Transcript Newest Trends in Diabetes Management in Schools

Newest Trends in Diabetes
Management in Schools
Fran Melchionne, EdD,RN,CDE
BD Pediatric Diabetes Center
Goryeb Children’s Hospital
Agenda
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1. Glucose monitors and CGMS
2. Nutrition Therapy
3. Basal – bolus insulin therapy
4. Injection technique
5. Insulin pumps
Objectives
• 1. Discuss the new trends in blood glucose
monitoring
• 2. State 2 advantages of CGMS
• 3. Identify 2 methods to accurately count
carbohydrates
• 4. Calculate a meal bolus and correction bolus
for basal-bolus insulin therapy
• 5. List 2 responsibilities for an insulin pump at
school
Glucose Monitors
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Trending with high and low patterns identified
Touch screens
Rechargeable batteries
Compatible with the iPod touch/iPhone
Insulinx
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Touch screen
3V lithium batteries
Can apply blood for up to 60 seconds
USB port to download reports
0.3 microliters of blood
20 – 500mg/dl results
Electronic logbook (insulin doses,exercise,etc)
Verio IQ
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Rechargeable battery
Data/battery charging port
Cannot apply more blood to test strip
20 – 600 mg/dl
Stores 750 results
BS results must be within 3 hours of each
other to determine a pattern
• 0.4 microliters of blood
iBG Star
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Rechargeable battery
Compatible with iPod touch/iPhone
Can email reports to diabetes team
Diabetes Manager App downloaded from APP
store
• 0.5 microliters of blood
• 20 – 600mg/dl
• Memory - 300
Continuous Glucose Monitoring
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CGMS records BS levels every 5 minutes
Interstitial fluid BS
Glucose sensor is inserted under the skin
Contact sports should be avoided
Usually worn 3 – 5 days
Downloads reports
Patterns seen will result in changes in therapy
CGMS
• Two types of iPro – placed by MD or pump
patient with Medtronic Paradigm pump
• Guardian – placed by patient, wears a
monitor to display results
• mySentry – remotely monitors blood sugar at
night – used with Medtronic Paradigm pump
• DexCom – placed by the patient, wears a
monitor to display results
Nutrition Therapy
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Counting Carbohydrates
Specific gram counting
Food measurement
Reading labels
Written resources – The Calorie King – Calorie,
Fat and Carbohydrate Counter
Basal – Bolus Insulin Therapy
• Lantus – basal insulin
• Novolog/Humalog/Apidra – bolus insulin
used for meal and correction boluses
• Lilly HumaPen Luxura HD:can deliver ½ unit
• Novo Junior Pen: does not deliver ½ unit onlywill begin ½ unit dose at 1 ½ units of insulin
• NovoFlex Pen and Lantus Solostar pen are
disposable – 1 unit increments only
Basal – Bolus Insulin Therapy
• Must do an “air shot” before each injection
with a pen
• BD smallest pen needle is the Nano –
32gx4mm
• Injecting with a pen: inject at a 90 degree
angle – no pinching needed – count to 10 and
then withdraw the needle
• Do not rub the injection site
Basal – Bolus Insulin Therapy
• Injection by syringe: prepare the skin – pinch
the skin using only your thumb and index
finger – inject the needle at a 90 degree angle
– wait 10 seconds and withdraw the needle
• Pinching up with your entire hand may cause
the injection into the muscle rather than
subcutaneous tissue
• Do not squeeze the skin tightly
Basal – Bolus Insulin Therapy
• Insulin storage:
• Unopened insulin is stored in refrigerator – do
not freeze
• Insulin pens in use must be refrigerated if
temperature is >85 degrees
• Insulin pens in use must be discarded 28 days
after opening
Basal – Bolus Insulin Therapy
• Insulin to carbohydrate ratios may be different
for each meal
• Corrections cannot be done less than 3 hours
after the last bolus (meal or correction)
• Targets vary for daytime and nightime
• Lantus is usually given in the evening
• If you treat a low BS before lunch and recheck
the BS in 15 minutes, do not correct if BS is
high
Basal – Bolus Insulin Therapy
• Calculating a meal bolus:
• If the insulin to carbohydrate ratio is 1unit of
insulin for every 15 grams of carb……..
