Insulin Administration Equipment
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Syringes
Pen injector
Jet injector
Insulin Pump
Inhaler (Exubera)
**Most rapid absorption site is abdomen**
Basic Nutrition Therapy
• Plate Method
• Exchange System
• Carbohydrate Counting
Main Diet Points
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Eat about same time each day
Eat foods from all food groups
Limit fat and sugar intake
Eat about the same amount each day
Use snacks to prevent low blood sugar
Plate Method
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1/3 protein
1/3 starch
1/3 vegetable
Plus fruit
Exchange System
• Physician/dietician orders number of
calories/day
– 50% CHO
– < 30% Fats
– 10 – 20 % Protein
• Exchange lists are groups of foods that contain
roughly same mix of CHO, protein, fat and
calories
Exchange List
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Breads/starch 1 serving = 80 cals
Fruits
1 serving = 60 cals
Vegetables
1 serving = 25 cals
Meat
1 serving = 55-100 cals
Fat
1 serving = 45 cals
Milk
1 serving = 90-150 cals
Example
• 1800 calorie ADA diet
– 50% CHO
– <30% fats
– 10-20 PRO
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900 cals from CHO
540 cals from fats
360 cals from PRO
CHO Counting
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Keeps CHO consistent
Focuses on foods that most affect BG
Grams of CHO or CHO choices are counted
All CHO’s can be eaten, if counted correctly
Protein, fat and calories still important
Protein is free (Not counted)
CHO Counting
• “Carb” choices: simple method
– 1 CHO choice = 15 gms of CHO
– 1 starch = 1 fruit = 1 milk
• Counting “carb” grams more precise and
allows more flexibility
CHO Counting: Meal Planning Example
• 15 gram CHO = 60 calories = 1 CHO choice
• 1400 – 1500 calories = 12 -13 CHO choices daily
• Because of combo CHO = more calories
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Breakfast (57 grams CHO) = 4 choices
Lunch (62 grams CHO) = 4 choices
Dinner (45 gram CHO)
= 3 choices
Snack (15 gram CHO)
= 1 choice
Exercise
• Metabolic effects
– Improves blood glucose control
• Increases sensitivity to insulin
• Increases use of glucose by muscles
• Increases counter regulatory hormones
• Increases liver production of glucose
Exercise
• Aerobic is best choice
• Check BG before and after
• No exercise:
– While insulin is peaking
– BG > 250 mg/dl
– Ketones in urine
• Eat snack if BG < 100 mg/dl
• Wear ID
• Carry fast acting sugar
Exercise and Insulin
• Adjust insulin if exercise is routine
• Adjust food if exercise plans change
Blood Glucose Monitoring
• Diabetes Control and Complication Trial
(DDCT)
• Greater frequency of testing = greater control
• Greater control = less long-term complications
• Intensive therapy = 4 – 6 X a day
• Average therapy = 2 X a day
• GOAL = maintain BG 70 -115mg/dl
• http://www.youtube.com/watch?v=_5AVRRR
wX_E
Type II Diabetes
• Many causes but same results =
hyperglycemia
• Increased glucose production and release
from liver
• Decreased uptake of insulin by cells
• Decreased insulin receptor sites
• Obesity increases insulin resistance at cellular
level
Obesity and DM
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Larger fat cells
Fat contained in many other cells
Cells are larger and altered
Insulin penetration into these altered cells
is difficult
Obesity and Diabetes
• Watch the snacks <200 calories
• Slow down when eating! Wait 20 minutes
before having seconds ( to realize you are
hungry) Stop before feeling stuffed
• Portion control
More choices
• Increase healthy choices:
– Vegetables
– Whole Grains
– Fiber
– Low fat milk
• No regular soda
• Limit 4oz- 8oz of juice or sweetened
beverage/day
• Do not eat in front of TV or computer
Age-adjusted Percentage of U.S. Adults Who Were Obese or Who
Had Diagnosed Diabetes
Obesity (BMI ≥30 kg/m2)
1994
No Data
>26.0%
2000
<14.0%
14.0-17.9%
2009
18.0-21.9%
22.0-25.9%
Diabetes
1994
No Data
>9.0%
2000
<4.5%
4.5-5.9%
2009
6.0-7.4%
7.5-8.9%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System
available at http://www.cdc.gov/diabetes/statistics
Type II
• May or may not have insulin deficiency with
insulin resistance
• Insulin production may be increased, normal,
or decreased
• Decrease production occurs most frequently
Type II
• Symptoms
– 3 P’s
– Fatigue
– Usually detected on a routine office visit
Management of Type 2 DM
• Non-pharmacological management
– Diet control: increase fiber, decrease simple CHO
and Fats
– Exercise: decreases insulin resistance, 3 to 5
times/week for 30 minutes.
