1 Diabetes Management Lisa Pezik RN, BScN Clinical Educator
2 Objectives Review the physiology of diabetes. Compare the difference between hypoglycemia and hyperglycemia. Learn how to best monitor diabetes. Become familiar with diabetic emergencies. Discuss pharmacological treatment.
3 Insulin A hormone produced by beta cells in the pancreas. Food= Glucose= Energy. Insulin moves glucose into the bloodstream. When insulin in the blood is insufficient, glucose will stay in the blood, and in the long-run lead to diabetes. (Type 2 and/or gestational develops) When beta-cells (the insulin production factory) die, the chance of new cells forming is relatively low. (Type 1 diabetes)
5 Type 1 Accounts for about 10% of cases The pancreas does not produce insulin or it stays in blood instead of being used for energy. Peak onset is between Caused 90% of the time by autoimmune destruction of beta cells via virus or infection. Idiopathic occurs 10% and has no known cause. Symptoms are increased hunger, thirst, urination, weight loss, weakness, fatigue and blurred vision.
6 Type 2 Accounts for 90% of cases. Impaired insulin secretion and resistance as the body cannot produce enough or it does not make use of the insulin properly. Increases with age putting elderly population at risk. Strong link between CAD, hyperlipidemia, obesity. Symptoms include Type 1 symptoms with numbness and tingling and recurrent infections.
7 Goals of Treatment Reduce symptoms and increase quality of life. Use a team approach with nursing, physio, dietician, social work, optometrist, podiatrist. Maintain blood glucose levels in normal range. AIC less than or equal to mmol/l fasting (prior to meals) mmol/l after eating
8 Confirmation Diabetes 7.0 mmol/l or more More than once
9 Monitoring GOLDEN RULE: Use your judgment! MD orders Trend of too high/low call MD Change in orders Infection present. Vomiting or reduced appetite/ eating. Post fall Ensure calibration and cleaning are accurate.
10 LTC Population and Diabetes Age Normal aging linked with changes in insulin secretion. Diet and Mobility Inactive decreased mobility Diets low in complex carbs and high in fat. Medications Increased rates of poly-pharmacy Alter normal glucose metabolism
11 Residents at Risk Long term complications Long term hyperglycemia Retinopathy Hyperlipidemia Nephropathy Neuropathy Psychosocial
12 Hyperglycemia Glucose is higher then 10 mmol/l and higher than 14 mmol/l in frail older adults. More than 20 mmol/l could be an emergency. Can occur with sickness, infection, stress medications, sudden inactivity, missing insulin or oral medication Thiazides (diuretics), Glucocorticoids (Steroids), Sympathomimetics (Inhalers) Impairs cognitive ability, reduces energy, impairs memory, decreases wound healing, increased urine output, increases risk of UTI, impairs immune system. Signs and symptoms include delirium, mood swings, irrational behavior, appetite changes. Treatment plan obtain vitals, give insulin (and PRN), monitor until resolved.
13 Diabetic Ketoacidosis (DKA) Acute, severe, and can be life threatening with increased risk of cerebral edema. Associated with poor control of diabetes or other illness such as infection or surgery. The body breaks down fat instead of glucose and ketones build up in the body. The result is osmotic diuresis hyperglycemia, dehydration, ketoacidosis and electrolyte deficits. Presents as shallow rapid breathing, dry sin, rapid pulse, nausea, vomiting, altered LOC, and fruity smelling breath. Ketones tests with a urine sample and blood sample. Treated in hospital with NACL, Sodium, Potassium, Insulin, Bicarbonate, D5W.
14 Hyperosmolar Hyperglycemic State (HHS) Also a medical emergency and life threatening. Blood glucose if greater than 34 mmol/l. Characterized by dehydration and reduction in circulating insulin and a fluid shift with intracellular dehydration. Signs and symptoms are lethargy, delirium, coma, seizures, visual and sensory disturbances. Caused by dehydration, infection, and illness. Treatment is the same as DKA.
