Infection Control Programs in Long Term Care Facilities

In last month’s blog I discussed the precautionary measures in place to prevent the transmission of infections that can occur in residents of Long Term Care (LTC) facilities. Now, I will discuss the most important aspects of a good Infection Control (IC) program and the nurse who is in charge of it.

The Centers for Medicare and Medicaid (CMS) regulations address the need for a comprehensive program that include surveillance of infections, implementation of methods for preventing the spread of infections; including the use of isolation measures when necessary, hand hygiene practices and the appropriate handling, processing and storage of linens. Health protocols for preventing infections by employees and residents should also be included. Policies and procedures relevant to Infections must be in place and readily available.

LTC facilities are required to establish and maintain

an IC program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

During a survey, surveyors will request to see this program and a list of residents/employees who had acquired infections during the previous year.

CMS has also established a final rule requiring LTC facilities offer annually, to each resident, immunization against influenza and offer a lifelong immunization against pneumococcal disease. Furthermore, each resident or their legal representative must receive education on the benefits and potential side effects of the immunizations prior to administration of the immunizations. A written consent and acknowledgement of the information must be signed by the resident/legal representation and maintained as part of their medical record. Review of residents admitted to facility with infections or on antibiotics should be included and should indicate “admitted with”.

The IC nurse is an essential component of a good infection control program who is  designated by the facility to be responsible for it. They should be a registered nurse, who has received formal infection control training and has the ability to interact tactfully with personnel, physicians, residents and their families. It would be beneficial for the IC nurse to belong to a professional organization, in order to keep abreast of any current prevention and control information. Peer networking is also very valuable. Based on the size and staffing of the facility, this should be a full-time position if possible.

All direct care nurses should be observing their residents for any signs of infections as well as observing the medication administration record (MAR). I have always advised my nursing staff that there are two reasons for a resident receiving an antibiotic, (1) they have an infection or (2) it is prescribed prophylactically.

One of the better Infection Control Programs I have seen

included the following components:

• The direct care nurse identified the resident with an infection, notified the physician and received appropriate orders.
• The nurse then filled out the IC report sheet.
• By the end of the shift, this form was given to the IC nurse.

The information in the report should include:

(1) Residents name and room number.

(2) date and time of onset of symptoms

(3) date and time of physician and family notification.

(4) cultures or x-rays if ordered.

(5) Antibiotics ordered, including name, dose, and duration.

(6) Type of isolation if indicated.

Upon receiving this report the IC nurse begins surveillance of the infection. This should be done timely and includes record review, laboratory and radiology reports, treatment reviews, antibiotic usage data and clinical observations as sources of data. It should also be determined if this was a healthcare associated infection (HAI). This surveillance should be performed for each infection identified. The  causative organism should be added to the report when identified.

Analysis of the surveillance reports should be done weekly or monthly. Computerized graphs and charts can assist in compiling data and it is important to identify causative organisms and trends in areas of the facility where similar infections occur. Other elements necessary for a good IC program include: outbreak control requires a system for detection, investigation and control of epidemics. Preparation for this event should be in readiness at all times.

Isolation: An isolation and precaution system to reduce the risk of transmission. Keep in mind that elderly residents can become easily depressed when isolated, therefore isolation should be for the shortest possible duration and modified if appropriate.

Education: continuing education in IC prevention and control is mandatory. Education on the principles of IC for employees should begin in orientation. We are all aware of the high rate of employee turnover in LTC facilities. Frequent review of the many aspects of the Infection Control Program should be presented and random monitoring of correct handwashing technique is very necessary.

Resident and employee health programs. Follow federal and state requirements and the facility policies. Disease reporting to public health authorities may vary from state to state. Infection control protocols for facility management, including environmental control, laundry services, waste management, sterilization and disinfection must be in place and followed.

Antibiotic stewardship is of vital importance. Antibiotic utilization and appropriateness should be monitored for each resident. Antibiotic resistant bacteria pose a significant hazard in LTC facilities and this resistance has been strongly associated with antibiotic use. Antimicrobials are the most frequently prescribed medications in LTC facilities.

