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Is your staff prepared to handle a diabetic crisis?

April 1, 2007
by LINDA WILLIAMS, RN
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According to the National Diabetes Information Clearinghouse (NDIC), 10.3 million people age 60 years or older in the United States have diabetes. While the majority of nursing facility residents with diabetes are diagnosed before entering the facility, some residents develop the disease afterward, since the risk of type 2 (late-onset) diabetes increases with age. In fact, the National Center for Health Statistics estimates that one in three Americans will develop this potentially debilitating disease during his or her lifetime.

Some serious complications of diabetes include heart disease and stroke, high blood pressure, blindness, kidney disease, nervous system disease, peripheral vascular disease, and dental disease. The prevalence of functional disability and multiple comorbid conditions in the long-term care population increases the complexity of diabetes management. The American Medical Directors Association (AMDA) reports that hyperglycemia impairs cognition and, when untreated, may contribute to further functional decline in residents with dementia, as well as decreased pain thresholds, impaired vision, and increased risk for falls. Frail elderly people with diabetes also are at higher risk for hypoglycemia, which can lead to falls or permanent neurological impairment. In addition, symptoms may be atypical for this population.

Overall, the risk for death among people with diabetes is about twice that of people without the disease of similar age. It is an urgent problem that nursing home caregivers need to be prepared to handle. Please review the following situation in which a caregiver was suddenly confronted with a diabetic crisis. Plan to make changes as appropriate in your facility.

The Situation

A 79-year-old woman was admitted to a nursing home with congestive heart failure. In addition, she had diabetes mellitus and was insulin-dependent. Her daughter lived nearby and visited her frequently, assisting her as needed. The daughter had a slight hearing impairment, but nevertheless interacted well with her mother's caregivers

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Two years went by and the woman became increasingly frail, to the point that she was totally dependent on others to meet her needs. The resident slept a lot and did not eat well; consequently, she began to lose weight. Her blood sugars were monitored daily and often remained on the low side within her parameters of 70 mg/dL to 200 mg/dL. The woman's physician had issued sliding scale orders for additional insulin administration if her blood sugars rose beyond the 200 mg/dL parameter, but did not address what to do if her blood sugar levels fell below 70 mg/dL. So, the nursing staff wrote on the woman's Medication Administration Record (MAR) to simply “call the doctor” if that should happen.

On New Year's Eve night, a nurse who was new to the facility walked into the woman's room and found her shaking and moaning. The woman's skin was pale and diaphoretic, so the nurse immediately tested the woman's blood sugar, which read 48 mg/dL. In response, the nurse obtained and administered glucagon from the facility's emergency medication box. After 20 minutes, she checked the woman's blood sugar again and found it to be 68 mg/dL. The woman appeared to be resting comfortably and her skin color had returned to normal. The facility did not have a hypoglycemia crisis protocol and so the nurse decided to check the woman frequently and test her blood sugars four more times throughout the night. The woman's countenance did not change, and her blood sugars hovered in the 60s until her last check at 4:00 a.m., which read 72 mg/dL. At 4:20 a.m., the nurse entered the woman's room to check on her again and found her unresponsive, with-out a pulse.

The woman had a “Do Not Resuscitate” (DNR) order, so the nurse called her daughter to notify her of her mother's death. Since the nurse was new, she had never met the woman's daughter and did not know that she had trouble hearing. Unfortunately, the nurse spoke softly and she was not fluent in English; therefore, the woman's daughter could not understand what she was trying to tell her on the phone. Finally, out of sheer frustration, the nurse blurted out, “Your mother is dead, dead, dead.” The daughter was stunned and quite upset.

The cause of the woman's death was later listed as Chronic Obstructive Pulmonary Disease (COPD) and respiratory insufficiency, with contributing factors of diabetes and congestive heart failure. The daughter remained very upset about her mother's death and the way that she had received the news. She hired an attorney to review her mother's medical records. Soon a lawsuit was filed against the facility for failing to provide adequate and appropriate care for the woman, specifically alleging negligence for not notifying her physician or family in a timely manner of her significant change in condition. In addition, there were several documentation problems, including gaps when blood sugars were supposed to be checked but weren't, and other instances where results were beyond the listed parameters, yet nothing was done. It was further noted that the staff had not routinely tested the glucometer machine, as directed by the manufacturer, so the accuracy of readings was questionable. To settle the lawsuit, the daughter sought $350,000. A mediation was eventually held and both parties agreed to a settlement for half that amount.

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