Diabetes

Chapter 52

TIA 2005

Stroke 2006

MI 2003

MI 2004

Bypass 2001

PAD 2002

Ischemic Toes Amputation 2004

Neuropathy 2003

CKD 2002

Retinopathy 2004

ACS 2001

Victor59 years oldType 2 Diabetes

Victor59 years oldType 2 Diabetes

TIA 2005

Stroke 2006

PAD 2002

Ischemic Toes Amputation 2004

MI 2003

MI 2004

Bypass 2001

ACS 2001

Macrovascular

Neuropathy 2003

CKD 2002

Retinopathy 2004

Microvascular

Reorganize his history

He has EVERY complication of DiabetesThat is what we need to avoid

What is diabetes

• A chronic disease resulting from deficient glucose metabolism

• Caused by insufficient insulin secretion from beta cells, or resistance to insulin’s action

• Result: hyperglycemia

Insulin is the key that opens the door

Classification of diabetes

• Type 1 diabetes - Beta cell destruction prone to ketoacidosis. Autoimmune process = no insulin

• Type 2 diabetes- Insulin deficiency and insulin resistance. Not prone to ketoacidosis

• Gestational diabetes - Glucose intolerance during pregnancy.

7

Risk factors for Type 2 DM

Aging

Family history

Gestational diabetes

Hypertension

Dyslipidemia

Prediabetes

Overweight ( esp. abdominal obesity)

PCOS

Member of high risk population (aboriginal, Hispanic,Asian or African descent)

Schizophrenia

8

Type 2 DM

• Causes are multlifactoral, see list of risks.

• Pancreas is making insulin, not enough, (too much in early years.)

• Insulin resistance at the cell level.

• Liver overproduces/releases stored sugar.

9

Type 1 diabetes

• Causes ? Genetics, viral , environmental

• No one knows for certain.

• Newborns to 30-40 year olds.

• Onset is rather dramatic, diagnosis based on symptoms and random or fasting sugar.

• No pancreatic insulin production

• Very sensitive to insulin.

10

FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hours

or

A1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the

accuracy of the A1C and not for suspected type 1 diabetes

or

2hPG in a 75-g OGTT ≥11.1 mmol/Lor

Random PG ≥11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal

2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

Diagnosis of Diabetes2013

Diagnosis of Prediabetes*Test Result Prediabetes Category

Fasting Plasma Glucose(mmol/L)

6.1 - 6.9

Impaired fasting glucose (IFG)

2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)

7.8 – 11.0 Impaired glucose tolerance (IGT)

GlycatedHemoglobin(A1C) (%)

6.0 - 6.4 Prediabetes

* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

2013

Symptoms / findings:

• 3 “P’s”• Polyuria

• Polydipsia

• Polyphagia

• Weight loss

• Hyperglycemia

• Ketonuria

Canadian Diabetes Association CDA

Goals in treatment of diabetes 1• Glycemic goals ( glucose)

Blood glucose tests with home monitoring

Before meals 4 - 7 mmol/L

2 hours after meal 5 - 10 mmol/L

A1C target of ≤ 7 %

(reflects past 3 months of sugar control)

14

Individualizing A1C Targets

which must be balanced against the risk of hypoglycemia

Consider 7.1-8.5% if:

2013

As important as glycemic goals…..

• Blood pressure control

130/80 or less.

Cholesterol control

LDL 2.5 or less

Stricter tighter control than non-diabetic pop.

16

Type 2 diabetes treatment

• Weight loss

• Regular exercise

• Healthy eating.

• Self blood glucose monitoring

• Pills

• Insulin may be needed.

• Both pills and insulin together is common.

• Stress management

17

Pills for type 2 diabetes

• Stimulate the pancreas to increase insulin secretion.

Glyburide (Diabeta)®

Gliclazide (Diamicron)®

Repaglinide (Gluconorm)®

Nateglinide (Starlix)®

Glimepiride (Amaryl)®

Risk of low blood sugars with this class.

May cause weight gain.

18

Pills for type 2 diabetes

• Decrease the overproduction of glucose by the liver.

Metformin (Glucophage)®

Can cause g.i. side effects, titrate slowly

Does not cause low blood sugar. No weight gain.

Controls appetite in some.Risk of lactic acidosis.

19

More pills

• Sensitize body cells to the insulin being produced. Muscle, fat and liver tissues mainly.

Rosiglitazone (Avandia) ®

Pioglitazone (Actos)®

Do not cause lows, contraindicated in CHF, advanced heart disease due to possible fluid like weight gain. Can add to all other classes of diabetes pills.

20

Pills for type 2 diabetes

• Act on small intestine to block the absorption of carbohydrates = glucose

Prandase (Acarbose) ®

Needs to be taken with the 1st bite of meal or large snack. On its own doesn’t cause lows.Can be added to all other classes.

