CP 4.7: Diabetic Follow-Up

Updated:
Reviewed: 

Purpose

To ensure the proper maintenance of blood sugar and insulin levels in the diabetic patient to be accomplished through the patient’s ability to self-manage their blood glucose monitoring, appropriate prescription drug usage, recognition of desired drug effects, recognition of hypo/hyperglycemia, and treatment of same.

Policy Statements

In response to a referral from a health authority or primary health care provider, the Community Paramedic (CP) will follow guidelines outlined on the Request for Service form and care plan for follow-up on diabetic patients.  It is expected that the CP will document findings and report them to the primary health care provider and collaborate with other health care team members to provide support as appropriate.

Procedure

1. OBTAIN and REVIEW patient’s health history and care plan prior to appointment.
2. REFER to Request for Service form and care plan for direction with respect to assessment, patient specific care parameters, and patient teaching as required.
3. REVIEW history and physical assessment including health care providers plan for diet, blood glucose targets, and medications.
4. OBSERVE patient’s physical state/general well-being.
5. INSPECT patient’s feet and DISCUSS foot care with patient and review information as required.  Proper footcare is critical for diabetic patients because they are prone to foot problems caused by neuropathy and poor circulation which can lead to loss of feeling in their feet, changes in the shape of their feet, and foot ulcers or sores that do not heal.  According to the National Institute of Health, simple daily footcare can prevent serious problems.  REVIEW the following information about footcare with the patient as necessary: 
   • Check your feet every day
     • Check your feet for cuts, sores, red spots, swelling, and infected toenails.  You may have foot problems, but feel no pain in your feet.
     • Check your feet each evening when you take off your shoes.
     • If you have trouble bending over to see your feet, use a mirror to help.  You can also ask a family member or caregiver to help you.
     • Call your doctor right away if a cut, blister, or bruise on your foot does not begin to heal after a few days.
   • Wash your feet every day
     • Wash your feet in warm, not hot, water.  Do not soak your feet because your skin will get dry. 
   • Before bathing or showering, test the water to make sure it is not too hot.  You can use a thermometer (32° to 35° C is safe) or your elbow to test the water.
   • Use cornstarch to keep the skin between your toes dry to prevent infection.
   • Keep your skin soft and smooth
     • Rub a thin coat of skin lotion or cream on the tops and bottoms of your feet.
     • Do not put lotion between your toes because this might cause an infection.
   • Smooth corns and calluses
     • Thick patches of skin called corns or calluses can grow on your feet.  If you have corns or calluses, check with your foot doctor about the best way to care for them.
     • If your doctor tells you to, use a pumice stone to smooth corns and calluses after bathing or showering.  Pumice stone is a type of rock used to smooth the skin.  Rub gently, only in one direction, to avoid tearing the skin.
     • Do not cut corns and calluses.
     • Do not use razor blades, corn plasters, or liquid corn and callus removers - they can damage your skin and cause an infection.
   • If you can see, reach, and feel your feet, trim your toenails regularly
     • Trim your toenails with nail clippers after you wash and dry your feet. 
     • Trim your toenails straight across and smooth the corners with an emery board or nail file.  This prevents the nails from growing into the skin.  Do not cut into the corners of the toenail.
     • Have a foot doctor trim your toenails if:
       • You cannot see or feel your feet
       • You cannot reach your feet
       • Your toenails are thick or yellowed
       • Your nails curve and grow into the skin
   • Wear shoes and socks at all times
     • Wear shoes and socks at all times.  Do not walk barefoot when indoors or outside.  It is easy to step on something and hurt your feet.  You may not feel any pain and not know that you hurt yourself.
     • Make sure you wear socks, stockings, or nylons with your shoes to prevent getting blisters and sores.
     • Choose clean, lightly padded socks that fit well.  Socks that have no seams are best.
     • Check inside your shoes before you put them on.  Make sure the lining is smooth and that there are no objects in your shoes. 
     • Wear shoes that fit well and protect your feet.
   • Protect your feet from hot and cold
     • Wear shoes at the beach and on hot pavement.  You may burn your feet and not know it.
     • Put sunscreen on the tops of your feet to prevent sunburn.
     • Keep your feet away from heaters and open fires.
     • Do not put hot water bottles or heating pads on your feet.
     • Wear socks at night if your feet get cold.  Choose socks carefully.  DO NOT wear socks with seams or bumpy areas.  Choose padded socks to protect your feet and make walking more comfortable.
     • Wear lined boots in the winter to keep your feet warm.  In cold weather, check your feet often, keep your feet warm, and avoid frostbite.
   • Keep the blood flowing to your feet
     • Put your feet up when you are sitting.
     • Wiggle your toes for 5 minutes, 2 or 3 times a day.  Move your ankles up and down and in and out to help blood flow in your feet and legs.
     • Do not cross your legs for long periods of time.
     • Do not wear tight socks, elastic, or rubber bands around your legs.  Do not wear restrictive footwear or foot products.  Foot products that can cut off circulation to the feet, such as products with elastic, should not be worn by diabetics.
     • Do not smoke.  Smoking can lower the amount of blood flow to your feet.
   • Be more active
     • Being active improves blood flow to the feet.  Ask your health care team for safe ways to be more active each day.  Move more by walking, dancing, swimming, or riding a bike.
     • If you are not very active, start slowly.
     • Find safe places to be active.
     • Wear athletic shoes that give support and are made for your activity.
6. MEASURE and RECORD blood pressure and weight.
7. ASSESS the patient’s understanding of the disease and the positive impacts of a healthy diet and exercise.  ENSURE the patient is using medications as prescribed and inform the primary care provider if they are not.  If the patient is on insulin, ensure correct use of devices and storage of vials (i.e., ensure the patient can visualize the proper amount of insulin they are to inject, utilizing correct injection sites, injection technique and site rotation, changing needles with each injection, not keeping opened/active insulin in the fridge, and ensuring insulin is not exposed to temperature extremes).  REVIEW information with the patient as required.  INSPECT injection sites for redness or irritation.
8. ENQUIRE about hypoglycemic episodes at each visit.  DISCUSS recognition and treatment of hypoglycemia as needed.
9. INSPECT glucose meter to ensure it turns on when a strip is inserted and does not provide error messages.  If not working, REFER to pharmacy for new meter.

