diabetes review salpn conference april 2011. objectives the licensed practical nurse will:...
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DIABETES REVIEW
SALPN ConferenceApril 2011
Objectives
The Licensed Practical Nurse will:
1. Describe the difference between Type 1 and Type 2 diabetes
2. State two risks of increased blood sugars in hospital
3. Describe four types of oral medication used in Type 2 diabetes
4. Describe how each medication improves glucose management
4. Describe five types of insulin
5. State two insulins that can not be mixed with other insulin
6. Describe symptoms of low blood sugars
7. State treatment options and follow up for a low blood sugar
Objectives
Type 1 Diabetes (IDDM)
Pancreas not producing insulin
Always need exogenous insulin
Usually younger children/adults
Often diagnosed when admitted with ketoacidosis
Types of Diabetes
Type 2 Diabetes (NIDDM)
Pancreas not producing enough insulin or insulin not being used properly (Insulin Resistance)
May be on diet, pills and/or insulin
Usually over 40 years
Overweight/obese
May or may not have symptoms of diabetes when diagnosed
Optimize Glycemic Control
Nutritional Management
Physical Activity
Pharmacological treatment
Balancing Act to Optimize Blood Glucose Balancing Act to Optimize Blood Glucose ControlControl
Illness
Meds Activity
Blood
Glucose
Monitoring
EDUCATION
Food
In Hospital
Factors that increase blood sugars:
Stress
Infection
Pain
Sleep deprivation
IV solutions
Medications
Hospital routines
Food intake
Increased blood sugars contribute to:
Increased risk of mortality
Longer hospital stays
Increased risk of MI and stroke
Increased risk of infection
In Hospital
Target Goal Ranges
Based on individual health status while in hospital
Premeal:
4 - 7 mmol/L (4 - 6 if possible)
5 - 8 mmol/L (if elderly or unstable)
2 hour pc meals:
5 - 10 mmol/L
When toTest
While in the hospital
QID
A1c (Glycosylated Hemoglobin)2008 CPG’s Target 0.07
A1cAverage Blood
Sugar Level (mmol/L)
0.12 19.50.11 17.50.10 15.50.09 13.50.08 11.50.07 9.50.06 7.5
Oral Diabetes
Medications
Oral Diabetes Medications
INSULIN SECRETAGOGUES
Stimulates insulin release
INSULIN SENSITZERS
Improves insulin response
Alpha-Glucosidase Inhibitors
Delays absorption of glucose from gut
DPP-4 Inhibitors
Inhibits glucagon release
Increases insulin secretion
Decreases gastric emptying
Oral Diabetes Medications
Metformin
Glyburide &
Diamicron
Prandase
Avandia &
Actos
Gluconorm
Starlix
Insulin Secretagogues
Glyburide (Diabeta)
Action - up to 24 hours
Need for snacks
Risk of hypoglycemia - especially in the elderly
Metabolized in liver- excreted by kidney
Contraindicated in renal and hepatic insufficiency
Gliclazide (Diamicron)
Action- up to 24 hr
Reduced risk of hypoglycemia- more appropriate for elderly
Can be used with caution in renal and hepatic insufficiency
Repaglinide (Gluconorm)
Action - 3 - 4 hours
Less chance of hypoglycemia
Take the occasional 2 hr pc blood sugar
Take with just prior meals
NO MEAL = NO GLUCONORM
Metabolized by liver - excreted in bile
Can be used with caution in renal and hepatic insufficiency
Insulin Secretagogues
Insulin Sensitizers
Metformin (Glucophage or Glycon)
Stops excess glucose release from liver
Take with meals
Discontinue 48 hours prior to tests using x-ray (IVP) dye
Metabolized in liver and excreted by kidney
Should not be used in hepatic, renal insufficiency or CHF
Rosiglitazone (Avandia)- Currently not recommended
Pioglitazone (Actos)
Monitor liver enzymes routinely
