- To establish a standard procedure in the provision of diagnostics and chronic management care for diabetes patients, in accordance with the provisions and guidelines of the American Diabetes Association for Nursing and Healthcare Practitioners.
- Development and review
- The development of standard procedures for chronic health problems involves the input and collaborative efforts of multiple stakeholders in the organization’s operations, with the organization’s interdisciplinary committee playing the central roles of moderation and leadership. The committee consists of professionals in the nursing, administration, and physician professions or departments in the organization.
- The organization’s interdisciplinary committee is the central body with a role in approving the standard procedures. The body shall make the sheets with the standard procedures available for use in the relevant departments within the organization.
- To ensure that the procedures are up-to-date and integrate the best current evidence in practice, the committee shall review them every 90 days (3 months).
- On hiring, and on an annual basis, each nursing professional shall signify agreement to the standard procedures and the personal dedication to adhere to them in work in collaborations with other stakeholders and professionals within the organization.
- The signature of each nursing professional shall indicate personal agreement, willingness, and readiness to collaborate with others and contribute to the preservation of quality in services to patients according to the standard procedures. The pages with NPs’ signatures shall be readily available along with the standard procedure sheets.
III. Scope and setting
- Nursing professionals have the mandate to serve and manage the functions outlined in the standard procedures according to the areas of their specialty and training and in ways that are consistent with legal credentialing and experience. In relation to this SP, these functions include diagnoses, assessments, treatment, and management of diabetes. They also include efforts in health promotion and guidance in nutrition, physical therapy, and other areas of patients’ wellbeing according to individual needs.
- NPs have the mandate to apply the SPs in the organization’s clinics for outpatients.
- Education Qualifications and Training
- The following qualifications and requirements are mandatory for NPs serving in the organization:
- Current and valid California RN (Registered Nurse) license
- State of California NP certification
- DEA registration number
- Board certification from a relevant organization
- Organization-level credentialing
- Besides these requirements and qualifications, NPs shall also require to pass annual and orientation competence validation tests. Supervisory staff have the obligation to observe, monitor, guide, and document the process of competence validation.
- Supervision and Evaluation
- NPs have the mandate to implement the approved SPs without the immediate or direct supervision or control of physicians, unless there are needs for otherwise specified procedures.
- Supervisory physicians in the organization will have the mandate to conduct monthly reviews of a number of NPs. The choice of NPs under review each month shall be random, and each physician shall maintain a coherent electronic record of the evaluation.
- A physician shall be responsible for the supervision and evaluation of not more than 3 NPS at a time to ensure the quality of this process.
- NPs have a responsibility to cooperate and consult with physicians and others in the process of performing their responsibilities.
VII. Patient Records
- NPs have the obligation to maintain complete, confidential, and accurate documentation of the electronic medical records of patients in line with current organizational and professional policies.
- To help NPs serving in the outpatient clinic setting to diagnose diabetes and identify patients in the pre-diabetic phase
- Key characteristic of diabetes is hyperglycemia – high level of blood sugar/glucose in the blood. The condition is caused by the body’s inability to produce or use adequate insulin, which is the hormone that helps in the absorption of glucose into the blood cells for use as energy. In effect, the observation of a high level of blood sugar is a leading indicator of diabetes. Hyperglycemia is the outcome of defects in insulin action or insulin secretion or both.
- Testing is recommendable for patients aged 45 years and above, pregnant/expectant women, and obese individuals.
- Risk factors include obesity/overweight, expectancy, and familial history. Diabetes is recognizable anywhere along the range of clinical scenarios, including ostensibly low-risk persons during glucose testing, individuals tested in the context of diabetes risk assessment, and patients already showing symptoms (ADA, 2014).
- Symptoms to look out for relate to marked hyperglycemia. They include (ADA, 2014):
- Excessive or large production and passage of urine (called polyuria)
- Excessive thirst (called polydipsia)
- Blurred vision
- Weight loss (which sometimes occurs with excessive appetite or eating – polyphagia)
- Possible indications/complications in physical/medical examinations and symptoms with advanced/long-term diabetes (ADA, 2014):
- Nephropathy (damage to kidneys) and renal failure
- Retinopathy (damage to eyesight) and potential loss of vision
- Peripheral neuropathy (damage to nerves in legs, hands, etc.)
- Autonomic neuropathy, leading to genitourinary, gastrointestinal, and cardiovascular symptoms
III. Differential diagnosis
- Two principal categories of diabetes: type 1 due to the destruction of autoimmune β-cells, thereby influencing absolute insulin deficiency and type 2 diabetes, owing to progressive loss of β-cell insulin secretion and relating to insulin resistance.
- Plasma glucose criteria applies as the basis of diagnosis of diabetes.
- Either the 2-h plasma glucose or the fasting plasma glucose (FPG) value in the course of a 75-g oral glucose tolerance test (OGTT) or A1C criteria.
