UNDERSTANDING THE BASIC FEATURES AND MANAGEMENT IN THE SCHOOL SETTING CHRISTINE HERTLER RN BSN CDE & MARY MCCARTHY RN CDE

Transcription

1 UNDERSTANDING THE BASIC FEATURES AND MANAGEMENT IN THE SCHOOL SETTING CHRISTINE HERTLER RN BSN CDE & MARY MCCARTHY RN CDE

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5 The insulin pump Replaces injections Delivers insulin through a soft cannula under the skin Infuses rapid acting insulin in precise programmable doses to meet individual patient needs The insulin pump closely mimics normal pancreatic insulin delivery

6 Skin Subcutaneous Tissue Cannula Insulin 6

7 Units of insulin The insulin pump delivers basal and bolus insulin precisely and can be easily customized as needed to meet individual requirements. Programmable Insulin Delivery with Medtronic MiniMed Pump Therapy 6.0 Bolus insulin delivery Basal insulin delivery Dual Wave Bolus for brunch Basal reduced to help prevent nocturnal hypoglycemia Basal programmed to help prevent dawn phenomenon Temporary basal during walking to help prevent hypoglycemia Dinner bolus am 4am 8am 12pm 4pm 8pm 12am Schematic representation only

8 It works more like a healthy pancreas It has more predictable insulin absorption It offers more flexible basal rates It offers more accurate bolus dosing Bode B, Sabbah H, Gross T, Fredrickson L, Davidson P. Diabetes management in the new millennium using insulin pump therapy. Diabetes Metabolism Research and Reviews. 2002; 18 (Suppl. 1): S14-S20.

9 Basal Bolus Insulin carb ratio -ICR Insulin sensitivity or correction factor-isf Target Active insulin or insulin on board -IOB

10 Basal Rate (background insulin) -provides insulin continuously Pre-programmed Continuous flow of fast-acting insulin Matches variable metabolic needs May be overridden by temporary basal rate

11 Bolus - provides insulin for: Food Intake High blood sugars Bolus is not automatic. User determines bolus amount based on: - Carbohydrate content of meal or snack - Current blood sugar reading

12 Active insulin is the amount of insulin (remaining from previous boluses) that is still working to lower glucose The pump tracks active insulin even if not using the Bolus Wizard feature Tracking active insulin helps avoid: Giving too much insulin and overcorrecting highs Lows that occur from over-correcting highs

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15 Change infusion site every 2-3 days Rotate site with every set change Recommended sites: Abdomen- 2 inches from umbilicus Buttocks- away from midline Perform hand hygiene and use clean technique when inserting/removing catheter Clean skin with alcohol or IV prep wipe Allow to dry thoroughly before insertion

16 Remove set at first sign of discomfort Place new set away from original site At the first sign of infection advise family to contact primary care provider Signs of infection include: Redness Hardness Tenderness Oozing from cannula Area warm to touch

17 Monitor site for any leakage, this may indicate displacement of cannula Monitor site for lipohypertrophy and lipodystrophy- benign lesions which can affect absorption of insulin If these occur stop using existing site for 4 weeks to allow healing

18 REVEL Basal increment Bolus increment 530G with Enlite Sensor First phase artificial pancreas Integrated sensor with pump Low glucose suspend Linking meter

19 Only tubeless pump PDM is linking meter and pump manager Insulin and pump in POD Bolus must be given with PDM Holds 200 units Basal.05 units

20 Dose from ping linking meter/remote Low dosing basal.025 Waterproof Holds 200 units

21 First touch screen Small Waterproof Rechargeablegreen Holds 300 units No linking meter

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29 Hyperglycemia Hypoglycemia What to do for Exercise What to do in an Emergency

30 Forgot to bolus? (Press Esc for last bolus) Miscounted carbs? Illness or infection? Blocked insulin flow (No Delivery) Kinked Cannula at the infusion site?

31 When blood sugar is over 300 mg/dl for long periods of time, the body burns other energy sources to provide food for the body s cells Cells begin to break down to provide this energy This cell breakdown can cause ketones to be released into the bloodstream

32 Risk of Ketoacidosis increases on pump because no long acting insulin is in the body Monitor 4-6 times daily Never ignore an unexplained high glucose

33 Early-loss of appetite, nausea Later-vomiting, abdominal pain Late-difficulty breathing, confusion

34 Is my infusion site red or irritated Is my site wet or does it smell like insulin Are there bubbles in the tubing Is there blood in the tubing Are there any leaks or breaks Is connection loose, easily moved Is reservoir loaded correctly? Is reservoir empty?

35 Are there excessive bubbles in reservoir? Has insulin vial expired? Has insulin been exposed to extreme temp? Was last meal bolus missed (check bolus history) Are basal rates set incorrectly? Is time (am or pm) set correctly? Is insulin pump not working????

