The Efficient Recording of Diabetic Care The nurse in an extended care facility needs an "at-a-glance" recording system to assess diabetic clients' blood glucose levels and other telltale symptoms of hypoglycemia.

BY R O B Y N T Y L E R

A bnormal blood values in the patient with diabetes are significant in the development of acute com- plications and long-term neuropathies. I To en-

sure that normoglycemia is being maintained and prevent the serious effects of hypoglycemic crisis, nurses in an ex- tended care facility must have a quick and reliable way to monitor diabetic control. 2 This is difficult if a uniform, organized method of charting diabetic treatments and glucose levels is not available. The nurse may not be able to identify when a client is at risk, and this may result in increased frequency of hypoglycemic reactions or more intense long-term complications.

Documenlation of Diabetic Care

Documentation practices for diabetic nursing proce- dures vary in different settings. Many facilities have no organized system to provide the nurse with an "at-a- glance" picture of diabetic treatment and control. This results in nurse frustration when reporting values and data to a physician and increases the patient's risk for hy- poglycemic reactions.

Because diet, exercise, stress, and medication all play important roles in maintaining gtycemic control, an ac- curate method of documenting medication administra- tion must exist. The nurse in an extended care setting must be able to track the patient's blood glucose levels, insulin dosages, physical symptoms of hypoglycemia, and factors that may alter the absorption of insulin over a weekly or monthly period.

Boyle et al. 3 reported in a 1988 study that during de- creases in plasma glucose concentration, patients with

ROBYN TYLER, RN-C, MS, is a gerontological clinical nurse spe- cialist and diabetes educator at the VA Medical Center in Sioux Falls, South Dakota. GERIA'rR Nums 1993;14:265-7. Copyright © •993 by Mosby-Year Book, Inc. ISSN 0197-4572/93/$1.00 + .10 34/1/42763

poorly controlled insulin-dependent diabetes mellitus may experience symptoms of hypoglycemia at higher plasma glucose concentrations than persons without dia- betes. This may result in unexpected acute complications if blood glucose levels are the only assessment data gath- ered when monitoring the diabetic patient.

Because of time constraints and the location of patient charts, physical signs of hypoglycemia may be inconsis- tently documented. Symptoms such as confusion, shaki- ness, irritability, slurred speech, hunger, fatigue, dizzi- ness, poor coordination, headache, and personality changes may be present before each episode of hypogly- cemia. The patient's unique pattern of preexisting symp- toms may be overlooked because the previous episodes were not observed by the same nurse, were inconsistently documented, or are hidden within the text of the narra- tive nurses notes.

SUGGESTED SEQUENCE FOR ]NSUEIN INJECTIONS

t. Right ~mgh 2. Right arm 3. Right abdomen

5. Left arm. 6. Left ~Igh

It has been reported that rapid-acting insulin is ab- sorbed at different rates from different parts of the body. 4 The rate of insulin absorption slows in diabetic persons as injection sites move from the abdomen to the arm, and it is slowest in the thigh. 5 These findings suggest that ran- dom injections may produce erratic insulin levels. Re- searchers propose that it is important to stay within one area (i.e., left arm) until all possible sites are used before going to another area of the body. To maintain normo- glycemic levels it is advised to rotate within all useable areas of one body region hefore moving to a different part

GERIATRIC NURSING Volume 14, Number 5 265

Patient Room Doctor

D iabet ic R e c o r d

Blood

"time Glucose /nsu~n Given Site ~ - n e e t Da~ Nurse's Sigrudum

SITE CODE

Ru~tu injec6cx~ per letter and numedcal sequence. Use gl pa~'ble site~ in one body area before ,,.,~-,i~ng to another a r e a / e ~ i t y .

For ex:e, mple, use ~ AI through ~ ,u~,= to BI through 138, then to CI through 08, etc.

Rac~ an "X" over sites that ~re c,o,;b-aindicat:ed in this pm~nt.

FIGURE 1. Diabetic record and injection sites.

266 GERIATRIC NURSING September/October 1993

of the body. The sequencing between body parts should move from the right thigh to the right arm to the right ab- domen to the left abdomen to the left arm to the left thigh. The sequence should then be repeated. Site codes often merely specify a body region (e.g. "right arm") and are not specific about which sites within the region have been used.

The Diabetic Record

After consultation with nurses from nursing homes, acute hospitals, and rehabilitation centers, a diabetic record was developed for use in documenting the assess- ment of the patient receiving hypoglycemic medications. A consistent method of documentation saves time and prevents omissions in charting.

A specific injection site code provides guidance by al- phabetical sequence of body part rotation and numerical sequence for rotation within a site. Individualization is possible by placing an "X" over sites contraindicated in each patient.

A column titled "Assessment Data" is provided to record significant data found in the initial assessment, such as diaphoresis, mental status, reports of pain, dizzi- ness, headache, nausea, activity level, diet, medication changes, infectious processes. Nursing observations and interventions affecting blood glucose metabolism must be recorded for most effective use of a diabetic record.

Thirty-two lines are available providing approximately 1 week's systematic documentation for the patient requir- ing glucose checks or insulin four times daily. The record is designed to be kept in the medication book or card file and to be updated at the bedside on completion of the as- sessment and intervention. This facilitates accurate re- cording of the data as it is collected and determining pat- terns.

The diabetic record combines on one form the data necessary to monitor potential complications of the indi- vidual patient. By having one source which combines blood glucose levels, insulin doses, significant changes in vital signs, behavioral or nutritional patterns, the nursing assessment may be completed quickly and recorded ac- curately. Consistent symptomatic patterns are easily identif ied thus p revent ing the compl ica t ion of hypoglycemia. •

REFERENCES

I. Armstrong N. Coping with diabetes mellitus: a full-time job. Nuts Clin North Am 1987;22:559-68.

2. Istre S, Michael S, Pecoraro S. Daily and monthly diabetic flowsheets. G~- mAtric Nurs~n~ 1984;5:363-5.

3. Boyle P J, Schwartz NS, Shah SD, Clutter WE, Cryer PE. Plasma glucose concentrations at the onset of hypoglycemic symptoms in patients with poorly controlled diabetes and in nondiahetics. N Engl J Med 1988;318:1487-92.

4. Bantle JP, Weber MS, Rao SM, Chattopadhyay MK, Robertson RP. Rota- tion of the anatomic regions used for insulin injections and day-to-day vari- ability of plasma glucose in type I diabetic subjects. JA MA 1990;263:1802-6.

5. Thatcher G. Insulin injections: the case against random rotations. A m J Nurs 1985;85:690-2.

II

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