Practice No.
149
Reference: 10/06
Version 1
HCC AS 31/00
HCC AS 06/09
Page 1 of 18
The Royal Marsden
Hospital Manual of
Clinical Nursing
Procedures
New
October 2009
NMC guidelines for records and
record keeping July 2009
NMC Code of Professional
Conduct
GSCC Code of Practice
Management of Diabetes Care in Residential and Nursing Homes
This summarises the nature, cause, effect, management and treatment of individuals with a
medical diagnosis of Diabetes Mellitus, who are resident in Hampshire County Council
Residential and Nursing homes. These guidelines should be read in conjunction with all other
Care Practice guidelines. These guidelines are written in association with the Diabetes
Programme of Learning©
Introduction
The aim of these guidelines is to provide information about diagnosis, continuing support,
management and appropriate referral of residents who have diabetes.
Complications associated with diabetes can shorten life and reduce its quality.
Common complications being: Heart attack and stroke [cardiovascular disease] which can be reduced by treating high
blood pressure [hypertension], stopping smoking and having a healthy diet
 Kidney damage [nephropathy] eye disease [retinopathy] and foot problems which can
be prevented by keeping blood glucose levels as near to normal as possible.
Where prevention fails, effective treatment can be given for foot problems, eye problems
and kidney problems if they are detected early.(Stephanie Frost. Diabetes Programme of
Learning [2009].)
These guidelines apply only to the care and treatment of Diabetes Mellitus
What is Diabetes?
Diabetes Mellitus is a condition in which the amount of glucose in the blood is too high
because the body is unable to utilise glucose efficiently. Glucose comes from the digestion of
starchy foods such as bread, potatoes or rice, and from sugar and other sweet foods. It is also
produced by the liver and passes straight into the blood stream.
To utilise glucose efficiently, it is necessary for the body to produce an appropriate level of
Insulin.
Insulin is a hormone produced by the pancreas. It helps glucose to enter the cells where it is
used as a fuel by the body, to produce energy. When there is a lack, or absence, of insulin
the glucose builds up in the blood.
Symptoms of Diabetes
The main symptoms of untreated diabetes are:
 Increased thirst
 Passing large amounts of urine or otherwise unexplained urinary incontinence
 Extreme tiredness
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Blurred vision
Weight loss
Itching of the genitals
Recurrent infections
Wounds failing to heal
Often, however, there are no symptoms and so it is good practice to screen elderly
residents for diabetes, at regular intervals.
Types of Diabetes
The most common types of diabetes are:
Type 1 diabetes:
This develops when there is a severe lack or absence of insulin in the body. This happens
when the cells which produce insulin have been severely damaged or destroyed. People with
this type of diabetes tend to be thin and younger when first diagnosed. They are treated with
insulin injection and diet.
Type 2 diabetes:
This develops when the body can still produce some insulin but insufficient for its needs, or
when the insulin produced cannot be utilised efficiently. People with this type of diabetes are
often older and overweight when first diagnosed. This type of diabetes is treated by diet,
exercise and tablets. Occasionally it may also be necessary to treat type 2 diabetes with
insulin injection.
Type 2 diabetes is progressive and treatment will need to be monitored regularly and revised
as necessary.
If left untreated or treated inadequately, diabetes can create complications such as damage to
the large and small blood vessels, the nerve endings, eyes, kidneys and feet. People with
diabetes also have a higher incidence of heart disease, problems with their circulation, leg
ulceration and general tissue viability, for which they often require additional treatment.
People with diabetes need regular care and support to enable them to achieve and maintain
the best possible level of health.
Diabetes care must meet the following requirements
Compliance with the Medication Management Policy
When a resident with diabetes does not wish to receive this care, it must be documented in
their care plan, in consultation with the resident, their family and other carers and health
professionals. This must include an appropriate risk assessment, done in conjunction with an
assessment of mental capacity and ‘best interest’, in accordance with the Mental Capacity Act
2000.
