Diabetes Monitoring

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  • Community Medical Center has embarked upon a process to improve our diabetes care and also to acquire Advanced Inpatient Diabetes Certification from The Joint Commission. During the next few months you will be receiving more information about diabetes management in general.
  • Joint Commission has developed the certification process to help organizations make improvements in their care and the certification recognizes the organization for making those improvements.
  • Our mulitdisciplinary team has chosen four performance measures to make improvements. We will be teaching you about documentation, coordination of meals and insulins, monitoring glucose levels and recognizing patterns, making sure that patients have the ability to manage their own glucose, and getting proper education referrals to nutritionists and diabetes educators when they don’t. We have protocols in place to help you do all these things in a more efficient manner.
  • When CMC receives certification we will be one of less than a dozen programs across the country with this certification. If you have suggestions about how we can make further improvements in the program, please contact your manager.
  • As you know diabetes management is a complex process that involves appropriate carbohydrate intake and frequent monitoring of blood glucose levels. This intake of carbohydrate needs to be balanced with exercise and insulin doses. When they are not properly balanced the patient will experience hyper or hypo glycemia. Appropriate management will keep those glucose levels in near normal ranges.
  • Diabetes management takes a team beginning with the patient. It is necessary to have their cooperation and willingness to learn how to manage themselves. The provider watches for trends and will change orders as needed.
  • Community Medical Center has developed this 24 hour Blood Glucose Pattern Record to help our team stay “on the same page” when managing diabetes for a patient. This fold out sheet has two sides that open up so that you can see 24 hours across the top of each of the three days. The left side of the page is for AM and the right side is for PM. The spaces are marked hourly so that specific times can be inserted in the boxes. There is also a space for writing in each dose of insulin whether it is scheduled or sliding scale. There is a space to write in the meal time when the patient actually ate. At the bottom of each hourly column, the nurse initials. A larger space is available to write in comments (e.g. when a dose of oral diabetes meds is given, if a patient eats his/her meal and vomits an hour later, if a patient has an episode of hypoglycemia the treatment can be included on this sheet). Place initials in the boxes as you enter information. For example if you enter a BG level, initial in the box with it. Don’t forget to put a signature in the designated box at the bottom of the sheet to match with initials.
  • This is an example of two correctly charted events with a patient. You can see on the morning that the patient had a pre breakfast BG of 300. According to sliding scale, the patient received 6 units of Humalog insulin. (You don’t have to write out “units” because of the note on the side that says “units of insulin given”.) If you read down further, this patient also received a scheduled dose of Humalog insulin and then ate breakfast five minutes later. Two hours after that the patient obviously had an episode of hypoglycemia which was treated with a 15 g of carbohydrate (4 ounces of orange juice). If on the second day the charting looks very similar this might lead the provider to change some orders to avoid the hypoglycemia in the future. This trend is quickly identified because both days would be easily visible showing exactly how much insulin the patient got at what time and how he/she reacted to those doses. Even if two different nurses took care of this patient the trend is still easy to identify because of the documentation that was done. Because our MAR’s are different every day, the glucose reports are printed out only once a day, and the intake and output is on a separate sheet, it is not easy to identify trends like this without taking all that paperwork out of the chart and spreading it out so that it can be seen and compared. This sheet will save time for everyone on the team because one will be able to quickly visualize what is happening with this patient’s diabetes management. Anyone can readily see the meals and glucose levels, how they were treated, and what the results of that treatment were. It also documents episodes of hypoglycemia and how those were treated.
  • This form will be filled out by the admitting nurse at the time of admission. The purpose of this form is to identify areas needing attention as far as care and education. It will give us a single area to locate information on patient’s diabetes status as well as an area to collect data and track provisions of good diabetes care. This form will help us facilitate continuation of diabetes care after discharge.
  • This referral form is important because it helps get patients into outpatient education. Anytime the patient has a need for diabetes education a nurse or physician can refer to the diabetes educators. When the patient is an inpatient, just call the diabetes educators and give them the patient’s information. The important information on this form to fill out would be the patient information, the reason for referral, and the physician’s signature. Hospitalists may not want to make these referrals because it is the primary provider’s responsibility to follow the patient’s care when they are not in the hospital. In that case, it will be necessary to fax the form to the patient’s primary provider to get signatures and then send it on to our diabetes education department.
  • This letter is part of the referral process. It’s like giving the primary provider a hand-off report on the patient’s diabetes care. Fill in the Primary Care Provider’s name, the patient’s name, and admitting diagnosis. Make sure the referral form and the screening form are attached or faxed with this letter to the provider.
  • This screening form will be used in all outpatients areas where patients are coming in for outpatient procedures (e.g. CT scan).
    If an outpatient is identified as having needs related to diabetes care, Fax this screening form along with the referral letter and referral form to the provider who referred the patient for the procedure.
  • Nursing staff is to educate the patient on all of the topics above and document the education on this form. When the education is more involved than a staff nurse will be able to handle, the Diabetes Education Department should be called. You do not need a physician order for Diabetes Education. If their needs extend beyond what is in the “Living Well With Diabetes” handout brochure, you may consider calling Diabetes Education.
