Roles and responsibilities
Nursing staff have an important role and clear responsibilities when treating patients with diabetes or who are having tests to diagnose diabetes. This role and associated responsibilities will be specified in local workplace guidance and policies and by each member of the nursing team's level of competence. If you are not familiar with the guidance in relation to diabetes care in your work setting, it is important to find out where it is so you can be sure you're providing safe patient care, particularly if you are required to perform tests and observations for your patients.
Explore the following activity to learn more about some of the specific competencies relating to caring for a patient with diabetes.
Screening, prevention and early detection of type 2 diabetes
To prevent and aid early detection of type 2 diabetes you should be able to:
- describe the risk factors for type 2 diabetes
- explain the importance of prevention or delay of onset of type 2 diabetes in individuals at risk
- explain the role that exercise plays in the prevention of, or delay in progression to, type 2 diabetes
- explain the importance of weight control and the role that diet plays in the prevention of, or delay in progression to, type 2 diabetes.
In order to support the patient to self-care their diabetes you should be able to:
- support the patient and help them develop their own self-care with guidance from a registered nurse
- observe and report any concerns that you may have about a patient that would affect their ability to self-care
- encourage patients to use their personalised care plans.
To care for someone with diabetes and mental illness you should be able to:
- have an understanding and awareness of how mental health issues, such as depression and anxiety, can affect people with diabetes
- report any changes that you notice in the patient’s normal mental health, to a registered nurse or doctor. This could include changes in medications adherence, mood and appearance and also anxiety.
To meet your patient’s individual nutritional needs you should be able to:
- identify foods and drinks with high sugar content
- follow the nutritional plan and report any related problems
- measure and record the waist circumference, height and weight of your patient accurately
- report if meals are not eaten, especially carbohydrates, if the patient is using insulin or blood glucose lowering therapies.
For the safe use of urine glucose or ketone monitoring and associated equipment you should be able to:
- perform the test according to the manufacturers’ instructions and local guidelines
- perform the test unsupervised at the request of a registered nurse
- document and report the results following local guidelines and procedures.
Blood glucose monitoring
For the safe use of blood glucose monitoring and associated equipment you should be able to:
- perform the test according to manufacturers’ instructions and local guidelines
- perform the test unsupervised, at the request of a registered nurse
- document and report the result according to local guidelines and procedures
- recognise and follow local quality assurance procedure, including disposal of sharps
- recognise hypoglycaemia and be able to administer glucose
- Understand the normal range of glycaemia and report any readings outside this range to the appropriate person.
For the safe administration and use of oral antihyperglycaemic medication you should be able to:
- describe the effect an oral antihyperglycaemic agent has on blood glucose levels
- demonstrate an understanding of the on-going nature of the therapy
- report any identified problems appropriately
- recognise the signs of hypoglycaemia and administer glucose
For the safe administration and use of insulin and GLP-1 receptor agonists you should be able to:
- describe the effect of insulin on blood glucose levels
- be aware of local sharps disposal policy
- show and understanding of the on-going nature of the therapy
- administer insulin competently where supported by local policy
- report identified problems appropriately
- all nursing staff who handle prescribe or administer insulin should undertake a training course e.g. NHS Diabetes - safe use of insulin e- learning.
For the identification and treatment of hypoglycaemia you should be able to:
- state the normal blood glucose range
- describe the mild and severe signs and symptoms of hypoglycaemia
- demonstrate competent use of blood glucose monitoring equipment to confirm hypoglycaemia
- offer appropriate treatment as per local guidelines
- know where treatment for hypoglycaemia is stored
- reassure and comfort the person with diabetes and their carer
- document and report a hypoglycaemia event to a registered nurse
- recognise that older people may not demonstrate clear signs and symptoms of hypoglycaemia
- if the person with diabetes is unresponsive, ensure their airway is clear and call emergency services.
For the identification and treatment of hyperglycaemia you should be able to:
- state the normal blood glucose range
- describe the signs and symptoms of hyperglycaemia
- perform blood and ketone tests according to local guidelines
- correctly document the results and report those out of the accepted range to the appropriate person
- recognise that older people may asymptomatic of hyperglycaemia.