Where service users are capable of giving or withholding consent, no assistance with
medication should be given without their documented agreement. For that agreement to be
effective, the service users must have received information from the prescriber at the time the
medication was prescribed, about the nature, purpose, associated risks and alternatives to the
proposed medication.
In an emergency situation, the existing consent or ‘best interest’ decision for the administration
of a prescribed medication will apply. Where it may not be possible to document consent at
the time, this must still be obtained and recorded as soon as possible, including the rationale
for actions taken to manage the emergency safely and effectively .
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Where a service user is capable of giving or withholding consent, no covert administration of
medication is permitted. In such situations, if consent is withheld staff must not administer
medication. If non Hampshire County Council employed health care practitioners work outside
of this statement they will be deemed to have taken full responsibility for their actions in that
administration.
Prior to providing assistance with prompting or administering medication, staff must have
the written consent of the service user. In circumstances where a service user is physically
unable to sign the consent form, they may verbally authorise another person to sign on their
behalf. The consent form must reflect that the person signing is doing so on behalf of the
service user and under their direction. This must be witnessed by a third person. Such
consent must be obtained by the care manager, following assessment of need and prior to the
commencement of provision of direct care services, associated with the prompting, assisting
or administration of medication.
The fact that a person is suffering from a mental disorder, as defined by the Mental Capacity
Act 2000, does not mean that they lack capacity to give or withhold consent. An individual
service user’s capacity to consent must be continually evaluated. Professional judgement
must be exercised at all times. It should be understood that consent can be withdrawn by
individuals at any time.
The service user’s written consent for assistance with administration of medication must be
reviewed, as a minimum, annually as their needs change.
Giving and obtaining consent is a process and not a one-off event. Service users may change
their minds and withdraw consent at any time; equally a service user’s mental capacity to
consent may fluctuate. If there is any doubt, it is the responsibility of the care provider
manager to check that the service user still consents to receiving assistance or administration
of medication from and by the care staff. Any changes must be referred to the care manager,
who in turn should discuss this with the prescribing practitioner or currently responsible
physician. If there is any doubt about the person’s mental capacity, a report from a consultant
psychiatrist or other medical practitioner must be obtained.
When a service user is considered incapable of providing consent, or refuses medication and
is judged to lack capacity, the care provider manager must discuss this with the care manager
and currently responsible physician. The terms of any advance decision must be considered,
to determine whether the advance decision is valid and applicable to the administering of
medication.
Disguising medication in order to save life, prevent physical or mental deterioration, or ensure
an improvement in a person’s physical or mental health, cannot be taken in isolation from the
recognition of the human right of that person to give consent. It may, in such situations, be
necessary to administer medication covertly, but in some cases, the only proper course of
action may be to seek the permission of the court to do so, in the best interest of the
individual.
Where a service user is considered to be lacking capacity to give consent, or where the
wishes of a mentally incapacitated service user appear to be contrary to the best interests of
that person, the currently responsible physician must provide an objective assessment of the
person’s needs and proposed care or treatment.
Relevant others, such as relatives, carers or care workers, authorised representatives and
other members of the multi-disciplinary team, must be consulted to determine the course of
action that is in the best interests of the service user.
All assessments of capacity and ‘best interest’ decisions must be undertaken and recorded in
accordance with the Mental Capacity Act, and associated guidance. Outcomes must be
recorded as part of the care plan and must detail the agreed action plan. Any previous
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instructions given by the service user must be respected and taken into consideration at this
time.
The decision to administer medication covertly must not be considered routine and must be
viewed only as a contingency measure. Any decision to do so must be concluded only after
assessment of the care needs and best interests of the individual service user in accordance
with the mental capacity act and associated guidance. It must be specific to an individual
service user in order to avoid the institutional administration of medication in this manner. The
care plan must be reviewed whenever medication is administered, to confirm the course of
action is still appropriate, and in the best interests of that individual.