– Weight loss: 10 pounds can make a BIG difference
• Lose fat in many cells
• Smaller healthier cells use insulin more easily
Oral Medications for Type II
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Increase insulin output in pancreas
Increase insulin sensitivity in tissues
Decrease glucose production by liver
Slow rate of CHO absorption from
stomach
Treatment Options
• Monotherapy
• Combined therapy
– 2 or more oral agents
– Oral medication(s) and insulin
• Insulin
Classifications of Oral Antidiabetic
Agents
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Sulfonylureas
Biguanides
Thiazolidinediones
Alpha-glucosidase inhibitors
Meglitinides
Sulfonylureas
• Increase insulin output by pancreas
• Increase tissue sensitivity
• Decrease liver production of glucose
glyburide (Micronase)
glipizide (Glucotrol and Glucotrol XL)
chlorpropamide (Diabinese)
glimepiride (Amaryl)
tolbutamide (Orinase)
Sulfonylureas
• Can cause hypoglycemia
• Use cautiously in elderly and persons with
allergy to sulfa drugs
• Used in combination with other agents
• Never break Glucotrol XL
• May increase effects of oral anticoagulants
Biguanides
• Decrease liver output of sugar
• Increase insulin sensitivity
• Can be given in combination with many
other hypoglycemic meds
• Does NOT cause low blood sugar
metformin (Glucophage)
Biguanides
• Kidney and liver tests required
• May help with weight loss and lowering
cholesterol
• Side Effects
– Abdominal pain
– Diarrhea
– Gas and bloating
Biguanides
• Lactic Acidosis
– Risk factors
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Renal and/or liver dysfunction
Hx of ETOH abuse
Acute or chronic acidosis
Iodine contrast materials
Given with furosemide (Lasix) and cimetidine
(Tagamet)
• Dehydration
• Surgery
Thiazolidinediones
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Increases insulin sensitivity
Diminishes liver glucose production
Can be taken with or without food
LIVER TESTS REQUIRED
pioglitazone (Actos)
rosiglitazone (Avandia)
saxagliptin (Onglyza)
Alpha-glucosidase Inhibitors
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Slows absorption of CHO
Take with first bite of meal
ALWAYS TAKE WITH FOOD
Does NOT cause low BG
Can combine with sulfonylureas and/or insulin
acarbose (Precose)
miglitol (Glyset)
Meglitinides
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Burst of insulin from pancreas
Works quickly
Take 15 - 30 min before meals
Add dose for extra meal
Use cautiously with liver disease
repaglinide (Prandin)
nateglinide (Starlix)
Major Classes of Medications
Sensitize body cells to
insulin and/or control
hepatic glucose
production
Thiazolidinediones
Biguanides
Stimulate pancreas to
produce more insulin
Sulfonylureas
Meglitinides
Slow absorption of starches
Alpha-glucosidase
inhibitors
pramlintide acetate (Symlin)
• Antidiabetic hormone
• Works with insulin to lower after meal
glucose
• Used in both type I and II
• SQ immediately before meals
• Cannot mix with insulin
• May cause hypoglycemia
exenatide (Byetta)
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Incetin Mimetics
New class of drug for type II
Increases insulin secretion
Promotes other mechanisms to lower glucose
SQ within 1 hour of morning and evening meal
sitagliptin/Januvia
• DPP-4 inhibitor
• Stimulates release of substances in that
make pancreas release more insulin.