21

Choice of oral agent (pills)

• Will be influenced by symptoms and

• A1C

• Adherence/financial concerns

• Family supports

• Alcohol history

• Liver enzymes

• Followup care

22

Combinations of all 4 classes

• Usually start with one drug and add on as its effect/ side effects are assessed.

• Try to keep it simple, yet nature of diabetes and its treatment is not simple.

• Adherence to routine is important to think about/ ask about.

• Assess,plan, implement and evaluate frequently, the clients self-management.

23

Type 1 diabetes treatment

• Insulin. (always)

• Healthy eating.

• Self blood glucose monitoring / ketone monitoring.

• Exercise.

• Stress management.

24

INSULIN (always Type 1 - often Type 2 )

• See attached reference, breaking the code.

• Many types

• Many routines used

• Various delivery devices ( syringe,pen,pump)

• Very little discomfort associated with injection.

• Psychological barriers.

25

Insulin • Insulin lowers the concentration of glucose mainly by:

• Inhibiting hepatic glucose production

• Stimulating the uptake and metabolism of glucose by muscle and adipose tissue

Types of Insulin

Types of Insulin (continued)

Ser

um

Insu

lin L

evel

Time

Analogue Bolus: Apidra, Humalog, NovoRapid

Human Basal: Humulin-N, Novolin ge NPH

Analogue Basal: Lantus, Levemir

Human Bolus: Humulin-R, Novolin ge Toronto

Time

Ser

um

Insu

lin L

evel

Human Premixed: Humulin 30/70, Novolin ge 30/70

Analogue Premixed: Humalog Mix25, NovoMix 30

Commercially prepared insulin

• Must be injected, due to destruction by GI secretions

• SC preferred method

• Only Regular (R) insulin can be given IV

• Comes in a multi-dose 10 ml vial, with a concentration of 100u/ml• **Insulin syringe marked in 100u/ml, and MUST be

used to administer insulin**

It is recommended that insulin injection sites be

rotated. Why?A. You don’t want to cause unsightly bruising

by over using one spot.

B. You need to have insulin absorbed at different rates at different times of the day.

C. Overuse of one injection site will affect the rate of insulin absorption due to lumps formed in the fatty layer (lipohypertrophy) and hardening and thickening of the dermis layer.

32

Specific notes Intermediate Duration

• Neutral Protamine Hagedorn (NPH)

• Regular insulin + protamine (large protein)• Presence of protein decreases solubility and slows

absorption

• Onset and duration are therefore delayed, prolonged

• Make sure to roll 10 times and to flip 10 times before drawing up

Insulin Preparation

Administer within 5 minutes of preparing it if insulin’s are mixed (short or rapid acting can combine with longer acting, reducing the action of the faster acting insulin)

When giving insulin, must always be checked with instructor or RN (have MAR cosigned)

Know blood glucose level before administration (is it safe to give) and know the S&S of hyperglycemia/hypoglycemia

Hypoglycemia….. Rule of 15

• Blood glucose of 4 mmol/L or less

• Provide 15 grams of sugar ( 3 tsps)

• Choose rapid absorbing sugar source

• Juice or regular pop, 1 cup.

• Recheck glucose in 15 mins.

• Repeat above treatment if Bg is same or less. Follow with a starch snack ( roll, crackers, granola bar etc.)

• For mild to moderate hypoglycemia.

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Severe Hypoglycemia

• Unable to swallow

• Unconscious

• Seizure

• Require Glucagon injection

• Or IV dextrose.

• It’s an emergency situation.

36

Skill

• always draw up the short acting insulin first • to avoid inadvertently adding the longer acting insulin

to the short acting insulin

• mix those with particles well to achieve accurate dose (want uniform cloudiness)

• do not aspirate

• safe disposal of needles

Factors affecting SC absorption• Site of injection (Fastest to slowest)

• Abdomen > arm > hip > thigh> buttock • Abd provides most consistent & rapid site for absorption

• Temp (High increases/Low decreases absorption)

• Local message increases amount absorbed

• Smoking: increases PVR and decreases absorption…so if someone quits…

• Lipohypertrophy• Fatty deposits in area of repeated injection will reduce insulin absorption

(may act as a reservoir)• Systematically rotate injection site by at least 1-2 inches to prevent

lipodystrophy

• Avoid scar tissue & stay away from 2” radius of belly button

• Dose – smaller doses absorbed more rapidly

• Dehydration • decreased blood flow to SC tissue decreases absorption

• Daily absorption can vary up to 30% using same site at the same time

Storage• Vials not in use – refrigerated (2 to 8 degrees)

• Avoid direct sunlight

• Insulin - kept at room temp if contents of the vial will be used within 28 days (exception insulin levemir which is stable for 42 days)

• Insulin at room temp decreases irritation at inj site

• Stability of insulin at temps 24-38 degrees

• Look it up! As things change….