Takes 8 -12 weeks to work
Less risk of hypoglycemia
Edema can be a side effect
Can be used with caution in renal and hepatic insufficiency and CHF
Insulin Sensitizers
Acarbose (Glucobay)
Decreases postprandial blood sugar
Should be taken with the first bite of the meal
Hypoglycemia must be treated with oral dextrose
Use glucose tablets, not juice
Binds with sugar in small intestine by interfering in the absorption of sugar
Contraindicated in inflammatory bowel disease, colonic ulceration or liver cirrhosis
Carbohydrate Delaying
DPP-4 Inhibitors
Sitagliptin (Januvia) and Saxagliptin (Onglyza)
A new class of diabetes medications for type 2 diabetes
Inhibits glucagon release
Increases insulin secretion
Decreases gastric emptying
Promotes earlier satiety
Sitagliptin (Januvia) and Saxagliptin (Onglyza)
Tablet OD
Used with TZD or metformin
Decreases A1c
Does not promote weight gain
Low incidence of hypoglycemia
DPP-4 Inhibitors
Insulin
Blood Glucose and Insulin Patterns in a Person Without Diabetes
Blo
od
Glu
co
se
Le
ve
l
Bolus Insulin
Basal Insulin
Insu
lin
Le
ve
l
B L S HS
24 0206 08 10 12 14 16 18 20 22
Types of Insulin
Peak Duration
HumalogNovorapidApidra
Humulin RNovolin Toronto
Humulin N * 1 - 3 5 - 8
Novolin NPH ** Significant variability in action with individuals
Combination of R (Toronto) and N (NPH)Humulin 30/70Novolin 10/90, 20/80, 30/70, 40/60, 50/50Humalog Mix 25 ( combo of Humalog and NPL)
Lantus (Glargine) 4 - 6 Flat Action Profile 24Levemir (Determir) 2 Predictable Flat Action Profile 24
* Must NOT be mixed with any other insulin
** Do NOT use if cloudy
Insulin Appearance
Long-Acting * **
0.5 - 1 2 - 4 5 - 8
Clear 0.16 - 0.25 1 - 1.5 4 - 5
Cloudy
Rapid-Acting (Meal Time)
Short-Acting
Intermediate-Acting
Premixed
Clear
18 - 24Cloudy
Onset (Hours)Characteristics (Hours)
0.25 - 0.5 2 - 12 24
Clear
Rapid Acting Insulin
2416 18 20 228 10 12 140 2 4 6
Short Acting Insulin
2416 18 20 228 10 12 140 2 4 6
Intermediate Acting Insulin
2416 18 20 228 10 12 140 2 4 6
Long Acting Insulin
0 2 4 6 8 10 12 14 16 18 20 22 24
Short Acting Insulin - q6h
DawnPhenomenon
B L S HS
06 08 10 1222 24 02 0414 16 18 2006 08 10 12
Short Acting Insulin with Meals and at HS
DawnPhenomenon
B L S HS
06 08 10 1222 24 02 0414 16 18 2006 08 10 12
Meal Time Short Acting Insulin with HS Intermediate Acting Insulin
B L S HS DawnPhenomenon
14 16 1806 08 10 12 20 22 24 02 1204 06 08 10
Regular- and Intermediate-Acting Insulin
Rapid- and Intermediate-Acting Insulin
Bolus and Basal Insulin
or
Principles for Using Bolusand Basal Insulin
Client is taught how to count the grams of CHO in the meal
and calculate the number of units of rapid acting insulin
needed
Client is taught how to treat pre-meal hyperglycemia with a
correction dose of rapid acting insulin
Add the CHO dose with the correction dose results in the
pre-meal dose (Bolus dose)
The longer acting insulin given OD or BID provides the
background insulin (Basal dose)
By giving the intermediate insulin at bedtime, it is more
effective at reducing the fasting blood glucose and
decreases nocturnal hypoglycemia
Principles for Using Bolusand Basal Insulin
Insulin Pens
Luxura Pen Novolin Pen 4
Insulin Pen
To insure accuracy
Cloudy insulin must be mixed
Must do an air shot each injection
Check to see that the cartridge is not cracked
Cost:
Pump $6,500
Maintenance $350.00 +/month
Insulin Pumps
MEDEC has three nurses that are certified pump trainers
A lot of learning and discipline required to get optimal control with pump
Pumps are not for everyone!
