Wallymahmed M (2007) Capillary blood glucose monitoring. Nursing Standard. 21, 38, 35-38.

Date of acceptance: December 15 2006.

patients with type 1 and type 2 diabetes especially
during periods of instability, for example, illness or
frequent hypoglycaemia. Improving diabetic
control can significantly reduce the risk of
microvascular complications (kidney, nerve and
eye damage) in patients with type 1 and type 2
diabetes (Diabetes Control and Complications
Trial (DCCT) Research Group 1993, UK
Prospective Diabetes Study (UKPDS) Group
1998). In addition, good blood glucose control has
been shown to be associated with more favourable
clinical outcomes in patients who have acute
cardiovascular events such as myocardial
infarction and stroke (Malmberg et al 1995).
The procedure
Blood specimens are obtained using a finger
pricking device and results are analysed by a near
patient blood glucose meter. A variety of meters
are available and to ensure accuracy of results the
manufacturers advice must be followed carefully.
Serious errors, leading to inappropriate
management decisions, have been identified and
the Department of Health (DH) has issued hazard
warnings. These warnings highlight the need
for staff training and formal quality control
programmes (DH 1987, Medical Devices Agency
(MDA) 1996). The MDA (2002) has issued
recommendations for the training of staff using
point of care devices such as blood glucose
meters. These recommendations include
education and training in the following areas:
Knowledge of what results to expect in normal
and abnormal situations.
Correct use of equipment and knowledge of the
consequences of incorrect use.
Instruction in the collection of blood samples
including gaining consent and health and safety
issues.
The importance of documentation of results.
Capillary blood glucose monitoring
may 30 :: vol 21 no 38 :: 2007 35 NURSING STANDARD
BLOOD GLUCOSE levels are normally
maintained within relatively narrow limits at
about 5-7mmol/l (Williams and Pickup 2004).
Insulin and glucagon, produced by the pancreas,
are largely responsible for the regulation of blood
glucose. Insulin is synthesised in and secreted
from the beta cells within the islets of Langerhans.
Insulin levels are low during periods of fasting
with increased stimulated levels in response to
high blood glucose levels, for example, after
meals. Glucagon is secreted by the alpha cells in
response to low blood glucose levels and inhibited
by high blood glucose levels.
Rationale
Capillary blood glucose monitoring is a convenient
way of monitoring blood glucose patterns and can
be a useful aid in guiding treatment changes in
Summary
This article, the first in a series of articles relating to clinical skills
in nursing, outlines the procedure of capillary blood glucose
monitoring. This is a convenient way of monitoring blood glucose
patterns and can be a useful aid in guiding treatment changes in
patients with type 1 and type 2 diabetes, especially during periods
of illness or frequent hypoglycaemia.
Author
Maureen Wallymahmed is nurse consultant, Aintree Hospitals NHS
Trust, Diabetes Centre, Walton Hospital, Liverpool.
Email: maureen.wallymahmed@aintree.nhs.uk
Keywords
Blood glucose monitoring; Clinical procedures; Diabetes;
Hyperglycaemia; Hypoglycaemia
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard,
The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW. email: gwen.clarke@rcnpublishing.co.uk
p35-38w38 22/5/07 2:21 pm Page 35
A knowledge of the meters limitations and
when use is contraindicated.
An in-depth knowledge of the individual
meter, including error codes, calibration and
quality control techniques.
Staff performing blood glucose monitoring should
also be involved in a formal quality control
programme. This involves performing and
documenting quality control checks in the clinical
area using specific high and low quality control
solutions on a daily basis. This is known as
internal quality control. External quality control
programmes should also be in operation. These
involve solutions of an unknown glucose level
being sent from the laboratories to the clinical
areas on a regular basis. Each user should perform
