diabetes self care Flashcards
Key self-management activities for diabetes
Managing relationships between food, activity and medications
Self-monitoring of blood glucose, BP and having retinal screening carried out
Targeting goals tailored to individual needs, for example around foot care, weight loss, injection technique
Applying sick day rules when ill, or what to do if going into hospital
Understanding diabetes
managing acute complications - hypo d hyperglycemia
Understanding legislative issues such as those related to driving and employment
how can education and training help
examples
Offer structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review
DESMOND (Diabetes Education and Self Management for Ongoing and Diagnosed)- the collaborative name for a family of group self management education modules, toolkits and care pathways for people with, or at risk of, Type 2 diabetes
X-PERT offer 15 hours of group education for Type 1 and 2 diabetes. Ensures people understand their condition. Training split into bite-sized chunks of weekly 2½ hour sessions over 6 weeks and covers a different topic each week.
DAFNE (dose adjustment for normal eating regimen) - way of managing Type 1 diabetes and provides people with the skillsnecessary to estimate the carbohydrate in each meal and to inject the right dose of insulin
how can the pharmacist help
Reinforce diet and lifestyle advice
Offer support through locally commissioned services e.g weight management programmes, blood pressure monitoring
NMS and MUR (until phased out, then through new consultation services run by GP pharmacists)
Ensure patients receive NICE-recommended care processes:
Glycated haemoglobin (HbA1c) measurement, with a suggested target of 48 mmol/mol (6.5%)
Blood pressure (BP) measurement, with a suggested target of ≤135/85 mm Hg
Cholesterol level measurement, with a suggested target for total cholesterol (TC) of 4 mmol/L
Retinal screening
Foot checks
Urinary albumin testing
Serum creatinine testing
Weight check
Smoking status check
what kind of monitoring is necessary?
Signs and symptoms of hypo/hyperglycaemia
Signs and symptoms of chronic complications
Blood glucose level (target level between 4-9mmol/L)
Offer self-monitoring of plasma glucose to a person newly diagnosed only as an integral part of his or her self-management education
For children and young people with Type 1 diabetes, routine daily monitoring is recommended
Self-monitoring of plasma glucose should be available to: those on insulin, those on oral medications to provide information on hypoglycaemia, assess changes in glucose control, monitor changes during intercurrent illness, ensure safety during activities, including driving.
To self-monitor blood glucose levels, patients would need a blood glucose monitor, lancets and testing strips
Self-monitoring of blood glucose is not routinely recommended for adults with type 2 diabetes, but it is recommended for people on insulin therapy
what are the treatment goals
Improve QoL
Prevent short-term hypo/hyperglycaemia
Prevent long-term complications
Reduce mortality
what is the treatment for type 1 and type 2 diabetes
Type 1
Insulin
Type 2
Diet
Metformin (especially if overweight) or sulphonylurea
Other newer drugs
Insulin
what should the patient know about insulin/be taught
Patients should:
know the types of insulin, the pen, syringes and other equipment they use
always check they have been prescribed and dispensed the right products – they should not be afraid to question any changes
be told to dispose of any old unused insulin to make sure it doesn’t get mixed up with new insulin
take responsibility to make sure they don’t run out of their products
Pharmacists can help with all of this.
If patients go into hospital they need to tell staff if they want to carry on administering their own insulin (dose and timing very important)
diff types of insulin and examples
Rapid acting insulin analogues Aspart (NovoRapid), glulisine (Apidra), lispro (Humalog)
Short-acting / soluble insulin Actrapid, Humulin S
Intermediate acting insulin Isophane (Humulin I, Insulatard)
Long-acting insulin glargine (Lantus), detemir (Levemir)
insulin devices and equipments
Insulin syringes, pre-loaded disposable pens, re-useable injection pens (choice depends on age, dexterity, visual impairment, personal choice)
Insulin administration should only be done using insulin syringes, NOT standard IV syringes
Needles – sterile and disposable, designed to fit pen injectors, come in different lengths (4mm to 12.7mm)
Blood glucose meter, test strips, and lancets (meters not prescribable on NHS, but testing strips and lancets are)
Urine ketone testing strips (Ketostix and Mission ketone strips on NHS)
Blood ketone meter test strips, and lancets (meters not prescribable on NHS, but testing strips and lancets are)
Glucose and/or glucagon kit (treating hypoglycaemia)
how should insulin be stored?
