemistry laboratory immediately. University Hospitals of Leicester NHS Trust

2 Blood Glucose - When to test This poster is to be used in conjunction with the document Bedside Monitoring of Capillary Glucose found in the ward pack. This document applies to all wards with the exception of ITU, Children s and Maternity, for which separate arrangements apply. It does not apply to patients on intravenous insulin or who are nil by mouth. When a patient with Diabetes is admitted to hospital: Perform: Venous Plasma Glucose HbA1c (unless previously recorded in last 2 wks). Urine test for Ketones. First 24 hours following admission: Perform: Capillary Blood Glucose profile using ward meter. each meal and before bed. ideal 4-6 mmol/l acceptable 4-8 mmol/l If acceptable, frequency of testing could be reduced. See guidance below. Treatment for Diabetes Diet alone Metformin alone Metformin plus either pioglitazone or rosiglitazone, or combined preparations thereof of Avandamet or Competact Any sulphonylurea: Gliclazide Gliclazide MR Glipizide Glimepiride Glibenclamide Tolbutamide Repaglinide Nateglinide either alone or in combination Insulin (alone or with tablets) Day 1 Day 2 Day 3 Day 4 Day 5 *Once daily testing at staggered times breakfast (Pattern repeats every 4 days) lunch NOT acceptable <4 OR >8 mmol/l Testing Schedule Once daily at staggered times* (See table below) Once daily at staggered times* (See table below) evening meal bed If not stable, return to four times daily testing Establish the patient s personal use of monitoring at home. Discuss and agree monitoring during this admission. Patient using their own meter should have it checked for accuracy against ward meter. See How to Test Guidelines. Basal Bolus/Insulin Pump patients Usually test Blood Glucose more frequently Continue to monitor (Minimum four times a day) This should be agreed and planned with the patient. OUT OF ACCEPTABLE RANGE IF NOT WITHIN AN ACCEPTABLE RANGE CONTINUE 4 DAILY TESTING BEFORE MEALS AND BEFORE BED. ENSURE DIABETES IS REVIEWED. Action to be taken if out of acceptable range or patient feels unwell: Low Blood Glucose If lower than acceptable, manage in accordance with Hypoglycaemia Guidelines and increase test frequency to 4 times daily before meals for at least 24 hours to ensure there is no recurrence. High Blood Glucose If higher than acceptable, increase test frequency to 4 times per day. If higher than acceptable on two consecutive occasions, inform medical staff. If >20 mmol/l inform medical staff. Check urine for ketones. Check Early Warning Score. References: UHL Guideline for Blood Glucose Monitoring Hypoglycaemia Poster Diabetes UK What care to expect in hospital (extracts) ADA Bedside Glucose Monitoring in Hospitals. Diabetes Care : 104 if in any doubt as to the clinical validity of a result, an urgent blood glucose sample must be sent to the clinical chemistry laboratory immediately. University Hospitals of Leicester NHS Trust