The IC nurse should oversee all aspects of the program and should have well defined support from administration and have additional support staff depending on the size of the facility. Some LTC facilities have an infection control oversight committee in place to review IC data, review policies and monitor program goals and activities. The committee should meet monthly and should consist of IC nurse, administrator, medical director and nursing supervisor or their designee. Written records of the meetings should be kept.

Over the last three months, I presented blogs on infections, precautions and control programs. I hope they have been beneficial.

Prevention of Infections in LTC Facilities

Precautions for Prevention of Infection Transmission in Long Term Care Facilities

Last month I discussed the more common infections that occur in long term care (LTC) facilities. I will discuss how these transmissions can be prevented or reduced.

Preventing the spread of infectious organisms include using standard precautions with every resident and practicing hand hygiene before and after every resident contact. Identification of infectious organisms quickly and initiating appropriate treatment in addition to prompt isolation when indicated is imperative.

These are the precautions that must be in place to prevent the spread of infections:

• Standard Precautions
• Contact Precautions
• Droplet Precautions
• Airborne Precautions

Standard precautions apply to all residents, and all healthcare workers in any setting without a specific infectious process or diagnosis identified. The other precautions are transmission-based precautions that should be applied when a specific organism is known or suspected to be present in a resident. These precautions are applied in conjunction with standard precautions.

Standard precautions should be applied in all healthcare delivery systems.They are based on the concept that all body fluids may contain transmissible infectious agents. Standard precautions are designed to eliminate exposure to blood and other potentially infectious material (OPIM).

 

Standard precautions include proper hand hygiene and the use of gloves, gown, mask, face shield, eye protection and safe injection practices including the proper disposal of needles as indicated.

Contact precautions are designed to cut down on the transmission of organisms that are easily spread by contact with hands and other objects, and areas of the residents’ environment that may be contaminated.

Droplet precautions attempt to prevent the transmission of diseases that are easily spread by particle droplets produced when a person sneezes, coughs or talks. Wearing a simple surgical mask will protect the caregiver when entering the the room or cubicle. When the resident shares a room, spacial separation of three feet or more and drawn cubicle curtains are required.

Airborne precautions are designed to prevent the spread of disease by the true airborne route. The organisms leave the resident in respiratory droplets that evaporate into the atmosphere. Most organisms die when they dry out but tuberculosis, chickenpox, measles and smallpox can survive drying out and can be widely dispersed by air currents. These precautions require a negative-pressure airborne infection isolation room (AIR) with the door closed and use of an N95 respirator. Please follow the facility policy.

As we all know hand hygiene is the single most important procedure for preventing the spread of infection. All employees should be randomly requested to perform hand hygiene on a routine basis. This will encourage using the correct technique. The use of an alcohol based hand rub should not replace hand washing.

Inservice education on infection control issues is mandatory and a record of the occurrences must be maintained. The infection control procedure manual should be available for review by all employees as needed.

Follow the facility policies for the routine care, cleaning and disinfection of environmental surfaces, beds and bedside equipment. Proper decontamination and sterilization of equipment and supplies is important.

Linens must be handled, transported and processed in a manner that prevents contamination. Ensure that single use items are discarded properly Do not use single dose vials for several residents.

Food and drink should be be removed from places where blood or OPIM is present. Environmental controls help prevent the spread of infection by reducing the concentration of organisms in the environment. Housekeeping, waste management and linen (laundry) management must be performed with this concept in mind.

Before I conclude this blog, I would like to discuss the Occupational Health and Safety Administration (OSHA) requirements.

OSHA was established by an Act of Congress in 1970 “to assure the safety and health of American workers, by setting and enforcing standards, providing training and education, by outreach and establishing partnerships and encouraging continual improvements in workplace safety and health”.

OSHA came to the forefront in the healthcare environment with the emergence of the HIV virus and concern for the risk of healthcare workers acquiring the virus through patient contact.