Insulin products that are IN USE do NOT usually have to be stored in a refrigerator, provided the temperature they are stored in is lower than 25-28 degrees C (can be kept at room temperature for 4 weeks as long as the specified temperature is not exceeded)
Open vials, cartridges or pre-filled pens used every day must be discarded after 28 days
Insulin products that are intended for future use should be stored in a refrigerator at 2-8 degrees C until they are used
what should you look out for in the site of injection
which site has more absorption
Check injection sites regularly
Lipohypertrophy (“lumpy” injection site) can affect absorption
Arms should be used with caution due to rapid onset of action
Rotate injection site (but may result in differing rates of absorption between sites e.g absorption quicker in abdomen than thighs)
Use different sites for different times of day
Rotate left and right
Other injection site problems:
Painful injections: review injection technique, shorter needles, new needle each injection, not cold insulin (if removed from the fridge leave at room temperature for at least 30mins before injecting)
Bleeding and bruising: may occasionally occur, consider changing size of needle
Redness, swelling and itching at site of injection: usually resolve after a few days (sometimes weeks), consider switching to an insulin analogue, exclude other causes
Insulin leakage: leave the needle in skin for 5-10s, check injection technique, change needle length
what is insulin passports
Insulin passports and patient information booklets should be offered to patients receiving insulin
Insulin passport – credit-card sized record of the patient’s current insulin preparations and has a section for emergency information
Patient information booklet – provides advice on safe use of insulin
what is hypoglycaemia?
treatment
advice
All patients must be carefully instructed on how to recognise, avoid and treat hypoglycaemia (<4mmol/L glucose)
Number of episodes of hypoglycaemia must be minimised as may reduce warning symptoms experienced by the patient
The immediate treatment is to have some sugary food or drink (about 10 to 20g of rapidly acting carbohydrate). For example:
a glass of fruit juice or non-diet soft drink (e.g 10g glucose in Lucozade original 55mL, Coca Cola 100mL, Ribena 19mL)
between three and five dextrose tablets
a handful of sweets
Avoid fatty foods and drinks, such as chocolate and milk, because they don’t usually contain as much sugar and the sugar they do contain may be absorbed more slowly
After having something sugary, should have a longer-acting carbohydrate food, such as a few biscuits, a cereal bar, a piece of fruit or a sandwich, or next meal if it’s due
Blood glucose measured again after 15 to 20 minutes. If it’s still too low (below 4mmol), then more sugary food or drink.
what is the advice for hyperglycemia
Patient may be advised to:
increase the dose of insulin
change their diet – for example, avoid foods that cause glucose levels to rise, such as cakes or sugary drinks
getmore exercise
monitor glucose levels
Extreme hyperglycaemia (when normal inhibitory effect of insulin on lipolysis is no longer effective)
= diabetic ketoacidosis A&E
what is sick day rule
what would you advice for somoene with type 1 or type 2
Illness generally increases physiological insulin requirements and will affect blood sugars
While unwell it is VERY likely that blood glucose will increase even if you are eating less than usual
Basic measures are ensuring:
Increased frequency of monitoring
Staying hydrated: drinking at least ½ cup (100mL) of water or any other sugar free drink every hour
Not fasting: maintain carbohydrate intake
If unable to eat or drink or are vomiting, replace meals with sugary fluids or ice cream
Continuing to take tablets and/or insulin as normal even if not eating much, although some of the tablets may need to be stopped whilst unwell
Patients on insulin should be provided with urine strips to test for ketones (e.g Ketostix) or a blood ketone testing kit.
Glucagon injection should also be available at home for family members to use in case of severe hypoglycaemia. They should also have clear contact criteria and contact telephone numbers for their healthcare provider team.
Should Never stop taking their insulin
Type 1 - more monitoring of blood glucose (every 4 hours) and urinary ketones
Type 2 – monitoring of blood glucose.
If the condition deteriorates, patients/family members should be prepared to go to the emergency room for urgent care.
For people with Type 2 diabetes who take tablets only some of these may need to be stopped but likely that blood sugar levels will increase (see table below) – monitor levels
Restart when the patient is well (normally after 24-48 hrs of eating and drinking normally)
Sulfonylureas
-if unable to eat or drink, it will be more likely cause a ‘hypo’
-if eating and drinking normally and blood sugars are high continue to take these.
GLP-1 analogues
dehydration can make it more likely to develop a serious side effect.
SGLT2 inhibitors
dehydration can make it more likely to develop ketoacidosis.
ARBs
Dehydration whilst on these can affect kidney function
Diuretics
Can make dehydration more likely
NSAIDs
Dehydration whilst on these can affect kidney function