15 Hypoglycemia Blood glucose reading 4 mmol/l. May cause heart arrhythmias and falls. Caused by too much insulin or oral drug therapy, missed meals, medication, and rapid increase in activity. Antipsychotics, Narcotics, Antidepressants, Beta blockers, ACE inhibitors, antibiotics Bedtime snack Characterized by changes in concentration, vision, cognition, sweating, nausea, tingling, dizziness, headache, unconsciousness is less than 2.8mmol/ L. Treat with 15grams of fast acting carbohydrates. If severe and unconscious treat with glucagon Typical dose is 1mg for adult x 2 doses max.
16 Oral Medications Classed differently as each work on a different part of the body. Liver Pancreas Intestine
17 Oral Medications Insulin Secretagogues Stimulate beta cells in pancreas to produce more insulin. Should be avoided with liver disease. Common side effects are GI upset and skin rashes. Should not be taken at bedtime due to increased risk of hypoglycemia. Glyburide (Diabeta), Gliclazide (Diamicron), Glimepiride (Amaryl), Repaglinide (Gluconorm), Nateglinide (Starlix).
18 Oral Medication Insulin Sensitizers Increase the effectiveness of insulin, glucose uptake by cells, and it decreases the body s resistance. Rarely cause hypoglycemia but side effects include swelling, weight gain, fatigue, and muscle cramps. Not to be used in conjunction with insulin. Pioglitazone (Actos), Rosiglitazone (Avancia), Avandemet (Combination of Avandia and Metformin).
19 Oral Medications Biguanides Works mainly on liver where glucose is stored by reducing glucose production. Rarely causes hypoglycemia, but should be taken with food. Most common side effect is loss of appetite and abdominal discomfort. Used cautiously with residents who have CHF, and should be avoided with residents who have impaired renal function. Should also be stopped 48 hours prior to IV contrast dye. Metformin (Glucophage)
20 Oral Medications Alpha Glucosidases Slows the absorption of carbohydrates and the rise of glucose after a meal. Does not cause hypoglycemia if used alone. If occurs must be treated with tablets or honey. Common side effects are bloating and gas. Recommended to take with first bite of food. Glucobay (Acarbose)
21 Oral Medications Intestinal Hormones Hormones regulate glucose by increasing the secretion of insulin, preventing the liver from releasing too much glucose, and lowering glucagon by delaying stomach emptying. Medications keeps the hormones active longer. They are well tolerated and do not need to be taken with food. Should be taken at the same time. Oral- Sitagliptin (Januvia), Saxagliptin (Onglyza), Combo Janumet Injectables- Liraglutide (Victoza), Exenatide (Byetta)
23 General Medications Considerations What is the onset, peak time, and duration?. What are the side effects? 5 Rights and date the vial of insulin. Regular blood work should be done. Where was the last site given if SQ injection? Hard lumps or fat deposits can develop. Can change the way insulin is absorbed. Pinch the skin to avoid IM. Always clean site with soap and water. Cold insulin can cause pain at the site. Draw up clear then cloudy and give immediately
24 Insulin Classed based on acting times.
25 Insulin Rapid Acting Humalog, Novorapid, Apidra Has an onset of minutes, peak in 1-1 ½ hours and duration 3-5 hours. Short Acting Humilin R, Novolin Toronto Has an onset of 30 minutes, peak in 2-3 hours and duration of 6 ½ hours. Intermediate Acting Humulin N, Novolin NPH Has an onset of 1-3 hours, peak in 5-8 hours and duration of 18 hours. Long Acting Lantus, Levemir Has an onset of 1 ½ hours, no peak and duration of 24 hours.
26 Mixed Insulin Combines rapid or short with intermediate. Humulin 30/70 and Novolin 30/70 Contains 30% short acting and 70% intermediate acting insulin. Has an onset of 30 minutes, short acting peak at 2-3 hours, intermediate peak at 5-8 hours and duration of 18 hours. Humalog Mix 25 or Novomix 30 Contains either 25 or 30% rapid acting insulin and 70 or 75% intermediate acting insulin. Has an onset of minutes, with peaks at 1-1 ½ hours and at 5-8 hours and a duration of 18 hours.
28 Pearls of Wisdom Listen, assess, track complaints. Refer to your charts Know your meds. Follow your gut feeling. Use your nursing measures. QUESTIONS?
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