Diabetes Management-

Insulin & Glucometer

Learning Lab
Week #4
September 18 & 19
Jennifer Briggs MSN, RN
Healthy Person
 Insulin released in continuous small
increments
 BASAL rate-steady glucose level in
bloodstream
 Release of insulin is after ingestion of
food leads to:
 Lowering blood glucose level to a normal
stable range
 NORMAL fasting range: 70-99 mg/dL

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Diabetes Mellitus
 A chronic multisystem disease
related to
 Abnormal insulin production
 Impaired insulin utilization
 Or both

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Diabetes Mellitus (cont.)
 Leading cause of
 End-stage renal disease
 Adult blindness
 Non-traumatic lower limb
amputations
 Major contributing factor
 Heart disease
 Stroke
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Etiology and Pathophysiology
 Two most common types
 Type 1
 Type 2
 Other types
 Gestational
 Prediabetes
 Secondary diabetes

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Type 1
 No insulin produced by pancreas
 Requires exogenous insulin

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Clinical Manifestations
Type 1 Diabetes Mellitus
 Classic symptoms
 Polyuria (frequent urination)
 Polydipsia (excessive thirst)
 Polyphagia (excessive hunger)
 Weight loss
 Weakness
 Fatigue

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 Type 2
 The most common type of diabetes
 Body has decreased production or
resistance to insulin
 Production of SOME ENDOgenous
insulin
 Usually onset is gradual & can go
undetected for years
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Type 2 Diabetes Mellitus
 Most prevalent type of diabetes
 90-95% of patients with this disease
 Usually occurs in people over 30 years
of age
 80% to 90% of patients are
overweight.

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Type 2 Diabetes
 Prevalence increases with age.
 Genetic basis
 Obesity (abdominal/visceral)
 Most powerful risk factor
 Greater in some ethnic populations
 African Americans, Asian Americans,
Hispanic Americans, and Native
Americans
 Native Americans and Alaskan Natives:
Highest rates of diabetes in the world
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 Insulin
 Normal insulin metabolism
 Released continuously into
bloodstream in small increments with
larger amounts released after food
 Stabilizes glucose range to 70 to
120 mg/dL
 Decreases glucose in the bloodstream

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Normal Insulin Secretion

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Question 1
Analyze the following diagnostic findings
for your patient with type 2 diabetes.
Which result will need further
assessment?
a) A1C 9%
b) BP 126/80 mmHg
c) FBG 90 mg/dL
d) LDL cholesterol 100 mg/dL
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Goals for Glycemic Control
 A1C > 6.5%  A1C > 6.5%

 For patients without  For patients with

concurrent serious concurrent serious
illness and at low risk illness and at risk for
for hypoglycemia hypoglycemia
Diabetes Mellitus
Diagnostic Studies
 Four methods of diagnosis
1. A1C ≥ 6.5%
2. Fasting plasma glucose level >126
mg/dL
3. Random or casual plasma glucose
measurement ≥200 mg/dL plus
symptoms
4. Two-hour OGTT level ≥200 mg/dL
when a glucose load of 75 g is used
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Diabetes Mellitus
Diagnostic Studies
 Hemoglobin A1C test
 Useful in determining glycemic levels
over time
 Shows the amount of glucose attached
to hemoglobin molecules over RBC life
span
 Approximately 120 days

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 Diabetes Mellitus
Diagnostic Studies
 Hemoglobin A1C (cont’d)
 Regular assessments required
 Ideal goal
 American College of Endocrinology <6.5%
 Normal A1C reduces risks of
 Retinopathy
 Nephropathy

 Neuropathy.

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Diabetes Mellitus
Collaborative Care
 Goals of diabetes management
 Decrease symptoms.
 Promote well-being.
 Prevent acute complications.
 Delay onset and progression of
long-term complications.

