Applying my learning - Case study 2

Mary

Mary, 74 years old, lives in a nursing home. She has had type 2 diabetes for 15 years and in addition to Metformin and Gliclazide takes insulin before bed to control her diabetes.

You have worked at the home for 6 months and have got to know Mary fairly well. Usually when her blood glucose levels are taken they range between 7 and 13mmol/l. You are aware that the GP responsible for Mary's care is anxious to improve her blood glucose as much as possible because Mary has leg ulcers that are slow to heal. You have recently been trained to monitor blood glucose levels and have been assessed as competent. On this particular evening you monitor Mary's blood glucose level before her evening meal and the result is 21.4 mmol/l.

What do you do?

  • Option 1: You know that this reading is unusually high for Mary and wonder what the cause could be. In order to reassure yourself that the test is accurate you check that the blood glucose meter had had the quality assurance check that it should have each day that it is in use as stated in the homes policy. You check the record book and find that the meter had indeed been checked and was reading within the expected target range. You know that you had washed Mary's hand before you had performed the test and so you are certain that the result is as accurate as can be.
  • Option 2: You know that it is important to keep Mary's levels as good as possible in order to help her leg ulcers to heal. When dealing with Mary you are aware that she is her usual chatty self. There is nothing unusual about her appearance in this particular evening and she has not complained about feeling unwell. You ask her how she is feeling and she reports nothing that would suggest her high blood glucose result is a problem.

The correct answer is Option 1.

Feedback: You should make sure that this meter has been checked each day that it has been used and in line with local policy. If all is ok then you would report this reading to the nurse in charge as it is outside the normal range. You would also report that Mary is her usual self and not reporting any of the symptoms of high glucose levels. The nurse in charge should then go and review Mary herself.

The symptoms of a high blood glucose level are:

  • Increased thirst
  • Feeling tired and unwell
  • Skin rash
  • Vomiting
  • Passing lots of urine

People may report increased thirst, passing lots of urine, feeling tired or unwell. Mary reports none of these symptoms.

You ask Mary if her day had been unusual in any way that may have led to this high result. Mary tells you that it was her Granddaughter’s birthday and that she had been taken out for lunch by her family. The lunch was much larger than she would usually have eaten and she had had a small piece of birthday cake.

Below are some causes for high blood glucose level. Which do you think explains Mary's increase in her blood glucose level?

  • More food than normal
  • Illness
  • Infection
  • Less exercise than usual
  • Forgotten medication

Feedback: Mary had more food than normal, some of which was sugary.

What are the consequences of a high blood glucose level?

If blood glucose levels are consistently high over a period of time they can leads a person to feeling unwell with the symptoms listed above. In addition they can delay healing if as in Mary’s situation you have ulcers or wounds for example if you are recovering from surgery. If glucose levels remain high in the very long term they can lead to the development of diabetes complications for example, eye disease, kidney disease, heart disease, peripheral vascular disease, neuropathy and increase your risk of a heart attack, stroke or amputation.

The reason for the raised blood glucose result here is the change in Mary’s daily routine. She does not feel unwell from this high glucose level. You report the high result to the nurse in charge and explain what you feel the reason for it may be. The nurse in Charge decides to re check Mary’s glucose levels during the evening and before bed. This additional testing is to monitor that the levels are returning to more normal limits for Mary and to check that the levels are not rising further. At this point, because Mary is not feeling the effects of this raised result, the nurse in Charge makes the decision not to inform the GP at this point but to continue monitoring the situation. The GP will be informed if the glucose levels rise further or if they do not return to levels more usual for Mary.

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