Where there is significant doubt or disagreement, the County Council may wish to make a
representation to the relevant health body to make application to the Court of Protection, as a
matter of good practice, to enable a judicial determination of ‘best interest’ to be made
All medication related procedures MUST be undertaken in accordance with the Medication
Management Policy 06/09, and service specific guidelines.
Annual Health Screening
All residents must be screened annually for diabetes as part of the Care Plan.
When a health check takes place, the urine will be checked for glucose.
Urine tests which are positive for glucose, or any other abnormality, must be reported to the
General Practitioner and documented in the resident’s care plan.
If a resident has any symptoms of diabetes, but their urine test is negative for glucose, this
must also be reported to the GP.
Care Planning
Each resident with diabetes will have a Diabetes Care Plan which will be reviewed monthly or
more frequently if necessary. (Appendix A)
Each resident with diabetes will also have an annual medical review of their condition in the
most appropriate location, either the G.P. surgery or in the Care home. (Appendix B)
If necessary, an appointment will be made to attend the hospital Diabetes clinic.
The frequency of this review and necessary associated arrangements and appointments must
be documented in the care plan.
In order to carry out a thorough assessment of the resident’s diabetes, the doctor will need the
following information:Diet
Current M.U.S.T. assessment and any M.U.S.T. care plan
Monitoring results A record of all blood and urine tests
A urine specimen in a clean bottle will usually be needed by the clinic
A blood test may have been requested 1-2 weeks prior to the review
Medication
A copy of the current Medication Administration Record sheet.
General Condition Information about any change in resident’s medical condition since their
last appointment
A Diabetes Review should consist of:
 General assessment of well being – mental and physical
 Review of diet & lifestyle issues – exercise, smoking status, influenza vaccination
status
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Height, weight, BMI
Detailed medical assessment - Blood pressure measurement – may be lying and
standing
Review of medication
Examination of feet, legs and assessment of foot risk status.
Waterlow or Braden Score risk assessment for tissue viability
Visual acuity and fundoscopy (eye sight test and examination of the back of the eye)
where possible, in certain situations sedation may be required to achieve this
Assessment of blood glucose control – discussion, blood test and records - incidences
of hypoglycaemia (low blood glucose)
Assessment of kidney function and cholesterol or lipids (blood and urine test)
Completion of the annual review record (Appendix B)
Lead Member of staff for Diabetes care
Each care home will have a named member of staff, trained and accredited in the care of
people with diabetes.
Training must include:
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Understanding of the types of diabetes
Importance of blood glucose control and monitoring, including blood testing, the
interpretation of results and maintenance of equipment
How to test urine and interpret results
Risk assessment and management issues in diabetic care
Cultural and ethical issues involved in diabetic care
Avoidance and management of hypo and hyperglycaemia
Screening for complications – e.g. foot care, eye disease and cardiovascular disease
Principles of healthy eating
Care of multiple health issues
Care plan development, recording, management and the annual review process
Awareness of organizations such as Diabetes UK
Maintaining knowledge and Skills
Following training and accreditation, Diabetes Care designated staff must ensure that they
maintain and update their knowledge regularly.
Diet
Dietary Guidelines
The recommendation for people with diabetes is a normal, varied, healthy diet, high in fibre
and low in sugar and saturated fat. On entry to a residential care or nursing home, all
individuals will be have a routine M.U.S.T. assessment, and if necessary a M.U.S.T. Care plan
will be developed, with subsequent monthly reviews. Some residents may be nutritionally at
risk, and where an individual is identified as being malnourished, and requiring nutritional
supplement drinks or a specialised diet, a registered dietician or specialist registered nurse
must be consulted for further advice.
Any M.U.S.T. care plan will be developed in consultation with the resident, their family and
carers and should be acceptable to the individual, taking into consideration their likes and
dislikes in order to stimulate their appetite. (Care Practice guidelines 145)
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A baseline M.U.S.T. assessment and BMI on admission, are essential to accurate nutritional
assessment. Wherever possible, residents should be encouraged to eat a varied, balanced
diet.
Meals should provide a varied and nutritionally balanced diet.
