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Jun.25.2020

Blood Glucose Monitoring (Pediatric) - CE

ALERT

Do not scrape blood onto the reagent strip or apply blood outside the intended specimen area because doing so may cause inaccurate results.

Hypoglycemia may result in diaphoresis, tremors, shakiness, paresthesia, pallor, dizziness, headache, and other neurologic signs.undefined#ref2">2 Hyperglycemia may result in polyuria, polydipsia, polyphagia, and lethargy.

OVERVIEW

Point-of-care (POC) blood glucose monitoring can be performed at any time on a portable machine, using a reagent (test) strip. POC measurement of blood glucose requires obtaining a drop of capillary blood by skin puncture using a single-use, auto-disabling lancet and applying a drop of blood to a specially prepared chemical reagent strip. After the drop of blood is applied to the reagent strip, a reflectance meter provides a measurement of the blood glucose level. Clinical laboratories measure glucose in serum; POC devices measure glucose in whole blood and convert the results so they are comparable with serum glucose test results.5

The quality of POC glucose meters continues to improve, although results may still be higher or lower than the true glucose level. Care must be taken to calibrate the device properly, use it per the manufacturer’s recommendations, minimize common and avoidable errors, and correlate the blood glucose results with a clinical assessment of the patient.

Blood glucose testing may be indicated for many conditions, including altered mental status, seizures, type 1 diabetes, type 2 diabetes, suspected hypoglycemia or hyperglycemia, and maintenance of tight glycemic control.1 Compared with an adult, a pediatric patient may have increased insulin sensitivity (related to physical growth and sexual maturity), more reliance on others to provide care (e.g., caregiver, teacher, daycare staff), and a limited ability to recognize and respond to hypoglycemic symptoms.1

The American Diabetes Association recommends individualized blood sugar level targets and a stepwise approach to lowering blood sugar to prevent hypoglycemia.1 Blood glucose targets for pediatric patients with type 1 diabetes are 90 to 130 mg/dl before meals and 90 to 150 mg/dl at bedtime.1 Pediatric patients with type 2 diabetes have individualized glycemic targets with recommendations for A1C levels every 3 months.1

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain blood glucose monitoring, including the reason for it and the steps involved.
  • Use developmentally appropriate strategies to prepare the patient and family.
    • For a toddler, incorporate the use of play to demonstrate what occurs during the test.
    • For a preschooler, consider acting out the procedure with a doll to help identify and address the patient’s concerns.
    • For a school-age patient, explain or demonstrate the procedure to reduce anxiety. Let the patient participate in selecting the finger to use, opening the alcohol wipes package, reading the device, and placing the adhesive bandage.
    • For an adolescent, explain or demonstrate the procedure to determine whether he or she wants a family member present during the procedure. Respect the adolescent’s privacy. Use target-age behaviors (e.g., phone or internet-based applications, face-to-face or peer-enhanced activities) to help engage the adolescent in lifestyle changes and adherence to the medication regimen.3
  • Explain that the patient may feel a small prick and may cry.
  • Explain how the patient can assist with the procedure by holding still.
  • Explain that a local infection may develop at the puncture site and instruct the patient and family to notify the health care team of signs or symptoms of a local infection.
  • Explain that a small amount of bleeding may occur after the procedure.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient and family.
  3. Verify the correct patient using two identifiers.
  4. Obtain the patient’s history of hypoglycemia or hyperglycemia and the related symptoms.
  5. Assess the patient’s developmental level and ability to interact.
  6. Assess the patient’s level of consciousness and cognitive ability.
  7. Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
  8. Assess skin integrity at the selected puncture site.

Preparation

  1. Consider the use of the treatment room if appropriate and available.
  2. Ensure that the device works properly and that the test strips are not outdated.
    Rationale: Delays may increase the patient’s anxiety level. Expired test strips may cause inaccurate results; therefore, the date a strip should be opened, and the strip’s expiration date should be documented. Strips must be stored in the original packaging and tightly sealed.
  3. Calibrate the blood glucose monitoring device per the manufacturer’s instructions. Most devices need quality control at least daily. Document or verify the opening and expiration dates for the quality-control solutions.
    Ensure that the device is not soiled. Soiling may affect the results.
  4. Enter the patient’s identifying information into the device per the manufacturer’s instructions and the organization’s practice. Some devices and organizations also require the operator to input his or her identifying information.
    Rationale: Data from a POC device may be downloaded to the laboratory for tracking and reporting purposes and entered in the electronic health record. Specimens are tracked with the patient’s unique identifier. Operator-identifying information may be used to reflect quality-control training or as a signature in the electronic health record.

