Management of Diabetes - Type 1 Diabetes Mellitus Flashcards
When living with a long term condition, how many hours a year are spent slef managing and how many are spent with a NHS professional?
what is involved in person centred care?
what are the aims of management of type 1 diabetes mellitus?
Prompt diagnosis
Self management skill set
Acute metabolic upsets at diagnosis and thereafter
Facilitate long term health and well being
why is an early diagnosis important?
Scotland has 5th highest incidence of Type 1 Diabetes in the world
In Scotland 300 children under the age of 15 years are diagnosed with Type 1 Diabetes annually
1 in 4 are diagnosed in DKA, rising to 1 in 3 under the age of 5 years
In the UK 10 children die and 10 children suffer permanent neurological disability
what are things to look out for in a possible diagnosis of diabetes?
thinner
thirsty
tired
using toliet more
symtpoms of diabetes can be due to what 2 things?
blood glucose and blood ketone
What is the benefit of managing HbA1c well at the starts?
Manage HbA1c good at the start and then this will have a legacy effect and work out better in the future
what are some current strategies in place to support people with type 1 diabetes?
Education:
- Team based DSN, practice nurse, dietitian, podiatrist, doctors
- Structured education e.g. DIANE, Dose Adjustment For Normal Eating
- Person with diabetes is main team member
Nutrition and Lifestyle management e.g. CHO counting, physical exercise
Skills training e.g. Home blood glucose monitoring, injection technique, hypos, sick day rules
Insulin- analogues, pens, pumps
What are the different types of insulin you can get and their duration?
Rapid acting insulins eg insulin lispro*, insulin aspart* (Humalog®,Novorapid®,Apidra®)
Short acting insulins eg soluble insulin, actrapid, Humulin S.
Intermediate acting insulins eg Isophane insulin;insulatard,HumulinI.
Long acting insulins eg glargine*, detemir*, degludec
Continuous sub cutaneous insulin infusion (CSII)
What do you need to check before you inject insulin?
Right insulin – check the name
Right dose – check strength and how much insulin to give. Check the numbers very carefully
Right time – with food? At bedtime?
Right way – via syringe, pen or pump?
Why is insulin taken IV and subcutaneously and not orally?
Insulin is a polypeptide which is inactivated by the gastrointestinal tract therefore it needs to be injected subcutaneously (usual route) or intravenously (e.g. during illness or surgery)
What happens to the insulin in the subcutaneous fat?
In the subcutaneous fat the Insulin molecule in solution has a tendency to self-associate into hexamers
Hexamers need to dissociate into monomers before absorption through the capillary bed. Thus soluble insulin is given 30 mins before eating
why can rapid acting analogues be injected?
Rapid acting analogues do not associate and can be injected just before eating
Changing the structure of insulin or binding it to other molecules will change the rate of _________
absorption
The amount of insulin injected for meals should balance the ___________ intake consumed
carbohydrate
What do Insulin Therapy Regimens allow?
Suitable for a flexible lifestyle
Better for shift workers
Rapid (Short) acting insulin to cover CHO at meals 1 unit per 10g CHO
Basal long acting insulin as background
Current Insulin Regimens:
Twice daily
Rapid acting mixed with intermediate acting
Before breakfast (BB) and evening meal (BT)
Current Insulin Regimens:
Three times daily
Rapid acting mixed with intermediate acting BB
Rapid acting BT
intermediate acting at bedtime BBed
Current Insulin Regimens:
Four times daily
Short acting BB BL BT
Intermediate BBed or long acting insulin at a fixed time once daily
Insulin administration to _________ ___
subcutaneous fat
Insulin administration to subcutaneous fat requires the correct what?
Needle size
Location
Rotation
Technique
What things may be used to educate a patient?
Patient Handbooks
Leaflets
Websites
Pregnancy
Insulin Pump starts
Rolling Programs/Topics
Education Days
CGM starts
Apps CHO/fitness
Health care professional education
House of Care
On Line
My Diabetes My Way
Think Check Act
3rd Sector
What are osme examples of when you would assess blood glucose control - home blood glucose monitoring and ketone testing
to adjust insulin dose, prior to driving, tighten control
What is this shown?
Continuous Subcutaneous Insulin Infusion (CSII)
what are some adjustments that may need to be made for someone living with type 1 diabetes?
