WELCOME TO METRO DIABETES MANAGEMENT CLASS
Kacy Aderhold, MSN, APRN-CNS, CMSRN Metro Diabetes Management
INTEGRIS Health is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s commission on accreditation.
This activity has been provided through INTEGRIS Health for 5.5 contact hours if all sessions are attended.
Participants are required to attend the complete session and turn in an evaluation for each session attended in order to receive contact hours for that session.
No influencing relationships or conflicts of interest have been identified in the planning or presentation of this activity. Course Objectives
• Discuss the disease process of diabetes • Differentiate between: Pre-diabetes, T1DM, T2DM, Gestational Diabetes, and Stress Induced Hyperglycemia • Identify Core Measures related to in-patient diabetes care • Identify patient education strategies and interventions • Discuss oral agents and insulin preparations for diabetic patients • Demonstrate insulin administration using an insulin pen device • Discuss goals of nutrition for patients with diabetes • Demonstrate knowledge of basic carbohydrate counting • Discuss POC testing and implication of uploading results • Demonstrate understanding of basal/bolus regimen with case scenarios • Recognize acute and chronic complications associated with diabetes • Discuss prevention and treatment of diabetes related complications • Discuss proper EMR documentation for patients with diabetes* • Discuss INTEGRIS protocols including HMP, Hypoglycemia Management Protocol, and Insulin Infusion Protocols* • Discuss INTEGRIS Resources* *Not included in contact hours DISEASE PROCESS
Kacy Aderhold, MSN, APRN-CNS, CMSRN What is Diabetes?
Diabetes is a metabolic disease resulting in elevated blood glucose levels caused by the body’s complete lack of insulin production, or the cell’s resistance to the circulating insulin.
Diabetes Basics The Role of Insulin Prevalence
• Diabetes affects 29.1 million people or 9.3% of the U.S. population
• Another 79 million have pre-diabetes and are at risk for developing type 2 diabetes.
• Diabetes is the seventh leading cause of death in the U.S. • 69,071 death certificates listed DM as cause of death • 234,051 death certificates listed DM as a contributing cause of death
• Recent estimates project that as many as one in three American adults will have diabetes in 2050.
(CDC, 2014)
Prevalence in the U.S.
2008 Age-Adjusted Estimates of the Percentage of Adults with Diagnosed Diabetes (CDC, 2011) Prevalence in Oklahoma
2008 Age-Adjusted Estimates of the Percentage of Adults† with Diagnosed Diabetes in Oklahoma (CDC, 2011) Three Main Types of Diabetes
• Type 1: body does not produce insulin
• Type 2: body’s cells are resistant to insulin
• Gestational: high blood glucose during pregnancy
Type 1 Diabetes (T1DM)
• Result of body’s failure to produce insulin
• Formerly known as juvenile diabetes or Insulin Dependent Diabetes Mellitus (IDDM)
• Auto-immune destruction of the β cells of the pancreas
• Causes largely unknown- environmental and genetic • Relatives of patients with T1DM have an increased risk for T1DM
• 5% of people that have diabetes have Type 1 (CDC, 2014)
• Usually a sudden onset
Type 1 Diabetes
The lack of insulin results in elevated blood sugar because the sugar is not getting into the cell. Type 1 Diabetes Treatment
• INSULIN • The pancreas in patients with T1DM does not make insulin, so these patients MUST be on insulin!
• Exercise
• Nutrition Type 2 Diabetes (T2DM) • Result of the body’s cells developing resistance to the circulating insulin
• Formerly known as Non- Insulin Dependent Diabetes Mellitus (NIDDM) or adult-onset diabetes
• May have excessive circulating insulin
• 90-95% of patients with diabetes have T2DM (CDC, 2014)
• Progressive
Type 2 Diabetes
Glucose cannot enter the cell in spite of insulin because the body’s cells are resistant to the insulin. To overcome the resistance, the pancreas has to produce more insulin to get the sugar into the cell. The pancreas works hard to produce more and more insulin, eventually the pancreas gets tired. That is what makes Type 2 diabetes a progressive disease.
What is Diabetes?
Risk Factors for T2DM
• Primarily genetic • Family history • Member of ethnic group with high prevalence of diabetes • Physical Inactivity • Obesity • History of GDM or delivery of large for gestational age infant • Hypertension • Depression • Low HDL cholesterol • Diagnosis of Polycystic Ovarian Syndrome (PCOS) • Age is no longer a reliable indicator (CDC, 2014) (CDC, 2014) Metabolic Syndrome A combination of metabolic risk factors that predispose individuals to CVD & T2DM, defined as any 3 of the following:
• Abdominal obesity, defined as a waist circumference in men ≥102 cm (40 in) and in women ≥88 cm (35 in) • Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides • Serum HDL cholesterol <40 mg/dL (1 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C • BP ≥130/85 mmHg or drug treatment for elevated BP • Fasting plasma glucose (FPG) ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose
(ATPIII, 2001) Type 2 Diabetes Treatment
• Exercise
• Nutrition
• Medications • Oral agents • Insulin Signs and Symptoms of Diabetes
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Slow healing
• Frequent infections
• Fatigue
These symptoms may be more of a sudden onset for Type 1 and develop more slowly in Type 2 Diagnosis of Diabetes
A1C > 6.5 % Fasting Plasma Glucose > 126 mg/dL (FPG) Oral Glucose Tolerance > 200 mg/dL Test (OGTT) 2 hour sample Random Plasma > 200 mg/dL plus Glucose classic symptoms* of hyperglycemia * Classic Symptoms of Diabetes: polyuria, polydipsia, unexplained weight loss (ADA, 2015) So what is a HbA1c?