a quality control test and return the result to the
laboratory. In this way inaccurate performance
can be identified and additional training arranged.
Each trust has a responsibility to develop and
implement a training and quality control
programme for all staff performing capillary
blood glucose monitoring.
Indications Capillary blood glucose monitoring
is indicated in the following situations:
Day-to-day management of patients with type
1 and type 2 diabetes.
Detection of hypoglycaemia.
Detection of persistent hyperglycaemia, for
example, during periods of illness.
Management of acute complications of
diabetes causing metabolic decompensation,
for example, diabetic ketoacidosis and
hyperosmolar non-ketotic coma (once severe
dehydration is corrected).
Management of patients during periods of
fasting, for example, surgery when a glucose-
potassium-insulin regimen may be required.
It is important to note that a diagnosis of diabetes
should not be made on the basis of a capillary
blood glucose measurement obtained using a
blood glucose meter. While meters are
convenient and readily available, there is
potential for error and the diagnosis should be
confirmed on a laboratory specimen. Blood
glucose levels for the diagnosis of diabetes and
other categories of glucose intolerance have been
agreed by the World Health Organization
(Alberti and Zimmet 1998). In the UK it is
estimated that there are currently more than two
million people with diagnosed diabetes and up
to 750,000 who have diabetes but are not yet
diagnosed (Diabetes UK 2006). Other possible
indications for capillary blood glucose
monitoring:
Patients taking medications such as steroids
and atypical antipsychotics which can cause
blood glucose levels to rise.
Specific situations, for example, parenteral
feeding which can lead to a rise in blood
glucose levels.
Contraindications Staff performing capillary
blood glucose monitoring should be aware that
the accuracy of results can be affected by the
following clinical conditions (MDA 1996):
Peripheral circulatory failure and severe
dehydration, for example, diabetic
ketoacidosis, hyperosmolar non-ketotic coma,
shock and hypotension. In these situations
capillary blood glucose readings can be
artificially low due to peripheral shut down.
Haematocrit values above 55% may lead to
inaccurate results if the blood glucose level
is more than 11mmol/l.
Intravenous (IV) infusion of ascorbic acid.
Pre-eclampsia.
Some treatments for renal dialysis.
Hyperlipidaemia cholesterol levels above
13mmol/l may lead to artificially raised
capillary blood glucose readings.
Capillary blood glucose monitoring should only
be performed by staff who have undergone
formal training as agreed by each trust (Table 1).
Hypoglycaemia:low blood glucose
Hypoglycaemia occurs when blood glucose
levels fall below 4mmol/l and should be treated
promptly. It can occur in patients on insulin and
sulphonylureas. Causes of hypoglycaemia
include missed or late meals, not eating enough,
taking too much insulin or tablets, exercise and
excessive alcohol. Common manifestations
include sweating, shaking, palpitations, hunger
and poor concentration. Hypoglycaemia should
be treated with fast-acting carbohydrate, for
example, three to six glucose tablets, 150ml fizzy
drink or 50-100ml Lucozade and followed up
with some longer-acting carbohydrate such as
biscuits or a sandwich. Blood glucose should be
recorded five to ten minutes after treatment.
Severe hypoglycaemia can be managed with
intramuscular glucagon or IV dextrose.
It is important to remember that bedside blood
glucose meters are not always accurate at low
readings and that hypoglycaemia should be
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may 30 :: vol 21 no 38 :: 2007 37 NURSING STANDARD
TABLE 1
Capillary blood glucose monitoring procedure
Action
Check that the blood glucose meter is ready for use. Ensure the following:
The test strips are in date, have been stored correctly and have not been exposed to
the air (this does not apply to strips that are individually wrapped).
The monitor is calibrated for use* with the pack of strips in use.
If a new pack of strips is required ensure the machine is recalibrated.

