CBG MONITORING & INSULIN ADMINISTRATION

WHAT IS DIABETES MELLITUS? Often referred to simply as /diabetes is a syndrome of disordered metabolism, usually due to a combination of hereditary and

environmental causes, resulting in abnormally high blood sugar levels (hyperglycemia)

TYPES OF DM1. Type I DM (Insulin-Dependent DM / Juvenile DM )

Because the body loses the ability to produce insulin.2. Type II DM (Non-insulin Dependent DM / Adult-onset DM )

If BG levels are uncontrolled if diet & oral agents fail.3. Gestational DM4. Impaired Glucose Tolerance (Pre-diabetes)

Exists when client have a BS that is higher than normal but not high enough to meet the criteria for DM. May delay or even prevent the occurrence of DM with regular exercises & weight reduction.

SIGNS AND SYMPTOMS OF DM: P olyphagia Polydypsia Polyuria F atigue Weight Loss

Complications of DM

Needs some

Sugar High

Blood Sugar Mnemonic

CAPILLARY BLOOD GLUCOSE MONITORING:

Blood glucose monitoring is the cornerstone of diabetes management.

BENEFITS OF CBG MONITORING: To obtain optimal blood glucose control. To adjust the treatment regimen. To allow detection of and prevention of hypoglycemia and hyperglycemia. To tell how the daily activities are working. Monitoring the effectiveness of MEDICATIONS, EXERCISE and DIET

Result: Patient will less likely to develop long term complications.

Goal: “BE AVERAGE” not too high or not too low.

RECOMMENDED BLOOD SUGAR LEVEL:

TIME OF DAY NORMAL BLOOD GLUCOSE GOAL

Before meals <110 mg/dl 80 – 120 mg/dl

2 hours after eating <140 mg/dl <180 mg/dl

Bed time <120 mg/dl 100 – 140 mg/dl

HbA1c <6% <7%

HbA1c (Glycosylated Hemoglobin) Blood test that reflects average blood glucose levels over a period of 2-3 months.

WHEN TO CHECK BLOOD GLUCOSE: FASTING GLUCOSE (at least 8 hrs. NPO) > tells whether the insulin you make/take is controlling

blood sugar overnight. PRE-MEAL GLUCOSE > can help guide decisions about food and insulin for the coming meal. AFTER MEAL GLUCOSE (1-2 hrs post-prandial) > tell whether you had the right amount of

insulin to cover the food you ate.

BLOOD GLUCOSE METER Measures the level of blood sugar and displays it on

screen.

EQUIPMENT FOR CBG MONITORING: Blood glucose meter Pricker (penlet) Lancet (needle) Calibrator strip Test pad or strip Cotton balls dry & wet

METER PREPARATION: Calibrate the meter using the “CALIBRATOR STRIP”. Compare the lot numbers to the calibrator strip to

lot numbers of test pad canister/bottle or foil wrapper.

Insert calibrator strip in meter. PUSH ON/OFF BUTTON: Numbers 888 appear on screen followed by the LOT NUMBER.

Remove the strip, proceed with the procedure.PROCEDURE:

Check the physicians order. Do the hand washing. Prepare the equipment to be use. Identify the client. Introduce yourself and explain the procedure. Put on the strip to the machine & wait until the sign “drop the blood” appear. Select a site to be prick.

BEST site is the side of your finger pads near the tip. Fewer nerve endingsMore blood is available

Wipe the side of the finger pads with alcoholized cotton balls and let it dry. Obtain blood specimen using the side pricker/penlet.

* Pricker can be adjusted to the depth that the lancets enter the skin.* To prevent deep penetration to the skin

Wipe the first blood & milk the finger for more blood.

Get the prepared machine & drop the 2nd blood into it.

Apply pressure to the pricked site to stop bleeding. Listen for “BEEP” or wait for (---) sign to register on screen.

( it indicates glucose reading is ready )

After 20 secs., result will appear on display screen. Remove the strip & dispose. Turn off the meter. Document findings.

FREQUENCY OF CBG or SMBG: For Insulin requiring client

2-4X daily - usually before meals & bedtime For Non-Insulin requiring

2-3X per week including 2 hrs. post prandial For ALL patients

CBG is recommended whenever hypoglycemia or hyperglycemia is suspected. Increase frequency of CBG monitoring with changes in medicine, activity or diet & with

stress & illness

COMMON CAUSE OF ERROR WHEN USING THE BG METER: Not applying enough blood into the strip/pad. Incorrect timing of the test. Failure to clean the meter. Improper handling & storage of test pads & meter.SOME METERS CAN CHECK KETONES

KETONES Ketones are by-product/or waste product when your body burns stored fat for energy. Your body produces KETONES (ACID) & releases then into the blood (KETOSIS) & urine

(KETONURIA) (+) KETONES in the blood indicates the BG are out of control & may lead to DKA

(DIABETIC KETOACIDOSIS) Normal range: 0-20 mg/dl

DIABETIC KETOACEDOSIS (DKA): Signs and Symptoms:

Fruity odor breath Increased thirst Increased urination Dry mouth Dry, flushed skin

Management:Needs…..

