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

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(1)

Managing the Diabetes Patient

Dan Kremer, RN, BSN

Diabetes Nurse Educator

(2)

Objectives

• Referring & assessing the inpatient

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

• Problem solving

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Inpatients

• Faces multiple changes:

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

– Change in eating times

– Change in times of medications & insulins – Possible steroids

(4)

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

(5)

What Patients Need Assessing?

• Admitting diagnosis: diabetes related • High A1c

• Started on insulin

• Not testing blood sugars • Food questions

(6)

Who Can Make Inpatient Referrals?

• MD • APRN/PA • Care Manager • RN • Dietician • Social Worker • Cardiac Rehab • Patient/Family

(7)

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

(8)

Education

• American Diabetes Association [ADA] Curriculum

• Evidence based

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

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AADE 7

American Association of Diabetes Educators

7 self care behaviors

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

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AADE 7

American Association of Diabetes Educators

7 self care behaviors

(11)

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

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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

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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

(14)

Monitoring Blood Sugars at Home

Best times in a day to test:

(15)

Monitoring

Testing 1 time a day:

(16)

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

(17)

Testing Blood Sugars

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Monitoring

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

•Steroids

•Noted increase in blood sugars

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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

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Taking a blood sugar

– Problem solving

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

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AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring

(22)

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

(23)

Being Active

Regular activity barriers

Physical barriers

Environmental Psychological

(24)

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

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Being Active

Activity Goal

150 minutes per week Minimum 30 minutes 5 times a week

(26)

AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring

Being Active

(27)

Hyperglycemia

• High blood sugars:

– Parameters often given by PCP

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

(28)

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

(29)

Sick Days

• Carbs: – As / meal plan: • Real – pop – Jell-o

• Test more frequently • Call MD as needed

(30)

AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring

Being Active

Problem Solving

(31)

Medications & Insulins

• Name

• How they work

• When you take them

• Side effects

(32)

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

(33)

Insulin

• Intermediate vs. Long [NPH vs. Lantus]

– Start to work : 1-2 hours 1 ½ hour

– Peaks: 4-5 hours NONE

(34)

Insulin

• Pen vs. Vial

– Volume – Accuracy

(35)

AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring

Being Active

Problem Solving

Taking Medication

(36)

Reducing Risks

• Being proactive

– Reduces risk of complications – Better quality of life

• How to reduce risks?

– Following up with MD – Continued education

(37)

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‟

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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

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• 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

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• A1c - Goal: < 7.0%

• Teeth see dentist [Every 6 months]

Reducing Risks

(41)

• Physical exam

• Complete foot exam

• Dilated eye exam – ophthalmologist • Flu Vaccination

Reducing Risks

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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

(43)

• Diabetes education

• Pneumonia vaccination

• Stop Smoking – Get help if needed • Taking aspirin

• Unusual symptoms • New therapies

Reducing Risks

(44)

AADE 7

American Association of Diabetes Educators

7 self care behaviors

Monitoring Being Active Problem Solving Taking Medication Reducing Risks

6

th

- Healthy Coping

(45)

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

(46)

Healthy Coping

Psychological and

social barriers can affect

ones health and quality of life.

(47)

Healthy Coping

When motivation is decreased

and barriers block your progress

it becomes difficult to cope

so that we are no longer able

(48)

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

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References

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