PEDIATRIC ASSESSMENT

PART 2 – FOLLOW-UP

GOALS

• Consistent approach to assessing pediatric patients with Type 1 or Type 2diabetes across Nova Scotia

• One form that can be used for pumpers and non pumpers

Consistency

• To collect all information required to provide the best possible care to a pediatric patient and their family

• Gather all information required for DCPNS data base

Information

HIGHLIGHTS

Name: Date: Non-NSIPP NSIPP

Duration of diabetes/Age at onset: Current age: Type 1 Type 2 Other

Accompanied by: mother father sibs: other:

Lives with: mother father other:

Information obtained from: mother father child other:

MEAL TIMES COMMENTS

Basal (%):

Bolus (%):

Bkfst AM Lunch PM Supper HS (e.g., changes in activity, insulin adjustment, omits, takes when ill, skips meals, etc.)

Usual

Weekend/OtherBASAL RATES:

Time Rate

TYPE OF INSULIN

and/or

Non-Insulin Therapy

DOSAGE and/or CHO/Ratio

ISF: ACTIVE INSULIN TIME: TOTAL UNITS: U/kg:

Glucose Targets: Uses Bolus Calculator: N Y Inject/Bolus before meals: N Y

How often are insulin/boluses missed? Avg. Bolus per day:

INSULIN N/A INSTRUCTED (see Education Checklist)

Prepared by: mother father child other:

Injected by: mother father child other:

Supervised by: mother father other:

Appropriate technique: N Y not observed

Sites used: buttock R L leg R L arm R L

abdomen R L calf (if applicable) R L

Appropriate site rotation: N Y

How often is the site changed? Daily Every 2 to 3 days Every 3 to 5 days Every 5 days or more

Lipodystrophy: N Y

Adjusts insulin: N Y

INSULIN

BLOOD GLUCOSE MONITORING N/A INSTRUCTED (see Education Checklist)

Tested by: mother father child other:

Recorded by: mother father child other:

Supervised by: mother father other:

Appropriate technique: N Y not observed Do you download regularly? N Y Details: Did you download your pump today? N Y

TIMERESULTS

Based on days

Based on: Record book Verbal report

Computer printout/download

AC 2-hr COMMENTS (e.g. weekend variations, range, etc.)

Bkfst

Lunch

Supper

hs

12 AM

3 AM

Interprets results and acts appropriately: N Y

Method: Frequency/day/week:_____________________ Tests ≥ 4x/day

HYPOGLYCEMIA Diabetes ID: N Y

SYMPTOMS: headache moody weak

shaky hungry sweaty

pallor nightmares dizzy other: none

Are symptoms recognized by the child? N Y N/A

MILD (frequency, times):

Treatment Appropriate? N Y What treatment does the child/adolescent carry? MODERATE/SEVERE (Severe hypoglycemia is defined as unable to help self): Y (see below) N

Date Treated by: 1) Care giver/family 2) EHS only 3) Emergency Dept. 4) Admission

Treated with glucagon

(√)

What was the cause of moderate/severe hypoglycemia (note number): 1) Exercise; 2) Insulin error; 3) Missed/late meal; 4) Slept in; 5) Alcohol; 6) Other (please note reason)

Glucagon at home: N Y Expiry date checked: N Y Prescription: N Y

SCHOOL PLAN IN PLACE: Y N Grade in school: INSTRUCTED (see Education Checklist)

Is school prepared to treat? N Y Has teacher been given appropriate information? N Y

ACTIVITY INSTRUCTED (see Education Checklist)

What types of exercise/activity do you do? None Screen time:

Please list:

What adjustments are made to insulin/food for exercise(s)? n/aTemporary basal rates Suspend pump Carb coverage Decrease bolus

Extra monitoring Insulin Adjustment Snack None

ACTIVITY

SICK DAYS INSTRUCTED (see Education Checklist)

Illness since last visit: N Y

Number of days sick:

Describe blood glucose problems when ill:

Diabetes symptoms: polyuria nocturia (___/night) headaches polydipsia enuresis Other:

Abdominal symptoms:

Ketones Checked: N Y When: By whom:

Ketones Testing: appropriate inappropriate never Expiry date checked: N Y

Action taken: appropriate inappropriate never

Date Treated in Hospital

Treated in Emergency

What was the cause of the DKA (note number)? 1) Insulin omission; 2) Illness; 3) Pump/Pump site failure; 4) Insufficient monitoring; 5) Other (please note reason)

DKA Since Last Visit Y (see below) N

SICK DAYS

SOCIAL ASSESSMENT

SOCIAL ASSESSMENT INSTRUCTED (see Education Checklist)

Smoking: N Y Amount: Willing to reduce/quit

Social drugs: N Y Type/freq:

Alcohol: N Y Type/amount/freq:

Sexually active: N Y Birth control:

STD prevention: N Y

Driving: N Y Safe practices: N Y n/a

Days missed from school since last visit:

School concerns/performance:

Family concerns/involvement/changes:

Religious, family, or cultural practices that may influence how child/family cares for health:

NUTRITIONAL ASSESSMENT

NUTRITION--DIETITIAN ONLY (for known patient or new referral if appropriate)

CHO counting: N Y Present meal plan (KJ/calories):

Meal plan: appropriate inappropriate Compensation for activities: appropriate inappropriate

Meal/snack timing: appropriate inappropriate School concerns: N Y

Treatment for hypoglycemia: appropriate inappropriate

Notable eating patterns: food restrictive behaviour overindulgence

Explain:

Comments:

QUESTIONS AND COMMENTS

Insulin Pump Follow-Up Form Update

Carrie Haggett RN BScN CDE

Objectives:

1. To review the history of the Insulin Pump Follow-Up form.

2. Review how the form was designed.3. Review the layout of the form.4. Give your input for the forms

improvement.

Insulin Pump Follow-up Form

• Concept designed in Sept 2012• Concept re-visited in June of 2014 we

started working with various NSIPP approved sites to develop a form that would allow patient self completion, capture the information needed for NSIPP renewal in the registry and assist educators who aren’t as familiar with pump therapy

• Current Insulin Pump Follow-up form dated Sept 2014

• Introduced at the DCPNS Pump Education Day in Nov 2014

• Please use for 1 year and than give us your feedback in Nov 2015.

Top of Page 1 of the Insulin Pump Follow-up FormINSULIN PUMP FOLLOW-UP FORM (Pages 1, 2 & 3 to be completed by patient/family) To help us make the most of your visit, please take a few minutes to complete this form. Please do not fill in the shaded area on page 3 & p age 4.

If there are parts you are unsure of, please leave blank and discuss with your team.

Page 1 & 2…• Are there other things you would like to

talk about (please check the most important ones)?

• Activity• Hypoglycemia• Self Monitoring of Blood Glucose• Goals• Sexual Health

Page 3…• Did you download your pump today?• Which Pump and Infusion set do you use?• What are your sites like and how often do

you change sites?• Basal insulin: insulin type and rates• Bolus: ICR and BG targets and • TDD, ISF and Active Insulin Time• Nutrition Notes (shaded)

Page 4…To be completed by Healthcare Providers• Hypoglycemia• DKA• B/P,Ht,Wt• Current A1C, Last A1C, A1C goal• School/Daycare plan in Place• Notes for Dietitian, Nurse, Physician

Let’s hear from you …

• If you have used the form and you have some constructive input to make the form more user friendly please submit your comments to…

carrie.haggett@dcpns.nshealth.ca

Partnerships, Quality, and Innovation (since 1991)

DCPNS Registry EnhancementsPump Day 2015

November 13, 2015

23Partnerships, Quality, and Innovation (since 1991)

DCPNS Registry – Medical Eligibility Criteria

● # DC visits, # A1Cs in last 12m (and the values), Goal A1C,

SMBG Freq & Use, DKAs, and S/Dcare plan at top of pump tab

24Partnerships, Quality, and Innovation (since 1991)

DCPNS Registry – Easier Entry

● No more extra clicks – just check the appropriate box/circle

– Enter Pump Start here & it will also appear under Present

Treatment & vice versa

25Partnerships, Quality, and Innovation (since 1991)

DCPNS Registry – Easier Entry

● Medical Eligibility (ME) area is always visible

– Critical to complete – populates the NSIPP side with the ME date

Partnerships, Quality, and Innovation (since 1991)

Thank-youQuestions?