  • Patients need to receive this information prior to discharge. Please read through this brochure so that you are familiar with the information in it. If the patient asks questions that you or your charge nurse are unable to answer, call a diabetes educator or the patient’s physician.
  • In Lawson form #26196, Diabetes Discharge Instructions, is for sick day management to send home with patients. information contained on this It is also in the resource manual for Inpatient Diabetes Program. Please make sure you read through it so that you are familiar with the information contained in this form. If patients have questions that you or your charge nurse are unable to answer, please call a Diabetes Educator or the patient’s physician.
  • The order list above should be available on the chart for every inpatient with diabetes. The physician will complete this order sheet at his/her discretion for each patient. The order sheet will be in the Diabetes Care packet. Nursing will complete the patient diabetes screening tools, and place these orders in the patient’s chart under the Order Tab for the physician to complete. These orders are in addition to the scheduled and sliding scale insulin orders.
  • Many of our patients are admitted with conditions other than diabetes or complications from their diabetes. Because many of these conditions can become very complicated, diabetes may seem to be a lower priority at the time. We are trying to overcome this problem and make sure that their diabetes does not complicate their stay further. These forms were developed to improve communication between providers so that we are all speaking the same language with patients. Thank you for the excellent care you give your patients on a daily basis!
  • Appropriate food choices, particularly carbohydrate intake, are directly related to glucose control. The approach presented seeks to provide a consistent carbohydrate diabetes meal plan. Priority is given to the total amount of carbohydrate consumed at each meal and snack rather than the source of carbohydrate (simple vs. complex). Current diabetes recommendations no longer restrict sugar, but the carbohydrates in foods with sugar must be counted just as it must be counted in foods containing complex carbohydrates.
  • These foods that are low in carbohydrate are NOT calorie free as they contain fat or protein or both.
  • A1c alone is not enough to measure good blood glucose control. But it is a good resource to use along with regular glucose levels drawn daily and throughout each day to work for the best possible control.
  • The calculation of eGFR is appropriate for adults, but not pediatric patients at the CMC lab, eGFR is not used for patients under 17 years of age.
  • Insulin resistance occurs primarily in liver, muscle and fat tissue. The body’s initial response is to boost insulin secretion by pancreatic beta cells. Eventually, however, beta cell function declines and insulin secretion drops off. As tissues become increasingly insulin resistant and insulin secretion slows, blood glucose levels rise, especially after meals.
    The incretin hormones GIP and GLP-1 play a major role in postprandial hyperglycemia. Normally, both hormones lower blood glucose levels by enhancing insulin secretion. GLP-1 also suppresses glucagon secretion. In type 2 diabetes production of these hormones is insufficient, causing excess glucagon production, especially after meals. Diminished insulin secretion added to inappropriate glucagon secretion and subsequent unrestrained hepatic glucose production further elevates the blood glucose level and the body is unable to produce enough insulin to normalize it.
    Body cells don’t receive the fuel that they need and the patient experiences hunger. But if any more glucose is ingested in this situation it only makes the glucose level go higher.
  • Metformin is the only drug in this class that is approved by FDA for use in the US. Metformin can rarely cause lactic acidosis. It should not be used in patients with renal dysfunction because the risk of lactic acidosis may be additive with metabolic acidosis from kidney disease.
  • TZD’s are approved for use in combination with metformin or other meds for diabetes including insulin. The primary effect of these drugs is to combat insulin resistance by amplifying insulin sensitivity in fat, liver and muscle tissues. They carry a black box warning that TZD’s may cause or exacerbate heart failure.
  • As beta cell function declines, patients will need to be monitored for dose response. Patients need to be taught about the signs and symptoms of hypoglycemia and how to treat it. They need to be used with caution in patients who skip meals or delay meals or reduce intake. When taken with beta-adrenergic blocking agents, the usual warning signs and symptoms of hypoglycemia may be partially masked.
  • There is the option to adjust individual doses based on the anticipated carbohydrate content of each meal. This gives patients more flexibility with their meal planning. Because these drugs cause insulin secretion they have the potential to cause hypoglycemia so again it is important for patients to understand signs, symptoms and treatment of hypoglycemia. If a meal is skipped, the dose associated with that meal should also be skipped.
  • This medication can cause various abdominal discomforts which may make them difficult for patients to tolerate. Although these meds don’t directly affect insulin secretion, patients who use these meds in combination with sulfonylureas, insulin or glinides can experience hypoglycemia. When treating hypoglycemia in patients on glucosidase inhibitors, it is important to use glucose.
  • These drugs have not been on the market very long, and there are more of these agents in development. They are not associated with weight gain and are reasonably well tolerated. They are approved for mono therapy or can be used in combination with metformin or TZD.
  • These combination formulations can improve adherence while addressing multiple aspects of therapy. It is necessary to instruct patients regarding the aspects of both medications.
