What are the best new nursing practices for a general patient population, including adults and geriatric individuals with various medical conditions, such as diabetes, heart failure, and impaired renal function?

Best New Nursing Practices for General Patient Populations

Implement multidisciplinary team-based care models with clearly defined nursing roles in chronic disease management, emphasizing patient education, medication reconciliation, and care coordination across settings to reduce morbidity and mortality. 1

Multidisciplinary Team Integration

The most impactful nursing practice advancement involves structured participation in multidisciplinary teams, which demonstrably reduces kidney function loss, emergent dialysis initiation, and potentially mortality in chronic disease populations. 1 This model requires:

• Nurse-led or nurse-integrated care teams depending on local context and available resources, with nurses serving as care coordinators for patients with diabetes, heart failure, and CKD 1
• Clear role delineation where nurses manage medication reconciliation, patient education, and serve as patient navigators for those with social challenges or low health literacy 1
• Electronic infrastructure support including clinical decision support systems and telehealth applications to enhance team effectiveness 1

Patient Education as Core Nursing Function

Provide diabetes and chronic disease education at every clinical encounter, focusing on incremental knowledge building rather than comprehensive single-session teaching. 1

Essential education components include:

• "Know Your Numbers" approach: Teach patients to understand BMI, A1C, blood pressure, LDL-C, eGFR, and UACR using plain-language explanations 1
• Shared decision-making techniques: Elicit patient priorities, ask open-ended questions, and reinforce belief in patient's ability to control health outcomes 1
• Avoid information overload: Repeat and reinforce key concepts across multiple visits rather than attempting comprehensive education in one session 1
• Tailor to health literacy level and account for socioeconomic factors and social determinants of health 1

Medication Management and Safety

Insulin Administration Protocols

Implement scheduled subcutaneous basal-bolus insulin regimens rather than sliding-scale-only approaches for hospitalized patients with adequate oral intake. 1

• For patients with poor oral intake or NPO status, use basal plus correction insulin regimen 1
• Completely discontinue sliding-scale insulin as sole therapy in hospitalized patients due to inferior outcomes 1
• For long-term care residents with unpredictable meal consumption, administer insulin after meals to match dose to actual carbohydrate intake 1

Hypoglycemia Prevention Protocols

Establish standardized alert systems for long-term care and hospital settings: 1

• Call provider immediately for blood glucose <70 mg/dL (though treatment should not be delayed) 1
• Call as soon as possible for glucose 70-100 mg/dL (regimen adjustment needed), >250 mg/dL within 24 hours, or >300 mg/dL over 2 consecutive days 1
• Monitor high-risk populations intensively: older adults with cognitive impairment, renal dysfunction, variable appetite, and polypharmacy 1

Medication Reconciliation for Older Adults

Actively pursue treatment regimen simplification and deprescribing in older adults with complex health status. 1

Specific actions include:

• Reduce injection frequency and fingerstick monitoring when patients have moderate-to-severe cognitive impairment or ADL dependencies 1
• Discontinue medications without clear benefits in patients at end of life or with very complex/poor health 1
• Avoid glyburide in older adults; prefer shorter-acting sulfonylureas like glipizide or glimepiride if insulin secretagogues are necessary 1
• Use once-daily basal insulin as preferred regimen for older adults rather than complex multiple daily injection protocols 1

Care Coordination Across Settings

Establish protocols to prevent care discontinuity during transitions between acute care, long-term care, and home settings. 1

Critical nursing interventions include:

• Document basal rates and bolus doses daily for patients using insulin pump therapy who continue self-management in hospital 1
• Verify patient self-management capability before allowing hospital-based diabetes self-management: assess consciousness level, physical skills for insulin administration, carbohydrate counting proficiency, and sick-day management knowledge 1
• Implement patient navigator roles for socially challenged patients to assist with appointments, language translation, and care coordination 1

Nutritional Management

Eliminate use of "ADA diet" terminology and implement individualized consistent carbohydrate meal plans that facilitate matching prandial insulin to carbohydrate intake. 1

For long-term care residents:

• Prioritize meals tailored to culture, preferences, and personal goals over restrictive therapeutic diets that contribute to unintentional weight loss 1
• Involve registered dietitians as integral team members for complex nutrition issues 1

Technology Integration

Leverage continuous glucose monitoring (CGM) and electronic medical records to improve outcomes and reduce hypoglycemia risk. 1

• CGM is Medicare-approved and reduces A1C, glycemic variability, and hypoglycemia risk in insulin-treated patients 1
• Use electronic medical records for plain-language patient information access and clinical decision support 1
• Encourage apps and wearable devices for activity monitoring and patient engagement 1

Long-Term Care Facility Requirements

Mandate diabetes-specific education for all long-term care facility staff to improve management of residents with diabetes. 1

Essential components:

• Training in hypoglycemia prevention and management protocols 1
• Understanding of individualized glycemic targets based on functional and cognitive status 1
• Competency in CGM devices, insulin pumps, and advanced insulin delivery systems 1

Common Pitfalls to Avoid

• Never rely solely on sliding-scale insulin in any setting—this practice is strongly discouraged and associated with worse outcomes 1
• Do not pursue tight glycemic control (A1C <7%) in older adults with limited life expectancy, moderate-to-severe cognitive impairment, or multiple ADL dependencies; target A1C <8.5% instead 1
• Avoid restrictive therapeutic diets in long-term care that decrease food intake and worsen nutritional status 1
• Do not assume all patients can self-manage in hospital—verify specific competencies before allowing self-administration 1