Transcript Document

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Health Professions Act
Revised Hypoglycemia Protocol
Insulin Subcutaneous Sliding Scale
Anar Dossa BScPharm CDE
September 14, 2007
HPA-Health Professions Act
What is it?
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Regulatory framework for health
professionals
Basic requirements for regulating every
health profession are similar
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Accountability for standards of practice
Quality assurance measurements
Rigorous registration process
Mechanism to review public concerns
HPA-Health Professions Act
Nursing Implications
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Increase in scope of practice for registered
nurses effective July 1, 2006
Allows registered nurses to initiate certain
patient care activities without a doctor’s
order
HPA-RN Scope of Practice
WITHIN SCOPE
CRNBC
CERTIFIED PRACTICE
OUT OF
SCOPE
Nursing practice
activities
Vital signs
Not reserved
actions
Current Practice
Reserved actions Reserved Reserved
without an order actions with actions for
an order
CRNBC
certified
Hypoglycemia:
practice
initiate IV access
& medications
Section 8
July 1, 2006
Reserved
actions
outside
scope of
practice
NP &
Section 9 Section 10
Delegated
July 1,
August
Fn
2006
2007
CRNBC Standards, Limits & Conditions
crnbc 2006
Controls on Practice
CRNBC 2006
Provincial Pilots
•VCH:
Hypoglycemia, Wound Care,
IV, Tylenol, Oxygen,Catheter
•IHA:
Venipuncture initiation
•NHA:
Catheter initiation
•VIHA:
Oxygen initiation
•FH
Wound Care
Hypoglycemia Protocol
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Hypoglycemia is defined as blood sugar
less than…
Hypoglycemia Protocol
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Risk factors for hypoglycemia
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Nutritional status
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Missed meals, delayed meals
Heart failure, renal or liver disease
Malignancy
Sudden reduction of steroid dose
Altered ability of patient to report symptoms
Vomiting
Hypoglycemia Protocol
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Risk factors for hypoglycemia
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New NPO status
Reduction in IV dextrose
Unexpected interruption of feeds/TPN
Altered consciousness from anesthesia
Advanced age
Previous history of severe hypoglycemia
Symptoms
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Variable from patient to patient
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Assess patient for his/her individual
symptoms
Symptoms
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Trembling
Palpitations
Sweating
Anxiety
Nausea
Hunger
Tingling
Clinical Practice Guidelines Can J Diabetes Dec 03
www.diabetes.ca
Symptoms
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Confusion
Difficulty concentrating
Weakness
Drowsiness
Vision changes
Difficulty speaking
Headache
Dizziness
Tiredness
Clinical Practice Guidelines Can J Diabetes Dec 03
www.diabetes.ca
Symptoms
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Night
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Crying out
Night sweats
Morning headache
Nightmares
Symptoms-severe
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Unresponsive
Unconscious
Coma
Seizure
Hypoglycemia Unawareness
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No warning signals
First sign may be loss of consciousness
Confusion
Hypoglycemia in the Elderly
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Reduced release of epinephrine and
glucagon
Cognitive impairment
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May not be able to communicate in timely
manner
Beta-blockers and Hypoglycemia
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What is the concern?
Not an absolute contraindication
Hypoglycemia Protocol
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Section A
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Conscious and able to swallow
Section B
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Conscious but NPO or unable to swallow
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Tube fed/TPN
Section C
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Unresponsive, unconscious, seizuring
Where will these items be kept?
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D10W
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D50W
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Omnicell machine
Glucagon
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Stores item, units to order via stores
Omnicell machine
Dextrosol
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Stores item
NIA Section 8: Hypoglycemia
Section 8 (1) Perform venipuncture for the purpose of:
Establishing intravenous access, maintaining patency or managing hypoglycemia
Administer a solution by instillation parenterally.
RN Assess Pt.
Diagnose Condition
Condition:
Hypoglycemia
Policy/Patient Care Guideline
Nurse Initiated Activity:
Document Assessment
Initiate Glucagon or IV insertion
IV Solution
Contraindications:
PCG
Contact Physician
Pharmacy:
Processes NIA
Records Glucagon
or D50W on MAR
RN accountable to anticipate &
monitior outcomes
Physician aware within 4 hrs
Follow Up
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Why did hypoglycemia occur?
Should the dose of insulin or oral agent be
adjusted?
Insulin Subcutaneous Sliding
Scale
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Refer to pre-printed order
When should an insulin sliding
scale be used?
Supplement
regularly scheduled
insulin or oral diabetes
medications
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be used as a dose finding
strategy
Goal
is to use as little sliding
scale insulin as possible
When should this sliding scale not
be used?
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Diabetic ketoacidosis
Intravenous insulin
Insulin Sliding Scale
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Scheduled insulin plus
Supplemental insulin
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Correction-dose insulin
Dose-finding strategy
Accommodate rapid changes in insulin
requirements
If correction doses are frequently required,
change scheduled dose
Which sliding scale?
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Low
Intermediate
High
Custom
Low
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Low or unknown insulin resistance
High or unknown insulin sensitivity
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How do you determine this?
Insulin Resistance Determination
Insulin Dose
(Total Daily Dose)
< 0.5 units/kg
Resistance Level
0.5 – 1 unit/kg
Intermediate
> 1 unit/kg
High
Low
Low Resistance
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Thin
NPO
Renal Failure
Elderly
High Resistance
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Obese
Insulin Sliding Scale
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Always use regular insulin
Do not give at hs
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Why?
Exception
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See protocol
Follow Up
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Evaluate total dose q24-48hrs
Does the basic dose need to be adjusted?
New Insulins on Formulary
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Insulin Aspart
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NovoRapid®
Rapid acting insulin analogue
Bolus insulin
Insulin Glargine
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Lantus®
Long acting insulin analogue
Basal insulin
Insulin Aspart
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Must be given immediately prior to meals
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Within 15 minutes
Risk of hypoglycemia if meal is delayed
Can be mixed with NPH as long as the
manufacturer is the same
Inject immediately after mixing
Cannot be given IV
Insulin Glargine
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Cannot be given IV
Clear solution
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Do not confuse with regular or aspart
Cannot be mixed with anything
Formulary Status
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Both insulins are restricted
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Endocrinology
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For Type 1 patients who experience hypoglycemia
or inadequate control on Regular/NPH
For patients on these insulins prior to
admission
Action Profiles of Bolus & Basal
Insulins
lispro/aspart 4–6 hours
regular 6-10 hours
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BOLUS INSULINS
BASAL INSULINS
NPH 12–20 hours
detemir ~ 6-23 hours (dose dependant)
glargine ~ 20-26 hours
Hours
Note: action curves are approximations for illustrative purposes. Actual patient response will vary.
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491
Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12
Insulin Comparison
Dur’n
(hrs)
3-5
Cost
Pcare
per mL Cov’ge
$2.30 Partial
Regular 0.5-1 2-4
6-8
$1.24
Yes
NPH
Insulin
Aspart
Onset Peak
(hrs) (hrs)
5-15* 1-2
1-2
6-12
18-24
$1.24
Yes
Glargine 2-4
No
peak
20-24
$5.51
SA**
*minutes **special authority
Insulin Mixing
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Regular and NPH
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OK to mix
Resuspend NPH
Inject adequate amount of air into NPH
Withdraw regular into syringe first
Then withdraw NPH
What if you don’t do it this way?
Questions?