  • Diabetes Monitoring

    1. 1.  Compile and organize patient-specific diabetes information with the help of a standardized format so that patterns and trends can be analyzed.  Recognize signs and symptoms of hypoglycemia and treat according to current ADA guidelines.  Calculate carbohydrate content of a meal and apply it to correct dosage administration of medication.  Classify various types of diabetes medications according to mechanism of action, identify medication side effects, and evaluate for appropriate application to individual patients.  Cite reasons and implications for withholding metformin- containing medications 48 hours post contrast administration.
    2. 2.  All authors of these modules for diabetes education have denied any conflict of interest  There is no commercial support of this educational activity  Approved provider status does not imply endorsement by the provider, ANCC or MNA of any commercial products displayed in conjunction with this activity.  Contact hours for this activity are good through May 5, 2012  To receive credit please complete MNA evaluation and return to Education Resources, attn. Stephanie Metcalfe
    3. 3.  To improve compliance with national standards  Clinical practice guidelines are used to improve patient outcomes  Use performance measurement data to improve quality of care and patient satisfaction
    4. 4.  Multidisciplinary team to manage  Staff education  Coordination of meals and insulin  Nutritional assessments  Written protocols for managing insulin infusions, hypo and hyperglycemia treatment  Glucose monitoring protocols  Patient understanding of self management
    5. 5.  Percent of patients who receive accurate documentation of glucose, meals and insulin doses  Staff will receive mandatory education  Percent of patients who receive follow up of contrast administration when they use metformin  Percent of patients with A1c results within 60 days.
    6. 6.  Carbohydrate intake › glucose monitoring  Insulin dosing  Exercise
    7. 7.  Patient  Dietitian › Monitor carbohydrate intake › Teach patients › Glucose draw  Nurse › Draw and monitor glucose › Dose insulin › Teach patients › Nurse Technician  If trained can do finger stick glucose  Provider › Monitor trends, change orders
    8. 8.  Fewer episodes of hypo/hyperglycemia  Time savings  More accurate management  Fewer complications  Shorter LOS  More patient satisfaction
    9. 9. Nursing Diabetes Screening Info obtained from: □ Patient □ Family member(name)___________________________________________________ □ Other(name)____________________________________________________________________________ Admitting diagnosis ________________________________________________________________________________ Which health care professional do you normally see about your diabetes? ___________________ Present Diabetes Medications: See Medication Reconciliation form How long have you had diabetes? ________________________________________________________________ Are you monitoring your own blood glucose? □ Yes □ No If no, do you have a monitor? □ Yes □ No Type of monitor? ____________________ Frequency? ______________ Range? __________________ Any diabetes related Emergency Department visits or admits in the past year? □ Yes □ No □ Unknown Have you had an HgbA1C greater than 8% in the past year? □ Yes □ No □ Unknown Do you have any of the following? □ CAD □ HTN □ Foot problems □ Kidney problems □ Eye problems □ Unknown LAB RESULTS A1C___________/date_____ Creatinine on admit_______/date________ eGFR on admit______/date_____ Date ________ Time ________ Nurse’s Signature _____________________________________________________ Diabetes Education Referral □ A1c frequently elevated >7% □ BG frequently <70 or >200mg/dl □ Questions about diabetes self care techniques □ Education for home care giver □ Questions about carb counts □ Will need to monitor BG, or other BG monitor problems □ Medication changes from Admit to Discharge □ Other ______________________________________________________________________________ ______________________________________________________________________________ □ Nursing order for referral made, phone 327-4323, fax 327-4728 CMC Diabetes Educator □ Physician order for referral Date ________ Time ________ Signature ____________________________________________ Community Medical Center Inpatient Diabetes Screening Patient Label
    10. 10. Dear ________________________; Your patient _____________________________ was recently admitted to Community Medical Center for _________________________________________. During that visit we noticed that he/she is having problems with blood glucose control. This is detailed on the attached screening form. Our staff is recommending diabetes education for your patient as there is evidence of improved glucose control when people receive diabetes education. If you would like him/her to participate, please complete the referral form included with this letter and fax to the Diabetesand Nutrition Center at 327-4790. We will contact the patient and make arrangements from there. Thank you, Date___________ Time__________ Nurse Signature__________________________________________ Community Medical Center Attachments: □ Referral Form □ Screening Form