PROCEDURE

  1. Perform hand hygiene and don gloves.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and family and ensure that the patient agrees to treatment.
  4. Instruct the patient to perform hand hygiene with soap and warm water.
    Rationale: Hand hygiene promotes vasodilation at the testing site and helps prevent an inaccurate blood glucose reading resulting from a contaminated puncture site.
  5. Turn the device on. Some devices turn on automatically when a reagent strip is inserted. Refer to the manufacturer’s instructions.
  6. Place the patient in a comfortable position.
  7. Select the puncture site. The preferred site is the side of the fingertip because the central tip of the finger has a denser nerve supply and may cause more discomfort.
    Rotate sites to minimize discomfort and ensure that there is adequate subcutaneous tissue at the selected site (the little finger may not have enough subcutaneous tissue). Do not use the heel of an infant who can walk.
  8. Hold the finger in a dependent position to enhance perfusion.
    Rationale: Poor perfusion increases the likelihood of an inaccurate glucose test result. If needed, consider warming the site.
  9. Cleanse the finger with an alcohol swab and allow it to air-dry.
    Rationale: Failure to cleanse the finger and allow it to dry can lead to errors in POC glucose measurements.
  10. Obtain a blood sample.
    1. Remove the cover or safety device of the lancet device. If using a single-use auto-disabling lancet, hold it perpendicular to the puncture site and actuate the lancet by pressing the button. The blade automatically pierces the skin and retracts.
      Rationale: Use of a single-use auto-disabling lancet reduces the possibility of accidental needlesticks and prevents exposure to blood-borne pathogens.
    2. Allow a small drop of blood to form by gently applying intermittent pressure above the puncture site.
      Rationale: Gently squeezing the finger pools blood to the fingertip and promotes blood flow.
      Avoid squeezing the finger excessively, which can force plasma from the tissue into the drop of blood and cause an inaccurate result.
    3. Wipe away the first droplet of blood with a cotton ball or gauze.
      Rationale: The alcohol used earlier to disinfect the skin may have contaminated the first droplet of blood, diluting its glucose level, so using the first droplet for testing may provide a less accurate result than using the second droplet. 4 Newer meters do not require the first drop to be wiped away. However, in an emergency, this difference may not be clinically relevant. 4
      Always follow the manufacturer’s instructions because all meters are slightly different.
    4. Apply the blood sample to the reagent strip according to the manufacturer’s directions. Some devices require the blood sample to be applied to the reagent strip before the strip is inserted into the device; others require the reagent strip to be inserted into the device before the blood sample is applied.
      Ensure that a sufficient sample is on the test strip to obtain accurate results. The sample must be tested immediately to avoid clotting or glycolysis, which affects the accuracy of the results.
  11. Obtain the test results per the manufacturer’s recommendations.
  12. Place an adhesive bandage on the patient’s finger if needed to control the bleeding.
    Do not use an adhesive bandage if the patient is likely to put his or her fingers in his or her mouth because of the risk of ingestion or choking. Apply firm pressure until the bleeding stops.
  13. Clean and prepare the device for the next use and store it as indicated.
  14. Contact the practitioner if the results are outside the expected range.
    Consider drawing blood for glucose to be analyzed by the laboratory if the results are abnormal.
  15. Discard supplies, remove gloves, and perform hand hygiene.
    At the completion of the procedure, ensure that all choking hazards (e.g., alcohol wipe, lancet cap) are removed from the patient’s linens and placed in the appropriate receptacle.
  16. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Monitor the patient’s tolerance of the procedure. Assess the patient for agitation and increased anxiety related to repeated fingersticks.
    Rationale: Changes in the patient’s condition may indicate complications from the procedure.
    Reportable conditions: Agitation resulting in an inability to obtain blood, signs of hypoglycemia or hyperglycemia, ongoing bleeding from site
  2. Monitor the puncture site for signs and symptoms of infection or bleeding.
    Reportable conditions: Signs and symptoms of local infection at the puncture site (e.g., redness, swelling, drainage)
  3. Monitor trends in the POC testing results.
    Rationale: A significant change in results without a correlating change in the patient’s condition may indicate that the device is not functioning correctly.
    Reportable condition: Abnormal results that do not correlate with the patient’s clinical condition
  4. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Blood glucose level is determined.
  • Patient cooperates with procedure.
  • Skin at puncture site is free from infection and excessive bleeding.

UNEXPECTED OUTCOMES

  • Inability to obtain blood sample volume adequate for test
  • Inability to determine blood glucose level
  • Difficulty obtaining sample or inability to obtain sample because patient was uncooperative
  • Infection at puncture site
  • Excessive bleeding from puncture site

DOCUMENTATION

  • Blood glucose level and time obtained
  • Procedure for obtaining blood sample (e.g., fingerstick)
  • Practitioner notification of abnormal results and treatment prescribed
  • Patient’s response to procedure
  • Unexpected outcomes and related interventions
  • Education

REFERENCES

  1. American Diabetes Association. (2019). Professional Practice Committee: Standards of medical care in diabetes—2019. Diabetes Care, 42(Suppl. 1), S3. doi:10.2337/dc19-SppC01 (Level D)
  2. Barry, A., Connelly, E. (2017). Chapter 28: The child with endocrine dysfunction. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s essentials of pediatric nursing (10th ed., pp. 911-942). St. Louis: Elsevier.
  3. Franklin, Q. (2020). Chapter 4: Through the years. In Emergency nursing pediatric course: Provider manual (5th ed., pp. 25-37). Burlington, MA: Jones and Bartlett Learning.
  4. Palese, A. and others. (2016). First or second drop of blood in capillary glucose monitoring: Findings from a quantitative study. Journal of Emergency Nursing, 42(5), 420-426. doi:10.1016/j.jen.2016.03.027 (Level C)
  5. Pereira, A.J. and others. (2015). Inaccuracy of venous point-of-care glucose measurements in critically ill patients: A cross-sectional study. PLoS ONE, 10(6), e0129568. doi:10.1371/journal.pone.0129568 (Level B)

AACN Levels of Evidence

  • Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
  • Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
  • Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
  • Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
  • Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
  • Level M - Manufacturer's recommendations only