1. An introduction to diabetes

2. 2 Aims  To give an overview of Type 1 and Type 2 diabetes  To give information on what normal blood glucose levels should be  Discuss hypo and hyper glycaemia  To identify the complications associated with diabetes  To give information on the different types of medication  To instruct how to monitor blood glucose levels

3. 3 Objectives  The Health Care Assistant will understand the differences between Type 1 and Type 2 Diabetes  The HCA will know what normal blood glucose levels should be  The HCA will know what the complications associated with diabetes are  The HCA will understand what medications are used in diabetic control  The HCA will be able to monitor blood glucose level and support the diabetic patient

4. 4 What is diabetes?  Diabetes mellitus is a common condition in which the amount of glucose in the blood is too high because the body is unable to use it properly  It can occur at any age but incidence increases with age  The hormone called insulin controls the amount of glucose in the blood  Insulin is made in a gland called the pancreas

5. 5 What is diabetes?  Food is digested and particularly sugary and starchy foods are turned into glucose  Glucose travels round the body in the blood  Glucose is used for energy  Insulin moves the glucose from the blood into the cells

6. 6 Food and Insulin  Food is taken in and travels through the gut  The pancreas secretes insulin when we eat  Food is broken into smaller molecules in the gut  Some of these are GLUCOSE

7. 7 What is diabetes?  After a meal blood glucose levels rise and insulin is normally released into the blood  Insulin is crucial to stop blood glucose levels rising too high  Diabetes develops when the pancreas is unable to produce insulin or when cells cannot use the insulin properly

8. 8 How the glucose gets into the cells

9. 9 What is normal blood glucose?  The aim is to restore blood glucose levels towards normal limits  General aim 4 – 7mmols before food  Hypoglycaemia (low blood sugar) is when blood glucose falls below 4mmols  Blood glucose levels fluctuate throughout the day. However persistently high or low readings need reviewing

10. 10 Two types of diabetes  Type 1 Develops when there is a severe lack of insulin in the body because most or all insulin producing beta cells in the pancreas have been destroyed. This is treated by insulin injections and diet  Type 2 Develops when pancreas still produces insulin but there is cellular resistance and insulin cannot be used properly by the body. This is treated by diet alone or diet and tablets, or diet and insulin injections (Tortora and Grabowski 1996)

11. 11 Type 1 Type 2 Age of onsetYoung <40yrOlder >40yr SymptomsYes -very sudden/intense Sometimes -slow gradual onset Auto immuneYesNo Producing own insulin NoYes Body WeightNormalNormal/overweight TreatmentInsulinDiet/tablets/Insulin

12. 12

13. 13 Treatment of diabetes  Diet (healthy eating) and lifestyle interventions  Oral hypoglycaemic agents  Injectables (Exenatide & Liraglutide)  Insulin & oral hypoglycaemic agents  Insulin

14. 14 Factors affecting glycaemic levels  Diet (amount,type and frequency of food)  Alcohol  Exercise levels  Stress/emotional upset  Illness/infection  Pregnancy

15. 15 Things which lower blood glucose  Insulin injections  Diabetes tablets  Exercise  Forgetting a meal or eating too little

16. 16 Things which will raise blood glucose  Over-eating, particularly starchy or sugary food  Missing an insulin injection  Forgetting a tablet  Illness/infection  Stress

17. 17 Hypoglycaemia Causes  Too much insulin  Too many ‘Diabetic’ tablets  Not enough food or delayed food intake  Increased exercise  Extremes of weather  Alcohol  Early Pregnancy

18. 18 Hypoglycaemia(below 4 mmol/l) signs and symptoms ??

19. 19 Hypoglycaemia (below 4 mmol/l) signs and symptoms  Sweating  Shaking  Headaches  Blurred vision  Dizziness  Tingling lips/fingers/tongue  Palpitations  Feeling hungry  Lack of concentration  Pallor  Glazed eyes  Personality changes/behavioural changes

20. 20 Hypoglycaemia Treatment  Group Activity

21. 21 Hypoglycaemia Treatment Quick acting Sugar  Glucose Sweets (2-3 sweets)  Lucozade (small glass)  Orange Juice (small glass)  Sugar (2-3 spoonfuls) Followed up with longer acting carbohydrate snack

22. 22 Hypoglycaemia Treatment continued  If patient is resisting food can try Glucogel (formerly Hypostop) if available  If unable to swallow/drowsy may use Glycogen if available  If unconscious will need 999 call