    11. 11. Nursing Diabetes Screening at OutPatient Contact  Info obtained from:  □ Patient □ Family member(name)__________________________________________________  □ Other(name)___________________________________________________________________________  Admitting diagnosis ________________________________________________________________________________  Which health care professional do you normally see about your diabetes? ___________________  Present Diabetes Medications: See Medication Reconciliation form  How long have you had diabetes? ________________________________________________________________  Are you monitoring your own blood glucose? □ Yes □ No  If no, do you have a monitor? □ Yes □ No  Type of monitor? ____________________ Frequency? ______________ Range? __________________  Any diabetes related Emergency Department visits or admits in the past year? □ Yes □ No □ Unknown  Have you had an HgbA1C greater than 8% in the past year? □ Yes □ No □ Unknown  Do you have any of the following?  □ CAD □ HTN □ Foot problems □ Kidney problems □ Eye problems □ Unknown   LAB RESULTS (if available)  A1C___________/date_____  Creatinine on admit_______/date________  eGFR on admit______/date_____  Date ________ Time ________ Nurses Signature ______________________________________________________   Assessment for Diabetes Care Needs as Identified by Patient  □ A1c frequently elevated >7% □ BG frequently <70 or >200 mg/dl  □ Questions about self care □ Education for home care giver  □ Questions about carb counts □ Will need to monitor BG, or other BG monitor problems  □ Medication changes from Admit to Discharge   □ Fax screening form, letter and referral form to Referring Provider _______________________  Comments _____________________________________________________________________  ______________________________________________________________________________ Date ______Time ______ Nurse Signature ___________________________________________
    12. 12. Education Topic Date/Initials Results Disease Process: □Living Well with Diabetes Home blood glucose monitor training Hypoglycemia treatment, hyperglycemia treatment □Living Weill with Diabetes Medication instruction □Review discharge mediations with patient Insulin: □ Onset/Peaks □Drawing Up □ Injections or □Patient not on insulin Diet Education Per dietitian ________________________Signature Diet Education □Living Well with Diabetes Exercise Education □Living Well with Diabetes Sick Day Management □Handout “Diabetes: “When you go home” Watched diabetes video (Peds only) Teaching Results: V= Verbalize Understanding DU= Demonstrates Understanding R= Needs Reinforcement *= Refused (more details in nurses notes) Initials Nurse Signature Fax both sides of this form to □PCP □ Diabetes Provider □ Outpatient Diabetes Education (#4728) Know their A1C can state the meaning □Living well with Diabetes
    13. 13.  Monitoring Blood Sugar  Taking Medication  Making Healthy Food Choices  Caring for Your Feet
    14. 14.  Check your blood glucose every 4 hours during the day  To prevent dehydration  If you take a diabetes medication containing metformin  Always take your usual amount of long- acting insulin  If possible, follow your usual meal plan
    15. 15. PHYSICIAN ORDERS for Diabetes Patients  □ Dietitian Consult  □ A1c (if not done in past 60 days)  □ Creatinine/ eGFR, if not done in ED  □ Label insulin pen for home use after discharge  □ Referral to diabetes education, Ext. 4323  Date _________ Time _________  Physician Signature________________
    16. 16.  Increase quality of diabetes care  Eliminate episodes of hypo/hyper- glycemia  Improve patient confidence with their self care  Improve patient satisfaction
    17. 17.  If you have any questions about any of the information in this module, please speak with your staff developer, call the Diabetes Education nurse at X4323, or Linda Hightower at X4133.
    18. 18.  To increase knowledge of carbohydrate counting skills for those caring for patients with diabetes  Identify the relationship between carbohydrates and blood sugar  Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools  Calculate the total grams of carbohydrate per meal
    19. 19.  A meal-planning approach for all patients with diabetes, based on the following ideas: › Carbohydrate is the main nutrient affecting postprandial glycemic response › Total amount of carbohydrates consumed is more important than the source of carbohydrates  CMC provides a Consistent Carbohydrate meal plan for diabetic management › The movement towards carbohydrate counting means the “ADA Diet” is no longer recognized. The correct diet order is “Consistent Carbohydrate”
    20. 20.  More flexible than other meal-planning methods › Allowing a wider array of foods to choose from  All carbohydrate sources are allowed › Complex carbohydrates that break down slowly › Simple sugars that break down almost right away  Focuses attention on the foods that are most likely to make blood glucose levels go up  Provide for tighter control over blood glucose readings
    21. 21.  Breads, cereals, pasta, and grains  Rice, beans, and legumes  Starchy vegetables-potatoes, corn, and peas  Fruit and fruit juices  Milk, soy milk, and yogurt  Regular soda, fruit and sports drinks  Cakes, cookies, ice cream, candy, and jelly
    22. 22.  One serving of carb is measured as 15 grams  One carbohydrate serving is a food that contains approximately 15 grams of carbohydrate  All carbohydrates affect blood glucose in the same way. It is the amount of carb eaten that is important, not the type of carb. For example, one slice of bread, a small piece of fruit, or ½ cup corn each have around 15 grams of carbohydrate = =
    23. 23.  FOOD GROUPS CONTAINING CARBOHYDRATES: › Starch: 1 serving equals about 15 grams carbohydrate › Fruit: 1 serving equals about 15 grams carbohydrate › Milk: 1 serving equals about 12 grams carbohydrate › Vegetables: 1 serving equals about 5 grams carbohydrate › Starchy Vegetables: 1 serving equals about 15 grams carbohydrate
    24. 24.  Each amount listed below = 15 g carbohydrate › 1 slice of bread › ¾ c cereal › ½ c cooked cereal › ½ of an English muffin or small bagel › ⅓ c cooked pasta or rice › ½ hamburger or hotdog bun › ½ c mashed potatoes › ½ c corn, beans, chickpeas, peas › 1 small baked potato (3 oz)
    25. 25.  Each amount listed below = 15 g carbohydrate › 1 small fresh fruit (4 oz) › ½ c canned fruit (in natural juice) › 2 T raisins or dried fruit › 17 grapes › ½ c fruit juice › 1 c melon or berries › ½ banana
    26. 26.  Each amount listed below = approximately 12 g carbohydrate › 1 c skim, 1%, 2%, or whole milk › 3/4 c yogurt (6 oz) › 1 cup soy milk