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Objective

Describe S/S of
hypoglycemia & hyperglycemia

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Hypoglycemia
 Low blood glucose
 Occurs when
 Too much insulin in proportion to glucose in
the blood
 Blood glucose level less than 70 mg/dL

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Hypoglycemia (cont’d)
Manifestations
 Cold, clammy skin
 Numbness of fingers, toes, mouth

 Rapid heartbeat

 Emotional changes

 Nervousness, tremors

 Faintness, dizziness

 Unsteady gait, slurred speech

 Hunger

 Changes in vision

 Seizures, coma

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Hypoglycemia (cont’d)
 Hypoglycemic unawareness
 Person does not experience
warning signs/symptoms,
increasing risk for decreased
blood glucose levels
Related to autonomic
neuropathy
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Hypoglycemia (cont’d)
 Causes
 Mismatch in timing
Food intake & peak action of
insulin or oral hypoglycemic
agents

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Hypoglycemia (cont’d)
 At the first sign
 Check blood glucose
 If <70 mg/dL, begin treatment
 If >70 mg/dL, investigate further for
cause of signs/symptoms
 If monitoring equipment not
available, treatment should be
initiated

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Hypoglycemia (cont’d)
 Treatment
 If alert enough to swallow
15 to 20 g of a simple
carbohydrate
4 to 6 oz fruit juice
Regular soft drink
Avoid foods with fat
decreases absorption of
sugar 25
Hypoglycemia (cont’d)
 Treatment
 If alert enough to swallow
 Recheck blood sugar 15 minutes after
treatment.
 Repeat until blood sugar >70 mg/dL.
 Patient should eat regularly scheduled
meal/snack to prevent rebound
hypoglycemia.
 Check blood sugar again 45 minutes after
treatment.

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Hypoglycemia (cont’d)
 Treatment
Patient not alert enough to swallow
 Administer 1 mg of glucagon IM or

subcutaneously.
 Have patient ingest a complex

carbohydrate after recovery.

 In acute care settings

 20 to 50 mL of 50% dextrose IV
push
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Hyperglycemia
 High blood glucose
 Elevated blood glucose levels: FBG > 126
mg/dL
 2 Hr plasma glucose level > 200 mg/dL
 A1C > 6.5%
 Increased urine output
 Increased appetite
 Fatigue

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Hyperglycemia
Manifestations
 High blood glucose
 Increased urination
 Increased appetite followed by lack of
 Weakness, fatigue
 Blurred vision
 Headache
 Glycosuria
 Abdominal cramps
 Nausea/vomiting
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Hyperglycemia
 Causes:
 Illness
 Infections
 Corticosteroids
 Too much food
 Not enough insulin
 Inactivity
 Stress
 Poor absorption of insulin

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Hyperglycemia
 Treatment
 Check Blood sugar frequently
 Treat with ordered medication
 Check for ketones
 Increase fluids (at least on hourly basis)

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 Question 2
What is the priority action for the nurse to
take if the patient with type 2 diabetes
complains of blurred vision?
a) Call the physician.
b) Administer insulin as ordered.
c) Check the patient’s blood glucose level.
d) Assess for other neurologic symptoms.

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Insulin Types
 Most common:
 Rapid acting
 Short acting
 Intermediate acting
 Long acting

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Drug Therapy
Insulin
 Types of insulin
 Insulins differ by
 onset
 peak action

 duration

 Different types of insulin may be used

for combination therapy.

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Sliding Scale
 Sliding scale therapy approximates
daily insulin requirements.
 The term "sliding scale" refers to the
progressive increase in pre-meal or
nighttime insulin doses.

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 Sliding Scale Principles
 The amount of CHO (carbohydrate) to be
eaten at each meal is pre-set.
 The basal (background) insulin dose does
not change.
 You take the same long-acting insulin
dose no matter what the blood glucose
level.
 The bolus insulin is based on the blood
sugar level before the meal or at bedtime
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 Mixing Insulins

Fig. 49-3. Commercially available insulin preparations showing onset, peak, and duration of action.

