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

(FPG)

> 126 mg/dL

Oral Glucose Tolerance

Test (OGTT) 2 hour

sample

> 200 mg/dL

Random Plasma

Glucose

> 200 mg/dL plus

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

between an A1C

result and the

patient’s

estimated

average glucose

number in mg/dL.

↓7 = well controlled

7-8.4 = mildly controlled

8.5-9.9 = moderately controlled ↑10 = severely uncontrolled

Fasting vs. Random

Blood Glucose Tests

Fasting Blood Glucose

• Done after not eating for 8

hours

• Usually done before

breakfast

• Tells how well the

pancreas is keeping up

with the liver

Random Blood Glucose

• Taken randomly throughout the day

• Take into account the effect of food

• Blood glucose is highest after a meal

• If blood glucose is high 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

Hormones

The hormones produced

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

• ↑ risk of pre-eclampsia

• ↑ risk for C-section

• More likely to develop type 2 diabetes later in life

• More likely to develop gestational DM in future pregnancies

Baby

• Neonatal macrosomia

• Shoulder dystocia

• Hypoglycemia after birth

• ↑ risk for childhood obesity

• ↑ risk for developing type 2 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

• 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

Survival Skills Discharge Education

(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.