Managing the Diabetes Patient. Dan Kremer, RN, BSN Diabetes Nurse Educator

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1 Managing the Diabetes Patient Dan Kremer, RN, BSN Diabetes Nurse Educator

2 Objectives Referring & assessing the inpatient Address the needed diabetes education for the patients survival skills Problem solving Tips for those caring for the diabetes patient

3 Inpatients Faces multiple changes: Unwanted illness Increased stress Decreased activity Decreased sleep Change in eating times Change in times of medications & insulins Possible steroids

4 Noncompliant Nurse Try to figure out why. Patient s fault Not doing what suppose to do: Testing blood sugars Watching what they eat Taking medications Exercising

5 What Patients Need Assessing? Admitting diagnosis: diabetes related High A1c Started on insulin Not testing blood sugars Food questions Questions about diabetes in general

6 Who Can Make Inpatient Referrals? MD APRN/PA Care Manager RN Dietician Social Worker Cardiac Rehab Patient/Family

7 Assessment of the Inpatient Patients New diagnosis or history of Type Medication Induced At risk Gestational How long have diabetes? Patient s PCP Meter When test Goals Foods that increase blood sugars Hypoglycemia Medications/Insulin

8 Education American Diabetes Association [ADA] Curriculum Evidence based Set up by American Association of Diabetes Educators [AADE]

9 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring Being Active Problem Solving Taking Medication Reducing Risks Healthy Coping Healthy Eating

10 AADE 7 American Association of Diabetes Educators 7 self care behaviors 1 st - Monitoring

11 Monitoring Why Monitor Blood sugars Only way you know how you are doing Blood sugars are affected by your: Food Activity Diabetes Medications Other Stress Infections Other medications: steroids, some psych drugs

12 Blood Sugar Goals ADA - Blood Sugar Goals: Before meals: Less than 130 mg/dl 2 hours after meals: Less than 180 mg/dl ******************************************************************************** Goals Individualized: Age Type Complications

13 Monitoring Blood Sugars in the hospital Test: Before Meals & at Bedtime - WHY? Often NPO status Starts in am and repeats about every 4-6 hours More convenient Patient available when eat post prandial they may be off floor Traditional especially in type 1 newly diagnosed endocrinologist model Will indicate if correction dose needed Will indicate if meal time insulin needed

14 Monitoring Blood Sugars at Home Best times in a day to test: 1 st Meal 2 nd Meal 3 rd Meal

15 Monitoring Testing 1 time a day: 1 st Meal 2 nd Meal 3 rd Meal

16 Home - Post Prandial Blood Sugars Fasting & 2 hours after meals Assess to see if medication & insulins working properly Getting desired results from medications Helps to determine if another medication is needed

17 Testing Blood Sugars Medicare Guidelines

18 Monitoring More frequently when: Change in health Increased stress Infection Steroids Noted increase in blood sugars Once under control 1 time a day

19 Taking a blood sugar Put strip in meter [Home vs. Hospital] Sticking finger [Depth Adjustment on lancet] Always hurts Stick finger and produce blood drop Touch strip to blood [Hospital strip only] Wait for results

20 Taking a blood sugar Problem solving IF high or low and surprised repeat Why test blood sugars - always high.

21 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring 2 nd - Being Active

22 Regular activity Being Active Increases cells sites sensitivity to your insulin Increases stamina and flexibility Increases feeling of well-being Decreases blood sugars Decreases blood pressure Decreases cholesterol Decreases stress Decreases weight Activity IS Free Medicine

23 Being Active Regular activity barriers Physical barriers Environmental Psychological Time limitations

24 Being Active Target activity plan Muscle movement counts - legs Like dog walkers Slow enough you can talk while walking Fast enough you can t sing Break a slight sweat

25 Being Active Activity Goal 150 minutes per week Minimum 30 minutes 5 times a week

26 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring Being Active 3 rd - Problem Solving

27 Hyperglycemia High blood sugars: Parameters often given by PCP Constantly running in the 200 s call PCP On sliding scale and always needing it

28 Hypoglycemia Blood sugars < 70 mg/dl Fast acting carb [15 grams 1 carb] Juice ½ cup [Juicy Juice Box] Pop ½ Cup Milk Skin or 1% - 1 cup NO candy bars Type 2 vs. Type 1

29 Sick Days Carbs: As / meal plan: Real pop Jell-o Test more frequently Call MD as needed

30 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring Being Active Problem Solving 4 th - Taking Medication

31 Medications & Insulins Name How they work When you take them Side effects

32 Insulin Rapid vs. Short [Novolog vs. Regular] Start to work : 10 min 45 min Peaks: 30 min 2 ½ hours Meal time insulin vs. Sliding scale Example: Meal time Sliding scale 8 units + sliding scale

33 Insulin Intermediate vs. Long [NPH vs. Lantus] Start to work : 1-2 hours 1 ½ hour Peaks: 4-5 hours NONE Timing 2 times a day Daily

34 Insulin Pen vs. Vial Volume Accuracy Label pen Butterfly method

35 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring Being Active Problem Solving Taking Medication 5 th - Reducing Risks

36 Reducing Risks Being proactive Reduces risk of complications Better quality of life How to reduce risks? Following up with MD Continued education

37 Reducing Risks Continued education Patient noncompliant Empower vs. enable Will take some time» Watch nonverbal communication» Sit down beside patient» One thing willing to change» Try to break the barrier

38 Reducing Risks Exam your feet every day. I.e. - After showering - When putting on socks Check: Tops and bottoms of feet Check: General appearance of feet Do you have any problems with feet? [I.e., Bunions, hammer toes, nail fungus] Any changes in them from yesterday? Check: To see if there is any redness or sores If any present evaluate each day to see if better If not getting better see your MD

39 Reducing Risks When Seeing MD Every Diabetes Visit Review blood sugars - logbook Check blood pressure; Goal: <130/80 Review meal plan Review activity level Check weight Discuss questions or concerns

40 Reducing Risks Every 3-6 months A1c - Goal: < 7.0% Teeth see dentist [Every 6 months]

41 Reducing Risks At least every year Physical exam Complete foot exam Dilated eye exam ophthalmologist Flu Vaccination

42 Reducing Risks At least every year Labs: Cholesterol Goal: < 200 HDL s Goal: > 40 in men; > 50 in women LDL s Goal: < 100 Triglycerides Goal: < 150 Microalbumin Goal: < 30

43 Reducing Risks Discuss with diabetes team Diabetes education Pneumonia vaccination Stop Smoking Get help if needed Taking aspirin Unusual symptoms New therapies

44 AADE 7 American Association of Diabetes Educators 7 self care behaviors Monitoring Being Active Problem Solving Taking Medication Reducing Risks 6 th - Healthy Coping

45 Healthy Coping ADA - Patient s Health Care Team: Endocrinologist Primary Care Provider/APRN/PA [Health Coach] Nurse Educator Registered Dietitian Ophthalmologist/Optometrist Social Worker/Psychologist/Psychiatrist/Marriage and Family Therapist Podiatrist Pharmacist Dentist Exercise Physiologist

46 Healthy Coping Psychological and social barriers can affect ones health and quality of life.

47 Healthy Coping When motivation is decreased and barriers block your progress it becomes difficult to cope so that we are no longer able to manage our diabetes.

48 Conclusion Survival Skills Lots of information Empower whenever possible Stay as positive as possible Encourage patient every chance you can Focus on the change patient is willing to do

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