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Drug Therapy
Insulin
 Types of insulin (cont’d)
 Rapid-acting: Lispro (Humalog), Aspart
(Novolog), and glulisine (Apidra)
 Short-acting: Regular
 Intermediate-acting: NPH
 Long-acting: Glargine (Lantus), detemir
(Levemir)

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Objective
Compare and contrast the use of
insulin by basal and bolus.

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Drug Therapy
Insulin
 Regimen that closely mimics
endogenous insulin production is
basal-bolus.
 Long-acting (basal) once a day
 Rapid/short-acting (bolus) before meals

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Drug Therapy
Insulin
 Insulin preparations
 Rapid-acting (bolus)
 Lispro, aspart, glulisine
 Injected 0 to 15 minutes before meal

 Onset of action 15 minutes

 Short-acting (bolus)
 Regular
 Injected 30 to 45 minutes before meal

 Onset of action 30 to 60 minutes

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Drug Therapy
Insulin
 Long-acting (basal)
 Injected once a day at bedtime or in
the morning
 Released steadily and continuously

 No peak action

 Cannot be mixed with any other

insulin or solution

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Insulin Regimens
 Bolus (Mealtime  Basal (Long- or
insulin) Intermediate-Acting)
 To control postmeal  In addition to
blood glucose (BG) mealtime insulin
levels  Must also use long-
 Timing of rapid-acting acting basal or
& short-acting insulin intermediate-acting
in relation to meals is insulin to control BG
CRUCIAL levels in between
meals & overnight
Drug Therapy
Insulin
 Administration of insulin
 Cannot be taken orally
 Subcutaneous injection for
self-administration
 IV administration (acute care)

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Drug Therapy
Insulin
 Administration of insulin (cont’d)
 Fastest absorption from abdomen,
followed by arm, thigh, and buttock
 Abdomen is the preferred site.
 Rotate injections within one particular
site.
 Do not inject in site to be exercised.
 Usually available as U100
 1 mL contains 100 units of insulin.

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Subcutaneous Injection Sites

Fig. 49-5. Injection sites for insulin.

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Drug Therapy
Insulin
 Administration of insulin (cont’d)
 Hand washing with soap adequate
 Do not recap needle after administration
 45- to 90-degree angle, depending on fat
thickness of the patient
 Insulin pens preloaded with insulin are
now available.

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Drug Therapy
Insulin
 Insulin pump
 Continuous subcutaneous infusion
 Battery-operated device
 Connected via plastic tubing to a
catheter inserted into subcutaneous
tissue in abdominal wall
 Potential for tight glucose control

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Objective

Discuss the accurate use of the

glucometer

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Blood Glucose Monitoring
 Skill 35.4 Pg 1256-1259 Taylor
1. Perform hand hygiene.
2. Remove reagent strip from
container.
3. Check code on test strip vial.
4. Insert strip into glucose meter
5. Apply clean gloves
6. Choose puncture site
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Blood Glucose Monitoring (cont.)
7. Hold finger to puncture in dependent
position
8. Clean site with antiseptic swab &
allow to dry
9. Prepare lancet & hold it perpendicular
to puncture site
10. Wipe away first droplet of blood w/
gauze
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Blood Glucose Monitoring (cont.)
11. Collect large droplet.
12. Obtain test results.
13. Turn meter off, dispose of test strip,
lancet & gloves properly.
14. Discuss test results with patient.
15. Record test results.

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Objective
Demonstrate how to accurately obtain
blood glucose reading from a glucometer

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Performing BG Testing
 Nursing Videos-Intermediate
 Specimen collection
 Performing Blood Glucose Testing

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Monitoring Blood Glucose
 Self-monitoring of blood glucose
(SMBG)
 Enables patient to make self-
management decisions regarding diet,
exercise, and medication

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Monitoring Blood Glucose
 Self-monitoring of blood glucose
(SMBG) (cont’d)
 Important for detecting episodic
hyperglycemia & hypoglycemia
 Patient training is crucial.
 Supplies immediate information about
blood glucose levels

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Monitoring Blood Glucose
 Continuous glucose monitoring
 Displays glucose values with updating
every 1 to 5 minutes
 Help identify trends and track patterns

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