Regular Eating
When residents are taking medication for diabetes, they need to eat regularly to prevent
hypoglycaemia (a low blood glucose level). High fibre, starchy foods should be encouraged at
each meal. Individual eating patterns and plans must be monitored and supplementary meals
provided as necessary.
Carbohydrate and Fibre
Meals should always include starchy carbohydrates such as bread, potatoes and or breakfast
cereals. Pasta and rice are also good sources. High fibre options, such as potatoes with
skins, wholemeal and whole grain bread, wholegrain cereals should be encouraged and will
also help to prevent constipation.
It is very important to maintain a good fluid balance and to drink at least 1.5 litres of fluid of
choice per day. This equates approximately to 10 teacups, although cups vary in size and
consequently will deliver different volumes.
Five portions of fruit, vegetables or pulses are recommended to be eaten each day.
Because of the natural sugar content, fruit needs to be spread across the day and fruit juice
limited to one small glass (100 ml) at mealtimes.
Sugar
The diet does not need to be sugar-free, but where possible, high sugar foods may be
replaced by low sugar alternatives, especially for overweight residents.
Small amounts of sugar do not adversely affect blood sugar when taken as part of a high fibre
meal. Residents with diabetes, may occasionally eat small portions of cake or chocolate,
providing this is part of a balanced, healthy diet.
The Diabetes UK booklet ‘Home Baking’ contains recipes for reduced sugar, high fibre cakes,
biscuits and breads.
Fat and Obesity
Weight loss is desirable for obese residents, however, for some this may be difficult e.g. those
with marked immobility when maintenance of current weight may be more realistic.
If residents are overweight, their total fat intake may be reduced to help them lose weight.
Individual eating plans will be developed to include individual choice and dietary advice. (Care
Practice guidelines 145). Family members, friends and other carers may be involved in the
development of a person centred eating plan.
Unless contraindicated by any medication or medical condition, alcohol may be taken, but
should be monitored
N.B. Special ‘diabetic’ foods should be avoided, as they are usually unnecessary. They
may contain substances that have a laxative effect and offer no special benefits.
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Monitoring
Diabetes control can be directly assessed by testing a person’s blood glucose level from a
finger prick blood sample, or indirectly by testing the urine.
The normal blood glucose level is between 4 and 7 mmol/l and in the non-diabetic individual
there is usually no sugar detected on a urine test. A blood glucose monitoring record
(Appendix C) must be kept in conjunction with the Diabetes Care plan.
All monitoring equipment must meet recognised standards for infection control, quality control
(accuracy) and health and safety. When staff are performing blood glucose monitoring, it
should be remembered that this is an invasive procedure, and is subject to all relevant service
specific and professional standards guidelines. (Care Practice guidelines 140)
Only single use, disposable finger pricking lancets may be used.
Venous blood sample
This test (the HbA1c) reflects the average blood glucose control over the last 6-8 weeks and is
a guide to how well an individual’s diabetes is controlled. The General Practitioner will request
this test if required. Results must be recorded in the relevant parts of the Care Plan. (Medical
notes; Diabetes Care Plan)
Frequency of tests
The care plan must describe the type and frequency of testing agreed for each person. This
must be based on the stability of their glucose control and the need for the results to be
considered for treatment changes.
Sudden changes in test results in a person who is usually stable may indicate that the resident
is unwell and may have an infection. If the results do not stabilise (e.g. overnight) the doctor
must be informed.
Medication
An individual’s diabetes may be controlled by diet, medication or a combination of both.
Diabetes is a chronic condition. It is expected that during a person’s life, their treatment will
be reviewed and changed to maintain best possible control of blood glucose levels with
optimum quality of life. A medication review should be carried out by the patient’s doctor at
least annually.
Diabetes medication varies dependent on the individual’s needs. In accordance with
Medication management protocol, all homes should have an up to date copy of the British
National Formulary (BNF) stored in the medication trolley, or have online access to the BNF
http://www.bnf.org This will provide accurate information about current medication.
