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Glycemic Control: The Ongoing Quest Kathy Bowers Ferris State University

Glycemic Control: The Ongoing Quest Kathy Bowers Ferris State University. Inpatient RN Focus F all 2013. Continuing Nursing Education Credit. Criteria/Disclaimers. To achieve 2 nursing contact hours, attendee must: Sign in Complete pre-test Attend entire session

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Glycemic Control: The Ongoing Quest Kathy Bowers Ferris State University

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  1. Glycemic Control:The Ongoing QuestKathy BowersFerris State University Inpatient RN Focus Fall 2013

  2. Continuing Nursing Education Credit Criteria/Disclaimers • To achieve 2 nursing contact hours, attendee must: • Sign in • Complete pre-test • Attend entire session • Complete post-test and evaluation • All planners and presenters deny conflict of interest McLaren Northern Michigan (OH-307, 6-1-2016) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

  3. Objectives At end of offering, participant will be able to: • Demonstrates understanding of hypoglycemia protocol and identifies measures to prevent further hypoglycemic events. • Demonstrates understanding of pharmacology of insulin’s and use of basal, prandial and correction dose insulin indications. • Demonstrates knowledge of blood sugar targets in critical and non critical care units. • Demonstrates understanding of carbohydrate counting and calculation of insulin to carbohydrate ratios. • Demonstrates understanding of continuous insulin infusion protocol and indications for use.

  4. Module 1:Diabetes 101

  5. Classifications Type 1 diabetes • β-cell destruction Type 2 diabetes • Progressive insulin secretory defect Other specific types of diabetes • Genetic defects in β-cell function, insulin action • Diseases of the exocrine pancreas • Drug- or chemical-induced Gestational diabetes mellitus (GDM) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.

  6. Pathophysiology of T2DM Inherited/acquired factors Acquired factors(obesity) Insulin deficiency Insulin resistance  FFA  Glucoseuptake  Production of glucose in the liver Gluco-lipotoxicity Hyperglycemia T2DM FFA = free fatty acid. Bergenstal R, et al. Endocrinology. Philadelphia, PA: WB Saunders Co; 2001:821-835. DeFronzo RA. Diabetes. 1988;37(6):667-687. Poitout V, et al. Endocrinology. 2002;143(2):339-342.

  7. Multiple Contributors Decreasedincretin effect Decreased insulinsecretion Increasedlipolysis Islet–A cell Hyperglycemia Increasedglucagon secretion Increasedglucose reabsorption IncreasedHGP Decreasedglucose uptake Neurotransmitterdysfunction HGP = hepatic glucose production. Defronzo RA. Diabetes. 2009;58(4):773-795.

  8. Primary Types of Diabetes Type 1 DM Type 2 DM • Life-long • Develops at any age • Onset sudden or gradual • Daily insulin dependent All patients with known T1DM should be given exogenous insulin DO NOT hold basal insulin in these patients • Occurs at any age • Onset in adolescents becoming more common • Usually due to insulin resistance with insulin deficiency, and/or insulin secretory defect with insulin resistance • Need for insulin variable • May worsen over time CPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010

  9. Complications Leading cause of kidney failure, nontraumatic lower-limb amputation, new cases of blindness among adults Major cause of heart disease and stroke Seventh leading cause of death National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

  10. Diabetes Frequency US Average • 8.3% population (25.8 million people) estimated to have diabetes, including 18.8 million diagnosed and 7 million undiagnosed • For every 2 known people with diabetes, there is an unknown • Type 1: 5-10% of diagnosis • Type 2: 90-95% National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

  11. Diabetes Frequency MNM Population • CDC reports Emmet County DM rate 8.1-9.4% in 2008 • Charlevoix, Cheboygan 9.5-11.1 • Mackinac > 11.1 • 20-30 (20-30%) Patients on Insulin on any given day www.cdc.gov

  12. Screening on Admission DM Risk Factors • Age >45 • 18-45 with additional risk factor: • Sedentary • Overweight/obese • Family history of DM • High-risk ethnicity (Pacific Islander, Native American, African American, Latino, Asian American) • Female with history of gestational diabetes or delivery of baby over 9 lbs

  13. Diagnosis A1C ≥6.5% OR Fasting plasma glucose (FPG)≥126 mg/dL (7.0 mmol/L) OR 2 random plasma glucose ≥200 mg/dL (11.1 mmol/L) ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.