For more details of what your role should be when treating patients with diabetes , see: An Integrated Career and Competency Framework for Diabetes Nursing
How to perform a blood glucose test
Work through the slide show below to follow the steps for carrying out a blood glucose test. Refer to the 'Managing diabetes' section for details about normal blood glucose levels. Note: the device in this slideshow is a single patient device. A multi-patient device would be used in a clinical environment. It is important to familiarise yourself with the instructions for using the blood glucose testing device in your work setting.
How to perform a urine ketone test
Diabetes UK recommends testing for ketones if blood glucose levels become high - above 15 mmol/L. Testing for ketones when blood glucose readings reach this level can help detect an escalating problem at an early stage. This allows for advice and treatment to be given before the level of ketones in the blood becomes dangerous. There are two ways to test for ketones:
- urine test - using urine ketone testing strip
- blood test - carried out in a similar way to blood glucose testing.
Modern blood glucose meters have now been developed to also test a blood sample for ketones. Before undertaking either a blood or urine test you must ensure that you have received training and are competent to use the equipment.
View the following slideshow to see how to conduct a urine test for ketones. It is important to note that urine ketone strips may differ slightly according to the manufacturer. Check the instructions and your local workplace guidelines. Be sure to document and report anything outside the 'normal' range to senior nursing staff or the medical team immediately.
Assemble the required equipment to perform the the urinalysis
· Clock or timer or stop watch
· Clean surface
· Tissue/absorbent paper
· Non-sterile gloves (+/- plastic apron)
· Urine specimen
· Test strips
· Clinical waste bag
Check the test strips are inside the stated expiry date.
Check the urine sample is fresh – observe the colour and odour. Cloudy urine may indicate the sample is contaminated or infection is present. A strong fishy smell may indicate infection and a sweet odour like pear drop sweet may indicate ketones are present.
Check the sample is from the correct person and note any medications they are taking (as some medications may affect the result).
Wash hands and apply gloves/apron.
Remove a test strip from the bottle and replace the lid.
Immerse the full length of the test strip in the urine sample, ensuring all the test pads are covered. Remove excess urine on the lip of the sample bottle.
Place the test strip on the tissue/absorbent paper to prevent the colours on the pads contaminating each other.
Start the timer/note the time.
Replace the lid on the urine specimen.
When the appropriate amount of time has passed, align the test pads with the corresponding result gauge on the test strip bottle.
Be sure to line the pads up with the corresponding test on the container. This is where most errors with urine testing are made!
Remove your glove and record the result of the urine test in the person’s medical record. Report any abnormal result to a senior nurse, the diabetes care team or the person’s doctor as appropriate to your role and care setting.
Dispose of all equipment in the clinical waste bag.
Wash your hands.
How to perform a blood ketone test
Blood ketone testing is a more reliable method of diagnosing and monitoring diabetic ketoacidosis than urine ketone testing. Blood ketone testing provides the current state of the ketones, whereas the urine sample may be hours old. Blood ketone testing is performed in the same way as a blood glucose test using a meter. Follow the steps in the blood glucose testing slideshow above, substituting blood glucose testing strips with ketone test strips. Always follow the manufacturer's instructions and ensure you are trained and competent in the use the equipment. Record the results in patient notes and notify a senior member of the nursing staff or a member of the medical team if the results are outside the normal range for this individual person. If the results are high, then you should seek guidance about the appropriate treatment to correct the high ketone level and the protocol for re-testing for ketones until the result is negative.
Managing blood ketone levels
A blood ketone level below 0.5 mmol/L is considered to be a trace level of ketones – no action is needed at this level.
A blood ketone level of around 1.5 mmol/L indicates that ketone levels are slightly higher than normal. It is recommended that the person drinks a glass of water or sugar-free drink each hour for three to four hours. The blood ketone test is then repeated to see if the ketone level has decreased or not. If blood glucose and ketone levels do not decrease after two tests, the diabetes team or medical staff should be contacted immediately for advice.
A blood ketone level of 3.0 mmol/L or above is considered a high reading. The diabetes team or medical staff should be contacted immediately for advice.
These ketone levels are a guide. It is important to check local workplace policies and liaise with the diabetes team or medical staff to determine what is to be considered a 'normal' result for this person.