Review of Diabetes Management and Patient Education Aspects

1. Review of Diabetes Management and Patient Education Aspects Nancy Dettori RN CDE St Luke’s Wood River Medical Center May 14, 2010

2. Objectives Each Nurse will: Gain basic knowledge about diabetes as a disease and how it is managed effectively Gain a basic understanding of the role of insulin in glucose metabolism and develop an understanding of commonly used insulin types including how to access information about their action, peak, duration Gain basic knowledge about low blood glucose levels including the dangers of untreated hypoglycemia, its causes, symptoms, and prevention Explain the steps for treating hypoglycemia using the Rule of 15’s Verbalize understanding about the purpose, techniques used, and recording of results of blood glucose monitoring Communicate acceptable blood glucose target ranges

3. Understanding the Problem of Diabetes 2007 Diabetes Rates United States - ~24 million Idaho- ~ 7.9 % of Adults Pre diabetes Prevalence (preventable) United States - ~ 57 million Estimated Costs (direct and indirect) $ 174 billion 2007 $ 218 billion 2008

4. Complications rob… the eyesight the kidneys the health of the feet the heart & mind via heart attack or stroke the body of sexual pleasure a person of years of quality life

5. Scope of Care Stabilize • Newly diagnosed or poorly controlled • Acute Hyperglycemic Metabolic Disturbances • DKA, HHS • Illness, injury, medications • Stress Hyperglycemia • Hypoglycemia Survival skills • Basic info/ skills to “survive” until further “outpatient “ education can be obtained Sustaining Success • Assess & address for knowledge/skills deficits

6. In Patient Care • Protocols • Insulin Infusion Orders • Subcutaneous Insulin Orders • Hypoglycemia Protocol • Clearly Defined Competencies/Expectations • Knowledge • Overview • Insulin • Hypoglycemia • Skills • Meter • Insulin Delivery - Syringe, Flexpen • Education Tools

7. WR Staff Orientation and Training Orientation • Meter Use Preceptor Period • Online Sum Total Training – 4 modules • Protocols reviewed • Review Curriculum for Patient Education • Overview • Insulin • Hypoglycemia • Meter Use

8. WR Staff Orientation and Training Preceptor Period • Patient training DVD’s for review • Patient assignment w/preceptor Scheduled Assignments • Diabetes plan discussed with RN CDE • Ongoing “skills labs” as needed

9. Sustain Success Self Management Practices • Opportunity to “Take Five” • Commend Successes • Identify & Address Gaps

10. What is Diabetes? Diabetes is the result of an insulin defect which causes a disturbance in normal glucose metabolism leading to higher than normal blood glucose levels.

12. Normal Insulin/Glucagon Response

13. Insulin Disturbances = Diabetes Insulin deficiency – not enough production Insulin resistance – insulin not used properly Type 1 diabetes = deficiency Type 2 diabetes = some deficiency; mostlyresistance Gestational diabetes = demand > production; resistance often present

14. Diagnosis Confirmation ADA (American Diabetes Association): Normal FBG < 100 mg/dl Pre – Diabetes FBG 100-125 mg/dl A1c 5.7 – 6.4% Diabetes Fasting Blood Glucose of 126 mg/dl or > Random /2 Hour OGT result of 200 mg/dl or > A1c of 6.5% or >

15. Diabetes Education Stress Reduction Exercise BG self testing Pillars of Management Meal Plan Medications

16. Lowers glucose Cholesterol Improved Goal = 30 min/day Exercise / Activity Increased Sense of Well Being Decreases B/P Improved Coping Response

17. Carbs = Energy No Diabetes Diet Carb Count or Portion Control Meal Plan No Forbidden Foods Food to be Enjoyed Balanced Carb Intake

18. Carbohydrates Serving Size = Choice, serving or exchange 1 carb choice = 15 grams of carbs Every meal requires ~ 3-5 carb choices or 45-75 grams Remind patients: Don’t stop eating carbs Don’t eat less than recommended carbs Eating rec’d carb intake can help with weight management

19. Diabetes is Progressive Exercise/Meal Plan Glucose Targets Options Medication Side Effects Purpose or Action Dose Current Maximum Timing

20. Actions for Most Common Meds Inhibit glucose from liver – Metformin Promote insulin secretion - Sulfonylureas (glipizide, glimepiride, glucotrol) Increase insulin sensitivity - Actos, Avandia Enhance/ Mimic gut hormones – oral = Januvia; injection = Byetta, Slow breakdown of carbohydrate – Acarbose, Precose; rarely used d/t obnoxious GI side effects Replacement or SupplementalInsulin

21. Insulin Needs Type of Diabetes: type 1 diabetes - insulin replacement essential. type 2 diabetes – depends on progression, may also need insulin replacement. Gestational diabetes – may require temporary use of insulin Special Considerations Blood glucose levels dangerously high at diagnosis- may need insulin while glucose brought under control. Certain conditions may require the temporary use of insulin for type 2 or gestational diabetes, e.g. illness, surgery, trauma, increased demands

22. Recommended Glucose Targets Type 1 or type 2 A1c – less than 7.0% Fastingor pre meal 90-130 mg/dl (ADA consensus) Post prandial (2 hours after start of meal) < 180 mg/dl (ADA consensus) Gestational diabetes Fasting or pre meal < 95 mg/dl (ACOG) Post prandial (1 hour after start of meal) < 130-140 mg/dl (ACOG)

23. Thinking like a pancreas Basal or background insulin Glucose coverage during fasting period Overnight Between meals Bolus insulin or mealtime insulin (prandial) Insulin in response to rising glucose from foods Designed to control post meal elevations Match with carbohydrate eaten each meal

