Think

SAFE

Four crucial elements for diabetes education

By Lucille Hughes, MSN/ED, RN, CDE

WHEN PATIENTS ARE discharged,

its often difficult to find the time to
provide proper education before they
leave your facility. Patients who are
newly diagnosed with diabetes need to
learn many new skills, including how
to monitor their blood glucose levels
and give themselves insulin injections
if needed. Yet theyre discharged in
less time than ever, and patients often
dont feel up to learning when theyre
feeling stressed, anxious, and wanting
to go home. So how can you make
sure your patients get proper diabetes
education before discharge?
Focusing on four crucial elements
of diabetes education will help you
give patients the information they
need to manage their diabetes when
theyre at home. This article describes
how to use the SAFE acronym to
improve your patients learning
experience.
The SAFE way
Using the acronym SAFE is an easy
way to remember the four crucial elements of diabetes education patients
need before discharge from an acute
care facility. (See Play it SAFE.)
Before you begin your patient
teaching, perform a learning needs
assessment and an assessment of the
patients readiness to learn. Results of
58 l Nursing2012 l January

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the learning needs assessment will tell

you two things: what your patient
already knows and what he or she
needs to know. Assessing the patients
readiness to learn helps you gauge
your patients ability and desire to
learn at this moment.1 Lets take a
look at each one.
Learning needs assessment: Assess
what your patient already knows.
Even newly diagnosed patients may
have some knowledge about their
disease. Make sure this knowledge is
current and applicable to their type of
diabetes. Ask open-ended questions
to assess your patients learning needs,
such as How does having diabetes
affect your life? or Tell me what
medications are you taking for
your diabetes, and how they work.
Observation is another important
assessment tool.1 If a patient requires
insulin but hasnt self-administered an
insulin injection or performed fingerstick blood glucose (FSBG) monitoring,
youve just identified two important
learning needs for your patient that
fall under the A and F of the
acronym SAFE.
Patients readiness to learn: At
times, you may be ready to teach
patients all the elements of SAFE
but theyre not ready to learn them.
In this situation, you may have to
prioritize which elements of the
SAFE acronym youll teach. For
example, you may only teach the
A and E. Ask questions to help
you assess your patients readiness
to learn, such as Would you like to

Play it SAFE
S Signs and symptoms of hypoglycemia and hyperglycemia as well as
management
A Administration of oral hypoglycemic
agents and/or insulin
F Finger-stick blood glucose monitoring
E Emergency numbers to call and
outpatient diabetes education

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Recognizing
hypoglycemia

Recognizing
hyperglycemia

Signs and symptoms of hypoglycemia

include:
dizziness
fast heartbeat
confusion
shaking
sweating
weakness
headache
passing out
getting very sleepy
seizures.4

Signs and symptoms of hyperglycemia

include:
high blood glucose
high levels of sugar in the urine
frequent urination
increased thirst.
Signs and symptoms of ketoacidosis
(very high blood glucose level thats
life threatening and requires immediate treatment) include:
shortness of breath
breath that smells fruity
nausea and vomiting
very dry mouth.2

learn some facts about your diabetes

self-management that can keep you
safe at home? or Are you interested in learning about the diabetes
medicine youll be taking at home?1
If your patient truly isnt ready to
learn, include additional diabetes
education material in the discharge
papers to be read at home.
Providing patients with a brightly
colored folder just for their diabetes
education material can be helpful. A
colorful folder will make it easy for
your patients to identify the diabetes
information from the sea of papers
they get at discharge. It may be quite
some time before your patient is
ready to read them, so make them
stand out from the rest.
Another helpful hint for situations when patients just arent ready
to learn would be to teach a family
member, spouse, child, parent, partner, or other caregiver. Ask patients if
theyre willing to give you permission
to teach someone close to them about
their diabetes treatment and ask the
patient who they would like that person to be. Be mindful of confidentiality issues and make sure patients give
you permission to discuss their care
with someone other than themselves.
S: Signs and symptoms
S stands for the signs and symptoms of
hypoglycemia and hyperglycemia as well

as their proper management. If your

patient is taking a sulfonylurea (such
as glipizide), a meglitinide (such as
repaglinide), or any kind of insulin,
provide education about the signs
and symptoms of hypoglycemia along
with the recommended treatment
options for a hypoglycemic episode
(see Recognizing hypoglycemia).2
Encourage patients to carry both a
blood glucose meter and appropriate
treatment options at all times. Let
them know about options that are
safe and reliable (see Oral treatment
options for hypoglycemia). Make sure
they understand that during a hypoglycemic episode, treatment must be
fast and appropriate.2-5
Teach patients that if they experience the signs and symptoms of
hypoglycemia, they need to check
their blood glucose levels to confirm.
(Youll show them how to use a
blood glucose monitor under F).
If the blood glucose level is less than
70 mg/dL, advise them to follow the
American Diabetes Associations
Rule of 15 (see Follow the rules).3,4
Tell patients that if they find themselves without a blood glucose
meter but are experiencing the signs
and symptoms of hypoglycemia, they
should follow the Rule of 15 just to
be safe.
January l Nursing2012 l 59

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Reinforce the importance of carrying a blood glucose monitor and

treatment options at all times. Remind
patients to stick to the guidelines
and eat 15 or 30 g of carbohydrate
depending on the blood glucose
reading.
Hyperglycemia, although not
considered an acute complication,
is a major cause of complications
associated with diabetes. Signs and
symptoms include a high blood glucose level, frequent urination, and
increased thirst (see Recognizing
hyperglycemia). Remind patients to
report these signs and symptoms to
their healthcare provider.6
Exercise is often used to lower
blood glucose levels. Advise patients
to check their urine for ketones if the
blood glucose level is above 240 mg/
dL. If ketones are present, exercise
should be avoided because ketones
may make blood glucose levels go
even higher. Advise patients to work
with their healthcare providers to find
the safest ways to lower blood glucose
levels.6
A: Administration
A stands for administration of oral
medications and/or insulin. Review
your patients prescribed medications.