3 Hypoglycaemia (Low Blood Glucose) low blood glucose = <4 mmol/l Who is at risk? People with diabetes who are treated with insulin. People with diabetes who are treated with the following tablets (either alone or in combination): Gliclazide, Gliclazide MR, Glipizide, Glimepiride, Glibenclamide, Tolbutamide, Repaglinide, Nateglinide, Pioglitazone, Rosiglitazone Signs and Symptoms Sweating Tremor Palpitations Hunger Pallor Blurred vision Tingling of lips Headache Lack of concentration Irritability Slurred speech Fits Apparent stroke Unconsciousness Management Confirm diagnosis Check capillary blood glucose - will be less than 4mmol/l Patient is able to swallow Give either: 200ml normal, non-diet cola 200ml fruit juice 120ml Lucozade Original Sparkling Glucose Drink 5-6 Dextrose tablets 3-4 teaspoons of glucose in water All provide about 20g of CHO, lemonade provides only 5g CHO per 100ml so they would need 400ml to get 20g. Remember Lucozade Sport is much lower in CHO per 100ml so Lucozade Original is better. Treatment Record Info Patient is semi-conscious and able to swallow and protect airways Glucogel (formerly known as Hypostop Gel ). One ampoule into buccal cavity. This does not need to be swallowed in order to be absorbed. This is just under 10g CHO per tube so once they come round enough to tolerate a drink they will need one of the above. Patient is unconscious - unable to swallow Place patient in recovery position Give Glucagon 1mg intramuscularly stat. This has to be prescribed. It will be stored in the ward refrigerator. NB: Carbohydrate should be given asap to prevent further hypoglycaemia.!! Warning If patient does not recover in 10 minutes, call medical staff to administer intravenous 50% D-Glucose. This has to be prescribed. Document the hypo on the diabetes chart and indicate action taken. Inform medical staff Patient Record All the above treatments are short lived and hypoglycaemia may recur. Offer the patient a carbohydrate-containing meal or snack to maintain normal blood sugar, eg. biscuits, yoghurt or a sandwich. (Refer to green Diabetes Prescribing Monitoring Chart). if in any doubt as to the clinical validity of a result, an urgent blood glucose sample must be sent to the clinical chemistry laboratory immediately. University Hospitals of Leicester NHS Trust

4 Bedside Monitoring of Capillary Blood Glucose in UHL This document applies to all wards with the exception of ITU, Childrens, and Maternity, for which separate arrangements apply. It does not apply to patients on intravenous insulin or who are nil by mouth. Standards: 1. All patients known to have diabetes will have a venous plasma glucose measurement, HbA1c (unless there is a result on record within previous 2 months) and a urine test for ketones on arrival in hospital. Their diabetes medication will be prescribed. 2. All patients will be offered a capillary blood glucose profile using a quality assured ward-based system for the first 24 hours(1). For the majority this will be measured before each meal and before bed (4 tests). Results will be recorded on the Diabetes Chart. Pre-meal ideal 4-6 mmol/l, acceptable 4-8 mmol/l 3. Patients who are accustomed to testing their own blood glucose should be encouraged to do so in hospital and should be asked to bring their own meter and strips for this purpose. A QA process must be undertaken first. The patient should be asked to test the same drop of blood as is used for the ward meter and the two results should be entered on the chart as self and ward respectively. If these paired results differ by no more than 10% (or 0.5 mmol/l whichever is greater), then the patient can continue to use their own meter and strips as and when they wish. If the difference is unacceptable, explain to the patient that there is a discrepancy that means their results cannot be relied upon until a further check has been made. Then refer to the Diabetes Team for their action. This QA process should be repeated weekly. 4. If all results in the first 24 hours are in the acceptable range, and the patient s condition is considered to be stable, the test frequency should be reduced according to the type of treatment the patient is taking for diabetes as shown in the table below. Check prescription chart: Treatment for Diabetes Diet alone Metformin alone Metformin plus either pioglitazone or rosiglitazone, or combined preparations thereof Avandamet or Competact Any sulphonylurea (gliclazide, glibenclamide, glipizide, glimepiride, or glinide (repaglinide or nateglinide) either alone or in any combination Insulin (alone or with tablets) Testing schedule Once daily at staggered times* Once daily at staggered times*