36 WHEN BLOOD GLUCOSE IS 300 OR HIGHER Positive Ketones CHECK FOR KETONES AND FOLLOW THESE GUIDELINES Negative Ketones Give correction dose by injection Change infusion set, reservoir and insulin Monitor blood sugar every hour to make sure until BG is lowering Check ketones with every void until negative Force fluids Never exercise when ketones are positive Give correction dose via insulin pump Recheck blood sugar in 1 hour If blood sugar has not decreased: -give ½ dose by syringe -change infusion set, reservoir and insulin Continue to check for ketones Check blood glucose 2 hrs from correction dose

37 If moderate to large ketones present, there is an increased resistance to insulin---call HOTLINE The insulin given for correction may need to be increased by 50% Example: If mg/dl = 1 unit 1 divided by 2 = unit units = 1.5 units (correction increased by 50%) This increase in correction can only be done twice, unless recommended by the hotline 32

38 Muscles will use glucose during exercise and activity this can affect BG levels for several hours Disconnecting from the pump Using a temporary basal rate decrease Consuming extra carbs before exercise per physician order Discuss which plan to use with parents (504) and follow physician school orders

39 Manage hypoglycemia the same way as you would if child were on injections 15 and 15 rule=15gm recheck in 15 min follow physician school order and parents guidelines No need to disconnect pump

40 Fast acting carbohydrates for low blood sugar Insulin and syringes Extra infusion set and reservoir (plus inserter if necessary) Extra batteries Alcohol or skin prep Phone # of student s diabetes clinician Blood glucose meter Keto-stix Glucagon kit

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42 BENEFITS OF CGM Aids in the detection of highs and lows allowing for adjustments for minimizing excursions Identifies patterns that otherwise would not be detected by fingerstick alone Provides info about the effects of food intake, EXERCISE and timing of insulin Provides glucose direction and rate of change Accuracy within % at this time Complements but does not replace monitoring 42

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44 Medtronic Enlite 530G-pump integrated Dexcom G4 -pump -integrated with Animas Vibe an T-Slim G5 -stand alone sensor

45 530G with Enlite Sensor First phase artificial pancreas Integrated sensor with pump Low glucose suspend Linking meter

46 BLUE TOOTH COMMUNICATIO N FROM DEXCOM G4 SENSOR TO PUMP NO METER REMOTE SEPARATE DEXCOM RECEIVER MAY BE USED TO ALLOW FOR COMMUNICATIO N TO CELL PHONE STUDENT WILL ALSO HAVE TO CARRY CELL PHONE FOR CLOUD

47 CGM enabled Large capacity Rechargeable Watertight Touch Screen

48 MiniLink transmitter Enlite glucose sensor MiniMed 530G insulin pump

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50 DEXCOM SENSOR COMPONENTS 50

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52 Recommended sites: Abdomen & Buttocks At least 2 inches away from insulin pump site Change sensor site every 6-7 days May encounter issues with tape adherence and skin sensitivity Products that may help Skin Tac Bard Barrier Wipe Mastisol IV 3000 Tegaderm Tincture of Benzoin

53 CURRENT GLUCOSE READING WHEN IN ACTIVE SESSION TREND GRAPH VIEWS BY TIME HIGH ALERT LOW ALERT TARGET GLUCOSE RANGE 53

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56 My CGM IS TALKING TO ME! WHY ARE YOU USING YOUR CELL PHONE IN SCHOOL?

57 When glucose is rising, then the difference between the Sensor Glucose and Blood Glucose readings tends to be greater

58 Blood Glucose tends to be ahead of the Sensor Glucose Both SG and BG readings will be similar

59 Focus on the direction and speed of your sensor glucose Arrows mean the sensor glucose has been changing rapidly

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63 RESPONDING TO ALERTS

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67 Dexcom receiver and/or cell phone must be within 20 foot range for communication Medtronic enlite sensor, will communicate directly to pump and is already in range-if using a uploader, it must be within 6 foot range of body and cell phone The sensor is worn continuously-the cell receiver, pump or cell phone has audible alerts warning to indicate glucose level out of range

68 When an alarm or alert sound is sounding, student, teacher or other designated person will need to clear alarm and check blood glucose by fingerstick ALL ALERTS MUST BE CONFIRMED WITH A FINGERSTICK BEFORE TREATING ANY GLUCOSE READINGS The nurse (or other designated person) should the low glucose as per protocol, notify parent as usual, and document both the fingerstick and sensor glucose results, along with the necessary treatment given Please note that looking at TREND ARROW DIRECTION is helpful If the glucose sensor becomes detached from the body, store the device safely without discarding any components-return this to the parent THIS IS NOT AN EMERGENCY AND DOES NOT REQUIRE ANY SPECIAL INTERVENTION OR EXCUSING THE CHILD FROM SCHOOL ACTIVITY

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70 Physician school orders still take precedence Monitoring at regular intervals Confirming alerts with fingersticks before treatment 504 plans will need to be updated which address parental concerns, use of cell phones, and accountability of student to report to health office

71 QUESTIONS???