Blood Glucose Measurement And Insulin Administration

Outline Blood Glucose monitoring Purpose/ Indication of BGM Types of Blood Glucose Tests Medications that can affect blood glucose levels Normal and diabetic blood sugar ranges Insulin Types Mixing Insulin References

Introduction Blood Glucose Monitoring is a cornerstone of diabetes management and Self Monitoring of blood Glucose (SBMG) levels by patient has dramatically altered diabetes care Frequent SBMG enables diabetic patients to adjust the treatment regimen to obtain optimal blood glucose control

1. Blood Glucose Measurement Blood glucose is the amount of glucose in the blood (mmol/L). Blood glucose is regulated by insulin and glucagon. Blood monitoring (BM) is used to indicate when blood glucose is not within the normal range (4-7mmol/L) ( 70-120 mg/dl) . It is used to monitor and manage the treatment of both insulin-dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM).

Goals for BGM To maintain blood glucose within target range. Immediate benefit: Identification, treatment, and prevention of high and low blood glucose levels. Long-term benefit: Decrease risk of long-term complications.

Purpose/ Indication of BGM type 1 and type 2 diabetic patients. unstable diabetes, (hyperglycemia, hypoglycemia, and diabetic ketoacidosis). For diagnostic purposes of diabetes (signs and symptoms of polyuria, polydipsia, weight loss of type 1 or weight gain, family history of type 2 .) Patients taking steroids and other drugs that cause raised blood glucose.

Some conditions that may affect the accuracy of blood glucose monitoring (may need a venous sample) : Peripheral circulatory failure and severe dehydration e.g., diabetic ketoacidosis, shock, hypotension. These conditions cause peripheral shutdown, which can cause artificially low capillary readings. Some renal dialysis treatments. Hyperlipidemia: cholesterol levels above 13 mmol/L may lead to artificially raised capillary blood glucose readings Pre-eclampsia

Types of Blood Glucose Tests Preparation What it measures PURPOSE 1. Fasting  blood sugar (FBS) - NPO for least 8 hours. measures blood glucose often the first test done to check for prediabetes and diabetes. 2. Two (2)-hour postprandial blood sugar  Client eats a meal exactly 2 hours before the blood sample is taken measures blood glucose exactly 2 hours after having a meal; not used to diagnose diabetes; used to check if a  diabetic client is taking the right amount of insulin with meals. 3. Random blood sugar (RBS) No preparation measures blood glucose regardless of when the client last ate. may be taken throughout the day. Blood glucose levels that vary widely may mean a problem.

Types of Blood Glucose Tests preparation PURPOSE 4. Oral glucose tolerance test - fasting sample of blood and then taking a very sweet drink containing 75g of glucose. a series of blood glucose measurements used to diagnose prediabetes and diabetes, gestational diabetes. 5. Hemoglobin A1c, or Glycohemoglo bin, None measures how much sugar (glucose) is stuck to red blood cells; used to diagnose diabetes; shows how well diabetes has been controlled in the past 2 to 3 months and whether diabetic medications needed to be changed. The result of  A1c test can be used to estimate the average blood sugar level.

Medications that can affect blood glucose levels Acetaminophen corticosteroids steroids diuretics oral contraceptives (birth control pills) hormone therapy aspirin Atypical antipsychotics lithium epinephrine tricyclic antidepressants monoamine oxidase inhibitors (MAOIs) phenytoin sulfonylurea medications

Equipment Blood glucose monitor Patient record book disposable test strips Disposable lancets Quality control solution Gauze swabs disposable gloves Sharps container cleaning wipes

Blood glucose monitoring

Normal and diabetic blood sugar ranges healthy individuals Diabetics Before meals: Between 4.0 to 6.0 mmol/L (72 to 108 mg/dL) when fasting type 1 or type 2 diabetes - 4 to 7 mmol/L After meals: Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating type 1 diabetes - under 9 mmol/L type 2 diabetes - under 8.5mmol/L http://www.diabetes.co.uk/

Role of nurse Check BG as ordered Document results Give medication or glucose (insulin\oral diabetic drug) Communicate blood glucose results to physician according to policy.