    27. 27.  Each amount listed below = 5 g carbohydrate › ½ c cooked vegetables › 1 c raw vegetables › ½ c vegetable juice  Remember - starchy vegetables (corn, peas, and potatoes) count as 15 g carbohydrate per serving
    28. 28.  Free foods have 5 or fewer grams of carbohydrate  and fewer than 20 calories per serving.  They have no significant effect on blood glucose levels Unlimited Diet soft drinks, Club soda Sugar-free drinks Coffee Hot or iced tea (unsweetened) Sugar-free gelatin Seasonings Sugar substitutes Three or less servings per day Sugar-free jam or jelly, 2 tsp Ketchup, 1 T Mustard, 2 T Dill Pickle, 1 medium Sugar-free popsicle, 1 Salsa, ¼ cup Sugar-free syrup, 2 T
    29. 29.  Low carbohydrate foods differ from free foods in that they contain more calories per serving, and when eaten in large amounts can affect blood glucose levels.  For example: A serving of almonds (2 Tbsp) contains approximately 5 g carbohydrate, if you ate 2 servings (or 4 Tbsp) it would total 10 g carb!  Be mindful of serving sizes with low carb foods Examples of carbohydrate-free or low carbohydrate snacks: Cheese, 1 oz Cottage Cheese, ½ cup Tomato juice, ½ c Meats, 1 oz Nuts or seeds, 2 T Raw Vegetables, 1 c Hard boiled egg, 1 Beef jerky, 1 oz Peanut butter, 2 T
    30. 30.  Carbohydrate grams can be found using various sources: › CMC Menus › Food labels › Clinical diet manual › Dietitian or diet aide
    31. 31. CMC provides CONSISTENT CARBOHYDRATE menus for diabetes management  The patient’s carb goal is written on the menu, the goal is based on physician orders and/or dietitian recommendations Meal plans are based on individual needs and can range from 30 to over 90 g carb per meal, (the default meal plan is 60 g carb per meal)  The menus list the number of grams in each carbohydrate food item  Foods without carb grams listed contain either no carbohydrates or less than 5 grams per serving  At the end of a meal, total the grams of carb based on the patient’s intake
    32. 32.  You will find the serving size and grams of carb per serving on food labels  Total Carbohydrates includes all starches, sugars, and dietary fiber  Always start by checking the serving size on the label, if more than 1 serving is eaten, you need to do the math! For example, if a patient ate 6 crackers, how many total grams did they actually eat? What is the serving size on the label: 2 crackers How many grams of Total Carb per serving: 10 g How many servings did they actually eat: 3 servings 3 servings x 10 grams per serving = 30 g carb
    33. 33.  The Clinical Diet Manual includes all diets provided at CMC and can be accessed in two ways: 1. The manuals are located on each unit, look for the large white binders, labeled “Clinical Diet Manual” 2. The manual is also available on CMC’s intranet  From the home page, click Departments, then click Nutrition, then Nutrition Manual  Scroll through to find “Diabetes - Consistent Carbohydrate Diet”  Food lists with carb grams are located on page 7-9
    34. 34.  The Carbohydrate-to-Insulin ratio (CHO : INSULIN) is the number of carbohydrate grams that 1 unit of insulin will cover For example, if a patient has a ratio of 15:1, it means that for every 15 grams of Carbohydrates he/she eats, 1 unit of insulin must be injected -- so that blood glucose readings are within normal range two hours later Based on the above ratio, if a patient eats 45 grams of carbohydrate, how many units of insulin do you need to give?
    35. 35.  The goal is to include a variety of foods as long as the total carbs specified for each meal and snack stay about the same For a patient on a 45 gram per meal plan, here are two different breakfasts that each total around 45 grams carb: BREAKFAST #1 2 slices whole wheat toast 28 g 1 pkt Sugar-free jelly Scrambled Eggs ½ cup Orange Juice 15 g Coffee w/ sugar substitute ____ 43 g BREAKFAST #2 ¾ cup Bran cereal 25 g ½ cup Skim milk 6 g ½ Banana 14 g Coffee w/ sugar substitute ____ 46 g The goal is to come within a 10 gram range of the meal plan
    36. 36.  Carb counting allows for improved blood glucose control  Carb counting is more flexible and allows for a greater variety of food choices  Being consistent is the key to successful carb counting  Carb counting increases the quality of diabetes care For further information contact a clinical dietitian
    37. 37.  A1C is a lab test used to assess a patient’s average blood glucose level  The test measures the amount of glucose adherent to the hemoglobin protein in the patient’s red blood cells (RBCs). Since the average lifetime of RBCs is 3 months, A1C reflects the patient’s average blood glucose level during that time period. Conditions which affect RBCs such as profound anemia, recent transfusion, hemoglobinopathies & pregnancy may result in inaccurate results  An A1C below 7% is the target goal to reduce complications from chronically elevated blood glucose  There are tables which correlate A1C to average daily blood sugar
    38. 38. A1c (%) Mg/dl 5 97 6 126 7 154 8 183 9 212 10 240 11 269 12 298
    39. 39.  eGFR , or estimated glomerular filtration rate, is a measure of kidney function. It is a calculated value based on the patient’s serum Cr (creatinine), age & gender.  Creatinine in the bloodstream comes predominantly from the normal breakdown of muscle. Cr is then removed from the bloodstream by the kidneys. Serum Cr will rise if kidney filtration is below normal. However, patients who are elderly, female or underweight generally have less muscle mass than average males, which will result in a lower serum Cr level. In these populations the Cr level may appear falsely normal even when their kidney function is markedly decreased.  The creatinine level will not be raised above the normal range stated by most laboratories until 60% of normal kidney function is lost. Therefore The National Kidney Foundation recommends the reporting of eGFR when a metabolic profile is ordered, as it is a more accurate reflection of kidney function.