Hydration

Insulin

Electrolyte replacement

INSULIN ADMINISTRATION:INSULIN

A hormone produced by the BETA CELL’s in the Islet’s of Langerhans in the pancreas. Works to lower the blood glucose level after meals by facilitating the uptake & utilization of

glucose by muscle, fat & liver cells. It is measured in units “u” – 100 insulin contains 100 units/ml.

GLUCOSE Body’s major fuel for energy it needs.

Absence or Ineffective Insulin Blood glucose level is increased

Goal of insulin administration To achieve euglycemia, in order to avoid hypoglycemia, hyperglycemia or ketoacidosis

and avoid long-term complications.

Who Needs Insulin Therapy Type I DM Type II DM Type II DM during illness, infection, surgery or some other stressful event. Pregnant women with GDM ( Gestational DM )

INSULIN PREPARATIONS BEFORE – insulin was extracted from the pancreas of cattle & pigs. NOW – Human Insulin can be produced from yeast & bacteria ( finest insulin which is identical to

insulin made by our body )

HOW DOES INSULIN WORK? Insulin preparation can only be given by injection as they will be destroyed in the stomach if

taken orally.

TYPES OF INSULIN VARY IN 3 MAIN CHARACTERISTICS ONSET – how quick the insulin starts to work. PEAK OF ACTIVITY – when the insulin works the hardest. DURATION – how long the insulin continues to work

Type Names Onset Peak Duration

Ultra short (clear) Lispro (Humalog)

5-15 minutes

45-90 minutes 2-4 hours

Short (clear) Regular (R) 30 minutes 2-5 hours 5-8 hours

Intermediate (cloudy)

NPH (N) or Lente (L)

1-3 hours 6-12 hours 16-24 hours

Long acting Ultralente 4-6 hours 8-20 hours 24-28 hours

Types of Insulin

EQUIPMENT FOR INSULIN ADMINISTRATION Insulin Syringes

Sizes 30, 50 & 100 units Disposable

Devices for insulin deliveryInsulin syringes

Plastic fixed-needle syringes are designed for single use

Insulin syringes must have a measuring scale consistent with the insulin concentration (e.g. U 100 syringes)

Subcutaneous indwelling catheters Such catheters inserted using topical local

anesthetic cream may be useful to overcome problems with painful injections. These catheters are used in some centers for introduction of multiple injection therapy.

Also called insulin infusers, provide an alternative to injections. A catheter (a flexible hollow tube) is inserted into the tissue just beneath the skin and remains in place for several days. Insulin is then injected into the infuser instead of through the skin.

Pen injector devices

An insulin pen looks like a pen with a cartridge.

Some of these devices use replaceable cartridges of insulin; other pen models are totally disposable.

A short, fine needle, similar to the needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin. Insulin pens, like pumps, are a valuable tool for those who are on intensive (flexible) insulin therapy.

Pen injector devices are useful in children on multiple injection regimens or fixed mixtures of insulin but are less acceptable when free mixing of insulin’s is used

Automatic injection deviceso Useful for children who have a fear of

needles. Usually a loaded syringe is placed within the device, locked into place and inserted automatically into the skin by a spring-loaded system

The benefits of these devices are that the needle is hidden from view and inserted rapidly through the skin

Automatic injection devices for specific insulin pen injectors are now available

Jet injectors High pressure jet injection of insulin into

the skin has been designed to avoid the use of needle injection

Jet injectors may have a role in cases of needle phobia

Problems with jet injectors have included a variable depth of penetration, bruising, variable absorption of insulin, and cost

Subcutaneous insulin infusion pumps External insulin pumps are devices that

deliver insulin through narrow, flexible plastic tubing that ends with a needle inserted just under the skin near the abdomen.

The insulin pump is about the size of a deck of cards, weighs about 3 ounces, and can be worn on a belt or carried in a pocket. Users set the pump to give a steady trickle or "basal" amount of insulin continuously throughout the day.

Pumps release "bolus" doses of insulin (several units at a time) at meals and at times when blood glucose is too high based on the programming set entered by the user.

They also can be programmed to release smaller amounts of insulin throughout the day. Frequent blood glucose monitoring is essential to determine insulin dosages and to ensure that insulin is delivered

SYRINGE & VIAL PREPARATION

Get Supplies Insulin (Verify) Syringe Alcohol wipe Disposable gloves Sharps container

DRAWING UP A SINGLE TYPE OF INSULIN:Bottles of insulin are airtight. Before you take insulin out, you need to pump in some air.

