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Self-Monitoring of Blood Glucose in Practice (2020)

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Self-Monitoring of Blood Glucose in Practice (2020)

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From Clinical Skills.net: Self-monitoring Blood Glucose in Practice Checklist that ensures that Blood Glucose is undertaken correctly.

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From Clinical Skills.net: Self-monitoring Blood Glucose in Practice Checklist that ensures that Blood Glucose is undertaken correctly.

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Published March 2020

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Online Resource: Blood Glucose Monitoring: Skill Overview; Demonstration; Equipment. Self-Test; Quick Sheet. Checklist; References.

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Online Resource: Blood Glucose Monitoring: Skill Overview; Demonstration; Equipment. Self-Test; Quick Sheet. Checklist; References.

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Elsevier Clinical Skills and enrol

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Introduction

Blood glucose testing is a simple investigation to detect hyper- or hypoglycaemia, the main cause of which is diabetes mellitus, where the body is unable to produce sufficient insulin (Higgins 2008). Monitoring a patient's blood glucose provides an accurate indication of how the body is controlling glucose metabolism (Dougherty et al. 2015). Diabetes UK suggests that people with diabetes should keep their blood glucose levels as near as possible to that of a person without diabetes, namely 4-7 mmol/l before meals (Diabetes UK 2016). Insulin and glucagon, both produced by the pancreas, are largely responsible for the regulation of blood glucose (Wallymahmed 2007).

The body regulates the blood glucose levels by producing insulin, the main effect of which is to lower blood glucose (Dougherty et al. 2015). Glucose is obtained from carbohydrates, the digestion of which generates a rise in blood glucose levels (Higgins 2008). This rise in glucose stimulates the beta cells in the pancreas to release the hormone insulin, which allows the passage of glucose into the cells, thus bringing blood glucose levels back to normal. Insulin also facilitates the storage of glucose in the liver and muscles (Higgins 2008).

Conversely, if the body's blood sugar levels fall (e.g., patient fasting), the alpha cells of the pancreas release the hormone glucagon, which stimulates the movement of stored glucose and the blood sugar level rises (Higgins 2008).

Capillary blood glucose monitoring is a convenient method for monitoring blood glucose patterns and can be useful in guiding treatment changes in patients with type 1 and type 2 diabetes, especially during periods of instability (e.g., illness or frequent hypoglycaemia) (Wallymahmed 2007). According to Dougherty et al. (2015), the following are indications for careful monitoring of a patient's blood glucose:

To assist in making a diagnosis of diabetes mellitus.

The acute management of unstable diabetic states: diabetic ketoacidosis, hyperosmolar non-ketotic coma, and hypoglycaemia.

To monitor and manage the treatment of insulin-dependent diabetes mellitus (IDDM or type 1) and non-insulin dependent diabetes mellitus (NIDDM or type 2).

To manage patients during periods of fasting.

To monitor patients taking medication such as steroids and atypical antipsychotics, which can cause blood glucose to rise.

Specific situations that can lead to a rise in blood glucose (e.g., parenteral feeding) (Wallymahmed 2007).

Wallymahmed (2007) describes hypoglycaemia as a blood glucose level that falls below 4 mmol/l and requires prompt treatment. Causes of hypoglycaemia include missed or late meals, not eating enough, administration of too much insulin or diabetic tablets, exercise, and excessive alcohol. Common manifestations include sweating, palpations, shaking, poor concentration, and hunger. Treatment is the administration of glucose (Dougherty et al. 2015).

Hyperglycaemia is described as a high blood glucose level, consistently above 8 mmol/l (Wallymahmed 2007). This is a result of the absence or deficiency of insulin production in the body (Dougherty et al. 2015). Diabetic ketoacidosis is a serious and common condition that can arise if hyperglycaemia is not treated (Marni & Wheeler 2006). Diabetic ketoacidosis can be precipitated by infection, myocardial infarction, stroke, or physical or emotional trauma (Allwinkle & Barclay 2011).

According to Wallymahmed (2007), all hospital inpatients with diabetes require regular blood glucose monitoring because acute illness can seriously affect blood glucose levels. The frequency of monitoring will vary according to the individual patient's clinical condition. The most common method currently in use is capillary sampling and testing at the bedside using a glucometer (Figure 1). The Medicines and Healthcare Products Regulatory Agency (MHRA 2013a) refers to this bedside testing as point of care testing (POCT) and defines it as any analytical test that is performed for a patient by a healthcare professional outside the laboratory setting.