• The child plans to eat 45 grams of carb for
lunch = 45 divided by 15 = 3 units of insulin
Basal – Bolus Insulin Therapy
• Calculating a correction bolus:
• If the correction is 1 unit of insulin for every
50 mg/dl over target:
• Child has a target BS at lunch of 100, takes BS
and has 255……
• Take the actual BS (255) – 100 (target) =
155mg/dl over target. Divide 155 by 50 = 3
units of insulin to correct BS of 255
Basal – Bolus Insulin Therapy
• If in the example just given it was the same
child who was going to eat 45 grams of
carbohydrate for lunch and BS was 255 the
insulin dose prior to lunch would be:
• 3 units for the meal bolus and 3 units for the
blood sugar correction = 6 units of Novolog
being given.
Insulin Pumps
• Insulin pumps: continuous subcutaneous
insulin infusion
• Many brands on the market
• Features vary on each pump – child/family
should choose what will work for them
• Delivers basal insulin 24 hours a day
• Will bolus for meal and corrections of BS
Insulin Pumps
• Pumps are pager size devices that mimic
normal insulin delivery
• Uses only rapid acting insulin
• It is an external device
• Battery operated
• Delivers insulin through a small teflon catheter
Insulin Pumps
• Insulin on Board is a feature of most pumps
• The amount of insulin still active at a given
time after a bolus
• Advantages: decreases the risk of “stacking”
insulin
• May decrease risk of intentionally running
high BS due to fear of hypoglycemia
Insulin Pumps
• The pumps are able to track the insulin that is
still working in the body from the previous
bolus (meal or correction) and will subtract
Insulin on Board from the next correction
bolus calculation to prevent hypoglycemia
Insulin Pumps
• I:C ratio, correction bolus, and target BS are
entered into the pumps and when the carbs to
be eaten and the BS are added … the pump
will calculate the bolus to be given.
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Carbs
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BG
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IOB
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Total
4.4
Pumping at School
• Diabetes Medical Management Plan
• specific medical orders for medication,
dosing, monitoring, carbohydrates and
exercise
• treatment of hypo/hyperglycemia
• child’s ability to manage the pump
• diabetes equipment needed at school
Pumping at School
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Parental Responsibilities:
Provide all equipment for diabetes care
Assess carbs for school lunches
Have emergency plan if pump malfunctions
Plan for pump when child is disconnected
Able to perform infusion set changes if needed or
have alternate plan
• Have a plan to insure all bolus doses are given
Pumping at School
• Pump Supply Kit
• Infusion sets, meter and test strips, pump
cartridges, insulin, pump batteries, ketone
strips, glucose tabs or gel, glucagon kit, insulin
syringes or pens
Pumping at School
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School Responsibilities:
Follow medical plan of care
Provide for immediate treatment of low BS
Student can visit nurse as needed
Unrestricted access to fluids and restroom
Privacy to carry out diabetes care
Storage of all supplies
Notify all personnel child wears pump
Pumping at School
• School Responsibilities:
• Provide training to all personnel on
symptoms and treatment of hypoglycemia
• Have back up plan in the event the nurse is
not in the building
Pumping at School
• Hypoglycemia:
• On the pump is treated as usual – 15 grams
of carbohydrate, wait 15 minutes and recheck
BS.
• If BS is > 70 mg/dl no further action
• If BS is < 70 mg/dl retreat as above
• Mild to moderate hypoglycemia does not
require the pump to be suspended or
removed
Pumping at School
• Severe hypoglycemia: unable to treat low BS
without help, potential loss of consciousness,
seizure activity …… need an emergency plan
• Call 911
• Give Glucagon
• Notify parents/physician
Pumping at School
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Hyperglycemia without Ketones
Follow medical management plan
Check BG
Check ketones – negative
Give correction bolus for high BS
Drink water – 8 oz/30 minutes
Recheck BS in 2 hours
Pumping at School
• Hyperglycemia with Ketones
• Follow medical management plan
• Give correction bolus by INJECTION
• Push fluids – 8 oz/30 minutes
• Replace infusion set and cartridge
• Recheck BS and ketones in 2 hours
• Need to treat quickly to prevent DKA
• Insulin injection every 2 hrs until cleared
Pumping at School
• Infusion set issues: bent, crimped, dislodged
or have fallen out
• Insulin: ineffective
• Site: could have infection
• Tubing: air in tubing, make sure tubing is
connected at infusion set and on pump
Pumping at School
• Consider attending pump training with the
student/family
• Count carbs carefully
• Perform or supervise BS testing per medical
management plan
• Test for ketones with BS> 300mg/dl
• Hydrate for high BS
• Adjust for activity with snacks or temporary basal
rate
Pumping at School
• Pumps
• Animas Corporation – One Touch Ping
• Medtronic Minimed – Paradigm Revel
• Insulet – Omni pod (wireless)
• Tandem Diabetes Care – t:slim
Thank you for your kind attention