Welcome to CNIB’s InFocus
Webinar Series
Webinar 3: Diabetes Management and Vision Loss
Lynn Baughan RN, MN, CDE
Kathryn MacDonald, RD, CDE
19th November 2012
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Learning Objectives
Participants will be able to:
1.Identify the key components for diabetes
management.
2.Describe techniques for teaching clients with vision
loss, blood glucose monitoring, medication and
insulin administration, meal preparation and foot
examination.
3.Identify resources for ongoing education and support
for managing diabetes.
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Diabetes in Canada….
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2.7 million Canadians have diabetes
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Estimated number of people diagnosed with diabetes
will increase to 4.4 million by 2020 if trends continue
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Estimated cost for treatment of diabetes in 2010 is
11.7 billion dollars
Reference: Canadian Diabetes Association (2010). Diabetes: Canada at the Tipping Point.
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Management of Diabetes
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A balance of…
 Healthy Eating
 Regular Physical Activity
 Monitoring
 Taking Prescribed Medications
 Self Management and Coping Skills
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Manage blood glucose, lipids and blood pressure
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Management of Diabetes
 Working as a team with the client at the centre
 Instead of “No” and “Can’t” it is “How”
 Connect with a Diabetes Care Team and other available
resources
 Provide self management support
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General Teaching Tips
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Use large print materials
• High contrast black on white, at least a 16 point bold
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serif type (arial) and with lots of white space
Prefer to use 20 point arial font
Use a fine tip black felt marker (CNIB or Sharpie)
Use models (food, foot, meters)
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Next Webinar
Practical tips and strategies on how to work
with clients in a clinical setting:
- Basic etiquette
- How to navigate the patient
- Communication and education
Webinar: Supporting your patients
www.cnib.ca/infocuswebinarseries
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Adaptive Diabetes Education
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Must be individualized
Matches techniques and equipment for the person
Provides choices
Must ensure safe, accurate performance of skills
Evaluates skills on a regular basis
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Healthy Eating and Diabetes
 Individualized approach to meal planning
 Balanced, regularly spaced meals, consistent
 Emphasis on high fibre
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Plenty of raw vegetables
Moderate amounts of whole fruits and whole grains
 Low fat and low sodium
 Sugar is OK in moderation as part of a balanced intake
 Weight management
• Portion Moderation
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CDA Nutrition Guide - Just The Basics
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Meal Planning Tips
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Strive to maintain enjoyment in food preparation,
eating and independence
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Use specific sized serving spoons and dishes to
estimate portions
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Rehabilitation specialist:
• Does an in-home assessment
• Teaches skills for safe meal preparation
• Teaches how to label items
• Puts tactile labels on the stove or microwave
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Meal Planning Tips
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Use modified visual aids
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Special products are available for meal preparation
and cooking (i.e. extra long oven mitts, fluid level
indicators, audible weigh scales etc.)
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Working Safely In The Kitchen
Large print, braille, tactile and audible cues
Bright colours and colour contrasts on cooking utensils
Techniques for spreading, measuring, pouring, and
chopping
Safe food storage
Shopping for groceries
Organizing the kitchen
• www.balancefba.org
• www.lowvisionchef.com
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Physical Activity - Getting Started Safely
Medical check-up first
Eyes, heart and feet checked
Proper fitting foot wear
Check blood glucose before and after
Plan activity 1 to 11/2 hours after meals
Carry a fast acting glucose and identification
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Work up to goal of 150 minutes per week total
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Side Effects of Increased Activity
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Risk of Hypoglycemia: for people taking insulin and/or
some oral agents
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Potential Aggravation of Complications: such as cardiac,
neuropathy in the feet and retinopathy
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Potential Deterioration of Glycemic Control in Type 1:
through counter regulatory hormone response when blood
glucose is above 14 mmol/L and ketones are present
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Hypoglycemia = Low Blood Glucose
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Blood glucose less than 4 mmol/L
Signs and Symptoms:
• Tremors
• Palpitations
• Sweaty
• Headache
• Mood changes
• Irritable
• Difficult thinking
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Test blood glucose if able to
Treat first if unable to test
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Treatment of Hypoglycemia
Rule of 15
• Treat with 15 gm glucose
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3 BD glucose tabs OR 4 dextrose tabs OR 175 ml orange
juice
Wait 15 minutes, recheck blood glucose
Repeat treatment until blood glucose is > 4 mmol./L
More than 1 hour to next usual meal or snack?