• Signals liver to stop producing glucose
• Type 2 ONLY
• Used with metformin or a sulfonylurea
• May cause HYPOGLYCEMIA and pancreatitis
Acute Complications of DM
• Hypoglycemia
• Hyperglycemia
Hypoglycemia
• BG < 70 mg/dl with symptoms
• Causes
– Not enough food
– Too much medication
– Missed meals
– Increased exercise
Hypoglycemia
• Symptoms
– Early
• Hunger
• Lightheadedness
• Trembling
• Sweating
• Irritability
• Weakness/fatigue
– Late
• Changes of LOC
• Tachycardia
• Disorientation
• Seizure
• Death
Hypoglycemia
• Treatment = 15/15 Rule
– Take 15 grams of fast acting sugar, if alert
– If unconscious, inject with glucagon
– Wait 15 minutes and recheck BG
– If > 70 eat a snack or meal
– If < 70 repeat above
Hypoglycemia
• 15 grams of CHO:
– 4 oz. of OJ
– 3 tsp. sugar
– 5-6 lifesavers
– ½ cup regular soda
– Prepackaged low blood sugar products
Hyperglycemia
• Causes
– Too much food
– Illness
– Stress
– Too little medication
– Not enough exercise
– Other medications
Hyperglycemia
• Symptoms
– Increased thirst
– Increased urination
– Nausea
– Several blood tests > 200 mg/dl
Hyperglycemia
• Treatment
– Check blood sugar
– Check urine for ketones
– Increase fluids
– Call physician and obtain order for extra
injection(s) of insulin or change in prescribed dose
Diabetic Ketoacidosis Pathophysiology
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Blood glucose > 240 mg/dl
Body attempts to use fats for energy
By product of fat metabolism is ketones
Ketone levels rise
decreased blood pH
metabolic acidosis
• Kidneys attempt to excrete glucose and ketones
• urine production
dehydration
Diabetic Ketoacidosis (DKA)
• Symptoms
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Extremely high blood glucose
3 poly’s
Ketone positive urine
Dehydration
Fruity breath
Weakness/Nausea/Vomiting
Kussmal’s respirations*
As progresses:
• Weak pulse
• Hypotension
• Changes in LOC
• Coma
• Death
Diabetic Ketoacidosis
• Occurs with
– Undetected Type I DM
– Untreated/poorly controlled Type I DM
– Episode of illness/stress in client with Type I DM
Diabetic Ketoacidosis
• Treatment:
– IV SHORT-ACTING (REGULAR) INSULIN
– IV fluids
– Correct acidosis
– Correct electrolyte imbalances
– Patient teaching to prevent reoccurrence
Long Term Complications
• #1 cause of
– Blindness
– Amputations
– Kidney Failure
– Impotence
• Twice the rate of heart attacks
• Three times the rate of CVA
Long Term Complications
Long Term Complications
• Alterations in vascular and nerve cells
• Extended exposure to high blood glucose
levels cause pathological changes
Areas of Concern
• Microvascular complications
– Eyes (retinopathy)
– Kidneys (nephropathy)
– Nerves (neuropathy)
• Macrovascular complications
– Accelerated Cardiovascular Disease
– Peripheral Vascular Disease
• Feet
Retinopathy
Nephropathy
Neuropathy
PERIPHERAL
AUTONOMIC
Cardiovascular Disease
Peripheral Vascular Disease
Proper Blood Glucose Control
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Decrease mortality by 30%
Decrease amputation by 60%
Decrease kidney disease by 50%
Decrease vision loss by 90%
Diabetic Foot Care
Diabetic Foot Care
• Inspect feet daily
• Report abnormalities immediately
• Wash daily with warm (not hot) water and soap (no
soaking)
• Apply lotion to prevent cracking
• Wear well fitting leather shoes
• Wear well fitting cotton socks
• Avoid tight socks or garters
• Avoid crossing legs
• NO BARE FEET
• Cut toenails across/not into corners (use clippers)
• See Podiatrist 3-4 times/year
Nursing Care
• Patient and family teaching is essential
– Pathophysiology of DM
– Diet
– Exercise
– Foot care
– Blood glucose monitoring
– Medications
– Hypo and hyperglycemia
New Technology
• Monitoring Devices
– Non-invasive monitors
– Glucometer/pump combinations
– Continuous glucose monitoring sensors
New Technology
• Implantable Continuous Glucose Monitor
– Investigational
– Sensor inserted into superior vena cava similar to
pacemaker lead
– Designed to display glucose every 5 minutes
New Technology
• Islet Cell Transplant
– Islet cells isolated from donor organ
– Process of purification over 6-8 hours
– Cells are infused into hepatic circulation
– Cells take up residence in liver
– 138 have had transplant, 67 no longer require
insulin therapy
New Technology
• Pancreatic Transplant
– Done alone or with kidney
– Must met criteria
– Benefits
– Risks
New Technology
• Implantable Artificial Pancreas
– Currently in human trials
– Implanted under skin in abdomen
– Insulin delivery controlled by computer
– Insulin filled every 45 days in MD office
– Battery life is 6 years