Diabetes Mellitus: Conference #2

MEDICATIONS: Insulin (High Alert Medication) Oral Agents (High Alert Medications) Nutrition Therapy

Jackie Dorsey RN, MS, ANP

High Alert Medications

As described by the FDA, High-

Alert Medications are those

most likely to cause significant

harm to patients of any age,

even when used as intended by

the prescriber. While errors in

these medications are not more

common than in others, high-

alert medications more

commonly cause harm and their

adverse reactions are usually

more serious, especially in the

geriatric population.

Some examples listed

adrenergic agonists, IV (e.g., epinephrine, phenylephrine, norepinephrine)

adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)

anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)

antiarrhythmics, IV (e.g., lidocaine, amiodarone)

antithrombotic agents (anticoagulants), including warfarin, low-molecular-weight

heparin, IV unfractionated heparin, Factor Xa inhibitors (fondaparinux), direct

thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin), thrombolytics

Nursing Management of a patient With Diabetes Mellitus

Collaborative Care of Patient with DM

Goals:

1. Reduce Symptoms

2. Promote well-being

3. Prevent acute complications

4. Delay onset of long term complications

Nursing Management of a patient With Diabetes Mellitus

Collaborative Care of Patient with DM

Method:

Goals are accomplished by thorough patient teaching and encouraging patient to be an active participant in their own care!

Nursing Management of a patient With Diabetes Mellitus

Collaborative Care of Patient with DM

Team:

Providers

Nursing

Diabetes Educators

Registered Dieticians

Pt/family/Significant others

PRECONFERENCE ACTIVITY

6

Readings on Nutritional Therapy

National Guidelines

ChooseMyPlate.gov

Calorie Meal Plan

This content (pages 20-22) is Pre-conference learning and answers will be posted on Angel.

View VHS-006

Putting Carbohydrate Counting into Practice

Note taking Guide provided p 23

Goals of Nutritional Therapy

Maintain blood glucose

Achieve lipid profiles and blood pressure levels

Modify lifestyle

Improve health

Address individual nutritional needs

Nutritional Therapy

DIFFERENCES TYPE 1 TYPE 2

Total calories Possible necessary to achieve desirable body weight

Decrease calories for overweight or

obese patients.

Effect of diet Diet & insulin necessary for glucose control

Diet alone may be sufficient

Emphasis is on achieving glucose,

lipid and BP goals.

Distribution of calories Equal distribution of CHO for insulin activity

Equal distribution recommended

Consistency of CHO at meals

desirable

Consistency of daily intake Necessary Desirable

Uniform timing of meals Crucial if on intermediate or long acting insulin

Desirable

Between meal and bedtime

snack

Frequently necessary Not usually recommended

Nutritional supplement for

exercise.

Adjusted for exercise May need adjustment for exercise

Antidiabetic Medications Insulin Therapy (High Alert Medications)

Classification

Generic Name

Trade Name

Normal Insulin Secretion in the Body

Medication Card: Insulin (High Alert Medication)

Classification

Types

Indications for Use

Action

Side/adverse effects

Storage

Types: High Alert Medications

Insulin Lispro (Humalog)

Regular Insulin(Humulin R)

NPH Insulin (Humulin N)

Insulin Glargine (Lantus)

Insulin Lispro (Humalog)

Clear

SC

Rapid Acting

15-20 minutes

60-90 minutes

3-4 hours

Regular Insulin (Humulin R)

Clear

SC or IV

Short Acting

30-60 minutes

2-3 hours

3-6 hours

NPH Insulin (Humulin N)

Cloudy

SC

Intermediate Acting

2 hours

4-10 hours

10-16 hours

Insulin Glargine (Lantus)

Clear

SC

Long Acting

1-2 hours

No significant peak

24+ hours

Site Selection

Abdomen

fastest absorption

Back of arms

second fastest absorption

Anterior thighs

Buttocks

slowest absorption

Site Rotation

Rotate injection site within a particular anatomical area (checkerboard)

Rotation to different anatomical sites no longer recommended

Prevention of lipodystrophy- Lumps and dents from repeated injections

20

Lipodystrophy

Alternate Administration Methods

Insulin Pump

Delivers predetermined amount of insulin on a continuous rate via a subcutaneous needle

Closely mimics basal supply of insulin

Insertion sites changed every 2-3 days

Requires close BG monitoring 22

Alternate Administration Methods

Insulin

Pump

High Alert Medication Review Insulin Post-Conference Activity

Complete table on the bottom of p 27

See Angel for answers

Insulin Practice Questions

Post-Conference Activity or faculty may do on the board if time allows.

CRITICAL THINKING ACTIVITY

What is Humulin 70/30 Insulin (high alert medication)?

Answer: Combination insulin preparation

70% of dose NPH insulin 30% of dose Regular insulin

More convenient for some patients

There is a second form of 70/30 insulin made with NPH/Humalog

CRITICAL THINKING ACTIVITY

A patient has an order for Humalog (high alert medication) ac. The patient receives 10 units of insulin at 0730 and eats breakfast at 0800 . At what time would a hypoglycemic episode most likely occur?

Answer:

Between 0830 and 0900 when Lispro insulin is peaking

CRITICAL THINKING ACTIVITY

What nursing interventions would the RN implement for a hypoglycemic reaction?

Answer: Follow the 15-15 Rule: Give 15 gm of simple CHO

120-180 ml juice 180-200 ml regular soda

After 15 minutes check BG if < 60 treat with another 15 gm of fast acting CHO

If no relief, another 15 gm of simple CHO Keep doing so until BG gets to > 60. Call MD if no change Follow with longer lasting CHO like skim milk

CRITICAL THINKING ACTIVITY

A 5 year old child is a newly diagnosed Type 1 diabetic. His mother asked you what she should do about giving him Lispro (Humalog) insulin (high alert medication) before he eats. The mother states that the child is such a finicky eater.

Answer: This insulin is fast-acting and provides better control for

finicky eaters Humalog insulin can be given immediately after he eats &

the dose could be adjusted based on what and how much he eats

Post-conference Activity

Why are Lispro and Lantus used together? (Refer to text)

Oral Antidiabetic Agents

Oral agents are not oral insulin nor are they a substitute for insulin

Antidiabetic Medications for Type 2 DM Oral Agents (high alert medication)

Classification (Insulin Secretagogues insulin secretion)

Sulfonylureas

Biguanides

Dipeptidyl-peptidase-4 inhibitor

Sulfonylureas

Biguanide

Dipeptidyl-peptidase-4 inhibitor

Oral Agents and Patient Teaching

Store in tight container/cool environment

Symptoms of hypo/hyperglycemia & treatment

Medications must be used daily.

Consequences of discontinuing medication abruptly

Diet plan to prevent hypoglycemia

Avoid OTC medications unless prescribed

Carry emergency ID-Provider name and meds

Diabetes is lifelong disease-meds are no cure

NCLEX Review Questions 1. Answer: 1

Text Reference: Lewis p. 1266, Table 49-7

2. Answer: 1

Text Reference: Lewis p. 1267, Table 49-8