Wallymahmed (2007) states that all staff performing capillary blood glucose monitoring should be trained and assessed according to Trust policy, and must be aware of the expected results and when to seek medical advice. More recently, the MHRA (2013b) has stated that all staff who undertake blood glucose testing should have their training and competence established and recorded. Higgins (2008) states that systems should be in place to ensure that any devices used are subject to quality control procedures, the frequency of which should be in accordance with manufacturer's recommendations.

Explain the procedure, to gain consent and cooperation.

The patient's hands should be clean, and washing the hands in warm water will encourage blood flow. Taking time to encourage blood flow before pricking the finger will reduce the need for pricking again, which can be distressing for the patient.

If the patient is unable to wash their hands, Nicol et al. (2012) say that the finger should be washed or wiped with a wet swab or tissue, and that alcohol swabs must not be used, as this may give a false reading.

Ask the patient to choose the finger to be used for the procedure. The site should be rotated because even the side of the finger can become painful if the procedure is performed several times a day (Nicol et al. 2012). The thumb and index finger should be avoided when possible as these are 'grippers'.

Most Trusts require nurses to attend formal training in the use of the glucometer and may require a bar code to operate the glucometer.

The hands and glucometer must be clean, and apron and gloves should be worn.

Gather equipment required: glucose monitoring device, quality control solutions, test strips, disposable lancet, gauze or tissue, sharps disposal box, and relevant patient documentation.

Additional protective clothing may be necessary if indicated by the patient's condition.

Check any manufacturer's recommendations for the product. Perform and document quality assurance procedures. Wallymahmed (2007) states the following should be checked:

the test strips are in date, have been stored correctly, and have not been exposed to the air (this does not apply to test strips that are individually wrapped)

the monitor is calibrated for use with the pack of strips in use (some meters calibrate automatically)

if a new pack of strips is required, ensure the machine is recalibrated

quality control tests (high and low) have been carried out and documented in line with hospital policy and manufacturer's instructions.

1. Ensure that the quality assurance procedures are carried out in line with manufacturer's instructions and hospital policy.
Rationale - To reduce the risk of error and ensure maximum efficiency.

2. Ensure all equipment is within easy reach and the patient is comfortable, either sitting or lying.
Rationale - To reduce anxiety and ensure the patient's comfort and safety.

3. Explain the procedure to the patient.
Rationale - To inform the patient about the procedure and to gain consent.

4. Wash your hands and put on gloves and plastic apron. Ensure the glucometer is clean and has been disinfected.
Rationale - To prevent cross-infection and reduce the risk of contamination.

5. Turn on the glucometer. Check the expiry date and code number of the testing strips.
Rationale - To ensure efficiency.

6. Touching only the middle of the strip, remove one and insert it into the glucometer. The number shown must correlate with the number on the container.
Rationale - To prevent contamination and ensure accuracy.

7. Ask the patient to indicate which finger they would like to be used.
Rationale - To avoid overuse of any one site and thus reduce discomfort for the patient.

8. Clean the finger with a wet swab and allow to dry.
Rationale - To ensure that skin surface is clean and avoid dilution.

9. Hold the hand downwards to encourage blood flow and use the disposable lancet to prick the side of the finger.
Rationale - The side of the finger is used as it is less painful and easier to obtain a hanging droplet of blood.

10. Wait for a drop of blood to form. Do not 'milk' blood into the finger.
Rationale - Milking the finger may lead to the local blood composition being disturbed by intermingling with tissue fluid.

11. Allow a drop of blood to fall onto the testing strip; do not smear.
Rationale - To ensure even coverage of the strip and to obtain an accurate blood glucose measurement.

12. Dispose of the lancet in the sharps disposal box.
Rationale - To reduce the risk of a needlestick injury.

13. Ask the patient to press on the site, using the swab until the bleeding has stopped.
Rationale - To reduce the risk of bruising.

14. After a few seconds, the meter will provide a digital display of the result.
Rationale - According to manufacturer's instructions.

15. Check that the bleeding has stopped.
Rationale - To ensure that the patient is comfortable.

16. Read the result on the glucose meter and document the blood glucose level according to local policy.
Rationale - To ensure accurate recording of results. Local policy usually requires your signature, the date and time of the test, and the lot number and expiry date of testing strips.

