preparing the patient for insulinshort

International Diabetes CenterPreparing the Patient for Insulin Therapy • Understand natural history of diabetes and treatment options SDM... Preparing the Patient for Insulin Therapy •

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Preparing the Patient

for Insulin Therapy

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International Diabetes Center

Preparing the Patient for

Insulin Therapy

• Understand natural history of diabetes

and treatment options (SDM)

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Treat to Target

Fasting and Pre meal glucose 70-140 mg/dL (3.9-7.7 mmol/L)

Postprandial glucose <160 mg/dL (8.8 mmol/L)

(Two hours after the start of a meal the BG should

be no more than 20 to 40 mg/dL or 1.1 to 2.2 mmol/L

above the pre-meal BG)

Bedtime glucose 100-160 mg/dL (5.5-8.9 mmol/L)

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Insulin Therapy

• Understand natural history of diabetes and treatment

options (SDM)

• Review targets for blood glucose and HbA1c

• Review insulin therapy options:

physiologic vs conventional

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Normal Insulin Secretion:

Basal and Bolus Patterns

Basal Insulin Needs

Bolus insulin needs

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Insulin Therapy

options (SDM)

• Review insulin therapy options: physiologic vs

conventional

• Review benefits and potential side

effects of insulin therapy

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Benefits and Potential Side Effects

of Insulin Therapy

Benefits:

• Improved well-being; increased energy; decreased

fatigue

• Improved glucose control

• Reduction in risk of complications

Side effects:

• Weight gain

• Hypoglycemia

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Insulin Therapy

options (SDM)

• Review insulin therapy options: physiologic vs

conventional

• Review benefits and potential side effects of insulin

therapy

• If patient resistant to insulin or needle

phobia, demonstrate insulin injection

using sterile normal saline

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Preparing the Patient for Insulin

Overcoming Patient Resistance

Misinformation

• Insulin means I have “serious” diabetes

• Insulin causes hypoglycemia

• Insulin causes the complications of diabetes (heart disease, blindness, kidney failure)

• Insulin makes you gain weight

• Injections cause infection

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Preparing the Patient for Insulin

Overcoming Patient Resistance

Behavioral issues

• Taking insulin is inconvenient

• Taking insulin is embarrassing

• Taking insulin is painful

• Why should I take insulin when I feel well

• I would rather take a pill than take insulin

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Overcoming Patient Barriers to

• Improved comfort (fine and short

needles), convenience (pens, pumps)

• Severe hypoglycemia rare in type 2

DM (< 3 %)

• Explain that weight gain is seen with

most effective therapies (not insulin alone)

• Glucose lowering is the KEY

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Starting the Patient on Insulin

• Determine insulin therapy and starting dose

– Physiologic vs conventional

• Teach insulin administration

– Syringe and vial

– Insulin pen

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Mixing Insulin Using a Syringe and

Vial

Step 1

Step 2

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Sites for Insulin Administration

From My Insulin Plan, International Diabetes Center, 2001

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Insulin Injection Technique:

Abdomen

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Insulin Pens

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Insulin Pen Injection Technique

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– Insulin pen

• Review/teach blood glucose monitoring

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Blood Glucose Monitoring

• To improve clinical decision-making

• To adjust insulin therapy

• To evaluate efficacy of the therapy

• To pin point problems

• To support adherence to regimen

• Feedback for the patient

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Testing Frequency

Patients on Insulin

• Four times/day recommended

• Testing before each meal and before bedtime

• May also test pre-meal and 2 hours post meal to

evaluate effect of insulin on post-meal glucose

• Modify frequency of monitoring if necessary

• Encourage patients to record values in a record book

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Blood Glucose Monitoring

Current Technology

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Glycosylated HbA1c and Average

Blood Glucose Correlation

4% -50 mg/dL (2.8 mmol/L)5% -80 mg/dL (4.4 mmol/L)6% -115 mg/dL (6.3 mmol/L)7% -150 mg/dL (8.3 mmol/L)8% -180 mg/dL (9.9 mmol/L)

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– Insulin pen

• Reinforce meal planning using

carbohydrate counting

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– 1 to 2 choices at snacktime, if desired

• Emphasize day-to-day consistency

• Test blood glucose pre/post-meal to assess impact

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– (0.3 u/kg recommended)

– Insulin pen

• Reinforce meal planning using carbohydrate counting

• Prevention and treatment of

hypoglycemia

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• Definition

– Low blood glucose

– Blood glucose < 70 mg/dL (3.8 mmol/L)

• Causes

– Incorrect amount of insulin or oral agents

– Skipped or delayed meal/snack

– Carbohydrate intake less than normal

– Alcohol intake without food

– Physical activity without insulin/food adjustment

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– Yawning – Difficulty speaking – Poor coordination – Odd behavior/giddy – Irritable/angry

– Unconsciousness,

seizure, death

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Treatment of Hypoglycemia

Rule of 15

1 Test, if possible

2 Treat with 15 gm CHO

3-4 glucose tabs, 1/2 cup juice

-↑BG 50-75 mg/dL (2.8-4.2 mmol/L)-convenient, readily available choice

3 Wait 15 minutes

4 Test & repeat treatment if glucose

below target

15

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Severe Hypoglycemia

• Requires assistance to treat

• Modify carbohydrate source

– Glucose gel

• Loss of consciousness or seizure

– Use of injected glucagon

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Glucagon Emergency Kit

• Injection which releases stored glycogen

• To be used if unable to safely ingest oral CHO

• Administered by another person

• Standard doses – 0.5 mg for children/1.0 mg for adults

May be given IM or SC

• May cause nausea/vomiting/headache

• Increase fluids following injection

• Call physician

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Moderate to Severe Hypoglycemia

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Hypoglycemia Prevention

• Preventing hypoglycemia is a delicate balancing act

of food, medications and insulin

• Instruct patients to

– Carry carbohydrate at all times

– Test before driving (if possible)

– Wear medical identification

– Teach others how to inject glucagon

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– Insulin pen

• Prevention and treatment of hypoglycemia

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Exercise

• Recommendations

– 30 minutes of exercise per day

– Exercise generally lowers blood glucose levels

– May be planned or unplanned

• If possible, test blood glucose before exercise

– BG < 100 mg/dL (5.5 mmol/L), treat hypoglycemia

before exercising Retest if > 30 minutes activity

– BG > 250 mg/dL (13.9 mmol/L), , do not exercise

– BG 100-250 mg/dL (5.5-13.9 mmol/L): Get

moving!

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Late-Onset Hypoglycemia

• Most common 6-15 hours after exercise

• Due to body’s replacement of muscle glucose stores

• Greater in untrained or inactive

• Greater with strenuous exercise or play

• Not greater with “tighter” blood glucose control

• To Prevent: carbohydrate replacement during/after

exercise, adjust insulin after exercise

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Carbohydrate & Insulin Adjustment

For Exercise

– 15 gm carbohydrate per hour low intensity exercise

– 30 gm carbohydrate per hour vigorous exercise

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– Physiologic vs Conventional

– Insulin pen

• Prevention and treatment of hypoglycemia

• Exercise

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Summary

Introduce insulin early!!!

• Teaching patients to use insulin is more

than how to inject insulin

• Utilize diabetes educators (if available)

Tiêu đề	Preparing the Patient for Insulin Therapy
Trường học	International Diabetes Center
Chuyên ngành	Diabetes Management
Thể loại	guideline

Định dạng
Số trang	42
Dung lượng	2,06 MB