The Bloodborne Pathogens Act became law in 1991 and Standards were put in place to provide  workplace safety.

Employers should have an exposure control plan in place that makes universal precautions mandatory where all blood and body fluids (except sweat) are considered infectious.

• Personal Protective Equipment (PPE) must be available to employees at no personal cost.
• Employees who are in contact with contaminated laundry must wear gloves and other PPE as appropriate.
• All employees whose job involves tasks with potential exposure to blood and OPIM must be offered Hepatitis B vaccination. This vaccination is free, safe and highly effective.
• Provide bloodborne pathogen training to employees annually.
• Employers must provide safe needles and sharps containers their disposal.

As healthcare workers, we should remember if we do not explicitly follow these directives we are breaking the law and are subject to legal ramifications.

Refer to the OSHA website for a complete list of guidelines.

Infections in Long Term Care Facilities

Infections are a common occurrence in Long Term Care (LTC) facilities. Residents who reside there are usually elderly, are in declining health and have comorbid chronic illnesses. More than one and a half million people reside in LTC facilities and as the acuity of illness has increased drastically, therefore, the risk of acquiring Healthcare Associated Infections (HAI) has also increased.

Residents are frequently transferred between LTC facilities and hospitals, providing additional dynamics to the transmission and acquisition of HAIs.   

The causative agents of infections are microorganisms (germs). Bacteria, fungi, protozoa, viruses and parasites are the most common types. These are usually harmless in the environment. It takes thousands to cause disease and vary in infectivity (how easy are they to catch) and in virulence (the severity of illness from the infection they cause). Residents in LTC facilities are, as mentioned above, more susceptible to infection and their immune systems are weaker.

Bacteria are single cell organisms. All people live with many bacteria (normal flora) in their bodies. Usually they  do not cause disease unless (1) their balance is disturbed or (2) they are moved to a part of the body where they do not belong or (3) to a new susceptible host.

Important bacteria causing human disease include:

• E. coli (urinary tract infections and diarrhea).
• Streptococcal (wound infections, cellulitis  sepsis, and death)
• Clostridium difficile (severe diarrhea, colitis)
• Staphylococcus (skin boils, pneumonia, endocarditis  sepsis, death).
• Mycobacterium (tuberculosis)

Fungi have a worldwide prevalence and healthy people are not usually affected. Fungi illnesses usually affect the skin, nails and subcutaneous tissue. Candida is a fungus that causes yeast infections. These are often seen in obese residents with pendulous breasts and abdominal folds.

Protozoa are also singled celled organisms but are larger than bacteria. The disease causing variety include amoebas, giardia and Pneumocystis carinii. The latter often causes pneumonia and may be fatal in immunocompromised individuals.

Viruses are intracellular parasites because they can reproduce inside a living cell. Some viruses, such as human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) have the ability to enter and survive in the body for years before symptoms of the disease occur. These viruses can be transmitted to others before the source is aware they are infected.

The influenza virus makes its presence known quickly

through characteristic symptoms. All of these viruses are of concern in the healthcare setting.

Parasites are larger organisms that can infect or infest residents. Infestation with lice or scabies occur by direct contact and is highly contagious. Ingestion of the eggs of roundworm, tapeworms and pinworms can occur. Penetration of the skin or mucous membranes with their larvae can also cause infections.

We need to be aware of how infections occur and are  transmitted. This process is called the Chain of Infection:

The causative organism (pathogen) has many paths for entering the human body and these are referred to the Port of Entry. This can be through the mouth, nose, eye, cuts, skin abrasions, surgical incisions, wounds, needle sticks and intravenous sites. Anatomical openings with tubes, such as gastrostomy tubes, tracheostomy tubes or surpapubic catheters can also be ports of entry as well as urinary tract catheters.

The reservoir is the person in whom the organism lives and multiplies. The gastrointestinal (GI) tract is the place in the body for many different types of organisms, including viruses, bacteria and parasites.