10. OBSERVE the patient as he/she performs blood glucose reading on personal home glucose meter.  ASK patient to read out loud the glucometer reading.  REVIEW usage with the patient if required.  ENCOURAGE the patient to use a new lancet with each poke.

    NOTE: patients should follow SPECIFIC directions from their health care provider regarding frequency of blood glucose monitoring.  In the absence of those directions and if not using insulin, testing is only recommended when suspecting hypoglycemia, or if feeling unwell.
11. If blood glucose (BG) is less than 4 mmol/L, or if the patient is experiencing signs and symptoms of hypoglycemia:
    • ASSESS vital signs and level of consciousness.
    • If airway, breathing, or vital signs are compromised, immediately initiate emergency response.
    • ASSIST patient with treatment including 15-20 grams of carbohydrate – some suggestions include:
      • 15 g of glucose in the form of glucose tablets/gel (preferred choice) OR
      • 15 mL (3 teaspoons) sugar dissolved in water OR
      • 175 mL (3/4 cup) of juice or regular soft drink OR
      • 6 LifeSavers® (1=2.5 g of carbohydrate) OR
      • 15 mL (1 tablespoon) of honey
    • REPEAT BG measurement in 10-15 minutes.  If BG remains under 4 mmol/L, repeat administration of glucose product(s).
    • If their next meal is more than one hour away, they should eat a snack, such as a half- sandwich or cheese and crackers (something with 15 grams of carbohydrate and a protein source).
    • CONTACT health care provider for further direction.
12. RECORD the patient's concerns about treatment (e.g., insulin levels, blood sugar levels, foot problems, etc).
13. COMMUNICATE with health care provider or health care team if blood glucose falls outside acceptable parameters as noted on care plan or if any self-care difficulties are noted or suspected such as vision problems or inability to perform own footcare due to mobility, co-ordination, diminished sensation, or other difficulties.
    
    

Patient Education Resources

Canadian Diabetes Association – Diabetes and You

Canadian Diabetes Association – Health Living Resources

Diabetes – Take Care of Your Feet for a Lifetime

Documentation

DOCUMENT details of the visit on the CP progress notes and notify primary health care provider or health care team of findings and any concerns.

References

1. Canadian Diabetes Self-Management Education - Help your patient take charge. [Link]
2. Eagle County Paramedic Services. Community Paramedic Protocols Manual. 2013. [Link]
3. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes - Take Care of Your Feet for a Lifetime. 2014. [Link]
4. Tri-County Health Care Emergency Medical Services. Community Paramedic Policy & Procedure Manual. 2016. [Link]
5. Vancouver Coastal Health. Hypoglycemia in Diabetes: Adult Management Protocol – Acute and Residential. 2013.