Basal Bolus – What Adjustments? Pt Weighs 80Kg
Diabetes Boot Camp – Class 4 Beverly Dyck Thomassian, RN, MPH, BC‐ADM, CDE President, Diabetes Education Services
2017 www.DiabetesEd.net
Boot Camp 4 – Insulin, Patterns and More Determine appropriate insulin dosing Calculate insulin sensitivity and Carbs Consider individual patient characteristics Sick Days, Hospital and Lower Extremity Assessment, Hypoglycemia
Basal Bolus – What Adjustments? Pt weighs 80kg
Diabetes Educational Services© www.DiabetesEd.net Page 1 Basal Bolus Therapy Insulin Dosing Strategy
50/50 Rule Example 0.5‐1.0 units/kg day Wt 50kg x 0.5 = 25 units of (.5 units/kg most common) insulin/day Basal = 50% of total Basal dose: 13 units Glargine Q day Glargine 13 units Q day NPH or Detemir BID NPH/Detemir 6u BID
Bolus = 50% of total Bolus dose: 12 units usually divided into 3 4 units NovoLog, Apidra, Reg, meals Humalog each meal
Intensive Diabetes Therapy Insulin Dosing Strategy 50/50 Rule Example – You Try 0.3‐1.0 units/kg day Wt 80 kg x 0.5 = ___ (.5 units/kg most common) units of insulin/day
Basal = 50% of total Basal dose: ____ units Glargine Q day Glargine ____ units QD NPH or Detemir BID NPH/Detemir ____ BID
Bolus = 50% of total Bolus dose: ____ units usually divided into 3 ___units NovoLog, Apidra meals Humalog each meal
Basal Bolus – Using 50/50 Rule – Pt weighs 80kg
Diabetes Educational Services© www.DiabetesEd.net Page 2 Poll Question 1 Calvin takes 5 units reg before breakfast and dinner and 18 units of Lantus at HS. His am BG ranges from 143 to 172. What is best action? a. Increase dinner regular insulin to 6 units b. Decrease Lantus at HS by 2 units c. Increase Lantus dose at HS d. Evaluate him for somogyi effect
Poll Question 2 Calvin takes 5 units reg at dinner and 18 units of NPH at HS. His am BG ranges from 63 to 72. What is best action? a. Decrease dinner regular to 4 units b. Encourage him to eat bedtime snack c. Decrease NPH insulin at HS d. Have him check a 2am BG
Based on Mr R’s clinical picture – In hospital How Much Insulin Needed?
Creatinine 1.6 76 years old Not very hungry BMI 21 Weighs 80kg Glucotrol 5mg at home A1c 7.2%
Diabetes Educational Services© www.DiabetesEd.net Page 3 Calculate Daily Insulin Needs
Based on unique characteristics of pt, where would you start? Body wt in Kg x ______= total daily dose May need more or less based on clinical presentation
Less 0.3 u/kg 0.5u/kg More 1.0 u/kg
Thin, elderly, creat Heavy, infection, steroids
Calculate Insulin Needs Basal/ insulin carb/ correct
Body wt in Kg x 0.3 80kg x 0.3 = 24 units daily
Basal = 12 units Bolus = 12 units / 3 meals = 4 units each meal What if he is nauseated?