  14. Screening on Admission ID the Unknown: Random BG • Report >200 • A1c next step • 3 month avg. BG control • Normal <5.7% • Pre Diabetes 5.7-6.5% • Diabetes Target <7%

  15. Pre Diabetes FPG 100–125 mg/dL OR A1C 5.7–6.4% *Risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.

  16. Recommendations Prevention/Delay of Type 2 Diabetes Patients with FBG 100–125 mg/dL or A1C 5.7–6.4% to ongoing support program • Targeting weight loss of 7% of body weight • At least 150 min/week moderate physical activity • Follow-up counseling ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2013;36(suppl 1):S16.

  17. In-Hospital Hyperglycemia Risks • Prevention in critical and non-critical care settings can reduce mortality, morbidity and costs associated with prolonged length of stay. • Independent factor for poor clinical outcomes: • Infection • 2 hours over 180mg/dL=5 times risk • Sepsis • Delayed wound healing • Skin breakdown • DKA • Coma • Death

  18. In-Hospital Hyperglycemia Causes (Even unrelated to Diabetes) • Most Common • Insulin deficiency • Inappropriate insulin therapy • Infection • Other • Surgery • Illness • Stress • Medication induced (e.g. steroids) CPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010

  19. BG Targets Non Critical Care • AC 80-140 mg/dL • PC blood glucose targets <180 mg/dL • Random blood glucose targets <180 mg/dL • 110-140 mg/dLfor most patients Critical Care

  20. Targets

  21. In-Hospital Hyperglycemia Treatment may differ from home • Critical Care: IV insulin infusion is preferred • Rapid onset • Short duration of action • Predictable glucose lowering effect • Low risk of prolonged hypoglycemia • Non Critical Care: Subcutaneous insulin is preferred—even if patient is not on insulin at home. • Adjustable • Predictable response • Does not necessarily mean patient will be discharged on insulin 1. Schmeltz LR et al. EndocrPract.2006;12:641-650. 2. Umpierrez GE. J ClinEndocrinol . 2002; 87:978-982. 3. Capes SE. et al. Stroke.2001;32:2426-2432. 4. Furnary AP et al. Am J Cardiol.2006;98:557-564. 5. Clement S et al. Diabetes Care.2004;27:553-591. 6.Moghissi ES et al. Diabetes Care. 2009;32:1119-1131. Metab

  22. Module 2:Menus, Carbohydrates and Carb Counting

  23. Medical Nutritional Therapy: Carbs

  24. Why Count Carbohydrates? • Carbohydrates include food composed of starches, sugar, and/or fiber. They are the most common form of energy found in food. Most carbohydrates break down into glucose. • Proteins and fats make up the other two sources of energy and do not break down into glucose.

  25. Starch Group Includes breads, cereals, rice, pasta, dried beans, starchy vegetables Carbohydrate Foods

  26. Carbohydrate Foods Fruit Group Includes all fruit (fresh, frozen, canned, dried) and fruit juices

  27. Carbohydrate Foods Milk Group Includes all milk and yogurt

  28. Carbohydrate Foods Non Starchy Vegetables Contain roughly 1/3 of the carbohydrate of starchy vegetables

  29. Carbohydrate Foods Foods for Occasional Use

  30. Convert to glucose starting in 10 minutes—100% 2 hours Snacks may be offered to meet nutritional needs, but not required if diabetes management plan is appropriate Clear and Full Liquid Diets should NOT be sugar-free, unless carb level met (3 carb choices/meal for women and 4 carb choices for men). Enteral Nutrition and TPN often causehyperglycemia Beware of hypoglycemia when: Tube/IV dislodges Feeding/infusion D/C temporarily Reduction in rate Carbohydrate Considerations So you know…

  31. Diabetes Diets Carbohydrate info for menu selections is essential to integrate patient’s intake with their insulin or oral diabetes medication regimes Carbohydrates per food item will be on: MNM Menu: Both choices and grams (at next reprinting) Tray Ticket: Only grams listed Menu/Tray Ticket Updates

  32. MNM Patient Menus

  33. MNM Patient Menus

  34. Range of Carbohydrate Grams / Choice

  35. Tray Tickets • Beginning in mid-late May, • all tray tickets will have • carbohydrate grams listed • next to food items containing • carbohydrates. • If a food item has less than • 2 grams per serving, it will • NOT appear on the tray • ticket. • You will only have to • calculate carb grams • consumed, if there is a • prandial order to dose meal- • time insulin on carb grams • consumed.