• Also called glycosylated or glycated hemoglobin test.
• Measures what percentage of your hemoglobin (a protein in red blood cells that carries oxygen) is coated with sugar (glycated).
• A measure of blood glucose levels over the previous 90 days.
• Measuring A1C gives a big picture of glucose levels, while a blood glucose check gives a snapshot of that moment.
• This number tells about the risk for complications. Research has shown that keeping A1C levels at 7% or lower helps prevent or delay long-term complications of diabetes.
• An A1C of 6.5 can be used to diagnose someone with diabetes.
This table shows the relationship ↓7 = well controlled between an A1C result and the 7-8.4 = mildly controlled patient’s 8.5-9.9 = moderately estimated controlled average glucose number in mg/dL. ↑10 = severely uncontrolled Fasting vs. Random Blood Glucose Tests Fasting Blood Glucose Random Blood Glucose
• Done after not eating for 8 • Taken randomly hours throughout the day • Usually done before • Take into account the breakfast effect of food • Blood glucose is highest • Tells how well the after a meal pancreas is keeping up • If blood glucose is high with the liver before a meal, the pancreas is not keeping up with the food the patient is eating. Gestational Diabetes
• When a woman not previously diagnosed with diabetes has high blood glucose levels during pregnancy
• Occurs in approximately 2-10% of all pregnancies (CDC, 2012)
• Screen at first prenatal visit for those with risk factors and 24-28 weeks gestation for all others OGTT: Oral Glucose Tolerance Test
• First test is taken while fasting • The patient drinks a sweet liquid that contains glucose, usually 75 grams of carbohydrates • A series of tests are taken every 30-60 minutes after drinking the drink, up to 3 hours
The diagnosis of GDM is made when any of the plasma glucose values are exceeded:
(ADA, 2015) Causes
The hormones produced Hormones during pregnancy increase the amount of insulin needed to control blood glucose levels. If the body can’t meet this increased need for insulin, women can develop gestational diabetes during the late stages of pregnancy.
Risk Factors for Gestational Diabetes
• Obesity • First degree relatives with type 2 diabetes • History of abnormal glucose tolerance or poor obstetric outcome • Diagnosis of PCOS • Member of an ethnic group with a high prevalence of DM • Hispanic • African American • Native American • South or East Asian • Pacific Islanders Diabetes Complications in Pregnancy
• Poorly controlled diabetes before conception and during the first trimester among women with type 1 diabetes can cause major birth defects and spontaneous abortions
• Poorly controlled diabetes during the second and third trimesters can result in excessively large babies, posing a risk to both mother and child.
Complications of Gestational Diabetes (cont.)
Mother Baby • ↑ risk of pre-eclampsia • Neonatal macrosomia
• ↑ risk for C-section • Shoulder dystocia
• More likely to develop type • Hypoglycemia after birth 2 diabetes later in life • ↑ risk for childhood obesity • More likely to develop gestational DM in future • ↑ risk for developing type 2 pregnancies diabetes later in life
Gestational Diabetes Treatment
• Exercise
• Nutrition
• Insulin
• F/U 6-12 weeks post partum for T2DM screening Gestational Diabetes Goals of Control
(ACOG, 2005) What is Normal?
Euglycemia = normal blood sugar
A1C about 5
Fasting plasma glucose 99 or below
OGTT 139 or below
What is Normal?
• The body’s goal is homeostasis. Many hormones work together in the body to regulate blood sugar:
Insulin- produced in β-cells of pancreas, gatekeeper for transporting glucose into cells
Amylin- produced in β- cells of pancreas, works post-prandial (after meal), moderates appetite
Glucagon- produced in the ά-cells of pancreas, makes energy available in the absence of food
Incretin- secreted from intestinal cells in response to absorption of nutrients, gives “full” feeling
Others: cortisol, norepinephrine, epinephrine, growth hormone Definitions of Abnormalities
• Hyperglycemia is any BG > 140 mg/dL • Pre-diabetes (or at risk for diabetes) describes those metabolic states that occur when blood glucose levels are elevated, but remain below levels established for the clinical diagnosis of diabetes mellitus.