    40. 40.  Currently, the severity of Chronic Kidney Disease, (CKD), is described by 5 stages: › Normal kidney function: GFR> 90ml/min without proteinuria › CKD stage 1: GFR> 90 ml/min WITH proteinuria › CKD stage 2 (mild): GFR 60-89 ml/min › CKD stage 3 (moderate): GFR 30-59 ml/min › CKD stage 4 (severe): GFR 15-29 ml/min › CKD stage 5 (end stage renal disease): GFR<15 ml/min. Some of these patients are on dialysis; many are not.  Diabetes & hypertension are the two most common causes of chronic kidney disease (as well as of cardiovascular disease). Both diabetes and hypertension damage the kidney filtration system. Therefore CKD is an early marker for risk of cardiac disease, stroke and peripheral arterial disease.
    41. 41.  The goal of blood glucose(BG) management is to keep BG between 70 and 180 mg/dl as much of the time as is feasible and safe for each person.  When BG goes below 70 mg/dl, treatment is warranted to bring the BG back into the normal range.
    42. 42.  People who have become accustomed to frequent high BG’s may develop symptoms of hypoglycemia even when their BG is in the lower end of the normal range.  A small amount of food for treatment may be given to relieve these symptoms but the BG does not need to be elevated into the range above normal.  This “inappropriate” sensation of low blood glucose is called “pseudohypoglycemia.”
    43. 43.  Symptoms of hypoglycemia may include feeling shaky, hunger, diaphoresis (sweating), rapid heart rate, pallor, difficulty concentrating, confusion, irritability or irrational behavior, blurred vision, slurred speech, slowed reaction time, or extreme fatigue.
    44. 44.  When BG goes below normal, the body naturally releases epinephrine (adrenaline) which helps to make the BG rise again. (Epinephrine releases glucose molecules which had been stored in muscle and liver cells.) Most symptoms of hypoglycemia are actually caused by this epinephrine release, not by the low blood glucose itself.
    45. 45.  This epinephrine may still be present in circulation even after the BG has been corrected back up to normal. Therefore, the symptoms of hypoglycemia may persist until the epinephrine wears off, even though the BG may already be normal. As long as the CBG (capillary blood glucose; finger stick test) is above 80 mg/dl, giving additional carbohydrate food is not helpful. Giving excessive carbohydrate food may then cause a subsequent high blood sugar, which is not helpful. The epinephrine related symptoms will resolve over the next half hour or so. If there is concern about the BG going low again, retest the CBG.
    46. 46.  Treat with 15 gm carbohydrate food such as 4 ounces of unsweetened fruit juice, 8 ounces of milk, 1 slice of bread, 3 graham crackers, 4 ounces of gelatin (“regular,” not sugar free).  When symptoms are more pronounced, a liquid form of carbohydrate may be preferred for faster absorption.  If the person is unable to take carbohydrate food orally, carbohydrate may be given as D-50 (50% dextrose) 25 ml (12.5 gm carb) IV push.
    47. 47.  It is not helpful to give more than 15 gm of carbohydrate initially.  Wait 15 minutes for the carbohydrate to be absorbed, then recheck capillary BG (CBG).  If BG is now above 80mg/dl, no further treatment is needed.  If BG is still below 80 mg/dl, give another portion of 15 gm of carbohydrate, wait another 15 minutes and retest CBG.  Repeat this cycle until BG is above 80 mg/dl, then stop.
    48. 48.  In most cases the BG will continue to rise after the 15 minute CBG is done. If there is concern about the BG going below normal again, retest the BG again after 15-30 minutes or as needed.  This technique is called the “15-15 Rule” (15 gm carbohydrate/15 minutes)  Symptoms of hypoglycemia may persist after the BG comes up into the normal range. As long as the BG is above 80 mg/dl, giving additional food or sugar is not helpful. The symptoms will resolve over the next half hour or so. If there is concern about the BG going low again, retest the BG.
    49. 49.  Severe hypoglycemia is defined as an episode during which the patient’s consciousness is sufficiently impaired that he/she cannot correct the problem without the assistance of another person. Symptoms of severe hypoglycemia include disoriented behavior, inability to swallow, loss of consciousness, inability to be aroused from sleep, or seizures.