The mode of transmission is how the organism is transferred from the infected person to another person, who is named the susceptible host. The mechanisms by which the transmission may occur are as follows:

• The most common mode of transmission is unwashed hands.

• Direct contact is person-to-person transmission of the pathogens.
• Indirect contact is the spread of pathogens by a person or an inanimate go-between, such as unwashed hands and unclean instruments.
• Droplet transmission occurs by coughing, sneezing, and speaking and the pathogens can travel approximately three to six feet before dying off or falling on another surface.
• Airborne transmission can occur when respiratory droplets evaporate and are suspended in the air.

     Diseases transmitted by this route are smallpox,       tuberculosis chickenpox and measles.

The portal of Exit is the path by which the organism gets out of the reservoir. In a person, this is often by a bodily fluid. Blood, feces, nasal exudates, respiratory secretions and wound drainages are all examples of body fluids and how pathogens can exit the body. However, some bacteria, such a Methicillin Resistant Staphylococcus Aureus (MRSA) can live and grow on the skin.

Not all people who become infected with a pathogen have symptoms or signs of a disease at the time they transmit the infection to others, that person is asymptomatic and the transmission is referred to as asymptomatic transmission.

Some individuals are prone to becoming transiently or permanently colonized with organisms they have been exposed to. They may never develop symptoms of the infection but are an important source of transmission to others.

An endogenous infection occurs when a person becomes infected with microbes from their own natural flora, when their own germs get in the wrong place. For example, the urinary tract may become infected with microbes from the

GI tract, such as with Enterococcus (e-coli).

Due to the high occurrence of infections in LTC facilities, not just treatment but prevention is of the utmost importance. There are many standards and guidelines designed to proactively prevent the spread of infections.

Many states and most medical professional organizations

have designed standards of professional behavior and responsibility as the pertain to infection control.

Prevention and Control standards are a collaborative effort between the Centers for Disease Control (CDC),

the Joint Commision (JC), World Health Organisation (WHO), the Occupational Health and Safety Administration (OSHA). ( Further information on their standards may be obtained online at their individual websites.)

The immune system is the body’s defense mechanism against disease. In frail elderly or ill residents this may be compromised and these individuals are said to be immunocompromised. The immune system becomes less responsive with age.  Nutritional status is a key factor in the immune system and a person who is poorly nourished may not be able to fight an infection. Also, gastric acid which is a natural barrier against invading organisms decrease with age. Certain medications can impair immunity.Anti- inflammatory drugs like corticosteroids, and cancer drugs can interfere with the immune system.

Infections and Infection Control is so diverse and of such vital importance that I will continue the subject in my blog over the next two months. I will discuss infection control precautions and what constitutes a good Infection Control Program and who should be responsible for it in the coming months.

When I was researching for this blog I came across “Wild Iris Medical Education” online. They had a fantastic course on Infection Control. I took the course, passed the examination and for a very reasonable fee, I got a certificate and 6 hours of Continuous Education credit. The course was well laid out with current information and was easy to comprehend.  I would recommend it to any nurse. I will certainly revisit them for further continuing education programs.

Dehydration

Dehydration is the abnormal loss of body fluids and if not corrected can lead to electrolyte imbalance. It is caused by increased fluid loss or decreased fluid intake and is a common occurrence for residents in Long Term Care (LTC) facilities. The advancement of disease is a major cause of dehydration in residents.

The Mayo Clinic’s definition: Dehydration occurs when you use or lose more fluid than you take in and your body does not have enough water or other fluids to carry out its normal functions. If you don’t replace lost fluids, you will become dehydrated

Nurses need to be aware that aging causes change in the body’s water composition. Thirst perception and renal function decline among older adults. Age related changes make older adults more vulnerable to shifts in water balance that can result in overhydration but more commonly in dehydration. Also, the thirst center does not function as well in geriatric residents. Dehydration can also cause the delayed healing of wounds as the wound bed requires adequate moisture to granulate.

Approximately 50% of elderly people have chronic kidney disease (CKD).