Give a 15 gm carbohydrate snack (e.g. 4-6 crackers with
cheese, ½ sandwich)
Assess possible causes for the low blood glucose to prevent
recurrence.
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Blood Glucose Monitoring
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Education focuses on maximizing use of all available
senses
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Conduct assessment under conditions that maximize
client’s vision
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Demonstrate various meters to determine best choice
for client
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Options for those who cannot read display screen
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Options for Blood Glucose Monitoring
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Products For Testing Blood Glucose
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Meters with large, bold numbers include:
• Oracle
• Accu-Chek Compact
• One Touch Ultra
• Ascenia Contour
• Ascensia Breeze
• Precision Xtra
• BG Star
• Blood glucose monitors are available at pharmacies and medical
supply companies
• Prescription required for coverage under most health care plans
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Teaching Tips
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Break skill down into small components
Keep all supplies in consistent location
Use divided container to store supplies
Encourage use of all available senses
Reinforce over time, until independent in skill
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Obtain Sample
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Land mark by placing
thumb on 1st joint below
finger tip
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Poke finger
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Gently pump 4 times
Apply the Sample
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Slowly move strip back and forth across the fingertip
Record results in large print log book or on recording device
Upload results to audio log book
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Targets for Glycemic Control
Test
Target
Fasting Blood Glucose and
Before Meals
4.0 to 7.0 mmol/L
2 hours After Meals
5 to10 mmol/L (if A1C in
target)
5 to 8 mmol/L (if A1C not
at target and can be
achieved safely)
A1C Glycated Hemoglobin
Less than or equal to 7%
Targets are individualized to the client’s risk factors (age, co-morbidities,
duration of diabetes, risk of hypoglycemia etc.)
Reference: Adapted from Canadian Diabetes Association. (2008). Clinical Practice
Guidelines for Prevention and Management of Diabetes 1n Canada.
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Oral Medication
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Assess current ability in safe administration of
oral medications
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If difficulties encountered, consider:
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Personal markings on container lids
Different shaped container for each type of pill
Blister pack prepared by pharmacy
Individual dosettes
Memory aids
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Options for Preparation of Insulin
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Ensure safe accurate measurement
Maximize vision with magnifiers:
• Syringe (i.e. BD, Truhand, Insuleze etc.)