  36. Calculating Carb Grams Consumed Nurse, PCT, or Ambassador to write fraction of food consumed, next to food item Multiply fraction consumed by grams, this will give you grams consumed. Total all the grams consumed. Divide grams consumed by insulin:carb on prandial orders. Example:1 unit for 15 g carb: 31.25g / 15g = 2.08 units or 2 units. ALWAYS round down to whole number, unless told otherwise.

  37. Nutrition Labels: Carbohydrate Grams Counting • Note Serving Size • Note Total Carbohydrate Grams • Dietary Fiber and Sugar are included in Total Carbohydrate • Calculate Carb Grams based on actual serving size

  38. There is no “ADA Diet” The American Diabetes Association does not endorse any single meal plan or specified percentages of macronutrients Meal plans such as “no concentrated sweets,” “no sugar added,” and “liberal diabetic” diets are NOT appropriate Unnecessarily restrict sucrose Implies that simply limiting sugar will improve glycemic control Diabetes Diets Inappropriate Diet Orders

  39. MNM DM Appropriate Diet Orders Carbohydrate Gram Counting • Identifies exact number of carbohydrate grams per meal/snack • Insulin to carb ratio is used to calculate the amount of rapid-acting insulin needed to “cover” the grams of carbohydrate consumed • Ideal for intensive insulin therapy when tighter control is desired particularly CSII, Gestational Diabetes,Type 1.

  40. Carbohydrate Counting Food Log Can be ordered via CPOM/Diet Orders: Food Log Stored at HUC station on all units Calorie counting now on Food Log

  41. Goal: Consistent amounts of carbohydrates meal to meal and day to day. May be some variation between meals, per patient preference Based on heart-healthy diet principles Foods containing sucrose may be included, counted as part of the total carbohydrate allowance MNM DM Appropriate Diet Orders Carbohydrate Choice a.k.a. Consistent Carbohydrate

  42. MNM DM Appropriate Diet Orders Carbohydrate Choice • Designated on CPOM diet order • Default: • Male: 4 carb choices/meal • Female: 3 carb choices/meal • Prandial insulin is given based on provider ordered number of carbohydrate choices for each meal e.g. 4 carb choices/meal • Effective if the patient is eating consistently

  43. Carbohydrate Choice Diets at MNM 2 Carb Choices/Meal 3 Carb Choices/Meal 4 Carb Choices/Meal 5 Carb Choices/Meal 6 Carb Choices/Meal

  44. Carbohydrates Points to Remember • Carbohydrate grams listed on food package Nutrition Facts label can be converted to choices • Teach 15 grams=1 choice • Significant deviation from the carbohydrate plan resulting in poor glucose control (high or low) should be reported to the provider for modification to insulin orders

  45. Module 3:Insulin Safety & Administration

  46. Safety Takes A Vigilant Team Communication Critical

  47. MNM Insulin Safety Top Issues: 2012-YTD • Missed orders: • Watch for paper orders • 4-36 hour delay • Place upper section into CPOM • Attach new order onto Diabetes Record (pink sheet) • Acting without an order • Holding/changing doses without/outside parameters • Hypoglycemia • Over/under/improperly treating • Not reporting to provider • Good job! • Scanning 30,000 insulin administrations/year • Low error rate • Remember visual verification

  48. FlexPen – Single Patient Use!

  49. FlexPen Safe Practice Recommendations • Ensure that the patient name on the pen is verified against the patient’s wrist band prior to administration • The use of an insulin pen for more than one patient, even with a needle change may result in transmission of: • Human Immunodeficiency Virus (HIV) • Hepatitis B • Hepatitis C • Other blood borne pathogens • Do NOT withdraw insulin from pen

  50. FlexPen Patient Education Considerations • Different needles than at home • We have auto cover for safety • They will have 2 covers to remove • Teach patient to prepare/give own injections as appropriate

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