Poll Question 3 Mr. R is scheduled to get 4 units of Novolog insulin with his lunch tray. He tells you he is nauseated and not sure if he will be able to eat. What is the best action? A. Hold the insulin B. Give the insulin after he eats C. Have him drink 60 gms of juice and give insulin D. Give half the dose
Diabetes Educational Services© www.DiabetesEd.net Page 4 Basal Bolus Section Carb counting Prandial coverage Correcting for hyper and hypoglycemia
Poll Question 4 Mary takes 6 units lispro (Humalog) before dinner. Which BG result reflects that it was the right dose? a. Before breakfast BG of 97 b. 1 hr post dinner BG of 189 c. Before dinner blood glucose of 102 d. 2 hour post dinner BG of 178
Bolus Basics
Carbohydrate/ Prandial Coverage Match the insulin to the carbohydrates 1 unit for 15 gms ‐ Common starting point Or can use Carb/Insulin ratio formula Correction Bolus ‐ targets hyperglycemia 1 unit for every 30‐50 points over target Use 1500 – 1800 rule Adjust ratios depending on sensitivity and response
Diabetes Educational Services© www.DiabetesEd.net Page 5 Carb to Insulin Ratio > 450‐500 / Total Daily Dose 500 Rule - Humalog and Novolog • Divide 500 by total daily insulin dose. • Equals – Grams of carb covered by one unit of Humalog/Novolog insulin. • Example: Pt takes 33 total units /day. The equation is: 500 divided by 33 (total dose) = 15 • 1 unit insulin covers 15 grams carb
450 Rule for Regular Insulin • Divide 450 by total daily insulin dose. • Equals Grams of carb covered by one unit of regular insulin. • Example: Pt takes 45 units daily. The equation is: 450 divided by 45 (total dose) = 10 • 1 unit covers 10 grams of carb
Carbohydrate Ratio How does that work? Rapid/Fast Acting Insulin Serving Gms CHO Insulin Dinner (60 gms cho) Size Lemon Chicken 1 15 gms cho 1 unit 1 cup rice pilaf (45 gms cho) Asparagus 2 30 gms cho 2 units Dinner Roll (15 gms cho) 3 45 gms cho 3 units Blood Glucose 165mg/dl 4 60 gms cho 4 units
Poll Question 5 Pt on insulin pump takes 1 unit novolog for 15 gms of carb. Meal 1 cup rice, bbq steak, 1 c. skim milk, sm banana, SF ice tea. BG 118. How much insulin? a. 4.8 units b. 6.0 units c. 5.2 units d. 5.0 units
Diabetes Educational Services© www.DiabetesEd.net Page 6 Adjusting Bolus and Correction Doses Carbohydrate‐to‐Insulin Ratio
Based on three questions before meals:
1. How much carbohydrate am I going to eat? 2. What is my insulin dose for this amount of carbohydrate? 3. Should I lower the dose because I plan to be very active or have recently been active?
Correction Bolus Rapid/Fast Acting Insulin (1 unit:50 mg/dl>150)
Less than 70 Subtract 1 unit 70-150 mg/dl 0 units 151-200 mg/dl 1 unit 201-250 mg/dl 2 units 251-300 mg/dl 3 units 301-350 mg/dl 4 units 351-400 mg/dl 5 units
Poll Question 6 AR uses humalog insulin and the previous correction bolus. His blood glucose is 68 and he is going to eat 60 gms of carb (takes 1 unit for 10gms carb). How much insulin should he inject? 1. 4 units 2. 5 units 3. 6 units 4. Depends on his activity level
Diabetes Educational Services© www.DiabetesEd.net Page 7 Poll Question 7 Bob’s correction scale is 1 unit for every 30 above his target of 120. His BG is 270. How much correction insulin? 1. 4 units 2. 5 units 3. Needs to count carbs first 4. 3 units
Type 1 and a Teen Cindy is trying to carb count and adjust her insulin, but is still having trouble. She weighs 60kg. What is her daily dose of insulin? What is her basal dose? 1. Pre meal target BG is 120 2. Post meal goal < 180. 3. Carb ratio: 1 unit for every 15 gms 4. Hyperglycemic correction factor is 1700 Rule one unit for every 55 above goal 1700 / TDD = insulin sensitivity 1700 / 30 = 56 (she uses Humalog and 1700 rule) 1 unit drops BG 56 points
Correction Bolus for Cindy Analog Insulin (1 unit:55 mg/dl>120) Less than 70 mg/dl Subtract 1 unit 70-119 mg/dl 0 units 120-175 mg/dl 1 unit 176-230 mg/dl 2 units 231-285 mg/dl 3 units 286-340 mg/dl 4 units 341-395 mg/dl 5 units
Diabetes Educational Services© www.DiabetesEd.net Page 8 Adjusting Cindy’s Bolus Insulin With Ratios
BG before lunch 285, she plans to eat 45 gms of carbohydrate. 285‐120 = 165 over target, 165/55 = 3 45gms / 15 = 3 3 units bolus insulin to correct to target 3 units bolus insulin to cover carbs in meal
Total adjusted dose: 6 units humalog insulin
Adjusting Cindy’s Bolus Insulin With Ratios ‐You Try
BG before lunch 230, plans to eat 60 gms of carbohydrate. ____‐120 = ____ over target, ____/55 = ____units ______gms / ____ = ____ units ins for carbs _____ units insulin to correct for hyperglycemia _____ units insulin to cover carbs in meal Total adjusted dose: ___ units humalog insulin
How much Insulin Needed?