• Stress Hyperglycemia is hyperglycemia in a patient without previous diagnosis of diabetes, can be determined by A1C
• Hypoglycemia is a BG < 70 mg/dL
• Severe hypoglycemia is a BG < 40 mg/dL
(ADA, 2011) CLINICAL DIAGNOSIS
(ADA, 2012) Prediabetes
• 86 million or 37% of U.S. adults have prediabetes
• Treatment • Supportive, ongoing weight loss program • Follow-up counseling • 5-10% body weight loss • At least 150 minutes per week moderate activity • Metformin (Glucophage®) for high risk individuals • Individualized diet • Reduced calories and fat • 14 g fiber / 1000 calories • Whole grains (1/2 of grain intake)
(CDC, 2014) Stress Induced Hyperglycemia
• Transient elevation in blood glucose levels in response to the stress of an illness
• Typically resolves spontaneously
• Especially common in dehydrated patients and those with elevated catecholamine levels (fight-or-flight hormones)
• Result of an inflammatory response
• Result of medication therapy
• Treat like diabetes
Stress Hyperglycemia Patient Education Evidence-Based Practice
• There is substantial evidence linking hyperglycemia in patients (with and without diabetes) to poor outcomes.
Evidence
• Leuven Medical Trial, 2001 • The first study that provided evidence of a decrease in morbidity, mortality, and LOS while using an intensive insulin infusion keeping patients’ blood glucose levels 80-110 mg/dL in the ICU. • NICE-SUGAR Study, 2009 • The most recent and largest random control trial. This study revealed that intensive insulin therapy (at or below 110) increased morbidity. This may have been due to hypoglycemia.
• Currently, the American Diabetes Association and American Association of Clinical Endocrinologists regularly review literature and provide evidence-based Clinical Practice Recommendations & Position Statements. Hyperglycemia Treatment Goals Non-Critically Ill Patients in the Hospital
These goals are identified to provide “reasonable, achievable, and safe glycemic targets”
• Premeal BG target < 140 mg/dL • Random BG target < 180 mg/dL • IBMC Goal: 80-139 mg/dL • INTEGRIS HMP initiated for patients with FSBS>140 mg/dL • More stringent targets on stable patients with previous tight control • Less stringent targets for patients with severe comorbidities or who are terminally ill (ADA, 2015) Hyperglycemia Treatment Goals Critically-Ill Patients in the Hospital
• For the majority of critically ill patients in the ICU, insulin infusions should be used to control hyperglycemia (ADA, 2015)
• The Intensive Insulin Infusion Protocol is initiated via physician order and only used in the ICU
• Insulin infusion should maintain glucose level of 140-180 mg/dL (ADA, 2015)
• DKA patients have a separate protocol
Diabetes - The Iceberg Effect!
Hyperglycemia in the hospital: • Increases Infection • Increases morbidity • Increases mortality • Increases Length of Stay
Survival Skills Discharge Education
• Provider who will manage DM after discharge • Assess need for HH or outpatient DM education • Diagnosis • SMBG & home goals • Information on consistent eating patterns • When & how to take BG lowering medications • Sick day management • Proper use & disposal of needles & syringes
(ADA, 2015) Diabetes Pearls of Wisdom
• Diabetes is hard work.
• “Diabetes management is a full-time job…It involves thinking about what, when, and how much to eat, while also factoring in exercise, medication, stress, blood sugar monitoring, and so much more – each and every day” (Behavioral Diabetes Institute, 2011).
• Patients with diabetes can live a long healthy, and happy life with diabetes
References
American College of Obstetricians and Gynecologists (2005). Pregestational diabetes mellitus (Practice Bulletin No. 60). Washington, DC: Author.
American Diabetes Association (2010). Diabetes Basics: What is Diabetes Video. https://www.youtube.com/watch?v=MHlWM8_iqfA
American Diabetes Association (2015). Standards of Care. Diabetes Care 38 (1), S1-S99.
American Diabetes Association. Standards of Medical Care in Diabetes—2011 (Position Statement). Diabetes Care, 34(1), S4-S48.
Behavioral Diabetes Institute, (2011). Tools to face the psychological demands of diabetes. http://behavioraldiabetesinstitute.org/
Centers for Disease Control, (2011). National Diabetes Factsheet, 2011. http://www.cdc.gov/
Centers for Disease Control ,(2014). National Diabetes Statistics Report, 2014. http://www.cdc.gov/diabetes/pubs/estimates14.htm
Centers for Disease Control, (2014). Children and Diabetes- more information. http://www.cdc.gov/diabetes/projects/cda2.htm
Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III), (2001). JAMA, 285(19), 2486.
Kruger, D. F., Aronoff, S. L., Edelman, S. V., 2007. Current and future perspectives on the role of hormonal interplay in glucose homeostasis. The Diabetes Educator. 33(S2), 32S-46S.
Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., et al. (2009). American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on inpatient glycemic control. Endocrine Practice, 15(4), 1-15.
The NICE-SUGAR Study Investigators (2009). Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine, 360(13), 1283-1297.
Van den Burghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., Vlasserlaers, D., Ferdinande,P., Lauwers, P., & Bouillon, R. (2001). Intensive insulin therapy in critically ill patients. The New England Journal of Medicine, 345(19), 1359-1367.