Usually, elderly people can maintain normal electrolyte balance. However, under stressful conditions hyponatremia, hypernatremia, volume depletion, hyperkalemia and metabolic acidosis can occur and if not quickly corrected can lead to high rates of morbidity and mortality.

It is also important that direct care staff know the residents who are at high risk for dehydration and recognize the risk factors, assess those risk factors and develop a care plan with measurable goals.

In order to maintain a good hydration program in a LTC facility, the following factors must be in place:

1. Staff education: the direct care staff must know the risks of dehydration and the signs and symptoms associated with the condition. Make the staff realize that restricting fluids, does not decrease episodes of incontinence. Fever, infections, intense diarrhea, vomiting, excessive sweating in hot weather, inadequate intake and profuse wound drainage can all lead to dehydration.
2. Staff assistance: you must have adequate staff and must give them enough time to feed residents as necessary and provide adequate fluids. Staff should also be aware of residents’ preference ( use of a straw, water temperature, ice etc.)
3. A beverage cart during rounds should be used at least twice daily and between meals to provide water, fruit juice, watermelon and/or jello to provide additional hydration. The Activity department may be employed for that task.
4. During the medication pass, 4-6 ounces of fluid should be provided to the patient. The staff should always be assisting, encouraging, providing verbal prompts and praise for the patient’s fluid intake.
5. Nurses need to be aware of any medication or other situations that can cause increased output (diuretics or profuse diaphoresis in hypoglycemia).
6. Water pitchers must be replenished as needed, placed within reach of the patient and be light enough for easy lifting. Clean cups or glasses should be provided.
7. Fluids may also be provided during group activities and therapies and ambulatory residents should be provided with a water bottle.   

Many of the residents in LTC facilities may be on thickened liquids. I have never found a resident who liked them. Neither taste nor consistency are very palatable. There are some that are fruit flavored but they are more costly. However with the help of the dietician and an order from the physician, naturally thick beverages may be substituted. Nectars, tomato juice, buttermilk, drinkable yogurt, ice cream, soups, jello and milk shakes offered frequently and in small volume may be an appropriate alternative.

The power of attorney holder or family need to be made aware of the risks of dehydration and may be very helpful in encouraging the resident to consume more fluids. As always, keep the care plan up to date.  Monitoring intake and output (I&O) especially during an acute phase of an illness will keep you aware of progress or decline.

Monitoring Weight Variance

Monitoring weight variance, either loss or gain, is an important factor in keeping Long Term Care (LTC) residents as healthy as possible. Accurate weight measurement is critical to a nutritional assessment. The information is necessary to calculate fluid needs as well as macronutrient amounts and is often used to calculate medication dosages. A patient’s weight  measures health and nutritional status over time.

The resident should be weighed as soon as possible after admission to obtain a base weight and provide the dietician with the information prior to the nutritional assessment. The resident should be weighed weekly for the next three weeks and monthly thereafter (follow the facility protocol).

The physician may request a daily weight for some diagnosis (like congestive heart failure) or if the resident is receiving diuretics or is on hyperalimentation. The resident should be weighed at the same time and if possible, by the same person. Having the same caregiver assigned to the weighing process will assure procedural consistency. The resident should be weighed without shoes and with as little clothing as possible.

Scales need to be calibrated monthly and a log maintained of the measurements. Ambulatory residents may use a platform scale. The resident should stand on the center of the platform without hanging on to anything. If the resident wears an adaptive device or a prosthesis, it should be documented if the weight was obtained with or without the device and should be consistent every month.

Chair scales should be used for non ambulatory residents. The wheelchair is weighed separately and then the resident is weighed in the wheelchair. The resident should be seated in the center of the chair and the wheelchair centered on scale for accurate measurement. Subtract the chair weight from the overall  weight to obtain the resident’s weight and be sure the math is accurate.  Sling scales and bed scales may be used but follow the manufacturer's’ directions for safety and make sure staff receive appropriate training on their use.

