Managing the Diabetes Patient. Dan Kremer, RN, BSN Diabetes Nurse Educator

Managing the Diabetes Patient

Dan Kremer, RN, BSN

Diabetes Nurse Educator

Objectives

• Referring & assessing the inpatient

• Address the needed diabetes education for the patients – survival skills

• Problem solving

Inpatients

• Faces multiple changes:

– Unwanted illness – Increased stress – Decreased activity – Decreased sleep

– Change in eating times

– Change in times of medications & insulins – Possible steroids

Nurse

• “Noncompliant”

– Try to figure out why.

• Patient‟s fault

– Not doing what suppose to do:

• Testing blood sugars • Watching what they eat • Taking medications

What Patients Need Assessing?

• Admitting diagnosis: diabetes related • High A1c

• Started on insulin

• Not testing blood sugars • Food questions

Who Can Make Inpatient Referrals?

Assessment of the Inpatient

• Patients

– New diagnosis or history of – Type

– Medication Induced – At risk

– Gestational

• How long have diabetes? • Patient‟s PCP

• Meter

– When test – Goals

• Foods that increase blood sugars • Hypoglycemia

Education

• American Diabetes Association [ADA] Curriculum

• Evidence based

• Set up by American Association of Diabetes Educators [AADE]

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring  Being Active  Problem Solving  Taking Medication  Reducing Risks  Healthy Coping  Healthy Eating

AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring

Why Monitor Blood sugars

Only way you know how you are doing

Blood sugars are affected by your:

 Food  Activity  Diabetes Medications  Other  Stress  Infections

Blood Sugar Goals

ADA - Blood Sugar Goals:

Before meals: Less than 130 mg/dl

2 hours after meals: Less than 180 mg/dl

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Goals Individualized: • Age

• Type

Monitoring Blood Sugars in the hospital

Test: Before Meals & at Bedtime - WHY?

Often NPO status

Starts in am and repeats about every 4-6 hours More convenient – Patient available when eat –

post prandial they may be off floor

Traditional especially in type 1 – newly diagnosed – endocrinologist model

Will indicate if correction dose needed

Monitoring Blood Sugars at Home

Monitoring

Home - Post Prandial Blood Sugars

Fasting & 2 hours after meals

 Assess to see if medication & insulins working properly

 Getting desired results from medications

 Helps to determine if another medication is needed

Testing Blood Sugars

Monitoring

More frequently when: •Change in health •Increased stress •Infection

•Steroids

•Noted increase in blood sugars

Taking a blood sugar

• Put strip in meter [Home vs. Hospital]

• Sticking finger – [Depth – Adjustment on lancet]

“Always hurts”

• Stick finger and produce blood drop

• Touch strip to blood – [Hospital – strip only] • Wait for results

Taking a blood sugar

– Problem solving

• IF high or low and surprised repeat • “Why test blood sugars - always high.”

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring

Being Active

Regular activity

–Increases cells sites sensitivity to your insulin –Increases stamina and flexibility

–Increases feeling of well-being –Decreases blood sugars

–Decreases blood pressure –Decreases cholesterol

–Decreases stress –Decreases weight

Being Active

Regular activity barriers

Physical barriers

_{Environmental} Psychological

Being Active

Target activity plan

 Muscle movement counts - legs

 Like dog walkers

 Slow enough you can talk while walking

 Fast enough you can‟t sing  Break a slight sweat

Being Active

Activity Goal

150 minutes per week Minimum 30 minutes 5 times a week

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring

 Being Active

Hyperglycemia

• High blood sugars:

– Parameters often given by PCP

– Constantly running in the 200‟s call PCP – On sliding scale and always needing it

Hypoglycemia

• Blood sugars < 70 mg/dl

– Fast acting carb [15 grams – 1 carb]

• Juice ½ cup [Juicy Juice Box] • Pop – ½ Cup

• Milk – Skin or 1% - 1 cup

– NO candy bars

Sick Days

• Test more frequently • Call MD as needed

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring

 Being Active

 Problem Solving

Medications & Insulins

• Name

• How they work

• When you take them

• Side effects

Insulin

• Rapid vs. Short [Novolog vs. Regular]

– Start to work : 10 min 45 min

– Peaks: 30 min 2 ½ hours

• Meal time insulin vs. Sliding scale Example:

Meal time Sliding scale

Insulin

• Intermediate vs. Long [NPH vs. Lantus]

– Start to work : 1-2 hours 1 ½ hour

– Peaks: 4-5 hours NONE

Insulin

• Pen vs. Vial

– Volume – Accuracy

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring

 Being Active

 Problem Solving

 Taking Medication

Reducing Risks

• Being proactive

– Reduces risk of complications – Better quality of life

• How to reduce risks?

– Following up with MD – Continued education

Reducing Risks

•Continued education

• Patient – „noncompliant‟

– Empower vs. enable – Will take some time

» Watch nonverbal communication » Sit down beside patient

» “One thing willing to change” » Try to „break the barrier‟

Reducing Risks

Exam your feet every day.

I.e. - After showering - When putting on socks

•Check: Tops and bottoms of feet

Check: General appearance of feet

Do you have any problems with feet?

[I.e., Bunions, hammer toes, nail fungus]

Any changes in them from yesterday?

Check: To see if there is any redness or sores

If any present evaluate each day to see if better If not getting better see your MD

• Review blood sugars - logbook

• Check blood pressure; Goal: <130/80 • Review meal plan

• Review activity level • Check weight

• Discuss questions or concerns

Reducing Risks When Seeing MD

• A1c - Goal: < 7.0%

• Teeth see dentist [Every 6 months]

Reducing Risks

• Physical exam

• Complete foot exam

• Dilated eye exam – ophthalmologist • Flu Vaccination

Reducing Risks

• Labs:

– Cholesterol Goal: < 200

– HDL‟s Goal: > 40 in men; > 50 in women – LDL‟s Goal: < 100

– Triglycerides Goal: < 150 – Microalbumin Goal: < 30

Reducing Risks

• Diabetes education

• Pneumonia vaccination

• Stop Smoking – Get help if needed • Taking aspirin

• Unusual symptoms • New therapies

Reducing Risks

AADE 7

American Association of Diabetes Educators

7 self care behaviors

 Monitoring  Being Active  Problem Solving  Taking Medication  Reducing Risks 

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_{- Healthy Coping}

Healthy Coping

ADA - Patient’s Health Care Team:

 Endocrinologist

 Primary Care Provider/APRN/PA [Health Coach]

 Nurse Educator

 Registered Dietitian

 Ophthalmologist/Optometrist

 Social Worker/Psychologist/Psychiatrist/Marriage and Family Therapist

 Podiatrist

 Pharmacist

 Dentist

Healthy Coping

Psychological and

social barriers can affect

ones health and quality of life.

Healthy Coping

When motivation is decreased

and barriers block your progress

it becomes difficult to cope

so that we are no longer able

Conclusion

– Survival Skills – Lots of information – Empower whenever possible

– Stay as positive as possible

– Encourage patient every chance you can – Focus on the change patient is willing to do