Applying clinical diabetes guidelines to home care can curb patient problems ranging from falls to vision loss.

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ach year, the American Diabetes Association (ADA) publishes clinical practice recommendations for diagnosing and treating persons with diabetes, updating and revising best practices as research studies and medical advances dictate.¹ The home health nurse has a unique opportunity to transition these national guidelines to the public health arena.
       Diabetes is a leading diagnosis for home care patients, whether primary or as an underlying comorbidity. The average patient age is slightly above 65 years, and the number of patients 75 years of age and older increases each year.² Patients statistically have 2 or more comorbidities, the most common being a cardiac diagnosis, as well as a high rate of polypharmacy.² Understanding diabetes control and how it impacts episodes of care can help to improve patient outcomes and patient satisfaction while reducing the length of stay. The ADA national standards address the following areas (see Table 1 for further detail):

Table 1

• Screening for diabetes
• Diagnosing diabetes
• Controlling glycemia
• Preventing complications
• Promoting self care and wellness.
       Diagnosis is not within the domain of the home care nurse, but case finding in a family/community setting is common; relatives or friends of the patient often ask “How can I find out if I have diabetes?” However, controlling glycemia, preventing complications, and promoting self care are major focus areas for the home care clinician. The initial patient assessment is a key opportunity to assess which barriers might interfere with a patient’s ability to take charge of diabetes. Are physical barriers preventing patient participation in diabetes control? What impact do comorbidities have on diabetes, and conversely, how does diabetes affect other diagnoses? Are psychosocial issues interfering with patient outcomes? See Table 2 for physical barriers to diabetes control.

Table 2

       Hyper- and hypoglycemia have significant impacts. Does the patient appear disoriented, angry, or withdrawn? Are these findings due to age, glycemic state, or another cause? Blood glucose out of target range can cause a variety of mental states mistakenly assigned as function of age. Normal neuropathy of aging is compounded by diabetes, particularly diabetes of long duration. Autonomic neuropathy increases risk of incontinence, atonic bladder leading to urinary retention, and urinary tract infection (UTI). Falls may result from peripheral neuropathy, when a patient is unable to feel where his or her foot is on the floor. Other risk factors for falls include visual deficit, medication errors, and urinary incontinence.Vision loss jeopardizes accuracy in medication management and blood-glucose monitoring.
       Urinary incontinence is a subject for embarrassment or shame for some patients, and again, they may try to avoid detection. However, it is an important assessment as a risk for hyperglycemia as well as other factors impacting patient outcomes. Seniors who are at risk for dehydration may avoid drinking water to prevent urine dribbling or frequent trips to the bathroom. Dehydration increases hyperglycemia, and conversely, hyperglycemia is a major cause of dehydration.
       Polypharmacy presents a great challenge both to the patient and the clinician. Patients often believe that their physicians all communicate with each other, each knowing what the others have prescribed. Patients seldom reveal what over-the-counter products they use. Open-ended questions may help determine adherence and accuracy with medication regime. For example, “All these medications must be expensive. Are you able to manage?” or, “Which of these medications do you try to refill most often?” lets a patient verbalize any financial barriers. “How many times in a week do you think you forget to take your medication?” will also yield a meaningful response. Patients generally take new or intermittent medications, such as antibiotics or steroids, as ordered, but chronic care medications are often taken sporadically. These include antihypertensives and diabetes medications.
       Certain classes of drugs will increase insulin resistance and hyperglycemia, including steroids, some antipsychotics, and certain HIV medications. Patients should be informed and should consult with their physicians for adjusting diabetes medications to keep blood glucose within target. The patient’s response, “It’s okay, I’m on steroids,” when explaining his or her hyperglycemia is not appropriate. Where the clinician has assessed a vision or manual dexterity deficit, the appropriate intervention should be made to improve patient’s self-care potential. Adaptive equipment is available to assist patients with blood-glucose monitoring and medication management like insulin dosing and administration. Physical therapy, occupational therapy, and social work referrals are important components of overcoming barriers and moving a patient toward self management.
       Diabetes may or may not be the primary diagnosis for home care, but the disease impacts all other diagnoses. Delayed healing, infection, and dehiscence of surgical wounds are likely if blood glucose is greater than 240mg/dL during the peri- and post-operative periods. Table 3 identifies comorbidities and the effect they may have on diabetes and diabetes outcomes.
       Perhaps the most difficult area for home health teams to embrace is the psychosocial.

Table 3

Documenting “nonadherence” for a behavior puts the onus on the patient but may be premature. Does a patient take his medication as prescribed or understand the timing and action of the medication? Did anyone communicate to the patient that the medication should be taken with the first bite of the meal but not taken if the meal is skipped? Ask a patient on insulin what kind of insulin he or she is taking. A frequent answer is by brand, not by type. If patient is unaware of the type of insulin he or she uses, it is likely that he or she is also unaware of the timing and the action.
       Meal planning is an area where patients are labeled nonadherent when they fail to follow the plan set forth by the clinician. Coaching patients toward healthy choices is important, but it depends on what a patient is willing and able to do. Working within the framework of the patient’s reality will improve the likelihood of increased understanding of diabetes and how to take charge.
       Small, achievable goals are the key. Being the “diet police” is counterproductive. Working with patients to identify areas for change is more useful. For example, many people with diabetes continue to drink sugared sodas and juices. If this single behavior is modified, blood glucose control may be dramatically improved. Once patients begin to connect positive actions with good outcomes, the seeds of self management are in place. Build on small successes; expect occasional failures. Physicians diagnose and treat diabetes, but nurses teach patients how to live with diabetes.