Insulin Pump and Continuous Glucose Monitoring:

1. Insulin Pump and Continuous Glucose Monitoring: Benefits and the Barriers NRS-410v Pathophysiology Professor A. Johnson Carl R. Fulton RN April 1, 2016

2. Objectives: 10 Importance of adherence to DM regimen Benefits of Pump Use Reasons for Noncompliance: Barriers Identify Barriers Educate

3. Importance of adherence to DM regimen 9 Diabetes increases the risk of infection, chronic heart and kidney diseases…2 …Stroke, blood-circulatory problems, decreased vision, ulcers, amputation, and more… May also result in fetal problems (such as babies who are large for gestational age).

4. Diabetes Type I • Diabetes Type 1 is characterized by destruction of most pancreatic insulin secretion cells. 2 • Results in ketoacidosis if untreated. • May benefit from an insulin pump the most.1 8

5. Benefits of Pump Use Its efficacy has been clinically proven: • No Improvement with Diminished Use: • The pump needs to be used, at a minimum, 60% of the week.1 • Patient’s Use Frequency is dependent upon Quality of Life improvements.1 • Quality of Life improvements depend upon Use Frequency1

6. How to Use an Insulin Pump The glucose trend is displayed on the screen. • Consist of an insulin reservoir, a pump, battery, computer chip and screen.5 • Small as a pager. • Basal and Bolus doses of insulin are separate settings. • Prior to insulin changes, may require confirmation with a Glucometer: • Abnormal values • Older equipment & battery failure. 4 3 Pay close attention to when to re-load the insulin or change the battery.

7. How to Use an Insulin Pump (Continued) • Connected to tubing that delivers the insulin. • Needle and tubing must be changed once every 3 Days. Insert into fatty tissue.1 • If sold with a continuous glucose monitor: • Requires two needles be inserted.1 • Monitors blood glucose continually. • 3 to 12 minute lag time • between capillary glucose & displayed glucose 1

8. Reasons for Noncompliance Endogenous versus Exogenous: Patient Motivation vs. Barriers Barriers: Training in Device Use and Diabetes Management. Financial Challenges Pain at the Insertion Site Lifestyle Considerations It is the Nurse’s Responsibility to Identify Barriers and to Educate

9. Noncompliance & Education Financial Challenges: Medtronic offers financing for gaps in coverage or employment 1.800.646.4633 Pain at the Insertion Site: Numb with ice or lidocaine1 Pinch insertion site; preferably abdomen. Lifestyle Considerations: May remove for showering. May remove in other circumstances: swimming, personal relationships, etc. Some devices are waterproof, like the OmniPod 7 7

10. Education • Training in Device Use and Diabetes Management: • Carb counting for bolus doses. • Use the glucose trend (up/down), instead of the Number Displayed, for treatment.1 Must be worn > 60% of the time to benefit.1 Continue to use a glucometer: (8) 1. For continuous glucose monitor calibration. 2. For verification before dose changes. 3. If battery or device malfunction suspected.

11. Review Objectives Importance of adherence to DM regimen Benefits of Pump Use Reasons for Noncompliance: Barriers (Endogenous and exogenous) Identify Barriers Educate Questions? 6

12. References: 1: Tumminia, A., Sciacca, L., Frittitta, L., Squatrito, S., Vigneri, R., Le Moli, R., & Tomaselli, L. (2015). Integrated insulin pump therapy with continuous glucose monitoring for improved adherence: technology update. Patient Preference & Adherence, 2015:9, 1263-1270. doi:10.2147/PPA.S69482 2: Copstead, L.E., & Banasik, J. (2013). Pathophysiology (5th ed.). St. Louis: Elsevier Saunders. 3: Medtronic Diabetes. (2016). Reservoir volume [Electronic Image]. In Settings and Features. Obtained April 1, 2016 from Medtronic MiniMed, Inc: http://www.medtronicdiabetes.com/customer-support/device-settings-and-features/utility-settings/read-screen 4: Medtronic Diabetes. (2016). MiniMed banner [Electronic Image]. In Settings and Features. Obtained April 1, 2016 from Medtronic MiniMed, Inc: http://www.medtronicdiabetes.com/customer-support/device-settings-and-features/utility-settings/read-screen 5: Kennedy, M.N. (2016). What is an insulin pump? In Diabetes Education Online. Retrieved April 1, 2016 from the University of California, San Francisco, Diabetes Teaching Center Web site: http://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/medications-and-therapies/type-1-insulin-pump-therapy/what-is-an-insulin-pump/ 6: Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (12th ed.). Philadelphia: Lippincott William’s & Wilkins

13. References (Continued): 7: Insulet Canada Corporation. (2015). Shower and swim [Electronic Image]. In Life with the Omnipod. Retrieved April 1, 2016 from: https://www.myomnipod.ca/content/en/life-with-omnipod/life-with-omnipod.html 8: Larsen, A. (n.d.). Working with Special Populations Part 3: Diabetes Mellitus [Electronic Image]. Obtained April 1, 2016 from: http://breakingmuscle.com/health-medicine/working-with-special-populations-part-3-diabetes-mellitus 9: LaBorde, M. (2012). What a new study reveals about tendon lengthening for diabetic plantar foot ulcers [Electronic Image]. Podiatry Today, 25(11). Obtained April 1, 2016 from: http://www.podiatrytoday.com/files/imagecache/normal/PT1112Online2a.png 10: Chawla, J. (2014). Insulin Pump Pros And Cons, You Should Be Aware Of [Electronic Image]. Obtained April 1, 2016 from: http://www.ehealthyblog.com/diabetes/insulin-pump-pros-and-cons-you-should-be-aware-of.html