    50. 50.  Do not attempt to give oral food or liquid to a person who is unconscious, as this could cause aspiration.  Assess ABC’s (airway, breathing, and circulation) & treat accordingly. Do not leave the patient alone. Notify the physician immediately and administer 25ml of D-50 (50% Dextrose) ( ½ amp of 25g/50ml), given IV.  If there is no IV, administer glucagon IM. Dissolve 1 mg glucagon powder in 1 ml of diluent. Give the entire 1 ml for adults; give 0.5 ml (0.5 mg) for pediatric patients under 44 lb (20 kg). Try to obtain IV access.  The person should become responsive within about 15 minutes. If not, glucagon can be repeated. However, a more rapid correction of CNS effects of hypoglycemia will be obtained if D-50 can be given IV.  Glucagon can be given subQ if IM injection is contraindicated, but the response will likely be slower.
    51. 51.  If glucagon has been given, then once the patient is responsive, give 15 gm of carbohydrate food orally. If the patient is treated with IV dextrose and not glucagon, he/she will be less likely to need additional carbohydrate food after regaining consciousness. However, either way, the patient should continue to be observed, with CBG checked periodically, such as every half hour or so, for a period of 1 to 2 hours. Additional carbohydrate food can be given orally if the BG goes below normal again.  Nausea can occur after severe hypoglycemia, especially if glucagon is given. If this occurs, and additional carbohydrate administration is needed, IV dextrose can be used again.
    52. 52.  Common causes of hypoglycemia include: › Insulin errors: improper timing in relation to food, excessive insulin dose, or wrong type of insulin given › Erratic absorption of insulin: inadvertent IM injection of insulin; more rapid absorption due to baths or heat; injection into a body area which is physically active › Increased exercise: either prolonged or intense › Oral diabetes medications: inadequate food intake; overdose; renal failure leading to reduced clearance of medication
    53. 53.  After any episode of hypoglycemia is resolved, notify the patient’s physician/provider so that he/she can address strategies to prevent a repeat episode.  Before calling the provider, assemble information about events leading up to the hypoglycemia to help understand possible causes of the event. (Use SBAR technique.)
    54. 54.  Biguanides (metformin)  Thiazolidinediones (TZD’s): pioglitazone (Actos), rosiglitazone (Avandia)  Sulfonylurea secretagogues: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (Micronase, Glynase, Diabeta)  Nonsulfonylurea secretagogues: repaglinide (Prandin), nateglinide (Starlix)  α-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset)  DPP-4 inhibitors (dipeptidyl-peptidase 4): sitagliptin (Januvia), saxagliptin (Onglyza)  GLP-1 agonists (glucagon-like peptide): exenatide (Byetta), liraglutide (Victoza)
    55. 55.  Insulin resistance  Causes BG to rise, especially after meals  Endogenous glucagon-like peptide 1 (GLP-1)and glucose-dependent insulinotropic polypeptide (GIP) lower BG levels by enhancing insulin secretion  Production of these hormones is insufficient in diabetes  Body cells don’t absorb fuel
    56. 56. Biguanides: metformin  Reduces hepatic glucose production  Boosts insulin sensitivity in liver, muscle and fat  Little risk of hypoglycemia  Contraindicated in renal dysfunction, due to risk of lactic acidosis: › Serum Cr >1.5mg/dL men; >1.4 mg/dL women › Increased risk of lactic acidosis in dehydration, severe CHF or liver disease, history of alcohol abuse, or pre-existing metabolic acidosis.
    57. 57.  It should be stopped day of surgery  It may be taken up to the time of any radiology or diagnostic imaging procedure.  It should not be restarted for at least 48 hours after contrast administration. Renal function should then be confirmed to be at normal levels before restarting metformin.  Adverse effects may include nausea, abdominal gassiness and cramping, or diarrhea. Take with a meal.
    58. 58. TZD’s: pioglitazone (Actos), rosiglitazone (Avandia)  Used in combination with other diabetes meds  Not associated with hypoglycemia  Adverse effects: weight gain, fluid retention  Contraindicated in patients with class III or IV heart failure
    59. 59. Sulfonylurea insulin secretagogues: glimepiride (Amaryl), glipizide (Glucotrol) and glyburide (Micronase, Glynase, Diabeta)  Stimulate the pancreas to increase insulin secretion  Need adequate β-cell function to be effective  Quick onset of action  Can cause hypoglycemia  Contraindicated in kidney or liver disease, sulfa allergy
    60. 60. Nonsulfonylurea insulin secretagogues or glinides: repaglinide (Prandin), nateglinide (Starlix)  Stimulate the pancreas to produce insulin in response to ingested carbohydrate  More rapid onset and shorter duration of action than sulfonylureas  Give 30 min before meal  Can cause hypoglycemia, but less so than sulfonylureas
    61. 61. α-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset)  Slows intestinal absorption of carbohydrates. Should be given with the first bite of a meal.  As diabetes patients often have a slowing of insulin production this allows more time for internal insulin production to coordinate with the absorption of food.  May cause flatulence, bloating, abdominal discomfort, diarrhea.  Can cause hypoglycemia when used in combination with other diabetes meds. If this occurs, treat with glucose, not complex carbohydrates. (This is because the medication will delay the absorption of complex carbohydrates, including sucrose (table sugar). Glucose itself will still be absorbed normally.
