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