INSULIN PUMP THERAPY NAPNN Fall Conference 9/10/2016 OBJECTIVES HOW TO DETERMINE IF SOMEONE HAS DIABETES WHAT IS DIABETES

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1 OBJECTIVES INSULIN PUMP THERAPY BY THE DIABETES TEAM AT ASPIRUS KEWEENAW HOSPITAL DEBORAH GRUVER, MSN, FNP-BC, JENNIFER PEAVEY, RN, DE, CPT, CATHY TASKILA, MA Define Diabetes. Decide who should use an insulin pump. Define what an insulin pump is. Detail how insulin pumps are set up. Describe the different kinds of insulin that can be used in the insulin pump Define data collection and interpretation of the insulin pump Define basic steps to adjust CareLink report to obtain therapeutic blood sugar control Learn how the insulin pump is inserted and applied to patient Learn how Continuous Glucose Monitor is used in outpatient setting WHAT IS DIABETES HOW TO DETERMINE IF SOMEONE HAS DIABETES Type 2 is when the bodies ability to produce or respond to the hormone insulin is impaired. It is a combination of resistance to the action of insulin and insufficient insulin production. Type 1 occurs when the body loses its ability to make insulin Glycated Hemoglobin A1C of 6.5% or greater indicates diabetes Two fasting blood tests greater than 126 indicates diabetes A random blood test greater than 200 indicated diabetes (Healthy People 2020, 2016). (American Diabetes Association, 2016) WHAT IS AN INSULIN PUMP? WHAT IS AN INSULIN PUMP? Automated device that allows the user to input specific information and make corrections in dosing of insulin. Decreases the need to mathematically calculate insulin doses Decreases the risk of stacking insulin Decreasing the frequent daily injections Allows for specific plans based on food intake, activity, sick days, and sleep (American Diabetes Association, 2016) Allows for the release of small doses of rapid acting or fast acting insulin 24 hours per day (basal rates) Allows several different basal times to accommodate the users needs Allows for larger rates of insulin to be released for meal coverage (bolus rates) Use of bolus wizard to help the computer figure out the correct insulin requirements based on blood sugar number correction and food intake coverage (American Diabetes Association, 2016) 1

2 WHAT IS AN INSULIN PUMP? AUDIENCE QUESTIONS Before we start the section who has used an insulin pump? Who works with insulin on a regular basis? What are your expectations for us? DEBORAH WILL DISCUSS WHO SHOULD USE AN INSULIN PUMP Someone that tests their blood sugars at least 4 times daily Someone that has blood sugars that fluctuate daily or even weekly Someone that doesn t eat on a regular basis Someone that wants better control of food coverage and blood sugar number coverage Someone that has a flexible life style and work schedule HOW ARE INSULIN PUMPS SET UP? Jennifer Peavy, RN, DE, CPT will present this section INSULIN PUMP INITIATION SETTINGS FINDING THE TOTAL DAILY DOSE Pump Total Daily Dose Basal Rate Insulin-To-Carb Ratio Insulin Sensitivity Factor Max Basal Rate Max Bolus Rate Active Insulin BG Target Ranges (day and night) Reduced Injection Dose: TDD x 0.75= reduced dose Weight Dose: Weight x 0.23 units= weight dose Pump TDD: Reduced Dose + Weight Dose/2=Pump TDD Example 2

3 FINDING BASAL RATES FINDING TOTAL DAILY BOLUS UNITS, ICR, AND ISF Total Daily Basal: Pump TDD x 50% = Total Daily Basal (units/day) Initial Basal Rate: Total Daily Basal/24 hours= Initial Basal Rate (start time 12am) Example Total Daily Bolus Units: Pump TDD-Total Daily Basal= Total Daily Bolus (units per day) ICR (450 Rule): 450/Pump TDD= ICR (units/day) ISF (1700 Rule): 1700/Pump TDD= ISF(grams/units) ACTIVE INSULIN AND BG TARGET RANGES DIFFERENT INSULIN USED IN AN INSULIN PUMP Active Insulin: Definition Adults 4-5 hours, Children 3-4 hours BG Target Ranges Day Night Patient Specific Rapid Acting Insulin Humalog Novolog Short Acting Insulin Humulin RU 100 Humulin RU 500 (off label) DATA COLLECTION OF INSULIN PUMP FIRST OFFICE VISIT AFTER PUMP APPLIED Open insulin pump icon (downloaded on your hard drive) We use Medtronic, Omnipod and Animas. Open patient, click on devise meter first then download the blood sugar readings. Click on devise pump second. Click on reports Select dates you want to run the reports on (I try to do the last month) Generate reports and print to color printer for best results DEBORAH WILL REVIEW OF DATA FROM REPORT Next 6 slides based off a patient that comes to our Diabetes Clinic She started the insulin pump about 18 months ago She is elderly in her 80 s Prior to the insulin pump she was having a lot of highs and lows Starting hemoglobin A1C 10% Last hemoglobin A1C 7.2% 1am: 0.7 units/hr ; 3:30 am: 1.1 units/hr ; 8am: 2.4 units/hr ; 11 am: 2.2 units/hr 1:30pm: 1.2 units/hr ; 3 pm: 1.4 units/hr ; 4 pm: 1.8 units/hr ; 7 pm: 2.20 units/hr 3

