Hello,

I am getting involved with diabetes management at my hospital and one of the recommendations has been to start having RNs document carbohydrate intake for patients on insulin. Dietary sends up cards with each meal that shows the CCHO count for each item, but documenting what is eaten would be an extra task for RNs.

Does anyone out there work at a facility that has RNs count carbs? How does it work? Do physicians use that information to guide treatment?

Thanks for any input!

From my experience, it is usually the patient themselves who do the carb counting, not the nurse. We occasionally have a patient who is used to doing this at home, and they continue with their same system while at the hospital, if they can, of course. I can see teaching patients how to do this, if it is someone who can actually learn to control their diabetes this way, but I cannot see why the nurse would be responsible for doing this. How long are your patients in the hospital? Who decides what regimen they will be on once they are back at home? Won't this interfere with the patients who already have control of their diabetes and do not count carbs?

applewhitern. Thanks for taking the time to respond. We also are not in the practice of counting carbs, but occasionally have a diabetic on a pump who records this information themselves.

The reason we change the system to have the RN count carbs and document that count is so that the provider would have more information to guide them when making decisions about insulin prescribing. We also have some providers order prandial insulin and RNs are dosing based on %meal eaten rather than %carbs.

Most of our patients do not stay in the hospital very long, but while they are inpatient most are managed with insulin only. As for what happens when patients are discharged, that can be tricky, most of the time RNs and Diabetic educators do not know in advance what regimen patients will go home on - if they were well controlled they go back to what they were using prior to admission. From a teaching stand-point, it would be AMAZING if this were addressed prior to discharge.

Finally, I don't think having RNs count and document carb intake would interfere with patients who have control of their diabetes without carb counting at home since this would just be done as a measure to help control blood sugars while in-patient. But, it can also be a teaching point for patients that have high A1Cs and Type Is.

I read the title as 'Impatient Carb Counting' and wondered why they were in such a hurry.

To answer your question: At one hospital I worked at the pts ordered food from a menu by phone whenever they wanted (while the kitchen was open. ) The menu listed the carbs in parentheses next to each dish plus the person taking their call plugged the order into the computer in real time. The computer kept track of how many carbs they had left for the day and wouldn't let them order something if it would put them over (but they would often help them make better choices throughout the day so they could fit in that 1 dessert or whatever. )

Not sure how they do it at my current hospital.

either remove the card yourself or ask aide or patient to do so. Then all you need to know if how much they ate. Be very careful about education - the patient needs to be aware why this count is important and the implications it has towards their medication administration.

Our dietary lists the number of carbs on the paper with the meal, but we use it for sliding scales that take into account how many carbs (baseline plus meal coverage). In the ED (for hold patients) I've never seen the amounts eaten documented though.

I haven't done it this way myself. At my first floor job and at my old LTACH, sometimes we had pts whose insulin dosing was based on carbs eaten, but generally that was adults w/ CF (in the case of my first job...for some reason they went to the neuro floor vs. med-surg) who knew ABSOLUTELY EVERYTHING about their health and POC; or people with Type 1 since they were kids and needed extra tight control (in the case of the LTACH). Anyway, we asked them how many carbs and they told us; we never documented number of carbs, only units of their meal coverage insulin on the MAR.

Almost every diabetic patient I've ever known had insulin doses based on carbs to be consumed so, yes, we counted carbs for our diabetic patients when I worked in the hospital.

I work with diabetic children. We use an insulin to carb ratio for insulin plus sliding scale if needed for BS. Example: patient ate 50 carbs and orders are 1 unit per 10 chos. Of course that would be 5 units of insulin given. I love working with diabetics. :-)

Carb counting is certainly important, however, a lot of nurses will need to be educated on how to count carbs properly. My main question would be, why isn't the patient counting carbs? Diabetes is a long-term disease, it doesn't stop at discharge, if the patient is not able to count, they or their family need to be educated on how to count and practice some while in the hospital. If the patient is just not willing to count, they need to be educated on the importance of counting, if they still are not willing, they aren't going to do it at home, either.

I think it would be best to get a dietician involved, along with the nurses to educate the patient in helping them properly count/manage their carb. intake.

Carb counting is certainly important, however, a lot of nurses will need to be educated on how to count carbs properly. My main question would be, why isn't the patient counting carbs? Diabetes is a long-term disease, it doesn't stop at discharge, if the patient is not able to count, they or their family need to be educated on how to count and practice some while in the hospital. If the patient is just not willing to count, they need to be educated on the importance of counting, if they still are not willing, they aren't going to do it at home, either.

I think it would be best to get a dietician involved, along with the nurses to educate the patient in helping them properly count/manage their carb. intake.

Of course the patient has to count but since, on the inpatient side, it's the nurse's responsibility to calculate and administer insulin, he/she needs to double check the calculations.

Thanks to everyone for your responses. I like the idea of a system that documents carbs as the patient orders meals. Even if they don't eat everything, at least it provides some data.

It seems like a simple reminder to save the dietary sheets for the RN would be easy. Do you think it would be inappropriate to have the aides or the patients write how much of each carb item was consumed on the sheet? Or is that delegating assessment? I am anticipating a lot of RN unhappiness if we take something that is currently in the realm of aides - documenting meal % - and adding an RN task - documenting carb intake.

However, it is a little crazy that right now we are giving insulin without taking carbs consumed into account at all.