Assessing the diabetic patient involves determining the reason for the visit and allows the health care practitioner an opportunity to continue to educate the patient about his disease process and prevent complications. Diabetic research continues to find new ways to achieve control and improve patient outcomes.
The successful control of diabetes relies heavily upon the patient's support system and her ability to cope with a chronic illness. The goals of the diabetic assessment include assessing patient's overall physical, emotional and mental health status; determining the status of glycemic control; and assessing for any complications of diabetes and beginning treatment.
Instructions
Instructions
1. Obtain vital signs including the patient's height and weight. Review this data along with any recent blood work. If no recent HbA1c is available, obtain this result now or get a random blood glucose level from a finger stick. (The HbA1c, also known as an A1c, is a blood test to determine the average blood glucose level over the last three months. It is best done fasting, but can be obtained from a random finger stick.)
2. Inquire about any complaints, issues or symptoms and ask the patient about his reason for the visit. Discuss the his lifestyle habits such as diet, sleep, exercise and stress level. Ascertain whether he smokes or drinks alcohol. How often does he check his blood sugar and has he had any issues? Review his complete list of medications and ask about compliance.
3. Inquire about other age- or gender-appropriate health care screenings and results in the past 12 months such as a mammogram, pap smear, chest X-ray, colonoscopy, bone density, dental and eye exams. If the patient has co-morbid disease such as kidney or heart conditions, inquire as to the status of these and when this was last assessed.
4. Assess for common symptoms or complaints the patient may have forgotten to mention.
Does she have any vision problems or changes, headaches or dizziness, any bleeding gums, sore mouth or problems swallowing, ear pain or ringing in the ear, cough or throat pain, chest pain or shortness of breath, indigestion or changes in bowel habits, changes in appetite or eating habits, numbness, pain or tingling in the extremities, swelling in the extremities, burning, pain or difficulty urinating, rashes, sores, body odors or other skin problems, generalized pain or stiffness? Review any problems reported and assess for treatment or remedy.
5. Perform a head-to-toe assessment including visualization of the inner eye and ear, assess for any rashes or sores especially on the feet, any redness or swelling in lymph glands or extremities, range of motion in the neck and extremities. Check the patient's balance and gait and assess hearing, vision, reflexes and nerve sensation. Perform gender appropriate exams such as a breast exam and inquire as to self-exam habits. Examine the scrotum and check the prostate.
6. Assess for any knowledge deficits, make changes in treatment and educate the patient. Make referrals as needed for tests, exams, education and support. Order labs and instruct as to follow-up visits.
Tags: blood glucose, blood glucose level, educate patient, finger stick, glucose level, health care