Lifestyle
Exercise
Driving
Alcohol
Conception
Drugs
Holidays
Employment
what are osme emergencies that may occur due to type 1 diabetes?
Hyperglycaemia - Diabetic Ketoacidosis
Hypoglycaemia
WHat level of BG is hypoglycaemia?
Low blood glucose level <4mmol/l
Reasons for hypoglycaemia - Imbalance between what?
Food - too little/wrong type
Activity - during/after
Insulin (or some Oral Hypoglycaemics) - dose, injection technique
What are hypoglycaemia causes?
Too much insulin/SU
Inappropriate timing of insulin/SU
Injection site problems
Inadequate food intake/fasting
Exercise
Alcohol
what are the groups at risk of hypoglycaemia?
Tight glycaemic control
Impaired awareness
Cognitive impairment
Extremes of age
Malabsorption/gastroparesis
Hypoadrenalism/abrupt steroid withdrawal
Coeliac disease
Renal/hepatic impairment
Pancreatectomy
Pregnancy
Patients should be advised about how to what?
avoid, recognise, and treat hypoglycaemia
Loss of warnings of hypoglycaemia is associated with what?
recurrent severe hypoglycaemia
long duration of disease
over tight control
loss of sweating/tremor
pregnancy
what is the treatment of hypoglycaemia?
All patients treated with insulin or sulphonylureas should be advised to carry carbohydrate with them
hypoglycaemia can cause what?
Hypoglycaemia can cause coma, hemiparesis and seizures
Prolonged hypoglycaemia cna lead to what?
If the hypoglycaemia is prolonged the neurological deficits may become permanent
what is this
hpyo box
how do you avoid hypoglycaemia in insulin treated diabetes?
Blood glucose monitoring
Rotate and check injection sites
Review snacks and diet –Carb counting
Consider a change of insulin regimen eg basal bolus, CSII
Avoid low glucose -“4 is the floor” (7 at bedtime & 5 to drive)
Alter insulin before and after exercise
DVLA
what should you do when you blood ketones are at each different levels?
what are the risk factors for DKA?
Known T1DM, inadequate insulin, infection, other precipitant
what are the symptoms of DKA?
- Polyuria
- Polydipsia
- Weight loss
- Weakness
- Nausea/vomiting
- Abdo pain
- Breathlessness
What are the signs of DKA?
- Dry mucus membranes
- Sunken eyes
- Tachycardia
- Hypotension
- Ketotic breath
- Kussmaul resp. (Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure)
- Altered mental state
- Hypothermia
how to treat an acute illness in insulin treated patients?
NEVER stop insulin
Increase/adjust insulin dose according to blood glucose
perform more frequent blood glucose checks
check urine or blood for ketones
carbohydrate intake must be maintained by fluids (eg fruit juice) if unable to tolerate food
study this summary diagram
Diabetic ketoacidosis = _______ + _______ + ______
Diabetic ketoacidosis = Glucose + Ketones + Acidosis
Diabetic ketoacidosis caues what?
Dehydrated
Thirsty
Abdominal pain
Acidotic breathing (Kussmauls)
Acetone on breath
Tachycardic and low BP
what investigations are done for DKA?
what are some complications of DKA?
Hyper and hypokalaemia
Hypoglycaemia
- Rebound ketosis
- Arrhythmias
- Acute brain injury
Cerebral oedema
- Children more susceptible
- 70-80% diabetes related deaths in children <12
Aspiration pneumonia
Arterial and venous thromboembolism
ARDS
How can you facilitate long term health and well being?
Optimal blood glucose control (HbA1c):
- to reduce microvascular disease e.g. retinopathy
- to improve pregnancy outcome
Optimal blood pressure control - to reduce nephropathy
Manage cardiovascular risk factors - e.g. smoking, cholesterol
Screen for early detection of complications - feet, eyes & kidneys
what do sensor augmented pumps do?
Full integration of insulin delivery with real time blood glucose monitoring – CLOSED LOOP
Potential to act like an artificial pancreas
Current: Type 1 diabetes care
Possible Vision Type 1 Diabetes Care
how do insulin pumps work?
how does an infusion set work?
what is the insulin reservoir?
what are the advantages and disadvantages of an insulin pump?