17. Dispose of waste (e.g., gloves, cotton wool, or gauze) appropriately and perform hand hygiene.
Rationale - To reduce the risk of cross-infection.

18. Report any unexpected result or out of range result to the nurse in charge.
Rationale - To ensure patient safety and determine appropriate action.

19. Disinfect the glucometer according to local policy.
Rationale - To prevent cross infection.

20. Return the glucometer to the storage area.
Rationale - To ensure it is readily available for the next use.

Ensure the patient is comfortable.

Inform the patient of their blood glucose level.

Ensure bleeding has stopped.

Dispose of all sharps and contaminated waste in the appropriate containers.

Remove gloves and apron and wash hands.

Documentation and reporting must be in line with local policy. Local policy usually requires your signature, date and time of the test, lot number and expiry date of testing strips.

According to the Nursing and Midwifery Council, nurses should keep clear and accurate records which are relevant to their practice, completing them accurately and as soon as possible after an event (NMC 2015).

In addition, they state that the nurse must identify any problems that have arisen and how they have been dealt with (NMC 2015) .

The National Institute for Health and Clinical Excellence (NICE) has stated that physiological 'track and trigger systems' such as Early Warning Scores (EWS) should be used to monitor all adult patients in acute hospital settings (NICE 2007).

Through documentation, registered nurses communicate to other nurses and members of the multidisciplinary team their assessment about the status of the patient.

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Introduction Blood glucose testing is a simple investigation to detect hyper- or hypoglycaemia, the main cause of which is diabetes mellitus, where the body is unable to produce sufficient insulin (Higgins 2008). Monitoring a patient's blood glucose provides an accurate indication of how the body is controlling glucose metabolism (Dougherty et al.

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Blood Glucose Monitoring Clinical Skill by Elsevier (Video 3mins)

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Blood Glucose Monitoring Clinical Skill by Elsevier (Video 3mins)

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Enrol onto Elsevier Clinical skills:

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In this essential skill training aid video we are going to show how to; Perform a Capillary Blood Glucose (2018) (2mins)

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In this essential skill training aid video we are going to show how to; Perform a Capillary Blood Glucose (2018) (2mins)

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Trent Simulation & Clinical Skills Centre

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NHS Diabetes-How to check your blood glucose level (1.24 mins)

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NHS Diabetes-How to check your blood glucose level (1.24 mins)

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Diabetes: How to check your blood glucose level | NHS

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How to test your blood sugar levels | Diabetes UK

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Meetoo, D., Wong, L., & Fatani, T. (2018). ‘Knowing where I am’: self-monitoring of blood glucose in diabetes. British Journal of Nursing, 27(10), 537–541.

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Meetoo, D., Wong, L., & Fatani, T. (2018). ‘Knowing where I am’: self-monitoring of blood glucose in diabetes. British Journal of Nursing, 27(10), 537–541.

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Research Paper

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Meetoo  D Wong L.& Fatani T 2018 ‘Knowing where I am  self-monitoring of blood glucose in diabetes British Journal of Nursing 2710 537–541

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It is an abbreviated name for a form of haemoglobin, the protein in the blood cells, which transports oxygen. HbA1c is also called haemoglobin A1c or just A1c.

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HbA1c is a term commonly used in relation to diabetes. This guide explains what HbA1c is, how it differs from blood glucose levels and how it's used for diagnosing diabetes

What is HbA1c?

The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming 'glycated'.

By measuring glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what our average blood sugar levels have been over a period of weeks/months.

For people with diabetes this is important as the higher the HbA1c, the greater the risk of developing diabetes-related complications.

HbA1c is also referred to as haemoglobin A1c or simply A1c

How does HBA1c return an accurate average measurement of average blood glucose?

When the body processes sugar, glucose in the bloodstream naturally attaches to haemoglobin.

The amount of glucose that combines with this protein is directly proportional to the total amount of sugar that is in your system at that time.

Because red blood cells in the human body survive for 8-12 weeks before renewal, measuring glycated haemoglobin (or HbA1c) can be used to reflect average blood glucose levels over that duration, providing a useful longer-term gauge of blood glucose control.

If your blood sugar levels have been high in recent weeks, your HbA1c will also be greater.

HbA1c targets

The HbA1c target for people with diabetes to aim for is:

Note that this is a general target and people with diabetes should be given an individual target to aim towards by their health team.

