Week 7: Administering Insulin Review, Diabetes Technology, and Administering on-Insulin Therapies for DM-2

Type 1 Diabetes (T1D)

-the body does not produce insulin due to autoimmune destruction

-ketosis present at onset

-more common in young people

-accounts for 5-10% of cases

Type 2 diabetes (T2D)

-the body does not produce or use insulin well due to insulin resistance

-ketosis not present unless infection or stress

-more common in adults

-accounts for 90-95%

S/s of T1D

-polydipsia

-polyuria

-polphagia

-fatigue

-weight loss without trying

S/s of T2D

-often NON

-fatigue

-recurrent infections

-may get polyuria, polydipsia, polyphagia

Screening T1D:

-family history or other genetic risk factors

-blood test to detect autoantibodies

Screening T2D:

-overweight or obese

-first degree relative with diabetes

-high risk ethnicity

-women with polycystic ovary syndrome

Criteria for diagnosis:

-A1C >6.5%

-fasting glucose >126 (no food for 8 hrs)

-2 hr plasma glucose >200

-s/s of hyperglycemia and random blood sugar >200

Long term consequences of Diabetes:

-coronary heart disease

-HTN

-stroke

-peripheral vascular disease

-retinopathy

-nephropathy

-neuropathy

Insulin and glucagon relationship:

-insulin released when serum glucose HIGH

-glucagon released when serum glucose LOW

3 Rapid acting analogs (insulin)

-insulin lispro

-insulin aspart

-insulin glulisine

-onset between 10-30 mins

-peak is 0.5-3 hr

-duration is 3-6 hr

Short acting analog (insulin)

regular human

-onset 30-60 mins

-peak 1-5 hr

-duration 3-5 hr

Intermediate acting insulin

NPH

-onset 1-2 hr

-peak 6-14 hr

-duration 16-24 hr

2 Long acting insulin

-insulin glargine

-insulin detemir

-onset 70 mins

-peakless

-duration 12-24 hr

2 Ultra long acting analogs (insulin)

-insulin glargine (300 instead of 100)

-insulin degludec

-onset is 6 hr

-peakless

-duration between 36-42 hr

Inhaled technosphere insulin

-powdered form of insulin delivered orally

-ultra rapid acting

-onset is 12 mins, duration is 1.5-3hr

-used in combo with basal insulin

-contraindicated w/chronic lung disease

Side effect of inhaled insulin:

-contraindicated w/chronic lung disease

-hypoglycemia

-dry cough

-scratchy or sore throat

Nursing considerations for administration of insulin:

-insert needle at 90* on average sized adult (subque)

-for children and thinner people 45*

-aspiration after injection not necessary

-do not massage the site after

-prime pens w/2 u

-rotate sites to prevent lipohypertrophy

Order for drawing up insulin

we are RN

-regular first

-NPH second

NPH should be rolled before its drawn into syringe

Where is insulin absorption the fastest?

abdomen

-followed by arm, thigh, buttock

Lipohypertrophy

buildup of fat under the skin caused by repeated insulin injections in the same spot

-appears as raised, firm, or lumpy bumps under the skin

-leads to altered insulin absorption

Insulin storage considerations:

-open vials and pens at room temp for 4 weeks

-store unopened pens or vials in refrigerator

-avoid exposure to direct sunlight

-roll prefilled syringes between palms 10-20x to warm and re suspend

S/s of hypoglycemia:

blood glucose <70

-tremor

-diaphoresis

-tachycardia, hypotension

-pallor

-LATER: dizziness, clouding of vision, slurred speech, abnormal behavior, LOC

Glucose replacements:

-15 g of glucose 40% gel

-4 oz of juice

-3 glucose tablets

Nursing considerations for Glucagon adminstration:

-an unconscious patient usually wake up 10-15 min following administration

-side effect can be nausea vomiting (turn patient on side)

-have patient consume MORE afterwards to avoid recurrent episode (carb and protein)

-stay w/patient until sugars resolve

Triggering events for hypoglycemia in hospital:

-pre meal insulin given, and no meal ingested

-sudden NPO status or reduction in oral intake

-enteral or TPN discontinued

-missed blood sugar checks

-reduced corticosteroid use

Hypoglycemia unawareness

-individuals with diabetes may not experience or recognize the typical warning signs of low blood sugar

-more common in T1D or long standing

-can occur in patients taking beta blockers

-patients w/this should be advised to stop driving

Beta blockers and hypoglycemia unawareness

beta blockers can be delay awareness of hypoglycemia

-mask s/s that are caused by activation of sympathetic nervous system

When to use blood glucose monitor intensive (BGM):

-before meal and snack

-at bedtime

-before, during, after exercise

-when suspecting hyper or hypo

-after treating hypo

When to use blood glucose monitor w/T2D:

-in the morning, while fasting

-at bedtime and anytime theres hypo concerns

Lag time

there can be a difference between actual blood glucose and sensor glucose by 5-20 mins

Indications for CGM:

-all patients w/T1D

-T2D on insulin or on meds for it

-pregnant individuals w/type 1 or gestational

-older adults at risk for hypoglycemia

-youth who are capable of using device safely

Time in range:

the percentage of time that glucose levels remain within a predetermined target range

-TIR correlates inversely with A1C

-HIGH TIR=LESS risk of long term

Time in range reference range:

>70% is recommended for most T1D and T2D

-TIR for older/high risk= >50%

-TIR for gestational pregnancy/T2D= >90%

-HIGH TIR=LESS risk of long term

Benefits to CGM:

-helps to clarify the effect of diet, exercise, and medication on blood sugar levels

-can lower A1C

-eliminates the need for finger sticks

-can be useful to reduce hypoglycemia

Considerations for CGM:

-cost, especially when not covered by insurance

-can be complicated to learn

-the amount of data is overwhelming

-alerts and alarm fatigue

-contact dermatitis

Insulin Pump therapy

small device worn outside body that delivers rapid-acting insulin into subque tissue at a predetermined rate per hour

-tubed vs tubeless pumps available

-rapid acting insulin is used

How often is tubing changed on an insulin pump?

every 2-3 days

-omnipod (tubeless administration) changed 2-3 days as well

What type of diabetes patients use patches?

T2D

-uses regular insulin

Hybrid Closed Loop Insulin Therapy

-most common type of automated insulin delivery

-automatically adjusts insulin based on reading

-user enters carbs for bolus insulin

Indications for Insulin Pumps and Automated Insulin Delivery:

-T1D

-insulin deficient diabetes

-T2D who are on multiple daily injections of insulin

Smart Insulin Pen

-phone app and pen link to provide sugar information and recommend how much insulin to inject

-works with any type of insulin

-pens and caps offer many features like pumps but are cheaper and not attached to patients body

Do we remove pumps during surgery?

YES- should be removed during the procedure