ED4 - Diabetes

7/29/2019 ED4 - Diabetes

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APM Diabetes Session

Rhonda Fruhling, MS, ARNP, CDE

Judy Sigler, BSN, CDE(updated 8/11)


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Correlation: A1c and Estimated

Average glucoseA1c (%) eAG

Estimated Average Glucose (mg/dl)

6 126

7 154

8 183

9 212

10 240

11 269

12 298

American Diabetes Association, 2011


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Goals for Outpatient Blood GlucoseControl

Pre-meal blood glucose levels

70-130 mg/dl

Post-prandial


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Key Concepts in Setting

Glycemic Goals Individualize

Certain populations need special considerations

Less intensive goals may be indicated in personswith severe or frequent hypoglycemia

More stringent goals may be appropriate (a

normal A1c, < 6 %) Postprandial glucose may be targeted if A1c

goals not met

American Diabetes Association, 2007


5/22

Continuous Glucose Monitoring

(CGM) Measures interstitial glucose

Require calibration with SMBG (treatment

decisions should be based on SMBG notCGM readings).

BG meter readings and sensor readings

will rarely match exactly. Focus on trends

Focus on direction and speed of thesensor glucose change.


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7/22

Insulin Therapy Principles

Basal insulin

Controls glucose production by the liver

Bolus insulin

Food insulin

Use and store carbohydrates eaten

Correction (supplemental) insulin Treat an acute elevation in blood glucose


8/22

Glucose & insulin concentration

Basal

Bolus


9/22

Insulin Preparations

Rapid-acting Insulin Analogs Lispro (Humalog), Aspart (Novolog), Glulisine (Apidra)

Short-acting Insulin Regular

Intermediate-acting Insulin NPH

Long-acting Insulin Analog Detemir (Levemir), Glargine (Lantus)


10/22

Insulin Action Patterns

InsulinPreparation

Onset ofAction

PeakAction

EffectiveDuration

Rapid-acting

Analogs

5-15

minutes

30-90

minutes

3-5 hours

Short-acting 30-60minutes

2-3 hours 5-8 hours

Intermediate-

acting

2-4 hours 4-10 hours 10-16 hours

Long-acting

(glargine)

2-4 hours Peakless 20-24 hours

Long-acting

(detemir)

2-4 hours(dose-related)

6-14 hours(relatively flat)

16-20 hours(dose-related)


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Pre-Mixed Insulins

Humalog Mix 50/50 50 % lispro protamine and 50 % lispro

Humulin 70/30 (human) 70 % NPH and 30 % Regular

Humalog Mix 75/25 (analog) 75 % lispro protamine and 25 % lispro

NovoLog Mix 70/30 (analog) 70 % aspart protamine suspension and 30 % aspart


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13/22

NPH and Fast-Acting Insulin


14/22


15/22

Syringes 1 cc (holds 100 units)

1/2 cc (holds 50 units)

1/3 cc (holds 30 units)


16/22

Insulin PensAdvantages

Convenient

Accurate

Often used by person on multi-dose regime

Disadvantage

Usually more expensive (exception is a personon a small dose insulin)

Injection force


17/22

Insulin Storage Keep current vial in refrigerator or at room

temperature (once opened, it is good for

28 days). Keep extra vials in the refrigerator

Avoid temperatures extremes (86

degrees) Not in direct sunlight

Never let freeze


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Insulin Resistance

Among Patients Lack of confidence/self-efficacy

Concern regarding the ability to handle insulin

therapy Fears and Concerns

Insulin will restrict lifestyle

Hypoglycemia

Diabetes has become more severe

Fear of pain, fear of giving injections

Kruger, D. (2007). Tying It All Together: Matching Insulin Regimens to

Individual Patient Needs. The Diabetes Educator, 33(Suppl. 4) 91-95.


20/22

Insulin Resistance

Among Patients Personal failure

The need for insulin is a result of not taking care of

his or her diabetes This sense of failure may be exacerbated by providers

who threaten patients with insulin

Perceived lack of benefit

Do not consider insulin efficacious

Kruger, D. (2007). Tying It All Together: Matching Insulin Regimens toIndividual Patient Needs. The Diabetes Educator, 33(Suppl. 4) 91-95.


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Insulin Resistance

Among Healthcare Providers Denial, avoidance, procrastination, wishful

thinking

Fear of alienating the patient Insulin therapy is time-consuming

Fear of hypoglycemia

Peragallo-Dittko,V. (2007). Removing Barriers to Insulin Therapy. TheDiabetes Educator, 33(Suppl.3) 60-65.


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Diabetes Education

Inpatient survival skills teaching

Contact by EPIC consult Int Med Diabetes

Nurse or contact by pager 7215 Outpatient (consult on EPIC)

Group Diabetes Self-Management Classes

Individual Diabetes Education appointment

ED4 - Diabetes

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Transcript of ED4 - Diabetes