An individual HbA1c should take into account your ability to achieve the target based on your day to day life and whether you are at risk of having regular or severe hypos.

HbA1c in diagnosis

HbA1c can indicate people with prediabetes or diabetes as follows:

What are the benefits of lowering HbA1c?

Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications by 25%.

Microvascular complications include:

Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1% are:

How does HbA1c differ from a blood glucose level?

HbA1c provides a longer-term trend, similar to an average, of how high your blood sugar levels have been over a period of time.

An HbA1c reading can be taken from blood from a finger but is often taken from a blood sample that is taken from your arm.

Blood glucose level is the concentration of glucose in your blood at a single point in time, i.e. the very moment of the test.

This is measured using a fasting plasma glucose test, which can be carried out using blood taken from a finger or can be taken from a blood sample from the arm.

However, fasting glucose tests provide an indication of your current glucose levels only, whereas the HbA1c test serves as an overall marker of what your average levels are over a period of 2-3 months.

HbA1c can be expressed as a percentage (DCCT unit) or as a value in mmol/mol (IFCC unit). Since 2009, mmol/mol has been the default unit to use in the UK.

Note that the HbA1c value, which is measured in mmol/mol, should not be confused with a blood glucose level which is measured in mmol/l. Use our HbA1c conversion tool to help with switching between the two measurement units.

HbA1c is a measure of how well controlled your blood sugar has been over a period of about 3 months. It essentially gives a good idea how high or low, on average, your blood glucose levels have been.

How is HbA1c measured?

A sample of blood will be take, usually from your arm. The test measures how much glucose has stuck to haemoglobin in the blood.

What result should I be aiming to get?

The result may either be expressed as a percentage or in mmols per mol. The target for people with diabetes is to get an HbA1c value of under 6.5%. This is the same as being under 48 mmols per mol. Generally speaking, the lower HbA1c value, the better.

Some people may be set less challenging targets by their doctor, particularly where hypoglycemia is a concern.

Confused about the units?

A lot of people get confused about the units used to measure HbA1c. Diabetes.co.uk has an HbA1c units converter on its website which translates percentages into mmols per mol and vice versa.

Get a FREE HbA1c chart and 50 Shades of HbA1c Infographic for your
phone, desktop or as a printout.

When should HbA1c levels be tested?

Everyone with diabetes mellitus in the UK should be offered an HbA1c test at least once a year.

Some people may have an HbA1c test more often. This may be more likely if you have recently had your medication changed or your health team are otherwise wishing to monitor your diabetes control more than once a year.

Although HbA1c level alone does not predict diabetes complications, good control is known to lower the risk of complications

How do blood glucose levels compare with HbA1c readings?

The table on the right (figure 2) shows how average blood sugar levels in mmol/L would be translated into HbA1c readings , and vice versa.

It is important to note that because blood glucose levels fluctuate constantly, literally on a minute by minute basis, regular blood glucose testing is required to understand how your levels are changing through the day and learning how different meals affect your glucose levels.

Read more about HbA1c:

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Glycosylated haemoglobin & diabetes. HbA1c facts, units, diagnosis, testing frequency, limitations, control & conversion. How blood glucose levels link to A1c.

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HbA1c is a term commonly used in relation to diabetes. This guide explains what HbA1c is, how it differs from blood glucose levels and how it's used for diagnosing diabetes The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming 'glycated'.

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Annual diabetes checks: You’re entitled to essential health checks – the care you need when you have diabetes. These checks will help to prevent serious diabetes complications, like problems with your feet, eyes, heart and kidneys (Diabetes UK)

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Annual diabetes checks: You’re entitled to essential health checks – the care you need when you have diabetes. These checks will help to prevent serious diabetes complications, like problems with your feet, eyes, heart and kidneys (Diabetes UK)

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Your annual review
When you have diabetes, you’re entitled to certain checks, tests and services every year to help you get the care you need. You’ll know this as your annual review, but you should have more than tests and checks. When you're first diagnosed it's especially helpful to find out what these are. There are 15 checks, tests and services you should be getting, so we call this package of care your 15 Healthcare Essentials.

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You're entitled to essential health checks - the care you need when you have diabetes. These checks will help to prevent serious diabetes complications, like problems with your feet, eyes, heart and kidneys.