There are set parameters for reporting weight gain or loss. These are reported to the physician and documented in the resident’s record.

5% gain or loss in one month

7.5% gain or loss in three months

10% gain or loss in six months

The dietician should also be informed and physician’s orders must be in place to correct any problems. Federal regulation 325 refers to a patient's nutrition, “Receives a therapeutic diet when their is a nutritional problem”.

I love acronyms as they help me remember important facts. The Texas Department of Aging and Disability (DADS) use the following to list the risk factors associated with weight loss.

M- medication

E-emotional problems

A-anorexia

L-late life paranoia

S-swallowing disorders

O-oral problems

N-nosocomial infections

W-wandering

H-hyperthyroidism

E-enteric problems

E-eating problems

L-low salt and low cholesterol diets

S-social problems.

Nurses need to recognise these factors and identify the residents who are at risk. Should a significant weight loss occur, the resident must be reweighed within 72 hours. If the weight loss continues, the physician, family and dietician must be notified and an intervention must be put in place immediately.

Interventions may include:

Reassess the effects of medication.

3 day calorie count, document food intake at each meal for 3 days.

Manage underlying conditions.

Facilitate increased food consumption by providing snacks, nutritional supplements, finger foods and provide socialization by inviting family members to sit with resident at meal times.

Staff may assist with feeding and should offer praise for improved endeavours.

It is very important to document dates and notifications concerning nutrition in the medical record. Results of interventions and a weekly weight needs to be documented until the patient's weight stabilizes.

Many times there is an apparent reason for loss or gain. If the resident is on a diuretic or has had a recent paracentesis, weight loss is the expected outcome. Awareness of the resident’s appetite and food dislikes is important. Certain religious beliefs may interfere with dietary choices (A social service assessment should have picked up on this and should be in the care plan). Cultural choices and dislike of certain foods may also play a role in weight loss. Depression is the most identified cause of weight loss and must be treated. As terminal illness advances and end of life approaches, loss of appetite and weight loss occurs naturally.

Weight gain is expected when a resident recovers from surgery or an infection. Nutritional supplements and mineral and vitamin therapy also help in increasing appetite and gaining weight. In cultural and religious areas, getting family involved in bringing an occasional appropriate meal from home can be helpful.

As always be sure to careplan problems, changes and interventions.

Diabetic Mangagement

Diabetes can be a lifelong condition that affects the body’s ability to use the energy contained in food. There are 3 types of diabetes, Type One, Type Two and Gestational.

The common factor involved in all three types is that the Insulin required to utilize glucose is either inadequate or unavailable. The hormone Insulin is required to enable the body’s cells to take in and utilize glucose. Without this hormone, high levels of glucose can accumulate in the blood stream, resulting in damage to the tiny vessels in the eyes, heart, kidneys and nervous system.

I will give a brief description of the other two types of diabetes. Type Two is, by far the most common, especially in patients in Long Term Care (LTC) facilities

In Type One diabetes, the hormone Insulin, secreted by the pancreas is not available. Studies show there may be two reasons for this: (1) the body may produce antibodies that damage the pancreas and therefore it is unable to  produce insulin or (2) there may be a genetic disposition that result in faulty beta cells that are unable to make Insulin.

Gestational diabetes is triggered by pregnancy and usually abates with childbirth. It can, however, put the mother at risk for developing Type Two diabetes later in life.

Type Two diabetes was previously called adult onset diabetes. However, it is now occurring in much younger people. If left untreated, it can eventually cause heart disease, stroke,kidney disease, blindness and nerve damage (neuropathy).

There is no cure for diabetes but it can be controlled with good nutrition, weight management and exercise.

Type Two diabetes occurs when the pancreas does not produce enough insulin or the insulin cannot be used appropriately by the body’s cells (insulin resistance) or a combination of both.

Statistics from the American Diabetic Association (ADA) indicate that 25% of residents living in LTC facilities have Type Two diabetes. Of this number, 80% of patients have cardiovascular disease, 56% have hypertension and 70% have 2 or more other chronic conditions, such as, chronic kidney disease (CKD), coronary artery disease (CAD) and stroke.

