DIABETES

1. DIABETES AND MEAL PLANNING

SN instructed patient/caregiver on the importance of following an individualized diabetic meal plan to help maintain blood glucose within the target range. Instructed to maintain consistent carbohydrate intake as recommended by the physician/dietitian and to avoid skipping meals, especially when taking medications that may cause hypoglycemia.

SN instructed patient/caregiver to choose nutrient-dense foods including non-starchy vegetables, whole grains, beans, lean proteins, low-fat dairy products, fruits, and healthy fats. Instructed to limit foods and beverages high in added sugars, refined carbohydrates, saturated fats, and sodium.

SN instructed patient/caregiver to monitor portion sizes and eat according to hunger, nutritional needs, prescribed diet, and medication regimen. Instructed to avoid overeating and to maintain regular meal timing when appropriate.

SN instructed patient/caregiver to read nutrition labels and pay particular attention to serving size, total carbohydrates, added sugars, sodium, and saturated fat.

SN instructed patient/caregiver to choose water or other unsweetened beverages whenever possible and to limit regular soda, sweetened tea, fruit drinks, energy drinks, and other sugar-sweetened beverages.

SN instructed patient/caregiver that sugar-free products and non-nutritive sweeteners may be used when appropriate but should not replace an overall balanced meal plan.

2. HEALTHY CARBOHYDRATE CHOICES

SN instructed patient/caregiver on choosing high-fiber carbohydrate sources such as whole-grain breads and cereals, oatmeal, brown rice, beans, lentils, chickpeas, peas, vegetables, whole fruits, and berries.

SN instructed patient/caregiver that carbohydrate-containing foods have the greatest immediate effect on blood glucose and that carbohydrate portions should be consistent with the prescribed meal plan and insulin regimen.

SN instructed patient/caregiver to choose whole fruit instead of fruit juice whenever possible because whole fruit generally provides more fiber and may produce a more gradual rise in blood glucose.

3. PROTEIN AND BALANCED MEALS

SN instructed patient/caregiver on appropriate protein sources including fish, lean meats, skinless poultry, eggs, low-fat dairy products, beans, lentils, tofu, and other plant-based proteins.

SN instructed patient/caregiver to combine carbohydrates with appropriate protein, vegetables, and healthy fats as part of a balanced meal plan.

SN instructed patient/caregiver that nutritional supplements such as Glucerna should be used according to nutritional needs and the physician/dietitian’s recommendations and should not automatically be considered necessary for every patient with diabetes.

4. BLOOD GLUCOSE MONITORING

SN instructed patient/caregiver on proper blood glucose monitoring technique and the importance of checking blood glucose at the frequency ordered by the physician.

SN instructed patient/caregiver to maintain a blood glucose log including date, time, glucose reading, insulin dose when applicable, meals, symptoms of hypo/hyperglycemia, and other relevant events.

SN instructed patient/caregiver to recognize blood glucose patterns and report persistent readings outside the physician-established parameters.

SN instructed patient/caregiver not to independently change the prescribed insulin dose unless specifically instructed to do so according to an established physician-approved insulin plan.

5. RECOGNITION OF HYPOGLYCEMIA

SN instructed patient/caregiver that hypoglycemia is generally defined as blood glucose below 70 mg/dL and may include sweating, shakiness, hunger, palpitations, dizziness, headache, weakness, irritability, confusion, blurred vision, abnormal behavior, drowsiness, seizures, or loss of consciousness.

SN instructed patient/caregiver that symptoms may vary and some patients may have hypoglycemia without obvious warning symptoms.

6. TREATMENT OF HYPOGLYCEMIA

How to recognize and manage hypoglycemia

SN instructed patient/caregiver on how to recognize and manage hypoglycemia, explaining that blood glucose levels below 70 mg/dL are considered low and may cause shakiness, sweating, dizziness, sudden hunger, headache, weakness, irritability, confusion, or rapid heartbeat. Educated on the importance of checking blood glucose immediately when symptoms occur and following the 15-15 rule: if blood glucose is below 70 mg/dL and the patient is conscious and able to swallow safely, administer 15 grams of fast-acting carbohydrates, such as 4 oz of fruit juice or regular soda, glucose tablets, or 1 tablespoon of sugar dissolved in water. Recheck blood glucose after 15 minutes and repeat treatment if the level remains below 70 mg/dL. Once blood glucose returns to normal, provide a snack containing carbohydrates and protein if the next meal is more than one hour away. Instructed that severe hypoglycemia may cause seizures, loss of consciousness, or inability to swallow, requiring immediate emergency assistance by calling 911 and administering prescribed glucagon if available. Emphasized never to give food or fluids by mouth to an unconscious patient. Reinforced the importance of regular blood glucose monitoring, consistent meal schedules, medication adherence, and reporting recurrent hypoglycemic episodes to the physician. Patient/caregiver was educated on preventive measures and appropriate emergency interventions.