Your annual review

When you have diabetes, you're entitled to certain checks, tests and services every year to help you get the care you need. You'll know this as your annual review, but you should have more than tests and checks. When you're first diagnosed it's especially helpful to find out what these are. There are 15 checks, tests and services you should be getting, so we call this package of care your 15 Healthcare Essentials.

Appointments during the coronavirus pandemic

During the coronavirus pandemic, most routine appointments like your annual diabetes review have been cancelled or postponed. You should be able to reschedule once things go back to normal.

Eye screening is still going ahead in some circumstances and for some people who are at higher risk of problems, such as pregnant women with diabetes. All eye screening clinics should be using personal protective equipment (PPE).

In the meantime, follow your current routine including checking your feet daily, keep to a healthy diet and try to keep active. If you spot something new you're concerned about, like a cut or blister on your foot, call your GP straight away and explain your situation. If you can't get through, call 111 for advice. If you have any change in your vision you should contact your local screening service or optometrist.

If you're already having treatment for something like a foot or eye problem, and you don't have coronavirus symptoms, then your appointments should still carry on. If you're worried about going to your clinic or hospital at this time or want to check whether your appointment is still going ahead, contact your diabetes team or call the number on your appointment letter. Take a look at our guide to going into hospital.

Your 15 Healthcare Essentials

So what are these checks and services? Here's the full list:

1. Blood glucose test (HbA1c test)

2. Blood pressure check

3. Cholesterol check (for blood fats)

4. Eye screening

5. Foot and leg check

6. Kidney tests

7. Advice on diet

8. Emotional and psychological support

9. Diabetes education course

10. Care from diabetes specialists

11. Free flu jab

12. Good care if you're in hospital

13. Support with any sexual problems

14. Help to stop smoking

15. Specialist care if you're planning to have a baby.

We've got more detail on each of your 15 Healthcare Essentials. You need to know what's involved in these checks and how to manage things yourself too.

Working with your healthcare team

This care is given by your very own specialist healthcare team.

Together, they will:

treat and monitor your diabetes

reduce your risk of serious complications in the future

work with you and give you a say in your care.

We've made a 15 Healthcare Essentials checklist (PDF, 90KB) to help you get what you're entitled to. Take it with you when you see your diabetes healthcare team so you can tick off what you've got coming up and chase up if anything's missing.

At these checks, your healthcare team will work with you to agree your personal targets for the year ahead. This is for things like your HbA1c level, blood pressure and cholesterol. All these targets will be written down in a diabetes care plan.

Your healthcare team help you create this, but it's important you understand what these target numbers mean and what you can do to keep them at an ideal level in between appointments.

Know your numbers between appointments

Having regular blood sugar, blood pressure and cholesterol checks helps your healthcare team pick up on important changes. This is so you can get the right advice or treatment you need.

But it makes all the difference if you're in the know too. Be informed, know what checks you're entitled to and keep a close eye on your test results. Write them down so you can see how things change over time. This will help you look after yourself between appointments.

What changes should you look out for yourself? How often do you need to have your eyes screened? What's an ideal HbA1c level?

And it's not just about looking after your body. It's about getting emotional support and talking about anything you're worried about too. You've got the right to talk about how you're feeling with healthcare professionals who specialise in this kind of support.

Owning your own care puts you in the driving seat. It's how you manage your diabetes and how you reduce your risk of serious diabetes complications.

If you're not getting all your essential checks

You're entitled to all these checks and services. And you shouldn't be charged for any of them - they're all free.

If you're not getting these checks, have to wait too long between appointments or aren't happy with your care, see your doctor. Take your 15 Healthcare Essentials checklist (PDF, 90KB) with you and work through the tick boxes.

In most cases, this will do it. But if you're not happy with what your doctors says, ask the GP practice, hospital or clinic for a copy of their complaints procedure. It'll tell you who to complain to and if there's any kind of time limit. Ask a family member or friend to help.

Put your complaint in writing and keep a copy. Be clear about what's wrong and what you want to happen. Keep a copy of their reply and if it's by phone, ask them to put it in writing.

If you're still not happy, complain to the Ombudsman. There's more information about this at Citizens Advice.

We can give you advice about your rights too - call our Helpline and we'll help you get the care you're entitled to.

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You're entitled to essential health checks - the care you need when you have diabetes. These checks will help to prevent serious diabetes complications, like problems with your feet, eyes, heart and kidneys. Your annual review When you have diabetes, you're entitled to certain checks, tests and services every year to help you get the care you need.