• Pen dosage dial (i.e. Novolin)
• Hand held with or without light source
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Preloaded syringes
• Filled by community pharmacist
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Disposable prefilled insulin pens
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Devices For Insulin Measurement
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Re-useable Insulin Pens
• HumaPen® Luxura, HD, Memoir
• Novolin ® Pen 4, Echo
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Disposable Insulin Pens
• HumaMix ® 25 prefilled
• Lantus ® Solostar
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Syringe Magnifiers
Count-a-dose
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Tips For Teaching Insulin Pens
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Clearly label pens
Store supplies in a consistent area
Record instructions on a recorder
Confirm priming of needle by flushing on tactile
area of hand or arm
Carefully count audible clicks for dosage
Teach how to reset pen to zero
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Tips For Teaching Insulin Pens
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Frequent return demonstrations of skills
Method for recording amount remaining in insulin
cartridge, when to change cartridge and injection
sites used
Extra pen available
Follow-ups to check equipment
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Adaptive Foot Care
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If touch is reliable, teach the client how to check
the feet
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Use the fingertips and thumb to check the feet
each day
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Feel for changes such as breaks in the skin,
blisters, corns, calluses, swollen areas
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Examine the top and bottom of both feet including
the surface of each toe
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Foot Care
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Use the back of the hand to feel for temperature
changes
Advise client to see doctor immediately if:
• A warm or unusually cold area is felt
• Other changes such as skin breakdown are felt
A foul odour may indicate infection
Arrange for a sighted person to do regular foot
checks
Suggest a foot care specialist to cut or file the nails
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Complication Prevention
A
B
C
D
E
F
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Hemaglobin A1C
Blood Pressure
Cholesterol
Dental Check
Eye
Foot Care
Successful Behavior Change
 Gradual small steps
 Match strategies to stage of readiness to change
 Move from story telling to problem solving
 Use diabetes friendly approaches ie healthy eating not
diet
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Helping Clients Change Behavior
 Determine client’s key concerns and address them first
 Gather information and use it
 Review the data with the client
 Ask questions – shift the responsibility/decision making
to the client
 Support skills training and knowledge building
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Diabetes and Self Management
Services
Inter-professional Team of Health Care Professionals
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Diabetes Education Program
Centers for Complex Diabetes Care
Community Care Access Centres
Community Pharmacist
Eye Care Specialists
Foot Care Specialists
Peer Support
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Support Groups
Self Management Programs
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Eye Connect: Diabetic Retinopathy
www.cnib.ca/dr
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Diabetic retinopathy basics
Prevention
Diagnosis and treatment
Living with diabetic retinopathy
- For Health Care Professionals
- “Your Guide to Diabetic
Retinopathy” Patient Guide
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CNIB Contacts & Resources
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CNIB Website: www.cnib.ca
Toll-free CNIB Helpline: 1-800-563-2642
Email: info@cnib.ca
Production of materials has been made possible through a financial contribution
from the Public Health Agency of Canada. The views expressed herein do not
necessarily represent the views of the Public Health Agency of Canada.
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Helpful Links for Resources
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Canadian Diabetes Association
www.diabetes.ca
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Stand Up To Diabetes
www.ontario.ca/diabetes
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The Diabetes Care Community
www.diabetescarecommunity.ca
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Eat Right Ontario
www.eatrightontario.ca
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Dietitians of Canada
www.dietitians.ca
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Presenters
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Lynn Baughan RN, MN, CDE
Central West Diabetes Regional Coordination Centre
Lynn.baughan@williamoslerhs.ca
Phone: 905-494-6752
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Kathryn MacDonald RD, CDE
Central West Diabetes Regional Coordination Centre
Kathryn.MacDonald@williamoslerhs.ca
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References
1. Bernbaum, M. et. Al. (1985). “A model clinical program for patients with
diabetes and vision impairment” .(1989). The Diabetes Educator, 15: 32530.
2. Cleary, M. (1985). “Aiding the person who is visually impaired from
diabetes”.The Diabetes Educator, Winter Ed.
3. CNIB website, retrieved July 26, 2012. http://www.cnib.ca/en/your-eyes/eyeconditions/eye-connect/DR/Pages/default.aspx
4. Haire-Joshu, D., (Ed.), Herman, W., &
Greene, D. (1996). Management of
diabetes mellitus perspectives of care across the life span. “Microvascualar
complications of diabetes ”. P-239-46. Chapter 7.
5. Jones, H., (Ed.) & Opsteen, C. (2010) 2nd Ed. Building Competencies in
Diabetes Education; Advancing Practice. Chapter 7. Management of Chronic
Complications, p. 7-56-64.
6. Wagner, H., Pizzimenti, J., Daniel, K., Naushira, P., & Hardigan, P. (2008).
“Eye on diabetes a multicultural patient education intervention ”. The
Diabetes Educator, Vol. 34., (1), p. 84-89.
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