Morning ‐ BG 173 Breakfast – slice cold pizza, ½ c. applesauce Lunch BG 69 Menu‐ ham sandwich, pear, diet 7‐up, mini snickers bar. 2 hours after lunch, BG 148 ‐ ran track Before dinner ‐ BG 98 Cheeseburger, small fries, chocolate chip cookie At bedtime, BG 173
Diabetes Educational Services© www.DiabetesEd.net Page 9 How much Insulin Needed? Morning ‐ BG 173 Breakfast – slice cold pizza, ½ c. applesauce 45 gms = 3 units 1 unit for hyper total = 4 units Lunch BG 69 Menu‐ ham sandwich, pear, diet 7‐up, mini snickers 60 gms = 4 units ‐1 unit since < 70 total = 3 units 2 hours after lunch, BG 148 – ran track Before dinner ‐ BG 98 Cheeseburger, small fries, chocolate chip cookie 75 gms = 5 units 0 units for hyper At bedtime, BG 173 – 15 unit Lantus
Cindy, 60kg, Carb (1u/15gms) Target 120 pre meal, Hyper 1 for 55
Poll question 8 Paul has had type 1 diabetes for 40 years and injects insulin 4 times a day. Which of the following is most important to assess? a. Does he clean his needle before he reuses it? b. Is he avoiding superficial blood vessels? c. Does he bend his needle before placing in trash? d. Is he rotating sites?
Diabetes Educational Services© www.DiabetesEd.net Page 10 Insulin Teaching Keys
Bolus insulin with meals Toss opened insulin vial after 28 days Basal 1‐2xs daily Proper disposal Abdomen preferred injection site Review patients ability to withdraw and inject. Stay 1” away from previous Side effects include site hypoglycemia/wt gain Don’t re‐use ultra fine Insulin pens – syringes Prime needle to assure accurate insulin dose given Keep unopened insulin in Hold needle in for 5 seconds refrigerator after injection Look for hyper Roll 70/30 pens
Sharps Disposal: Product and Info
Look in the Government section white pages for a household hazardous waste listing for your city or county. Call 1‐800‐CLEANUP (1‐800‐253‐2687) Search for collection centers online
Monitoring, Sick Days and Hospital, Lower Extremities Objectives: 1. Identify barriers to monitoring and strategies to overcome them. 2. Discuss sick day management 3. State glucose goals during hospitalization.
Diabetes Educational Services© www.DiabetesEd.net Page 11 Poll Question 9 What is the most effective way to teach blood glucose monitoring? a. Ask pt to carefully read instructions in the box b. Send patient home with video instruction c. Demonstrate how to use meter d. Review steps and ask patient for return demonstration
How will it help me?