Quality control tests (high and low) have been carried out and documented on that day.
*Some meters use test strips that have an automatic calibration system while others
need to be recalibrated when a new pack of strips is opened.

Refer to manufacturers instructions for information.

Ensure that you have the following equipment:
Blood glucose meter (as above).
Test strips.
Finger pricking device or lancets.
Cotton wool.
Sharps disposal container.
Gloves.
Prepare the patient
Describe the procedure to the patient, explain why it is needed, answer any questions and
gain verbal consent. Ask the patient to wash his or her hands in warm, soapy water and dry
thoroughly. Do not use alcohol swabs or rub as this can lead to an inaccurate result. Position
the patient comfortably.
Wash your hands and put on protective gloves
Take a sample of blood
Using a single use, retractable lancet take a sample from the side of the finger. If the finger
does not bleed readily, milk the finger until enough blood is obtained. Most strips need only
a small volume of blood for accurate testing (0.3-4l).
Apply the blood to the test strip
Most strips are now hydrophilic. The tip of the strip is gently applied to the drop of blood
and the blood is sucked up automatically, stopping when the correct volume of blood has
been obtained. However, some strips still require the blood to be dropped directly onto the
reagent strip.
Dispose of the lancet in the sharps disposal container
When the result is available record on the appropriate charts/nursing documentation
Dispose of waste, for example, gloves and cotton wool, appropriately
Observe the test site for bleeding, ensure that the patient is comfortable and explain the
result as required
Report any unexpected, out of range results to the nurse in charge
Results that are outside the expected range for an individual patient should be reported to
the nurse in charge and appropriate action taken.
Rationale
To ensure maximum efficiency, patient
comfort and safety.
To reduce anxiety and ensure that the
patient is aware of the reasons for
blood glucose monitoring.
To prevent cross-infection and reduce
the risk of contamination.
A single use retractable lancet is
recommended to reduce the risk of
needlestick injury and cross-infection.
The side of the finger is generally less
sensitive than the tip and sensitivity in
tips of fingers may be lost if used
regularly. Rotation of sites is advised
to avoid over use of one site as the
skin may become hard and painful.
To obtain an accurate blood
glucose measurement.
To reduce the risk of needlestick injury
and cross-infection.
To ensure accurate recording of results
which may influence management.
To reduce the risk of cross-infection.
To ensure that the patient is
comfortable and aware of the blood
glucose result. This is important
because many patients self-monitor
blood glucose at home and make
adjustments to insulin accordingly.
To ensure patient safety.
p35-38w38 22/5/07 2:21 pm Page 37
considered in patients with typical symptoms.
Diabetic treatment should not be omitted because
of a single hypoglycaemic episode; the
hypoglycaemia should be treated and the usual
medication given. However, if hypoglycaemia
occurs frequently a review of the patients
treatment should be sought.
Hyperglycaemia:raised blood glucose
Intercurrent illness can have an effect on
glycaemic control causing blood sugars to rise
and can lead to diabetic ketoacidosis especially
in patients with type 1 diabetes. If blood glucose
is persistently raised, the patients urine should
be tested for ketones and advice sought from
the diabetes team. If vomiting and diarrhoea
are present, dehydration can occur quickly
and advice should be sought. Other causes of
hyperglycaemia include systemic steroids,
dietary factors, non-concordance with
medication and stress.
Frequency of monitoring
All hospital inpatients with diabetes need regular
blood glucose monitoring because acute illness
can seriously affect blood glucose levels. The
frequency of monitoring should be decided on an
individual patient basis depending on the clinical
condition. However, on admission to hospital it
is advisable to monitor capillary blood glucose
four times a day pre-meal and pre-bed for 48
hours and then to review the frequency of
monitoring according to the results and the
patients condition. Patients being cared for at
home should have blood glucose monitoring
according to individual need.
Glycosylated haemoglobin
Glycosylated haemoglobin (HbA
1c
) is a
measurement of long-term diabetic control. This
blood test measures the percentage of
haemoglobin bound to glucose and is useful as it
reflects about two to three months of blood
glucose control. Target HbA
1c
levels are
6.5-7.5% depending on individual
circumstances, for example, complications
(National Institute for Clinical Excellence 2002,
2004). In addition to HbA
1c
and capillary blood
glucose monitoring, the following should be
considered when monitoring control: symptoms,
frequency of hypoglycaemia and weight. As
acute illness can adversely affect blood sugar
control, it is useful for all inpatients with diabetes
to have a HbA
1c
blood test while in hospital.
Conclusion
Capillary blood glucose monitoring is a useful
tool in the management of patients with diabetes.
However, there is potential for serious error if the
procedure is not followed correctly. All staff
performing capillary blood glucose monitoring
should be trained and assessed according to trust
policy, be aware of what results to expect and
when to seek advice NS
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art &science clinical skills: 1
Alberti KG, Zimmet PZ (1998)
Definition, diagnosis and
classification of diabetes mellitus
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Blood Glucose Measurements:
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Hazard Notice 15 October. NHS
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