Studies in Great Britain have shown that by keeping the Hemoglobin AIc levels of blood below 7, preferably at 6.5, the risk of these diseases occurring, are drastically reduced. When hemoglobin joins with glucose in the blood it becomes “glycated”. By measuring the “glycated” blood (HbA1c) clinicians can get an overall picture of the average blood glucose concentration over a 3 month period. In people without diabetes the level is 6 or less. For good control in diabetics it should be maintained at 7 or below. This test is taken a few times a year and can be used to monitor the effects of diet, exercise or medication.

In LTC facilities, the residents with Type Two diabetes, will decline in health if not treated. Dehydration, depression, confusion, eye problems, foot ulcers, neuropathy, and recurrent infections, slow healing wounds and decline in performing the activities of daily living (ADL) will be present if the diabetes is not controlled. This control is individualized according to the patient’s condition.

Many factors associated with aging can affect glucose metabolism in older adults. Selecting the correct medication based on these factors can be difficult. Some of these factors include, increased adipose tissue and decreased muscle mass. Alteration in food intake and ability to exercise. Insulin resistance in the cells, co-morbid health conditions and drug interactions. Some psychosocial factors include stress and depression.  As most of LTC residents are admitted with a history of type two diabetes of many years duration, the medical staff  need to be aware of the disease processes already present.

As always, the resident and family need to be  involved in discussing how aggressive treatment (diet, exercise, blood testing and medication) will be. The ADA has very good information on all issues pertaining to appropriate treatment. The hands-on care staff must follow the physician’s orders and be aware of the resident’s plan of care.

Blood sugar control is the key to good diabetes management. Preventing episodes of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) is of the utmost importance. Be aware of the parameters provided by the laboratory and follow the facility guidelines for treatment.

Hypoglycemia occurs when the blood glucose levels are at 70 mg/dL or less. Signs or symptoms  include:

Weakness or tiredness

Hunger

Dizziness or feeling shaky

Sweaty

Rapid pulse

Blurred vision

Unresponsiveness

The main reasons for hypoglycemic episodes are:

skipping a meal or consuming too few carbohydrates,

increased physical activity and some medications. A long time interval between taking insulin diabetes medications and eating can also cause hypoglycemia.

The best way to treat this illness is to be prepared. Follow the facility guidelines and know where the necessary equipment is stored. Nurses need to be aware of residents with dementia who also have diabetes. These residents are unable to recognize or discuss symptoms and must be monitored carefully. Parameters must always be available for administering insulin and other diabetes related medications. Physician and family must be notified of any episodes that may occur and these must be included in the nurses’ documentation in the clinical record.

Once again, I will say how important is good communication. “How do you feel this morning” can provide a wealth of information. The resident may not know why she is shaky, sweaty or thirsty, but we do and if she is a diabetic, we should test her blood sugar levels.

Hyperglycemia occurs when there is a high level of glucose in the blood. Some laboratories indicate a fasting blood sugar greater than 130 mg/dL as hyperglycemic.

S/Ss usually include increased thirst, headache,frequent urination, blurred vision, fatigue and weight loss.

May occur when an insulin dose or prescribed diabetes medication is omitted, consumption of high carbohydrate meals, an infection or illness and some medications (steroids) may produce hyperglycemia.

Blood sugar monitoring is ordered by the physician and should be performed exactly as prescribed and the results documented in the diabetic flow sheet immediately after testing.

Accu-chek Meters. There are many different types of meters in use for testing the levels of glucose in blood. The nurse must become familiar with the type used in the facility and must follow the policy for care, infection control and privacy during testing. An abnormal reading, high or low, should be followed by a nursing intervention.

Always refer to the physician’s orders and document.

It is very important that there is a limited time lapse between testing and administering the prescribed insulin or medication and between the medication and food intake. By being consistent and observant, our residents are kept more safe and our workload is made lighter by preventing complications.