5 *Once daily testing at staggered times - (Pattern repeats every 4 days) Day 1 Day 2 Day 3 Day 4 Day 5 breakfast lunch evening meal bed These test frequencies are regarded as minimum acceptable for patients whose clinical condition remains stable and whose glucose readings remain within the acceptable range. The test frequency must be increased to 4 times daily before meals and at bedtime if the patient s clinical condition deteriorates or if a result falls outside the acceptable range, or if an alteration is made to the patient s diabetes treatment, or to medication that might affect diabetes control, eg steroids added or steroid dose changed, or an ACE inhibitor added or nutritional supplements taken. Post meal testing: A minority of patients who are using intensive insulin regimens (4 or more injections per day or insulin pump treatment) are accustomed to testing their blood glucose before and two hours after meals. These patients should be permitted to test in this way, but should be strongly encouraged to bring in their own meter and test strips for this purpose. Target results: ideal 4-8 mmol/l acceptable 4-10 mmol/l. Actions to be taken if result out of acceptable range. If lower than acceptable, manage in accordance with Hypoglycaemia Guideline and increase test frequency to 4 times daily before meals for at least 24 hours to ensure there is no recurrence. If higher than acceptable, increase test frequency to 4 times per day. If higher than acceptable on two consecutive occasions, inform medical staff. If >20 mmol/l check urine for ketones and inform medical staff. If patient is vomiting, regardless of blood glucose result, check ketones and inform medical staff if present. Diabetes Charts will be audited regularly to assess compliance with this guidance. Refs: 1. UHL Guideline for Blood Glucose Monitoring on the Wards 2. Hypoglycaemia Poster R Gregory Head of Service Metabolic Medicine 9/3/2007

6 Appendix: Diabetes UK What care to expect in hospital (Extracts) You may be admitted to hospital for reasons related or unrelated to your diabetes. In hospital, responsibility for the management of diabetes should be shared between you and the health professionals. Good diabetes control is important for a speedy recovery and early discharge. You should. Inform the ward team of your usual diet, tablets or insulin treatment. Bring your own supplies with you if they are removed for safe keeping, make sure that they are returned to you at the end of your stay. Be allowed to discuss your diabetes so you can manage some aspects of it yourself, such as blood/urine monitoring and injections, if you wish however, the staff may need to check your technique and results and they may need to do additional tests of their own. Expect to be able to use your own emergency supplies of biscuits, sugary drinks, fruit or glucose tablets to treat hypoglycaemia if you are on insulin or sulphonylurea tablets you should bring these supplies with you. If you do experience a hypo, inform your nurse or doctor. ADA Bedside Blood Glucose Monitoring in Hospitals Diabetes Care : 104. The modern management of hospitalized patients with diabetes includes capillary blood glucose determinations at the bedside. This measure is analogous to an additional "vital sign" for people with diabetes. The rapidity with which results can be obtained, and therapeutic decisions made, can improve management and conceivably shorten hospital stays. Replacing venipunctures with capillary blood glucose tests enhances patient comfort. Bedside glucose determinations can be performed by adequately trained personnel. Use of bedside blood glucose monitoring requires: 1) clear administrative responsibility for the procedure, 2) a well-defined policy/procedure manual, 3) a training program for those personnel doing the testing, 4) quality control procedures, and 5) regularly scheduled equipment maintenance, 6) The frequency of measurement needs to be individualized.

7 American Diabetes Association Recommendations American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care 2005;28:S4-S36. All patients with diabetes have an order for blood glucose monitoring. Results of blood glucose monitoring are available to all members of the health care team. Joint Commission Expectation Written blood glucose monitoring protocols for patients with known diabetes are developed and include, at a minimum, the following: measuring blood glucose upon admission a plan for subsequent monitoring based on the patient s: type of diabetes desired level of control current treatment(s) (e.g. use of steroids, TPN, etc.) comorbidities and medical illnesses dietary status including patients who are nil by mouth Results of blood glucose monitoring are available to all members of the health care team. The patient and the practitioner managing his or her diabetes care after discharge are informed about.any unresolved issues related to glucose management. Clinical Resource Efficiency Support Team Safe and effective use of insulin in secondary care: Recommendations for Treating Hyperglycaemia in Adults. August 2006, Belfast. Audit of Safety and Effectiveness of protocols should be conducted regularly. Standards for audit could include the number of consecutive occasions that glucose levels exceeded defined upper limits, frequency of hypoglycaemia and corrective actions employed in each circumstance.