- Generally, the FPG, 2-h PG during 75-g OGTT, and A1C are similarly suitable for the diagnostic testing (ADA, 2019).
- Tests do not necessarily enable the detection of diabetes in the same persons. The same tests could be applicable for the screening and diagnosis of diabetes and detection of pre-diabetes.
- Normal scores: For the FPG test, a score of less than 100mg/dl is normal/healthy. For the 2-h PG test, the normal range is less than 140mg/dL. For the A1C test, the normal range is less than 5.7%.
- Diagnosis of diabetes: For the FPG test, diagnosis of diabetes is positive with at least 126mg/dL (7.0mmmol/L), fasting being no caloric intake for a minimum of 8hrs. For the 2-h PG test, a diagnosis of diabetes is positive with at least 200mg/dL (11.1mmmol/L). For the A1C test, an observation of at least 6.5% (48mmmol/mol) indicates diabetes (ADA, 2019).
- Diagnosis of pre-diabetes: For the FPG test, scores of between 100mg/dl and 125.99mg/dl imply pre-diabetes. For the 2-h PG test, observations of between 140mg/dL and 199.9mg/dL show pre-diabetes. For the A1C test, observations of between 5.7% and 5.99% indicate pre-diabetes (ADA, 2019).
- Management and Treatment
- Care and management of diabetes are complex processes and necessitate the combined and coordinated efforts of multiple stakeholders, including patients, families, physicians, and different professionals across the healthcare environment to address issues beyond glycemic control.
- Critical concepts: self-care and individuals’ adaptation to their environments. Patients need to adopt active positions of involvement in their own care to manage their health through better and healthier choices of diet and physical activity to manage weight (which is a risk factor for diabetes), as well as active engagement in healthcare to track their risks for and progress in diabetes.
- Weight management, nutrition therapy, and physical activity are essential components of effective programs of treatment and management of diabetes (ADA, 2019).
- Education, empowerment of patients to engage actively with diabetes in education, self-management, and treatment planning in collaboration with the health team.
- Nutrition therapy has integral role in overall management of diabetes. Goals of nutrition therapy are promoting and supporting healthful patterns of eating, emphasizing nutrient-dense foods in appropriate portion sizes, addressing individual nutrition needs, and providing practical tools for developing healthy eating patterns. Relevant sub-goals in this therapy are achievement and maintenance of an appropriate level of body weight.
- Reduction and management of weight are essential for type 1 and 2 diabetes patients and obese pre-diabetic patients; application of lifestyle intervention initiatives and frequent follow-up to achieve and maintain significant reductions in body weight and improvements in clinical indicators (ADA, 2019).
- Incorporation of physical activity to decrease risks for cardiovascular conditions, improve control of blood glucose, and contribute to weight loss.
- Physical activity especially important for the management of type 2 diabetes.
- Nutritional therapy: Need to focus on focus on the empowerment of patients to improve their self-care and to consider nutritional therapy as important as other treatments. This focus is important to address the tendency of patients to struggle with compliance with recommendations relating to the high value of control and discipline in dietary intake patterns in diabetes management and sustenance of this compliance after achieving it (Pinto et al., 2017).
- Physical activity: Regular physical exercise has a significant positive effect on insulin sensitivity in adults with type 2 diabetes mellitus, lasting up to three days following an exercise session (Way et al., 2016); need for NPs to insist on physical activity in education of patients and development of individualized care plans to manage type 2 diabetes mellitus effectively in the long term, and to improve patient clinical outcomes
- Development and approval of the SP
- The development and approval of this standard procedure occurred under the direct and mandated role of the organization’s inter-disciplinary committee. Its review and approval shall be due every two years, or as often as is necessary according to emerging and current best evidence.
Date of Revision …………………………………. Date of Review ………………………
- The following members of the inter-disciplinary committee reviewed and approved the standard procedure.
………………………………….. Date ………………………..
Geriatric Care Department Chair
………………………………….. Date ………………………..
Director of Nursing Practice
………………………………….. Date …………………………
VII. The list of practitioners with the mandate and authority to practice and function under the provisions of this SP shall be available in the geriatric nursing care department and the hospital administration.
American Diabetes Association (ADA) (2014). Diagnosis and classification of diabetes mellitus. Diabetes Care 37(1): 81-90. ADA Position Statement. Retrieved from: https://care.diabetesjournals.org/content/diacare/37/Supplement_1/S81.full.pdf
American Diabetes Association (ADA) (2019). Standards of medical care in diabetes – 2019. The Journal of Clinical and Applied Research and Education 42(1): 1-203.
Pinto, E., Braz, N., Nascimento, T., & Gomes, E. (2017). Do patients value nutritional therapy? A quantitative study in type 2 diabetes patients. International Journal of Diabetes and Clinical Research 4(2): 1-6.
Way, K., Hackett, D., Baker, M., & Johnson, N. (2016). The effect of regular exercise on insulin sensitivity in type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes and Metabolism Journal 40: 253-271.