24. New vs. Old Insulins Older Insulins NPH Regular Lente or Ultralente Newer Insulins – analogs

25. Background / Basal Insulins Long Acting – newer, analogs Lantus (glargine) Levemir (detemir) Longer period of coverage – 20-24 hours Little to no peak action – gentle rise and fall Hourly disbursement More predictable action 1 – 2 injections daily ~ same time each day Newer, more expensive to use

26. Background / Basal Insulins Intermediate ActingNPH – older Inadequate for 24 hour coverage ~ 16-24 hours Has peak effect ~ 6 – 14 hours Less predictable for peak and duration Increased hypoglycemia risk Requires 2 injections daily for 24 hour coverage Benefits Older, more affordable than Lantus or Levemir Appropriate for use with gestational diabetes

27. Mealtime / Bolus Insulin Covers mealtime glucose rise (prandial) Shorter duration of coverage Two types of mealtime insulins: Rapid acting – newer analog insulins Novolog (aspart) Humalog (lispro) Short acting – older human derived insulin Regular (Novulin R or Humulin R)

28. Rapid Acting Bolus Insulins Novolog and Humalog Start working within 5-15 minutes Work hardest (peak) 30-90 minutes Duration 3 – 5 hours; mostly done at 4 hours Benefits Faster onset to handle glucose rise as it occurs More predictable peak and duration Mostly used up by the next meal Less chance for “stacking” insulin

29. Short Acting Bolus Insulin Regular Starts working 30 – 60 minutes Duration 4-8 hours Works hardest (peak) 2-4 hours Disadvantages Less predictable in onset, peak and duration timing Increased hypoglycemia risk Less flexibility with meal timing Potential for “insulin stacking” for meal coverage Benefits Less expensive

30. Physiological Insulin Use

31. Correction Insulin • Patient able to eat: • Used to correct already high glucose level pre meal • Given along with mealtime insulin ordered • Use same bolus insulin – Rapid or Short • Patient not eating: • Rapid or Short acting insulin given in response to high blood glucose levels determined by routine BG testing every 4 – 6 hours.

32. Insulin Delivery Devices Syringes Pens – protective needle device (Novo Nordisk) Pumps – training/management out of area Inhaled – off the market

33. Insulin Injection Teaching Tools Insulin Injection Starter Kits Syringes- BD Kits Pen Devices – Novo Nordisk Practice Opportunities

34. Insulin Considerations Patients need to know: • Sites and Rotation – affects absorption • Storage Needs – varies; see PI or Table • Supplies Disposal – protection of others

35. Hypoglycemia Defined Blood Glucose < 70 mg/dl Requires: Recognition of symptoms Response with appropriate carbohydrate Reversal of symptoms Review of potential causes for future prevention

36. Causes May Include: More active than usual Decreased carbohydrate intake Too much diabetes medication(s) Alcohol intake without adequate carbohydrates Medical conditions: poor nutrition kidney or liver disease Age related: very young elderly

37. Hypoglycemia Symptoms MILD Hypoglycemia may include: Shakiness, trembling Sweating, chills, clamminess Weakness, fatigue Rapid or pounding heartbeat Body temperature changes Anxiety, nervousness Dizziness Hunger

38. Hypoglycemia Symptoms Neurological Changes: Mood changes, irritability Headache Decreased attentiveness, drowsiness, confusion Changes in vision Slurred speech Lack of coordination Disorientation

39. Hypoglycemia Danger! Untreated Hypoglycemia Progression: Seizures Unconsciousness Serious injuries or death to self or others during this period

40. Rule of 15’s for Treating Hypoglycemia Test glucose and confirm if hypoglycemia is suspected and time allows. Eat/drink 15 grams of fast acting carbohydrate if hypoglycemia confirmed (BG < 70mg/dl). Wait 15 minutes. Retest blood glucose level. Repeat 15 grams of carbohydrate if glucose still <70 mg/dl. Repeat steps 3 – 5 until BG is 70 or above.

41. Appropriate Carbohydrate Sources 15 grams of fast acting carbohydrate & free of fat ½ cup or 4 ounces of juice ½ cup or 4 ounces of regular soda 3-4 glucose tablets 1 cup or 8 ounces of skim or 1% milk 1 tablespoon of honey or sugar Small tube of cake decorating gel 5 – 6 hard candies -check food labels

42. Warning! Do not feed or give liquids when a person is: Unable to follow commands Unable to swallow NPO

43. Hypoglycemia Use Protocol for treating patients who are: • Hospitalized • Unable to swallow or follow commands • Unconscious • NPO

46. Record the Hypoglycemia Event Document in the patient glucose logbook: Blood glucose level Treatment used Ending blood glucose level Possible cause(s) Notify Provider for: > 2 events/week Several events/month

47. Response to Lifestyle Changes / Meds How Often Meter Use Glucose Self Testing Sharing Results Target Goals Recording Results

48. Frequency of testing Determined by: Type of diabetes Type 1 – usually more often, 4-6 times daily or more Type 2 – begin with 3 times daily if not on insulin and until able to get to a Diabetes Education class for new frequency schedule Medicationuse Use of insulin may increase frequency of testing Degree of control Poorly controlled - test more often Well controlled - test less often

49. Timing of Self Testing Early morning – after fasting all night Before a meal 2 hours after the start of meal - post prandial Bedtime Exception – Hypoglycemia suspected Establish a trend

50. Safe Target Glucose Ranges Recommended Glucose Targets Type 1 or type 2 A1c – less than 7.0% Fasting or pre meal 90-130 (ADA consensus) Post prandial (2 hours after start of meal) Less than 180 (ADA consensus) Gestational diabetes Fasting – less than 95 (ACOG) 1 hour after start of meal – less than 130-140 mg/dl (ACOG)