Blood Glucose Monitoring (Pediatric) - CE/NCPD

ALERT

Hypoglycemia may result in diaphoresis, tremors, shakiness, paresthesia, pallor, dizziness, headache, and other neurologic signs.^{undefined#ref1">1} 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 or venous 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.

Care must be taken to calibrate the device properly. Use it per the manufacturer’s recommendations to 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 type 1 diabetes, type 2 diabetes, altered mental status, seizures, suspected hypoglycemia or hyperglycemia, and maintenance of tight glycemic control.² Compared with an adult, a pediatric patient may have increased insulin sensitivity (related to physical growth and sexual maturity), may rely more on others to provide care (e.g., caregiver, teacher, daycare staff), and may have a limited ability to recognize and respond to hypoglycemic symptoms.²

The American Diabetes Association recommends individualized blood sugar level targets and a stepwise approach to lowering blood sugar to prevent hypoglycemia.² Blood glucose targets for pediatric patients with type 1 diabetes before exercise are 126 to 180 mg/dl.² Pediatric patients with diabetes have individualized glycemic targets with recommendations for A1C levels every 3 months with a goal of less than 7%, with less stringent goals for children who are unable to report symptoms of hypoglycemia or who have hypoglycemia unawareness and more stringent criteria during the honeymoon phase or if the targets can be achieved without significant hypoglycemia.²

SUPPLIES

See Supplies tab at the top of the page.

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.
• Review appropriate glucose values for the patient.
• 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 preschool-age patient, consider acting out the procedure with a doll to help identify and address the patient’s concerns. Explain the procedure using simple terms or a matter-of-fact approach.
  • 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 patient, explain or demonstrate the procedure to determine whether the patient wants a family member present during the procedure. Respect the adolescent patient’s privacy. Use target-age behaviors (e.g., phone or internet-based applications, face-to-face or peer-enhanced activities) to help engage the patient 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.
• For medications to be administered in the home, a return demonstration by the parent or patient (if age appropriate for the route) should be performed to allow for demonstration of an understanding of the procedure.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
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 operators to input their 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. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree 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 if the patient is unable to wash hand.

   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 if alcohol is used to wipe the finger.

       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.⁵ All blood drops have been found to be suitable for POC blood glucose analysis.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 after it is inserted into the device and others require the reagent strip be applied before the strip is inserted into the device.

       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 insert fingers into the 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 PPE, and perform hand hygiene.

    At the end of the procedure, ensure that all choking hazards are removed from the patient’s linens.

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

• Unable to obtain an adequate blood sample volume for test.
• Unable to determine blood glucose level.
• Infection at puncture site occurs.
• Excessive bleeding from puncture site occurs.

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. Barry, A., Connelly, E. (2022). Chapter 28: The child with endocrine dysfunction. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 935-968). St. Louis: Elsevier.
2. ElSayed, N.A. and others. (2023). Chapter 14: Children and adolescents: Standards of Care in Diabetes—2023. Diabetes Care, 46(Suppl. 1), S230-S253. doi:10.2337/dc23-S014 (Level VII)
3. Franklin, Q. (2020). Chapter 4: Through the years. In Emergency Nurses Association (ENA), ENPC: Emergency nursing pediatric course: Provider manual (5th ed., pp. 25-37). Burlington, MA: Jones & Bartlett Learning. (Level VII)
4. Johannis, W. and others. (2023). Measuring capillary blood glucose concentration: Is the first blood drop really the right blood drop? Primary Care Diabetes. doi.org/10.1016/j.pcd.2023.08.005. (Level III) Epub ahead of print.
5. 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 III)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Sarah A. Martin, DNP, MS, RN, CPNP-AC/PC, CCRN

Published: January 2024