See if your treatment plan is working Make decisions regarding food and/or med adjustment when exercising Find out how that pizza affected your BG Find patterns Manage illness
How Often Should I Check? Be realistic!! Type 2 on orals – Medicare covers 100 strips for 3 months Based on individual ‐ Consider: Types and timing of meds Goals Ability (physical and emotional) Finances / Insurance
Diabetes Educational Services© www.DiabetesEd.net Page 12 ADA Guidelines Self monitoring before: meals, snacks, bedtime Occasional postprandial and before exercise When patient suspects low blood glucose; after treating low blood glucose until patients are normoglycemic Before critical tasks such as driving Some patients will need to test more depending on activity level, frequency of eating. Be practical, no two patients or two days are alike
Glucose Monitoring Baseline Learning Care for meter and test strips Perform quality control Proper disposal of lancets Identify BG target and when to test Recording and interpreting data 800 number Adequate sample User Error most common reason for inaccurate results
Alternate Site Testing? Yes No Finger fatigue Pregnant No risk of hypo On intensive insulin Stable BG Levels therapy If BG< 90, recheck on During finger hypoglycemia During illness
Not as accurate during glucose fluctuations
Diabetes Educational Services© www.DiabetesEd.net Page 13 Poll Question 10 What is the best sick day recommendation for someone with type 2 diabetes? a. Stop all diabetes medications b. Test BG every 1‐2 hours c. Continue to take diabetes meds d. Only drink sugar free beverages
Sick Day Patient Guidelines
Continue to take diabetes medication, may need adjust dose down or up Test glucose at least every 4 hrs Drink plenty of liquids Rest Contact physician Plan ahead Check urine ketones, if BG >240 & ill
Sick Day Guidelines Reasons to Call MD
Vomiting more than once Diarrhea > than 5x’s or for > 24 hrs Difficulty breathing Blood glucose > than 300mg/dl on 2 consecutive readings Temperature > 101 F. Positive ketones in urine.
Diabetes Educational Services© www.DiabetesEd.net Page 14 Level 2 Online Courses to Review
Hyperglycemic Crises Setting up a Successful Diabetes Program ‐ Diabetes Self Chronic Complications Lower Extremity Assess Hospital Care and Diabetes
Life Study – Mrs. Jones Mrs. Jones is 62 years old, a little heavy and complains of feeling tired and urinating several times a night. Admitted with a foot infection. Her WBC is 12.3, glucose 237.
What are her BG goals? How would we manage BG in hospital?
ADA Goals and Treatments For Hospitalized Patients Non Critically Ill pts if BG 180 + Start subq insulin Blood glucose goals: 140 ‐ 180 Basal /bolus Insulin preferred treatment
Critically Ill pts Start insulin therapy at BG 180 Once insulin started, BG goal 140‐180 Insulin drip preferred treatment
Diabetes Educational Services© www.DiabetesEd.net Page 15 Steps to Prevent Hypo If fasting BG < 100, consider adjusting basal insulin If patient has renal failure, conservative insulin dosing required Patient has N/V or not consistent eater? Give bolus insulin after meals Anticipate events that put pt at risk of hypo: NPO for surgery, decreasing steroid dose, improving infection, recovering after cardiac event Strive to admin the least amount of insulin necessary to reach glycemic targets
Life Study – Mrs. Jones
What kind of education would we provide?