SN instructed patient/caregiver that if blood glucose is below 70 mg/dL and the patient is conscious and able to swallow safely, treat promptly with approximately 15 grams of fast-acting carbohydrate, such as glucose tablets/gel or another appropriate fast-acting glucose source.

SN instructed patient/caregiver to recheck blood glucose approximately 15 minutes after treatment. If blood glucose remains below 70 mg/dL, repeat treatment according to the prescribed hypoglycemia protocol.

SN instructed patient/caregiver not to use chocolate, high-fat foods, or protein-rich foods as the initial treatment for hypoglycemia because they may delay glucose absorption.

SN instructed patient/caregiver that severe hypoglycemia associated with unconsciousness, seizure, inability to swallow safely, or severe altered mental status requires emergency treatment. Do not give food or liquids by mouth. Administer glucagon if prescribed and available, according to instructions, and activate EMS/911 as indicated.

SN instructed patient/caregiver regarding the location and proper use of prescribed glucagon and encouraged family members/caregivers to become familiar with its administration.

7. RECOGNITION OF HYPERGLYCEMIA

How to recognize and manage hyperglycemia

SN instructed patient/caregiver on how to recognize and manage hyperglycemia, explaining that high blood glucose levels may cause increased thirst, frequent urination, dry mouth, fatigue, blurred vision, headache, and weakness. Educated on the importance of checking blood glucose regularly and whenever symptoms occur, maintaining adequate hydration with water or sugar-free fluids if not medically restricted, following a consistent carbohydrate-controlled diet, and taking prescribed diabetic medications or insulin exactly as ordered. Instructed to avoid sugary beverages and excessive carbohydrate intake, monitor and record blood glucose readings, and never administer additional insulin or adjust medication doses without physician orders or an established sliding-scale/correction protocol. Advised to notify the physician if blood glucose remains above the individualized target range or exceeds prescribed notification parameters, particularly if readings persist above 250–300 mg/dL. Instructed to check ketones when indicated by the diabetes management plan, especially during illness or persistent significant hyperglycemia. Educated on warning signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), including nausea, vomiting, abdominal pain, fruity-smelling breath, rapid or deep breathing, severe dehydration, increasing confusion, or altered level of consciousness. Advised to call 911 immediately for severe confusion, unconsciousness, difficulty breathing, or other signs of a diabetic emergency. Reinforced the importance of medication adherence, regular blood glucose monitoring, proper nutrition, hydration, and timely medical follow-up to prevent complications.

SN instructed patient/caregiver on signs and symptoms of hyperglycemia, which may include increased thirst, frequent urination, increased hunger, fatigue, blurred vision, dry mouth, dehydration, and unexplained weight loss.

SN instructed patient/caregiver to report persistent blood glucose readings above physician-established parameters and follow the prescribed diabetes management plan.

SN instructed patient/caregiver to seek prompt medical attention for severe hyperglycemia accompanied by vomiting, abdominal pain, difficulty breathing, confusion, severe weakness, dehydration, or other signs of acute illness.

8. INSULIN SAFETY

SN instructed patient/caregiver to verify the correct insulin name/type, prescribed dose, route, and administration time before each injection.

SN instructed patient/caregiver that different insulin preparations have different onset, peak, and duration of action and should be administered according to the physician’s order.

SN instructed patient/caregiver never to share insulin pens, needles, or syringes with another person.

SN instructed patient/caregiver to use a new needle for each injection and to dispose of used needles/syringes immediately in an appropriate FDA-cleared or approved sharps container or other container permitted by local regulations.

9. INSULIN INJECTION TECHNIQUE

SN instructed patient/caregiver that insulin should be administered into subcutaneous tissue as ordered and not intentionally injected into muscle.

SN instructed patient/caregiver on appropriate subcutaneous injection areas including the abdomen, outer thigh, upper arm, and buttock/hip area as appropriate.

SN instructed patient/caregiver to inspect the selected injection site before administration and avoid areas that are bruised, scarred, inflamed, infected, hardened, swollen, or otherwise abnormal.

SN instructed patient/caregiver to follow the insulin device manufacturer’s instructions regarding preparation, priming, dose selection, injection technique, and needle removal.