Medication must be given at the appropriate times to ensure accurate control of blood
glucose levels. The medication is intended either to increase the amount of insulin produced
by the pancreas, by increasing the amount of glucose required, or to delay the digestion and
absorption of starch and glucose.
Where Insulin injection is used to control blood glucose levels, if the resident is self
administering the insulin, this must be subject to appropriate risk assessments for both
storage and self administration, and these must be fully recorded in the Care Plan and
reviewed on each administration. Where a resident is self administering insulin, using a pen
device, this must be clearly labelled with the resident’s name and stored in a locked cupboard,
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to which the resident may hold the key, subject to an appropriate risk assessment. Self
administration may be subject to prompting or assisting as defined in the Medication
Management Policy 06/09. However, if the resident requires assistance with the disposal of
any sharps, an auto cover needle must be used. It may not be possible to achieve a low risk
assessment for the self administration of insulin, unless an auto sheathing needle is used.
The insulin in use may be stored securely in a locked cupboard at room temperature in
accordance with the manufacturers’ instructions. Otherwise, it should be stored in a
medication refrigerator as specified in the Medication Management Policy 06/09, until required
for use.
The Nurse Advisor will advise on medication and support where required.
Hypoglycaemia (low level of blood glucose)
This occurs when the blood glucose level drops below 4 mmol/l, or when it falls below the
level of range for the individual, and symptoms of hypoglycaemia, for that individual, are
present. The range and symptoms must be recorded in the Care Plan.
Causes may include
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Insufficient food
Too much insulin or incorrect dose of tablets
More exercise that usual
Symptoms
These may vary between individuals and all possible indications must be recorded in the care
plan. Individual signs and symptoms may give less warning with increasing age
Possible symptoms are :Cold and clammy to touch
Hunger
Confusion
Irritability
Tiredness
Feeling faint
Weakness
Drowsiness
Blurred vision
Feeling anxious
Lack of concentration
Sweating
Rapid pulse
Pounding heart
Shaking
Feeling of ‘Pins and needles’
Treatment
Prompt treatment is required to restore the blood glucose level.
Food or fluid should only be given to a conscious person - if in doubt, call an ambulance.
If the person is conscious, and able to swallow, they may have one of the following:
 5 glucose tablets as prescribed
 Half a glass of high energy drink
 Honey in a drink or sweet tea
 Where prescribed, Hypostop or similar treatment
Blood glucose testing must be done before and after treatment of hypoglycaemia. The target
should be to raise the blood sugar to a level greater than 6 mmol/l or as specified by the
prescribing clinician, after treatment.
If the resident does not recover within 10 minutes, an ambulance must be called.
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Following recovery, the resident should by encouraged to eat a snack e.g. sandwich or
some biscuits, to avoid another hypoglycaemic attack occurring.
It is important to try to identify the possible cause of the low blood sugar level and
adjust the care plan to avoid reoccurrence.
If the early symptoms are missed, the individual may have a seizure and lose
consciousness. In this situation, administer first aid by placing the person in the
recovery position and call an ambulance.
Hyperglycaemia (high level of blood glucose)
This occurs when the blood glucose level rises above 7 mmol/l, or when it rises above the
level of range for the individual, and symptoms of hyperglycaemia for that individual are
present. The range and symptoms must be recorded in the Care Plan.
Causes may include
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Undiagnosed Diabetes
Stress
Change of medication
Missed medication particularly Insulin
Reduction in levels of exercise
Change in diet
Infection
Some antipsychotic drugs such as Olanzapine and Respiridone
Symptoms
Hot, and dry skin to touch
Thirst
Increase in Urine output
Drowsiness
Nausea
Vomiting
Increased susceptibility to infection
Tiredness
Blurred vision
Weight loss
Treatment
For both types of Diabetes, if the blood glucose level is persistently above normal range for
the individual, medical advice must be sought as a matter of urgency.
If there is any risk or occurrence of unconsciousness, administer First Aid and call an
ambulance.