Is Inpatient Diabetes Education Realistic? Unique opportunity to address urgent learning needs Brief and targeted education effective Strategies Empathic listening and open ended questions “What are you most worried about when it comes to taking care of your Look for diabetes. “teaching moment” opportunities Assist w/ needed supplies and referrals
Diabetes Educational Services© www.DiabetesEd.net Page 16 General Recommendations Diabetes discharge planning starts on admit Type of DM clearly identified / documented Check A1c in hospital: If no A1c available for past 3 months Present with hyperglycemia and no DM history Pts with new hyperglycemia need appropriate follow‐up testing care and testing at d/c
Topics to Cover in Hospital Survival Skills Diabetes, self‐monitoring, BG Goals Hypo & Hyper – recognition, treatment and prevention Healthy eating Meds‐ how to take, potential side effects and action Proper use and disposal of needles and syringes ID of health care provider for post d/c care Schedule for f/u visit within 1 month Parameters of when to call for help Sick days, N/V, if BG < 70 or > 300
MNT In Hospital Setting Goal of MNT Optimize glycemic control Adequate calories for metabolic demands Create meal plan guidelines for post discharge Consistent Carb Meal plan most common RD responsible for integrating pts clinical condition to determine a realistic plan for MNT RD referral inpt > outpt
Diabetes Educational Services© www.DiabetesEd.net Page 17 Mrs. Jones on Insulin ‐ Now What? Nurse administered Nurse had an insulin and pt only ate emergency and pt a few bites of turkey already ate lunch? and drank non sugar tea?
You just gave 3 units of Novolog and patient needs to go to OR NOW!
Poll Question 11 Nurse gave 3 units aspart (Novolog) insulin and pt needs to go to OR now! Best action? A. Call OR and tell them to postpone surgery B. Give the patient 4 ounces of juice C. Push 1 amp of D50 D. Hang IV of 5‐10% Dextrose and alert anesthesia
Mrs. Jones needs to go to surgery In spite of antibiotics, her foot ulceration isn’t improving.
Diabetes Educational Services© www.DiabetesEd.net Page 18 Preparation for Surgery
Try to schedule surgery in am, resume meds/insulin when eating and stable. Oral medications: Hold morning dose. If on sulfonylurea, may need to hold night before Basal Insulin: Type 2, give 50%‐100% of usual am/pm basal dose for type 1s give 100% of basal dose (individualize) Bolus insulin: Use mild insulin bolus coverage for type 1 and type 2’s
Getting Mrs. Jones Ready for Discharge Mrs. Jones is improved and ready to go home. What glucose management strategies for home? Her A1c = 7.9%
Medication Reconciliation Pts meds must be crossed‐ checked to make sure no chronic meds were stopped Ensure the safety of new prescriptions New or changed prescriptions reviewed with pt/ family before discharge Avoid complex insulin regimens for those with limited cognition As pt heals, remind them that they may need less insulin / diabetes meds to control BG Supplies for insulin administration
Diabetes Educational Services© www.DiabetesEd.net Page 19 Moving on to the Lower Half
Diabetes and Amputations
Rate declined by 65% from 1996‐2008 From 11.2 per 1000 to 3.9 per 1000
Diabetes = 8 fold risk of amputations Highest rate in those over 75 50% of amputations can be avoided through self‐care skill education and early intervention Stats from CDC 2012
No Bathroom Surgery
Diabetes Educational Services© www.DiabetesEd.net Page 20 Lower Extremities Lift the Sheets and Look at the Feet
Foot Care Standards ADA Provide foot care education to pts w/ diabetes High risk pts – use multidisciplinary approach Wound specialist, Vascular specialist, Pedorthist etc. Refer to foot care specialists for lifelong surveillance if: smoke, loss of protective sensation, structural abnormalities, hx of lower extremity complications Initial screen for PAD includes: Assess for intermittent claudication and pedal pulses. Refer high risk pts for further vascular assess and consider exercise, meds, surgical options.
Profile of a High Risk Foot ADA Previous amputation Previous foot ulcer history Peripheral neuropathy Foot deformity Peripheral vascular disease Vision impairment Diabetic neuropathy (esp if on dialysis) Poor glycemic control Cigarette smoking
Diabetes Educational Services© www.DiabetesEd.net Page 21 You Can Make A Difference
Assess Nail condition, nail care, in between the toes Who trims your nails Have you ever cut your self? Shoes – type and how often Socks Skin/skin care and vascular health Ability to inspect Loss of protective sensation
5.07 monofilament delivers 10gms linear pressure
10 Free Monofilaments www.hrsa.gov/hansensdisease/leap/
Lower Extremities "Every time you see your doctor, take off your shoes and socks and show your feet!" For those at high risk for foot complications All patients with loss of protective sensation, foot deformities, or a history of foot ulcers
Diabetes Educational Services© www.DiabetesEd.net Page 22 Three Most Important Foot Care Tips Inspect and apply lotion to your feet every night before you go to bed.