Top 10 Reasons for Blood Sugar Variations When In the Hospital
Administering insulin after scheduled time
Holding insulin because of hypoglycemic event
Administering sliding scale insulin dose based on a blood sugar result done 2 hours earlier
Over treating hypoglycemia
Insulin sliding scale not appropriate
Lantus and Levemir being mixed with other insulins
Inactivity while in hospital
Staff unaware inconsistent food intake
Insulin not on the ward
Assigned times for insulin not appropriate
Hypoglycemia
Risk Factors for Hypoglycemia
Incorrect match of diabetes medication (type, amount and timing) to carbohydrate intake
History of severe hypoglycemia or hypoglycemia unawareness
General anesthesia or sedation
Decreased oral intake
Sudden NPO status
Large amounts of alcohol or ASA
Decreasing steroid dose
Emesis
Decreased or discontinuation of IV dextrose
Interruption of tube feeds
Diabetes medication error
Unexpected transport shortly after giving rapid or fast acting insulin
Illnesses that can alter the action of the diabetes medication
Risk Factors for Hypoglycemia
What Promotes Hypoglycemia
Stress resolution
Insufficient IV glucose
Infection resolution
Excessive insulin doses
Loss of appetite
Increased activity
Hypoglycemia Procedure
Only patients treated with insulin and insulin secretagogue oral agents (e.g. glyburide, gliclazide, etc.) experience drug-induced hypoglycemia and require treatment with fast acting carbohydrates.
Treatment of hypoglycemia must be initiated if the patient meets the stated blood glucose values even if they are asymptomatic.
Signs and Symptoms of Hypoglycemia
Trembling/shaky
Hunger
Sweating
Pale or clammy skin
Anxiety
Nausea
Tingling
Palpitations
Weakness/tiredness
Difficulty concentrating
Mental confusion
Dizziness
Vision changes
Difficulty speaking
Loss of coordination
Blood Glucose Level forTreatment of Hypoglycemia
Adults & Children < 4.0 mmol/L
Hypoglycemia treatment levels may be individualized for infants, elderly (> 75 years old) and adults with cardiovascular or renal complications (i.e. < 5 mmol/L)
Case Study- Hypoglycemia -
Case Study
Eva
65 years old
T2 Diabetes
On insulin for 1 year
Recent Hb1c is 0.094
Admitted for cellulitis of left foot
States she has gained a lot of weight
Blood glucose range 2.1 -17.0 mmol/L at home
At 14:30 hrs
States she does not feel well
Weak and shaky
BGM reading 2.3 mmol/L
What are the next 5 steps to take?
Case Study
Note
Call lab to draw stat blood glucose if blood glucose monitoring result is <3 mmol/L
then
proceed immediately to next step
Step 1
Treat the conscious patient with 15 g of fast-acting carbohydrate
Fast-acting carbohydrate choices for Adults and Children (over 25 kg)
15 g of carbohydrate, as glucose/dextrose tablets
3 packets sugar, dissolved in water
200 ml juice
1 packet honey
DO NOT use juice with patients on fluid and/or potassium restrictions.
Wait 10 - 15 minutes
Step 2
Re-check the blood glucose level with meter
Step 3
Repeat steps 1-3 if blood glucose remains below target level or if symptoms persist.
If blood glucose is above target level proceed to Follow up Treatment.
Step 4
Follow-up Treatment Once SafeBlood Glucose Level is Achieved
Do not treat further if meal or snack is less than an hour away.
If next scheduled meal or snack is more than an hour away, give a slower-acting carbohydrate and protein
Slower-Acting Protein Choices:Carbohydrate Choices:
- 2 cookies - 1 packet of peanut butter- 1 slice of bread or toast - 1 packet of cheese- 6 soda crackers
Omit protein choice for patients on restricted protein diets
Document time, blood glucose result and treatment used on Blood Glucose Monitoring Record.
Step 5
Prevention of Night Hypoglycemia
Give a bedtime snack of one slower-acting carbohydrate and protein if the bedtime blood glucose <7 mmol/L and patient is on insulin or sulfonylureas.
Case Study
What changes would you make if blood glucose was3.8 mmol/L?
What changes would you make if this blood glucose was taken at 16:45 hrs?
When do You Hold Insulin?
Never (especially with Type 1) or almost never.
The dose may need to be adjusted.
Call the doctor if you think dose should be changed.
4. Try to have the client drink CHO containing beverages
5. Test blood sugars more frequently.
6. If client is unable to eat or drink - contact doctor.
7. They will need diabetes medication but dose or type of the medication may need to be changed.
What Can be Done if the Client Does Not Want to Eat?
MEDEC
What is MEDEC?
Diabetes Education Centre
Who can refer?
Anyone with the client’s consent
How to contact?
Phone 766-4540
Questions ???