10. INJECTION-SITE ROTATION AND LIPOHYPERTROPHY

SN instructed patient/caregiver on the importance of systematically rotating insulin injection sites to prevent lipohypertrophy and other local tissue complications.

SN instructed patient/caregiver to avoid repeatedly injecting insulin into the same exact location and to rotate injections within the selected anatomical area according to the prescribed technique.

SN instructed patient/caregiver to inspect and palpate injection areas regularly for lumps, thickening, firmness, swelling, or other tissue changes and to avoid injecting insulin into areas of lipohypertrophy.

SN instructed patient/caregiver that injecting into abnormal or lipohypertrophic tissue may cause unpredictable insulin absorption and contribute to unexplained blood glucose fluctuations.

11. INSULIN AND MEALS

SN instructed patient/caregiver to understand the relationship between insulin administration, meals, carbohydrate intake, and physical activity.

SN instructed patient/caregiver that mealtime insulin should be administered according to the prescribed timing for the specific insulin product and meal plan.

SN instructed patient/caregiver not to skip or significantly delay a planned meal after taking mealtime insulin unless directed by the prescribed diabetes management plan.

SN instructed patient/caregiver to notify the physician when poor appetite, vomiting, diarrhea, difficulty swallowing, or other conditions interfere with usual food intake and could increase the risk of hypoglycemia.

12. INSULIN STORAGE

SN instructed patient/caregiver to store unopened insulin according to the manufacturer’s instructions, generally under refrigeration, and to avoid freezing insulin.

SN instructed patient/caregiver to follow product-specific recommendations regarding how long an opened insulin vial or pen may remain in use and whether it may be kept at room temperature.

SN instructed patient/caregiver to protect insulin from excessive heat, direct sunlight, and freezing temperatures and to check expiration dates before use.

SN instructed patient/caregiver not to use insulin that appears abnormal for the specific product, has been improperly stored, has expired, or has exceeded its recommended in-use period.

13. PHYSICAL ACTIVITY AND INSULIN

SN instructed patient/caregiver that physical activity may lower blood glucose during and after exercise and may increase the risk of hypoglycemia in patients receiving insulin.

SN instructed patient/caregiver to monitor blood glucose as recommended before, during, and/or after physical activity and to follow the individualized plan regarding carbohydrate intake and insulin adjustment.

SN instructed patient/caregiver not to independently adjust insulin doses for exercise unless instructed by the physician or diabetes care provider.

14. SICK-DAY MANAGEMENT

SN instructed patient/caregiver that illness, infection, fever, dehydration, changes in appetite, vomiting, and diarrhea may significantly affect blood glucose levels.

SN instructed patient/caregiver to monitor blood glucose more frequently during illness according to the prescribed sick-day plan and maintain adequate hydration when not contraindicated.

SN instructed patient/caregiver not to discontinue insulin without instructions from the physician/diabetes care provider, particularly basal insulin in patients with type 1 diabetes.

SN instructed patient/caregiver to contact the physician for persistent hyperglycemia, recurrent hypoglycemia, inability to maintain adequate food/fluid intake, persistent vomiting/diarrhea, or other symptoms specified in the patient’s individualized sick-day plan.

15. DIABETIC SKIN AND FOOT CARE

SN instructed patient/caregiver to inspect the skin and feet daily for cuts, blisters, redness, swelling, cracks, drainage, discoloration, or other abnormalities.

SN instructed patient/caregiver to keep skin clean and appropriately moisturized while avoiding excessive moisture between the toes.

SN instructed patient/caregiver to avoid walking barefoot and to wear properly fitting footwear.

SN instructed patient/caregiver to report wounds, signs of infection, persistent redness, drainage, swelling, or other changes in skin integrity promptly to the physician/SN.

16. PATIENT/CAREGIVER SELF-MANAGEMENT

SN instructed patient/caregiver on essential diabetes self-management skills including:

A. Knowing when and what to eat according to the prescribed meal plan.
B. Knowing how and when to monitor and record blood glucose.
C. Recognizing and appropriately treating hypoglycemia.
D. Recognizing and reporting persistent or severe hyperglycemia.
E. Knowing the correct insulin/medication name, dose, route, and administration schedule.
F. Demonstrating proper insulin preparation and injection technique.
G. Demonstrating proper injection-site rotation.
H. Understanding the relationship between insulin, meals, physical activity, and blood glucose.
I. Knowing when to contact the physician/SN and when emergency medical assistance is required.
J. Demonstrating appropriate storage and disposal of insulin supplies and sharps.

Patient/caregiver verbalized understanding of teaching provided. Reinforcement and reassessment of diabetes self-management knowledge and insulin administration technique will be continued as indicated.