Oral treatment options

for hypoglycemia
The following options contain 15 g of
carbohydrates:
4 oz (1/2 cup) of fruit juice
4 oz (1/2 cup) of regular (not diet)
soda
8 oz (1 cup) of milk
5 or 6 pieces of hard candy
2 tablespoons of raisins
4 teaspoons of sugar
1 tablespoon of honey or corn syrup
3 or 4 glucose tablets
1 serving of glucose gel.4,7

Provide printed materials to enhance

the learning process and provide
a reference when theyre at home.
Teach them the indication and
action of each medication. Let your
patients know which are best taken
with meals and review possible
adverse reactions, especially those
that have the potential to cause
hypoglycemia. Warn them not to
stop taking them on their own if
they experience adverse reactions. If
adverse reactions are troublesome,
they should contact their healthcare
provider for instructions.
Insulin analogues can cause hypoglycemia if not taken with enough
carbohydrate or if the patient skips a

Follow the rules

Teach your patients to follow the American Diabetes Associations Rule of 15
when their blood glucose level is low:
Eat or drink something with 15 g of carbohydrates.
Wait 15 minutes and recheck your blood glucose level.
If its still too low, eat another 15 g of carbohydrates and recheck your blood
glucose level after 15 minutes. Once your blood glucose level begins to move
into your target range, you should start to feel better.
Some patients overtreat themselves when their blood glucose level is low because
they treat the symptoms, not the blood glucose level. Even if you dont feel better
instantly after eating 15 g of carbohydrates, stick with the Rule of 15. If you keep
eating until you feel better, your blood glucose level may get too high too fast. Be
patient and wait the full 15 minutes.3
Let patients taking acarbose or miglitol know that only pure glucose (dextrose),
which is available in tablet or gel form, will raise their blood glucose level during a
low blood glucose episode. Food and drinks wont raise the blood glucose level fast
enough because these drugs slow the digestion of other carbohydrates.4

60 l Nursing2012 l January

meal. Let patients know this before

heading home and returning to their
usual meal plan and lifestyle.2
Before instructing patients about
insulin administration, ask the healthcare provider which delivery method
will be prescribed for use at home.
Have patients observe the insulin
administration process from start to
finish, following the specific manufacturers guidelines if an insulin pen is
prescribed.
After providing patients a few
opportunities to observe, have them
self-administer as you observe. This
same process holds true if theyre
going to use insulin vials and syringes
at home.
F: FSBG
F stands for FSBG monitoring. Performing an accurate finger-stick test
may be all you get to show your
patients before discharge. Learning
their personal target blood glucose
levels, when to check them, and
how to interpret the numbers can
be too much information for some
patients at discharge, but its important for them to know. Encourage
patients to learn at least the basics
of doing a finger stick and the general principles involved in using a
blood glucose monitor, especially
because the monitors they use at
home may not be the same ones
used in the hospital.
Before patients are discharged, let
them know what their target blood
glucose levels are and at what levels
they should call their healthcare provider.
E: Emergency numbers and
education
E stands for emergency numbers to
call and outpatient diabetes education.
Make sure your patients have the
phone number of their healthcare
provider in case blood glucose levels
get too high or too low. Encourage
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them to continue their education

about FSBG monitoring at a local
outpatient Diabetes Education Center. If youre not sure of one thats
close to where a patient lives, contact
the American Diabetes Association
(www.diabetes.org) or the American
Association of Diabetes Educators
(www.diabeteseducator.org). Instruct
them on when to call 911.
In the SAFE zone
Encouraging your patients to continue their diabetes education is a
lesson that will serve them long after
discharge. Even if you dont have the
time youd like to spend for proper

education, providing the crucial

elements of SAFE helps ensure that
your patients get the information
they need to manage their diabetes
at home.
REFERENCES
1. Moghissi ES, Korytkowski MT, DeNardo
M, et al. American Association of Clinical
Endocrinologists and American Diabetes
Association consensus statement on inpatient
glycemic control. Endocr Pract. 2009;15(4):
353-369.
2. Cryer PE. Hypoglycemia in Diabetes: Pathology,
Prevalence, and Prevention. Alexandria, VA:
American Diabetes Association; 2011.
3. American Diabetes Association. Hypoglycemia.
http://www.diabetes.org/living-with-diabetes/
parents-and-kids/planet-d/new-to-diabetes/
hypoglycemia.html.

4. American Diabetes Association. Living with

diabetes: hypoglycemia. http://www.diabetes.org/
living-with-diabetes/treatment-and-care/bloodglucose-control/hypoglycemia-low-blood.html.
5. National Diabetes Information Clearinghouse.
Hypoglycemia. http://diabetes.niddk.nih.gov/dm/
pubs/hypoglycemia/#treatment.
6. American Diabetes Association. Living with
diabetes: hyperglycemia. http://www.diabetes.org/
living-with-diabetes/treatment-and-care/bloodglucose-control/hyperglycemia.html.
7. Burkhart JA. Training nurses to be teachers. J
Contin Educ Nurs. 2008;39(11), 503-510.

Lucille Hughes is director of diabetes services at St.

Joseph Hospital in Bethpage, N.Y.
The author has disclosed that she has no financial
relationships related to this article.

DOI-10.1097/01.NURSE.0000406197.96182.bf

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