4 4

5 QUESTIONS ADJUST BASAL SETTINGS FROM REPORT What are some questions billing, safety, pain, supplies, etc. Medicare requirements Commercial insurance different Go through the report with the patient and discuss each page together Always review the basal review together to make sure the rates didn t change Include patient s basal rates before the visit and after the visit. In this patient consider not using blood sugar from 1 hour prior and rechecking blood sugar again Consider lowering night basal rate to bring up morning blood sugars to avoid hypoglycemia Check more blood sugars are night to avoid going into the night low. We recommend patients not giving a bolus after 9 pm. WHEN TO ADJUST CARB RATIO WHEN TO ADJUST THE SENSITIVITY LEVEL Adjust if 2 hour after blood sugars are high more than 50 points higher than the starting blood sugar number Any adjustments will affect all meals if it is only one meal can adjust the basal rate for that time frame or add a different sensitivity level during that time frame Calculate insulin dose for food: 45 carbs divided by 15 or 500 rule (type 1) = 3 units This is adjustable based on their needs rapid acting if not on a pump Different times of day the sensitivity may vary. This level is the amount your blood sugar will drop on one 1 unit insulin. The insulin pump can be set with 8 different sensitivity levels per day. Our patient has her set at 35. To figure out the math for this add up four days of total insulin divide by either 1500 or It varies depending on the insulin you are on. For example Average insulin used daily divided by 40 = 45 units. For every 1 unit of insulin her blood sugar will drop by 45. HOW THE INSULIN PUMP COVERS FOOD AND BLOOD SUGAR READING Calculate insulin dose for food: 45 carbs divided by 15 or 500 rule (type 1) = 3 units Calculate blood sugar coverage: Current BS# - Target divided by Insulin Sensitivity = correction dose Example divided by 35 = 1.7 units Combine the 2 insulin totals = 4.7 DEMONSTRATION OF INSULIN PUMP INSERTION Jennifer Peavy will demonstrate the set up on a live model. 5

6 RESERVOIR AND SET UP MENU INSULIN PUMP INSERTION Fill Reservoir with insulin Reservoir Set Up on Pump Menu Fill tubing Fill Cannula Pick Insertion Site (always rotate) Clean Skin Use the Quick Serter (re-usable) Use Disposable Infusion Set (MIO) (REMEMBER NO CIRCLE ON HOME SCREEN=INSULIN DELIVERY ) QUESTIONS CONTINUOUS GLUCOSE MONITOR Model walks around and shows everyone What are some questions pain, sleeping, showers, reimbursement, etc. Bill as office visit minutes must include greater than 50% of time on counseling and education. We have worked with Medtronic and Dexcom. There are two types a real time and intermittent. Today we will only discuss the intermittent. Benefits of continuous glucose monitoring include identifying shifting blood sugar numbers, how long the fluctuating blood sugars last, when they occur (what time of day), and which direction they occur high or low blood sugars. measure blood glucose with minimal invasiveness through continuous measurement of interstitial fluid (ISF) After a warm-up period of up to 2 h initialization) and a device-specific calibration process, each device s sensor will provide a blood glucose reading every 1 10 min for up to 72 h with the minimally invasive technology CONTINUOUS GLUCOSE MONITOR CONTINUOUS GLUCOSE MONITOR REPORT This discussion is only on the one you wear for 3 to 4 days. Why do you want to order one of these tests? Varying blood sugars Patient doesn t check their blood sugars (Talk about patient NA) Hemoglobin A1C doesn t match up meter blood sugars Any other reasons? Male patient in late 50 s new to the clinic Fluctuating blood sugars Hemoglobin A1C 7.4% What are is medications: Diabeta 2.5 mg 1 tab at breakfast and 3 tabs at supper Glucophage 500 mg 1 tab at breakfast and 1 tab at supper 6

7 WEARING THE CGM Must check blood sugars 4 times daily before meals and bedtime Record food and activity Record insulin injection times Don t change their life style 7

8 FOOD LOG Saturday: Blood sugar 930 am 146 ate 11 am food 3 glasses of Pepsi 1 bowl of cream of wheat 1137 banana and milk plus more Pepsi biked 22 miles Blood sugar 522 pm 119 Blood sugar 1030 pm 220 ate cheeseburger, fries, and 2 cokes Diet affects blood sugars high fat high sugars/ weird swings What insulin would you use? What would you avoid? Blood sugar average looks good but it is not showing all of the highs and lows WHAT DID WE DO FOR HIM WHAT WE DID FOR THE PATIENT What would all of you do? Plan is somewhat difficult because of the major difference in his blood sugars during the week and weekend. On the Weekends half dose the Diabeta at Breakfast and Supper. During the week keep your Diabeta the same dose. Start Januvia 100 mg 1 tab per day (completed the patient discount card) Continue Metformin one tab at breakfast and half tab at supper. (decreased the dose his LFT's are elevated history of fatty liver). Cut back on Pepsi. Check blood sugars before a meal, then 2 hours after the meal. QUESTIONS REFERENCES What questions do you have? What did you learn today? American Diabetes Association. (2016). Diagnosing diabetes and learning about prediabetes. Retrieved from American Diabetes Association. (2016). Continuous glucose monitoring. Retrieved from BD. (2016). How to calculate your insulin sensitivity. Retrieved from Healthy People (2016). Diabetes. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes 8

9 CONTACTS Our phone number at the clinic s address: 9

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