Type 1 Diabetes
 Contact prescriber to adjust medication
 Increase fluids to rehydrate
Type 2 diabetes
Hyperglycaemia is rare in Type 2 Diabetes but it may develop into Hyperosmolar non ketotic
coma
 Medical aid must be called as a matter of urgency
 If the resident is comatosed, administer First Aid and call an ambulance
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Multiple Illnesses
If a resident with diabetes is unwell as the result of a secondary illness, such as an infection,
their diabetes must be monitored more closely and it will be necessary to increase the
frequency of testing following medical advice. Medical advice must be sought if they are
unable to tolerate fluids. Urgent advice is needed if they are vomiting. Supplementary food
and drinks need to be considered to maintain adequate nutrition and fluid intake.
NEVER STOP INSULIN INJECTION as the body often needs more insulin when infection is
present. The normal dose of insulin should be given and medical advice sought.
In certain cases, people with diabetes may need their urine tested for ketones. This must be
documented in the care plan. NOTE: The accuracy of the blood glucose meter reading may
become unreliable if blood glucose levels are very high.
Tissue Viability
People with diabetes are more susceptible to skin damage as they may have reduced skin
sensitivity and ability to regenerate, and do not heal as efficiently. If damage to the skin
occurs, people with diabetes may not heal as quickly.
Risk Assessment
All Diabetic residents will have appropriate risk assessments recorded as part of their care
planning process.
Causes of pressure sores
Pressure sores are caused by a combination of extrinsic and intrinsic factors . (Ref: Guideline
139 Care of Pressure Areas)
Foot Care
People with diabetes may develop damage to the nerve endings in their feet (neuropathy) or
to the circulation in their lower limbs. This makes them more susceptible to developing foot
problems. The aim of foot care treatment is the prevention of skin damage and foot ulceration.
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Foot ulceration is responsible for a large proportion of all diabetes related admissions
to hospital
People with diabetes also account for a large proportion of all non-traumatic lower limb
amputations
The majority of amputations are preceded by a foot ulcer.
The risk of foot ulceration is further increased in those with advancing age, loss of sensation
and/or blood vessel disease, immobility, poor eyesight and other chronic states.
It is well established that podiatry (chiropody) with accurate assessment and identification of
risk can prevent ulceration.
Podiatry and Chiropody Services
Access to a Registered Podiatrist / Chiropodist may vary across areas, but this should be
available at the local medical centre or hospital. Referral can be made direct or via the GP.
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Where homes contract a private podiatrist / chiropodist, they should ensure that the
practitioners are registered with the Health Professions Council (HPC). HPC registration
ensures that a minimum standard of practice has been achieved. Details of whether a
podiatrist / chiropodist are registered can be checked on the HPC Website. http://register.hpcuk.org
Where podiatry / chiropody is provided in a care home, this may only be undertaken by staff
who are appropriately trained and accredited.
Foot Risks associated with Diabetes
Assessment of the foot risk status must be made by a registered podiatrist / chiropodist or
accredited person. Those at greatest risk should be seen by an NHS specialist diabetes
podiatrist / chiropodist. (See Appendix D)
Foot Care Management
Education Programme
Each care home must establish a local referral protocol for urgent or routine foot problems, to
ensure specialist assessment and treatment.
Each care home must have an identified member of staff responsible for overseeing foot care
for people with diabetes.
All care staff must have foot care education, which includes the special needs of people with
diabetes.
Simple nail cutting may only be undertaken by staff who have been trained and accredited in
diabetic foot care, and only after the resident has been assessed and is deemed to be of low
risk. When the resident is assessed to be at medium or high risk, nail cutting must only be
undertaken by a Registered Podiatrist/Chiropodist. (Appendix E)
Useful Contacts
Diabetes UK
10 Parkway, LONDON, NW1 7AA
Care-line
Website
Tel: 0845 120 2960
www.diabetes.org.uk
Tel: 020 7424 1000
Acknowledgements
These guidelines have been adapted for use by Hampshire County Council
Residential and Nursing Service in consultation with Stephanie Frost, Honorary
Lecturer, School of Medicine, University of Southampton.