2. Insulin administration

Insulin types

Delivery Methods 1. Insulin Syringe 2. Insulin Pump 3. Insulin Pen

4. Infusion Human regular insulin may be injected directly into the vein in a hospital setting, with doctor’s order, under close medical supervision only Insulin is added to intravenous fluids, and the insulin dose and blood sugar are strictly monitored.

Route: Subcutaneous

General Considerations concerning Insulin Administration 1. Dosage depends on glycemic response of the individual to food intake and exercise regimens. (Type 1 diabetic patients and some type 2 diabetic patients may require both rapid- or short- and longer-acting insulins, three or more injections per day to meet glycemic goals.) 2. The timing of the injection depends on blood glucose levels, food consumption, exercise, and types of insulin used. Variables in insulin action (e.g., onset, peak, and duration) must be considered. 3. Rapid-acting insulin analogs should be injected within 15 min before a meal or immediately after a meal. The most commonly recommended interval between injection of short-acting (regular) insulin and a meal is 30 min.

Mixing Insulin 1. Check the labels on the insulin bottles to make sure you have the correct insulin. Regular, lispro (Humalog) and aspart (NovoLog) Insulin should be clear. NPH insulin should be cloudy. 2. Throw away any insulin left in the bottle 30 days after you first open the bottle. 3. Gently roll the bottle of cloudy insulin between your hands until it is mixed, and there is no powder on the bottom of the bottle.

Mixing Insulin 4. Do not shake the insulin bottle because this can cause air bubbles. Tiny air bubbles are not dangerous, but they will decrease the amount of insulin in the syringe. 5. Aspirate clear Insulin first before the Cloudy Insulin 6. If you get more units of cloudy insulin in the syringe than are needed, do not push any insulin back into the bottle. Remove the syringe and throw it into your needle disposal box. Get a new syringe and start over.

Patient Education A - Storage 1. Vials of insulin not in use should be refrigerated. Extreme temperatures (<36 or >86°F, <2 or >30°C) and excess agitation should be avoided to prevent loss of potency, clumping, frosting, or precipitation. 2. Specific storage guidelines provided by the manufacturer should be followed. Insulin in use may be kept at room temperature to limit local irritation at the injection site, which may occur when cold insulin is used. 3. The patient should always have available a spare bottle of each type of insulin used. Although an expiration date is stamped on each vial of insulin, a loss in potency may occur after the bottle has been in use for >1 month, especially if it was stored at room temperature.

Patient Education 4. Inspect the bottle before each use for changes (i.e., clumping, frosting, precipitation, or change in clarity or color) that may signify a loss in potency. 5. Relate any unexplained increase in blood glucose to possible reductions in insulin potency. 6. If uncertain about the potency of a vial of insulin, the patient should replace the vial with another of the same type. . Rapid- and short-acting insulins as well as insulin glargine to be clear ; all other insulin types are uniformly cloudy

PATIENT MANAGEMENT B - Self-monitoring 1. Whenever possible, insulin-using patients should practice self-monitoring of blood glucose (SMBG 2. Illness, traveling, and any change in routine (e.g., increased exercise and a different diet during vacation) may require more frequent SMBG under the guidance of a physician. 3. During illness, it is important that insulin be continued even if the patient is unable to eat or is vomiting. 4. When accompanied by hyperglycemia, a positive urine or blood test for ketones during illness indicates a need for extra, not less, insulin. 5. Eating within a few minutes after (or before) injecting short-acting insulin is discouraged because it substantially reduces the ability of that insulin to prevent a rapid rise in blood glucose and may increase the risk of delayed hypoglycemia

PATIENT MANAGEMENT C - Hypoglycemia 1. All insulin-requiring individuals should be instructed to carry at least 15 g carbohydrate to be eaten or taken in liquid form in the event of a hypoglycemic reaction. 2. Family members, roommates, school personnel, and coworkers should be instructed in the use of glucagon for situations when the individual cannot be given carbohydrate orally. 3. All insulin users should carry medical identification (e.g., a bracelet or wallet card) that alerts others to the fact that the wearer uses insulin. .

Suggested video to watch https://www.youtube.com/watch?v=gizYDn2_0Io

References http://www.healthline.com/health/glucose-test-blood#TestPreparation3 http://www.webmd.com/diabetes/blood-glucose http://www.diabetes.co.uk/ https://www.healthinfotranslations.org/pdfDocs/MixingTwoInsulins.pdf