The Wheel of Life Exercise. What s Happening? Where to start the beginning. What's in a meter- are they all the same?

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1 Wharfedale Hospital Otley Linda Clapham BSc Hons. RGN, SEN,Cert. Ed. The Wheel of Life Exercise An exercise to Encourage self management Work What s going on! Medication Helping patients succeed Diabetes Nurse Specialist/ Centre Manager Self Monitoring Diet Diabetes UK What s Happening? Gadgets & Equipment Blood Glucose Levels Injection Sites Name of Medication Time of Medication How different at weekend Blood Glucose monitoring Pro s / Con s Know what's going on Motivation Help with Diet / exercise Feels of being in control Improves QoL % of those SBGM improved control Legal requirement for some since 0 regulation changes Cost Pain Fear / worry about results Availability of metes Time to teach & associated education Accuracy user / technology dependant QC issues Where to start the beginning Is what you think is happening really happening Timing of medication, meals, snacks Is monitoring being done, how often - why, is action taken on results Diet are they CHO aware Check medication compliance What's in a meter- are they all the same? Input CHO/exercise insulin dose Info Length of time to test Small Size Computer download Colour Pattern recognition Large size Vision Strips in foil Manual Dexterity No Strips Motivation Suggest insulin Choice dose iphone compatibility Blood Ketones Alternate site testing Disposal of sharps Lancing device lancet / drum Safety & reliability Ability/ willingness To record results

2 When & How Often What do you want to know What is the benefit to care What will happen to the results Does the information match with number of strips prescribed Does the patient act on results Is the cost justified Does there need to be discussion with patient (agreed plan) Is there a risk of hypoglycaemia Does the patient drive - pre driving BG must be above mmol, re test after hours if BG <.0 wait mins after it s come up before driving Is what is written in the diary the whole picture Before eve meal Pre Bed Before b fast Based on this book what would you do? What you see and what you get Patients can bring works of complete fiction Often don t understand the need to vary times of tests Use time as an excuse not to test (when really time to interpret and act on results is the problem) Carbohydrate (CHO) Carbohydrates are very important to people with diabetes because they affect blood glucose levels SUGARS STARCHY FOODS GLUCOSE BB BL BT BB Types of Carbohydrate Rapid Acting Carbohydrates: Tend to be sugary foods or drinks Are easy to digest and release glucose into the blood stream quickly Have a high Glycaemic Index (GI) Complex Carbohydrates: Tend to be starchy foods Are difficult to digest and release glucose into the bloodstream slowly Have a low Glycaemic Index (GI) BLOOD STREAM INSULIN CELLS OF THE BODY SPEEDY SUGARS SLOW STARCHES

3 Foods that contain CHO These foods contain CHO: These do not contain CHO: Bread, cereals, porridge, potatoes, rice, pasta & chapattis Fruit & fruit juice Milk, milk puddings, yoghurt, ice-cream, custard Biscuits, cakes, scones Pies, quiche, lasagne plain meat, fish, eggs, cheese, fats, oils vegetables & salad contain very little Carbs & Cals On-line CHO / Cals requirements tool Visual portion sizes Recommended CHO Intake CHO requirements are individual and depend on age, sex, height, weight & physical activity People with diabetes need to have enough, regular carbohydrate to maintain healthy blood glucose levels Portion size matters More focus on CHO intake Which would affect blood glucose most? Chocolate Eclair Banana Injected Therapies Introduced earlier Longer lifetime of injections Necessary to preserve injection sites Education and training in correct technique is as important as the prescription Needle Length is important mm mm. mm pen needle Original mm mm pen needle What are you dispensing There is no medical rationale for using needles > mm. Consider brand/device compatibility, and mm needles may be used by any adult patient including obese ones and do not generally require the lifting of a skin fold. Injection should be given in adults at 0 degrees to the skin surface. Currently mm shortest on syringe

4 Injection site issues Right handed most injections into left thigh Male patient Thought it was muscle from cycling long standing Type diabetes On referral to us May 0 - HBAc mmol/mol Aug 0 HBAc mmol/mol Oct 0 HBAc mmol/mol What did we do? Overused site caused unpredictable hypo, leading to RTA # ribs, car written off, month driving suspension by DVLA The Device often drives the insulin choice KIS Keep it simple Savio (Eli Lilly) Innolet Insulin Regimens Daily Twice Daily ( Breakfast & Evening Meal) Four times Daily Occasionally more often in special circumstances i.e. competitive sport, pregnancy, shift workers. Metformin used in combination with insulin One Injection of Isophane Per Day Breakfast 0 Lunch Evening Meal 0 Sleep Could also be Lantus or Levemir, with a flatter profile

5 Injections Per Day Short + Intermediate Acting (Basal Bolus) Two Injections of Mixed insulin Breakfast Breakfast Lunch Evening Meal Lunch Evening Meal 0 Sleep Sleep Suggestions for Testing Plans Before Breakfast Before Lunch Before Eve Meal Before Bed Before Eve Meal Before Bed OR Before Breakfast Before Lunch Basal insulin (Lantus) Interpretation of blood results Result pre lunch affected by morning quick acting insulin Result pre evening meal affected by morning long acting insulin Results pre bed affected by evening quick acting insulin Result first thing affected by previous evening long acting insulin General Principals Do not react to one off high/low sugar readings Consider what might have caused the problem Look for trends and adjust insulin prior to problem time Remember A blood glucose is what it is because of things in the past diet, medications Insulin is coping with what is coming Must look in both directions

6 InsulCheck Storage of Insulin Last dose given & how long ago Before use Store in fridge From. fit all common pens both disposable and durable In-use vials Store in fridge ( months) Out of fridge at max C (- weeks) In-use pens Out of fridge at max C ( weeks) Hypoglycaemia s the Floor no matter what! A higher level may be necessary in elderly people as the consequences can be fatal e.g. falls The fear of hypoglycaemia is often at the root of a reluctance to improve glycaemic control More emerging evidence on the harm of hypoglycaemia st bottle (0mls) of Glucose Liquid Re-test BG Repeat st step Up to times - Glucose tablets nd portion fruit Next meal if due ½ - tubes Glucose Gel 00mls slice of toast or tsp dissolved in water or jelly babies Hypo Wallet Offer Price. BBI HealthCare The keys to success, find the problem Issue Metformin 0mgs TDS GI upset with Metformin so not being taken as prescribed Solution Consider Glucophage SR Issue Missing doses Gliclazide Solution Daily Glimepiride Try to find a practical solution

7 New images of Sites Skin thickness

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11 Lifted skin fold

12 Sharp needle Reused needle