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Bibliography
British Diabetes Association (now Diabetes UK) Report
Guidelines of Practice for Residents with Diabetes in Care Homes 1999
Care Standards Act 2000
(The Care Homes for Older People National Minimum Standards. Dept of Health - March
2001)
Diabetes Care for Life audits, North Devon and Exeter 2004
Diabetes UK Publication
What diabetes care to expect – October 2003
National Service Framework for Diabetes
Standards 2001
http://www.doh.gov.uk/nsf/diabetes
National Service Framework for Older People 2001
http://www.doh.gov.uk/nsf/older
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Appendix A
Diabetes Care Plan
The aim of the diabetes care plan is to identify the presence or risk of complications and
develop a plan of care to meet relevant, current needs. It must be reviewed at least monthly or
as changes in health occur.
Name of Resident .....................................................................................................
Annual Review
Frequency and Date (month) of Diabetes review (minimum annually) ………………………
Preferred venue for review ...................................................................................................
Transport arrangements (if necessary) ..................................................................................
Diabetes related problems…………………………………………………………………………..
Blood Pressure (agreed target range) ....................................................................................
Cholesterol (agreed target range) ..........................................................................................
Retinal Screening ..................................................................................................................
Diabetes Care Plan
Monitoring Method of monitoring: (circle to specify) Blood testing using B G meter.
Urine testing using dip-stick for glucose. Any Other …………………………………………….
Frequency of monitoring : ……………………………………………………..…………………
Agreed target levels of blood glucose level: ……………………………………………….....
Specific dietary needs : …………………………………………………………………………….
..............................................................................................................................................
Diabetes Foot Screening problems identified : ………………………………………………...
……………………………………………………………………………………………………….…
..............................................................................................................................................
Date of monofilament test : ……………………………………………………………………….
Care Plan to be reviewed monthly.
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Appendix B
Annual Diabetes Care Review
Annual Diabetes Care Review As far as possible residential and nursing home staff should
complete this review document prior to the annual assessment by the General Practitioner.
Name of resident : ...................................................................................................
Date of birth : ......................................................................................................................
Name of Residential home : .................. ………………………………………………………..
Height (cms) ...........................................
Weight (kgs) ………………………………….
Body Mass Index : .................................
M.U.S.T. risk level ……………………………
Braden Score …………………………………
Smoking Status: Never smoked ..............
Stopped smoking (date) ................................
Current smoker (No per day) ....................
Type of tobacco ............................................
Advice given re smoking (date and sign)
.....................................................................
Alcohol (No of units per week) .................
Diet (difficulties with diet - if any) ...........................................................................................
Date if seen by dietician.........................................................................................................
Urinalysis : Date ........... …………….Protein …. ........................... Glucose……………..….
Ketones ...........................
Microalbumin (laboratory test if no protein)
.....................................................................
Date of last influenza vaccination : ……………………………………………………………..
Eyes Visual Acuity .......................................... Right Eye ............... Left Eye .........................
Date of Retinal Screening ……………………………………………………………………
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Blood Pressure .......................................
Pulse rate /min……………………………..
Mobility levels .........................................
Foot care
Foot pulses
Right Dorsalis pedis .................. Right Posterior tibial ....................................
Left Dorsalis pedis .................... Left Posterior tibial ......................................
Monofilament score
Right ....................... Left .............................................................
Date seen by Podiatrist
............................... Name of Podiatrist ......................................
Foot care problems ..............................................................................................................
............................................................................................................................................
Blood Tests :
HbA1c …………………..
Creatinine ……………………………………
Cholesterol ...................
Thyroid function test ....................................
Date of Medication review : ....................
Injection sites (as appropriate) .........................................................................................
Susceptibility to hypoglycaemia
...................................................................................
If so, Frequency ...................................................................................................................