23. 23 Hyperglycaemia signs and symptoms  Group Activity

24. 24 Hyperglycaemia signs and symptoms  Thirst  Tiredness  Polyuria (frequency passing urine particularly at night)  Weight loss  Fast breathing  Vomiting – late stages  Impaired consciousness  Increased risk of infections (in particular thrush)

25. 25 Treatment  Review patient and medication  Sick day rules ○Seek medical advice if vomiting or getting worse ○Give plenty of fluids ○If not eating, replace food with drinks ○i.e. lucozade / lemonade – small glass ○Don’t stop insulin / tablets ○Monitor closely

26. 26 Dietary Guidelines

27. 27 The Main Tablets  Tablets that help the body to use insulin more effectively – metformin - usually used in overweight people – affects the stomach  Tablets that stimulate the pancreas to produce more insulin – gliclazide - can cause low blood sugar

28. 28 Additional Tablets Less commonly used  Post prandial glucose regulators- glinides  Glitazones  Sitagliptin / Vitagliptin / Saxagliptin (Relatively new)

29. 29 New Options  Dipeptidyl Peptidase 4 Inhibitors (DPP-4, Gliptins) ○Sitagliptin ○Vildagliptin ○Saxigliptin  Glucagon-Like Peptide –1  (GLP-1) ○Exenatide – Byetta ○Liraglutide – Victoza

30. 30 Injectables For people with Type 2 diabetes not to be used in Type 1 diabetes  Exenatide – twice a day or a once weekly option  Liraglutide – once a day Both to be used in combination with tablets and are subcutaneous injections. These are not INSULIN

31. 31 Insulin  Once daily – long acting – can be used in type 2  Twice daily – medium acting – can be used in type 2  Four times daily – one long acting and three short acting with meals

32. 32 Insulin and Tablets  Importance of taking these at the correct time  Why do we say this?  Insulin and some tablets work with food  If given at the wrong time can cause ○Low blood sugar ○High blood sugar

33. 33 Complications of diabetes Eye damage  Diabetic Retinopathy (bleeding at the back of the eye & formation of new vessels)  If untreated can lead to blindness  People with diabetes need to have annual screening for early signs of eye damage

34. 34 Retinopathy

35. 35 Retinopathy

36. 36 Complications of Diabetes Kidney damage  Diabetic Nephropathy (formation of small new blood vessels in the kidneys)  Undetected can lead to renal failure  People with diabetes need to have good control of their blood pressure & blood sugar levels to reduce the risk of developing these problems

37. 37 Kidneys – renal disease

38. 38 Complications of Diabetes Increased risk of Heart Disease & Stroke  Build up of cholesterol (fatty deposits) on the linings of the blood vessels restrict the flow of blood through the vessels which can lead to heart attack & strokes To reduce the risk  No smoking  Good control of blood pressure & cholesterol  Maintain normal weight  Low fat diet  Regular exercise

39. 39 Heart Disease and Strokes

40. 40 Complications of Diabetes Foot problems  Diabetic Neuropathy, damage to the nerve supply to the feet  Affect blood supply to the legs & feet  Leading to reduced/slow healing of any injuries  Risk can be reduced by maintain good diabetes control and good foot care Report any cuts, sores, abnormal looking areas straight away – this may save the person’s foot

41. 41 Feet-Circulation, sensation and ulcers

42. 42 Monitoring Control  Practical session  How to take a blood glucose measurement  Completing blood glucose diary  Documentation (including prescription charts)  Safe disposal of sharps

43. 43 Procedure  Identify patient, obtain consent and cooperation  Wash and dry your hands and apply gloves  Ensure that patient has washed hands in warm soapy water, rinsed and dried completely  Carefully remove test strip from packaging  Insert test strip into meter and ensure meter coded  Use Unilet lancing device and puncture finger on side of fingertip (outer aspect) avoiding thumb and forefinger  Gently squeeze/massage fingertip to get round drop of blood

44. 44  If blood smears do not use this sample. Dry the area and gently squeeze another drop of blood. If still not effective, puncture a new site with a new lancet  Apply sample as per manufacturers instructions  Press cotton wool or gauze to puncture site  Dispose of used lancet and test strip in sharps bin  Remove gloves and wash hands with soap & water  Record BM result in patients notes  If BM result out of target range, act accordingly & seek advice From Qualified Nurse or GP

45. Quiz EVALUATION