1. Wash your hands with soap and water.

2. Clean insulin vial.

3. Pull air into the syringe by drawing back the plunger to the mark that shows the amount of the insulin dose.

4. Stick the needle through the rubber stopper and pump the air from the syringe into the bottle.

5. Holding the bottle and syringe, turn it so the bottle is on top. 6. Draw out the amount of insulin you need. If there are bubbles in the

syringe, tap it gently to make the bubbles move up. Push in the plunger to get the bubbles back into the bottle; then withdraw a dose of insulin without bubbles.

MIXING TWO TYPES OF INSULIN:If patient uses a combination of fast-acting insulin and the intermediate type (which is cloudy), follow these steps:

1. Wash your hands with soap and water.

2. Clean insulin vial.

3. Draw enough air into the syringe to match the dose of cloudy insulin.

4. Pump that air into the bottle of cloudy insulin but don't withdraw any of that insulin yet.

5. Draw air into the syringe to match the dose of clear insulin. Pump that air into the clear bottle, then turn it over and withdraw that amount of insulin, as in steps 3 - 6 above.

6. Now stick the needle through the top of the cloudy bottle. Be careful not to move the plunger. Turn the bottle over,

and pull back the plunger to match the total dose of insulin.

Clinical alert!!!What to aspirate FIRST for mixing 2 types of Insulin“Clear before cloudy” or Remember RN stands for Humulin R first before Humulin N

NURSING RESPONSIBILITIES IN INSULIN THERAPY Read the label carefully & be sure that correct type of insulin is administered. Indicate the date when you open the insulin, a bottle can only be used for 28 days upon opening. Proper storage of insulin – it should be placed inside the refrigerator (vegetable crisper) Avoid extreme heat & cold for it may destroy the drug potency Storing prefilled syringe in the refrigerator with the needle pointed up reduces problems that can

occur, such as crystals forming in the needle & blocking it up. Advice the client to eat after injection

SHORT – ACTING INSULINClients eat after 15 minutes

INTERMEDIATE – ACTINGClients eat after 30 minutes

Observe for some complications of insulin therapy. Documentation.

MEASURING & INJECTING INSULIN Insulin is injected into the fatty tissue beneath the skin (SQ) Insulin syringe (U100; U50; U30) Needles (G. 29 & G. 30, the higher the number the thinner & shorter the needle)

RECOMMENDED INJECTION SITES: ABDOMEN & ARMS can be used for morning insulin injection when blood sugars are usually high. fast absorption of insulin

THIGH & BUTTOCKS –evening injection when insulin is needed to last longer overnight -slow absorption of insulin

Don’t choose these sites: Navel part – increase vascularity Waist line – more nerve endings

INSULIN ADMINISTRATION1. Select injection site.2. Clean the injection site.

3. Check the insulin dose.4. Remove the cap from syringe.

5. Pinch up the skin.6. Push needle into skin at 90°.7. Release pinch.

8. Push the plunger in.

9. Count to “5”. 10. Remove needle and dispose of syringe.11. Document time, dosage, site, and blood glucose value.

SIDE EFFECTS: Hypoglycemia is the most common side effect that may occur during insulin therapy. Symptoms of hypoglycemia include:

Drugs that DECREASE the effect of insulin:1. Aspirin 2. Oral contraceptives3. Monoamine oxidase inhibitor4. Lasix5. Diltiazem6. Corticosteroids

Drugs that INCREASE the effect of insulin:1. Glucocorticoids2. Thiazide diuretics3. Estrogen

COMPLICATIONS OF INSULIN THERAPY1. LOCAL ALLERGIC REACTIONS

redness, swelling, tenderness @ the injection site2. INSULIN LIPODYSTROPHY

a wound of fat & fibrous tissue that develops from repeated injections in the same area.

3. INSULIN RESISTANCE daily insulin requirement of 200 “u” or more4. HYPOGLYCEMIA

sudden drop of blood sugar level5. MORNING HYPERGLYCEMIA

an elevated BS upon arising in the morning caused by insufficient level of insulin injection given at night time.

DAWN PHENOMENON Hyperglycemia @ 6am Common to growing children due to growth hormone

MANAGEMENT: Retain the dose of insulin or increase upon the doctor’s order

SOMOGYI EFFECT Rebound hyperglycemia followed by hypoglycemia Hyperglycemia @ 3am

Happens when the client experience BS then he was given insulin dose, then after several hours they Ö the BS of the client & found out that it was still , so they give another dose of insulin.

After 12 – 72 hours – hypoglycemia occurs MANAGEMENT:

Gradual decrease of insulin dose @ times of hypoglycemia Increase diet

EXERCISE GUIDE for…DIABETIC FITNESS

Frequency

Intensity

TimeAEROBIC ACTIVITY 20-

30 minutes. With 5 – 10 minutes WARM UP!!!

60 – 80% of Maximal Heart

Rate

3X a Week