Date: ........................................................
Signature : ………………………………………………………
Role Tile : ………………………………………………
Next Annual Review : ……………………………………
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Appendix C
Diabetes Blood Glucose Monitoring Chart
Name of
Resident…………………………………………………………………………………………………
…………………………
Date:
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
Blood / Glucose Level (mmol)
2hrsAfter Before Eve
2hrafter
Lunch
Meal
Eve Meal
Before
bed
Night
time
Signature:
Date:
Signature:
Date:
Signature:
Date:
Signature:
Date:
Signature:
Date:
Signature:
Blood / Glucose Level (mmol)
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Date:
Before
B’fast
2hrsAfter
B’fast
Before
Lunch
2hrsAfter
Lunch
Before Eve
Meal
2hrafter
Eve Meal
Before
bed
Night
time
Signature:
Appendix D
Foot Care Risk Assessment
Risk 1 – Foot is at Extreme Risk






Previous amputation / gangrene / ulceration
Ischaemic foot (circulation problem), suspect if foot is very cold, absent or abnormal
pulses, or the foot does not blanch to touch
Previous vascular surgery
Neuropathy (loss or altered sensation, numb or painful feet). The neuropathic foot will
have been assessed and documented by the doctor, registered podiatrist / chiropodist
or nurse.
Structural deformity of foot or toes present
Other foot problems present. Corns, excessive callus (hard skin), thickened deformed
nails
Risk 2 - (Medium Risk) – Foot is at Great Risk








Structural deformity of foot or toes present
Tight or ill fitting shoes
Foot or ankle oedema (swelling)
Other foot problems present. Corns, excessive callus (hard skin), thickened deformed
nails
Age >60
Poor diabetes control
Poor vision registered blind or partially sighted
Limited mobility – use of walking aid or wheel chair.
Risk 3 - (Low Risk) – Foot is at Moderate Risk
This is someone with diabetes who has none of the above.
These people still are at risk and need to be vigilant and should check their feet daily.
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Appendix E
Foot care advice sheet for staff working with Older Persons
The majority of serious damage begins with injury to the toes. It is important to house the toes
well and protect them from friction, pressure and shear stress.

Wash feet daily and dry very carefully, especially between the toes.

Inspect feet daily, look for blisters, scratches and areas of possible infection. Do not
miss looking between the toes. Contact the podiatrist, doctor or registered nurse if
there are any changes. (Appendix D)

Inspect shoes / slippers daily especially before they are put on and ensure they are
correctly fitting to avoid friction and falls. Check for foreign objects, nail points, torn
linings or other problems that might damage feet. All shoes / slippers should be a good
fit and comfortable, and not too tight to allow toes room to wiggle. Avoid pointed shoes
and those with seams in the front. If feet are misshapen / of a non-conventional
shape, there maybe a need to be referred to an orthotist through the GP for foot wear
advice and possible provision of specialist foot wear.

It is important to change socks daily. In addition, wear properly fitting stockings /
socks, avoiding those with seams or those that have been mended or have tight elastic
around the tops. Garter should not be worn. Do not wear shoes without socks or
stockings because there is a higher risk of damaging the skin through rubbing

Avoid extreme temperatures to feet. Do not use hot water bottles or heating pads. If
feet feel cold at night, wear good fitting bed socks

Minor infection can cause significant problems for people with diabetes, and it is very
important to contact the podiatrist / chiropodist, doctor or nurse at the first sign of
infection. Common signs of infections are:
Redness or any other discolouration of a toe or an area of the foot
Swelling
Discharge of pus / fluid from a toe or other part of the foot

Pain is another indication of a problem although pain may not be felt if they have loss
of sensation in the feet

Do not walk bare foot
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
Do not use chemical agents such as corn pads or hard skin remover

If there is any concern, seek advice from a registered chiropodist or podiatrist

Do not smoke. Smoking causes damage to the circulation in your legs and feet.
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