Vascular Protection Checklist A • A1C – optimal glycemic control (usually ≤7%)B • BP – optimal blood pressure control (<130/80)C • Cholesterol – LDL ≤2.0 mmol/L if decided to treat D • Drugs to protect the heart (regardless of baseline

BP or LDL)

A – ACEi or ARB │ S – Statin │ A – ASA if

indicated E • Exercise / Eating healthily – regular physical

activity, achieve and maintain healthy body weightS • Smoking cessation

2013

Long term complications

• Accounts for >90% of diabetic deaths

• Most complications occur secondary to disruption of blood flow.

• Prior to development of Insulin therapy, diabetics died before chronic complications could develop

…cont’d

• Macrovascular disease:• Cardiovascular (HTN, heart disease, CVA)

• Atherosclerosis develops earlier and faster than in nondiabetic.

…cont’d

• Microvascular:• Microangiopathy (destruction of small blood vessels)

• Retinopathy• Damage to retinal capillaries…blindness.

• Accelerated by hyperglycemia, HTN, smoking

• Nephropathy• Diabetes is the most common cause of end-stage

renal disease

• Results in proteinuria, ↓GFR, ↑art BP.

• 10 – 21% of diabetics have renal disease

• 12 X higher in type 1 DM

• Tight glucose control ↓es risk by 35 – 56%

• Neuropathy• Nerve degeneration

• Begins early in disease, but takes years for symptoms to develop

• Tingling fingers & toes, pain, loss of sensation

• Tight glucose control ↓es neuropathy by 60%

• Amputations

• Impotence

• Gastroparesis

Foot Care:What are the

DO’s and DON’Ts of foot care?

Educate patients on proper foot care – The “DO’s”DO …

Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual markings

Use a mirror to see the bottom of your feet if you can not lift them up

Check the colour of your legs & feet – seek help if there is swelling, warmth or redness

Wash and dry your feet every day, especially between the toes

Apply a good skin lotion every day on your heels and soles. Wipe off excess.

Change your socks every day

Trim your nails straight across

Clean a cut or scratch with mild soap and water and cover with dry dressing

Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)

Buy shoes in the late afternoon since your feet swell by then

Avoid extreme cold and heat (including the sun)

See a foot care specialist if you need advice or treatment

Educate patients on proper foot care – The “DON’Ts”

DO NOT …

Cut your own corns or callouses

Treat your own in-growing toenails or slivers with a razor or scissors. See your doctor or foot care specialist

Use over-the-counter medications to treat corns and warts

Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly

Soak your feet

Take very hot baths

Use lotion between your toes

Walk barefoot inside or outside

Wear tight socks, garter or elastics or knee highs

Wear over-the-counter insoles – may cause blisters if not right for your feet

Sit for long periods of time

Smoke

“Neither evidence nor clinical judgment alone is sufficient.

Evidence without judgment can be applied by a technician.

Judgment without evidence can be applied by a friend.

But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best clinical care.” (Hertzel Gerstein, 2012)

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients

Physician Order:

• 1. Insulin drip 100 units 50 ml N/S. Start at 6 units per hour.• Initial rate = __ ml/hr

• Later: Physician order: run insulin drip at 9 units / hr• IV rate =___ml / hr

Med Math: Physician Order

• 1. Insulin: 6 Units Humulin R + 10 Units Humulin N daily, ac bkfst.

• 2. Sliding scale Insulin, ac meals & HS• If sugar< 10 mmol: no insulin

• If sugar 10.1 – 15 mmol: 5 units humulin R

• If sugar 15.1 – 20: give 10 units humulinR

• If sugar > 20: notify physician

Problem:

• How much insulin will you give for a 0800 sugar reading of 12.3 mmol?• ___Regular (humulin R)

• ___ N (humulin N)

• Total in syringe=___ units

• The client is nauseated this morning. In order to prevent an insulin reaction, when should you recheck glucose level?

Humulin R Humulin N

Onset:

30-60 min

Peak:

2-4 hr

Duration:

6-8 hr

Onset:

1-2 hr

Peak:

6-12 hr

Duration:

18-24 hr

Order:

1. Humulin N 6 units ac breakfast and at HS daily.

2. Blood glucose monitoring ac meals and hs.

3. Sliding scale insulin ac meals and hs.

If glucose < 7……no sliding scale insulin

If glucose 7.1 – 12…..give 5 units humulin R insulin

If glucose 12.1 – 15…give 10 units humulin R insulin

If glucose 15.1 – 20…give 15 units humulin R insulin

If glucose > 20 ……...notify physician.

0800 1200 1700 2100

Glucose 8.6

Insulin given:

Glucose 6.9

Insulin given:

Glucose 21

Insulin given:

Glucose 12.3

Insulin given:

Order

• Humulin R 17 units and Humulin N 26 units, daily, subcutaneously, ac bkfst.

• What is total amt of units in syringe?

• How will you administer these?

• Can they be mixed in same syringe?