    62. 62. › GLP-1 agonists: exenatide (Byetta), liraglutide (Victoza) injectable › DPP-4 inhibitors: sitagliptin (Januvia), saxagliptin (Onglyza) oral  Promotes insulin secretion  Suppresses glucagon release  Improves insulin sensitivity  Increases satiety. GLP-1 agonists may therefore facilitate weight loss. However, weight loss has not been seen with DPP-4 inhibitors.
    63. 63. More than one agent to achieve glycemic target:  Metformin + glyburide (Glucovance)  Metformin + glipizide (Metaglip)  Metformin + rosiglitazone (Avandamet)  Metformin + pioglitazone (ActoPlusMet)  Metformin + sitagliptin (Janumet)
    64. 64.  Longo, Rebecca; Understanding Oral Antidiabetic Agents; American Journal of Nursing, Vol. 110, No. 2, Feb. 2010, 49-52.  McCarron, Kim, Riebel, Tena; Spotlight on Type 2 Diabetes; Nursing Made Incredibly Easy, Sept/Oct 2008, 44-54. (Contact hours available)  Pearson, Kathleen; Improve Patient Safety with Glucose Control; Operating Room Nurse; June, 2008, 45-50.  Hall, Mellisa; Type 2 Diabetes: The Many Facets of Care; Home Healthcare Nurse; vol. 26, no.6, June 2008, 346-353. (Contact hours available)
    65. 65.  Contrast- induced nephropathy (CIN) has become a significant source of hospital morbidity and mortality with the ever-increasing use of iodinated contrast media in diagnostic imaging and interventional procedures such as angiography in high-risk patients. It is the third most common cause of hospital- acquired acute renal failure after surgery and hypotension. [1]
    66. 66.  Contrast-induced nephropathy is most commonly defined as acute renal failure occurring within 48 hours of exposure to intravascular radiographic contrast material that is not attributable to other causes. [2] An arbitrary range of values between 25% and 50% increase in serum Creatinine levels from baseline has been suggested to define contrast- induced nephropathy. [2,3]
    67. 67.  Since acute renal failure has been documented as a complication in diabetic patients receiving contrast, baseline renal function is of concern prior to administration of intravascular contrast. CMC’s protocol requires all patients with diabetes have a baseline BUN, serum Creatinine and GFR done prior to administering IV contrast. This is especially important for patients receiving metformin–containing medications.
    68. 68.  Despite normal renal function, resources warn that metformin-containing medications should be held until kidney function (serum creatinine) is reassessed 48 hours later. This is to prevent, in the context of CIN (contrast induced nephropathy), high serum metformin concentrations, which could lead to lactic acidosis. [4] 8% of cases of metformin-induced lactic acidosis occur in the presence of contrast induced nephropathy. [5]
    69. 69.  Metformin does not need to be held prior to receiving intravascular iodinated contrast. If contrast nephropathy occurs, typically serum creatinine starts rising 24- 48 hours after exposure and peaks at 4-7 days. Creatinine values tend to return to normal within 7-14 days. [6]
    70. 70.  Given this information, CMC hospital policy states that all patients receiving metformin-containing medications will have their metformin held for 48 hours post-procedure until a repeat BUN and Creatinine is drawn and renal function evaluated. If the Creatinine level is elevated the radiologist will be contacted to inquire if metformin needs to be held longer, if patient needs more hydration and/or repeat BUN and Creatinine testing. Oftentimes, it is determined that kidney function, though slightly reduced, is adequate to restart metformin. The patient will be contacted by the radiology nurse and/or the patient’s personal care provider for post lab instructions. The personal care provider will be notified of any abnormal rises in Creatinine.
    71. 71.  In order to receive continuing nursing education credit from MNA for this activity, please do the following:  Sign in to Healthstream and complete post test with a passing grade of 80% or better.  Complete MNA evaluation form located in the learning packets on your unit and return it to Education Dept. for a certificate of completion & attendance.
    72. 72.  Tublin ME, Murphy ME. Tessler FN. Current concepts in contrast media-induced nephropathy . AJR 1998:171:933-939.  Barrett BJ, Parfrey PS: Prevention of the nephrotoxicity induced by radiocontrast agents. N England Journal Med 1994; 331-1449- 1450.  Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast material- induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. N England J Med1989; 320:143-153.  Mathew R et al. Acute renal failure induced by contrast medium: steps towards prevention. BMJ 2006:333: 539-40.  Thomas HS, Morcos SK. Contrast media and the kidney: European Society of Urogenitial Radiology (ESUR) guideline. BR J 2003:76: 51-8.  Narang, R. et al. Contrast Induced Nephropathy. Indian Heart Journal. 2004; 56(1): 1-12.

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