Do NOT go barefoot, even in your house. Always wear shoes!
Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away!
Hypoglycemia
Objectives: Describe identification and treatment of hypoglycemia. Discuss it’s impact on the person living with diabetes
Diabetes Educational Services© www.DiabetesEd.net Page 23 Mr. Jones ‐ What are Your Recommendations? Patient Profile Self‐Care Skills 64 yr old with type 2 for Walks dog around 11 yrs. Hx of CVD. On block 3 x’s a week glyburide 10mg BID. Bowls every Friday Labs: 3 beers daily A1c 6.3% HDL 37 mg/dl What concerns? Triglyceride 260mg/dl Tells you I get Proteinuria ‐ neg shaky a lot? B/P 152/94
Poll question 11 Which of the following put Mr. Jones at risk for hypoglycemia? a. 3 beers a day b. Elevated triglyceride levels c. Limited income to purchase food d. Hypoglycemia unawareness
Hypoglycemia – “Limiting Factor”
Defined as glucose of 70mg/dl or below 50% of episodes occur during night Mortality with severe hypoglycemia secondary to sulfonylureas Especially (glyburide) Micronase®, Diabeta® Blood glucose levels don’t describe severity, response is individual
Diabetes Educational Services© www.DiabetesEd.net Page 24 Hypoglycemia Symptoms
Autonomic Neuroglycopenia Anxiety Irritability Palpitations Drowsiness Sweating Dizziness Tingling Blurred Vision Trembling Difficulty with Hypoglycemic speech Unawareness Confusion Feeling faint
Hypoglycemia: Clinical Risk Factors
Diabetes medications Intensive insulin therapies Impaired kidney or liver function Advanced age, poor nutrition Near normal A1c History of frequent hypoglycemic episodes Neuropathy Alcohol intake
Nocturnal Hypoglycemia
Signs include: Vivid dreams Waking up with headache Night sweats Waking up hungry Elevated (rebound) or low morning blood glucose
Diabetes Educational Services© www.DiabetesEd.net Page 25 Hypoglycemia Awareness autonomic symptoms adrenergically based after 2‐5 yrs of type 1 diabetes, glucagon secretion impaired epinephrine secretion becomes primary mechanism to restore BG levels over time, epinephrine response diminished or delayed decreases awareness of hypo and hormonal response
Treatment of Hypoglycemia If blood glucose 70mg/dl or below: 10‐15 gms of carb to raise BG 30 ‐ 45mg/dl Retest in 15 minutes, if still low, treat again, even without symptoms Follow with usual meal or snack If BG less than 40, allow recovery time Decrease diabetes meds
Tx of Severe Hypoglycemia If can swallow w/out risk of aspiration, try gel, honey, etc. inside cheek If unable to swallow, D50 IV or Glucagon Glucagon injection – teach support person Dosing: Adults 1mg Children <20kg 0.5mg Glycemic effect 20 ‐ 30mg, short lived Must intake carb as soon as able Need prescription, check exp. date
Diabetes Educational Services© www.DiabetesEd.net Page 26 Glucagon Emergency Kit
Store 68‐77 degrees prior to reconstitution single use only
Preventing Hypoglycemia Nocturnal Lows Other On insulin, don’t skip Monitor kidney presleep snacks function / wt changes If bedtime glucose Monitor BG trends <110, reduce meds Don’t over medicate If increased activity, Balance food / activity increase cals Plan ahead Eval hs insulin/meds Alcohol
Thank You
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Diabetes Educational Services© www.DiabetesEd.net Page 27