1. Delivering Quality Care to Your Patients With Diabetes Slide Presentation for Certified Nursing Assistants and Medical Technicians US.NMH.15.01.105

2. Your Role in the Care of Your Patients With Diabetes Is Important You are a valuable member of a team that provides care for patients with diabetes. Your role is to help your patients better manage their diabetes by encouraging them to: –Eat a proper diet –Exercise –Take good care of their feet, skin, and personal hygiene –Report any potential problems to nursing staff 2

3. US.NMH.15.01.105 What Is Diabetes? Diabetes refers to a disease that affects how your body utilizes food for energy. 1 When you eat certain foods, your body converts them into a type of blood sugar called glucose. Glucose is used to satisfy your body’s daily energy needs. Blood glucose levels have to be maintained at a narrow range. To regulate this process, the pancreas secretes insulin and glucagon. 2 –When blood glucose levels increase, insulin is secreted which moves the blood glucose into tissues to be used as energy. –When blood glucose levels fall, glucagon is secreted and induces tissues (primarily the liver) to release stored glucose into the blood. 1. Diseases and conditions: Diabetes. Mayo Clinic web site. http://www.mayoclinic.org/diseases-conditions/diabetes/basics/definition/con-20033091. Accessed February 23, 2015.http://www.mayoclinic.org/diseases-conditions/diabetes/basics/definition/con-20033091 2. Norman J. Normal regulation of blood glucose. The important roles of insulin and glucagon: Diabetes and hypoglycemia. Endocrineweb website. http://www.endocrineweb.com/conditions/diabetes/normal-regulation-blood-glucose. Accessed February 23, 2015.http://www.endocrineweb.com/conditions/diabetes/normal-regulation-blood-glucose 3

4. US.NMH.15.01.105 The 2 Types of Diabetes Type 1 diabetes – A patient’s body makes little or no insulin. Without insulin, glucose cannot be moved into tissue and daily energy requirements cannot be met. 1 Type 2 diabetes – A patient’s body develops “insulin resistance” and cannot fully utilize the insulin it makes. Over time the pancreas loses its ability to create insulin, compounding the problem. 1 In both situations, blood glucose builds up in the patient’s body and can lead to serious health problems and premature death. 1 4 1.About diabetes. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/Diabetes/AboutDiabetes/About-Diabetes_UCM_002032_Article.jsp#.TxCcHr_hnfY. Accessed February 23, 2015.http://www.heart.org/HEARTORG/Conditions/Diabetes/AboutDiabetes/About-Diabetes_UCM_002032_Article.jsp#.TxCcHr_hnfY

5. US.NMH.15.01.105 The Importance of Controlling Blood Sugar It is important for patients with diabetes to get their blood sugar under control and keep it that way to reduce the risk of further damage to their bodies. There are a variety of things that can raise or lower glucose levels 1 : –Excess carbohydrates, sedentary lifestyle, dehydration, hormonal fluctuations due to illness, stress and/or pain, and menstrual cycles may all cause glucose levels to rise. –Not enough carbohydrates, too much exercise, alcohol, and side effects from some medications may cause glucose levels to fall. –Diabetes medicine (oral or insulin) lowers glucose levels. 1.Factors affecting blood glucose. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/factors-affecting-blood-glucose.html. Accessed February 23, 2015. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/factors-affecting-blood-glucose.html 5

6. US.NMH.15.01.105 How Blood Sugar Is Managed 1. Blood sugar monitoring Finger stick test –Done 1 or more times a day –Shows what blood sugar level is at any given time 1 Blood sugar goals for people who have diabetes 2 2. A1C test 1 –Draw blood and have it sent to a NGSP certified lab –Done at least 2 times a year –Shows average blood sugar level over the past 2 to 3 months –Goal for most patients is <7%. For some seniors, or patients with comorbidities, or other identified risk factors, more or less stringent glycemic goals may be appropriate for individual patients (eg, <8% might be considered for some seniors or patients with comorbidities) 2 Before meals80 to 130 mg/dL (milligrams per deciliter) 1 to 2 hours after the start of a mealLess than 180 mg/dL 6 1.Factors affecting blood glucose. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/factors-affecting-blood-glucose.html. Accessed February 23, 2015.http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/factors-affecting-blood-glucose.html 2.American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015; 38(suppl 1) S1-S94

7. US.NMH.15.01.105 7 Guidelines for Eating With Diabetes It is important to understand what people with diabetes can and cannot eat. Here are some guidelines. People with diabetes can 1 : –Eat small amounts of sugar as part of a healthy meal plan –Have fruit, as long as the carbohydrates are accounted for –Eat a healthy diet—low in fat; moderate in salt and sugar; meals with whole grains, vegetables, and fruit –Enjoy all carbohydrates (breads, pasta, fruit, cereals, and grains) Important: The key to a healthy diet is eating well-balanced meals with controlled portions. 1.Diabetes Myths. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/myths/. Accessed February 23, 2015.http://www.diabetes.org/diabetes-basics/myths/

8. US.NMH.15.01.105 How to Help Your Patients With Eating Discuss with patients what they like or don’t like to eat and recommend healthy alternatives 2 If possible, have a registered dietitian design a well-balanced meal plan 1,2 Offer practical tools for day-to-day meal planning such as “Choose My Plate”. 1-3 Remind patients of the importance of eating similar-sized portions and carbohydrate amounts with their meals and/or snacks every day 1,2 1.Nettles A, Reger L. Diabetes management in long-term care facilities: A practical guide. Diabetes CareWorks. http://ltcdiabetesguide.org/wp-content/uploads/2014/03/LTCguide6thEdition1.pdf. Accessed February 23, 2015.http://ltcdiabetesguide.org/wp-content/uploads/2014/03/LTCguide6thEdition1.pdf 2.American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015; 38(suppl 1) S1-S94. 3.Living Healthy with Diabetes: Your easy-to-use guide for living healthy with diabetes. American Diabetes Association website. http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living- healthy-with-diabetes-guide.pdf. Updated September 27, 2013. Accessed February 23, 2015.http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living- healthy-with-diabetes-guide.pdf 8

9. US.NMH.15.01.105 Benefits of Exercise for Patients With Diabetes The potential benefits include: –Boosting energy levels and relieving stress 1 –Weight control 1,2 –Improving strength, balance, and flexibility 1 –Controlling blood sugar 1,3 While exercise can help lower blood glucose, be sure your patients measure their glucose levels 30 minutes prior to exercise and every 30 minutes during exercising. If their glucose levels are lower than 100 mg/dL, a small carbohydrate snack will help raise it to safe levels. 1,3 9 1.Living Healthy with Diabetes: Your easy-to-use guide for living healthy with diabetes. American Diabetes Association website. http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living- healthy-with-diabetes-guide.pdf. Updated September 27, 2013. Accessed February 23, 2015.http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living- healthy-with-diabetes-guide.pdf 2.American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015; 38(suppl 1) S1-S94 3.Diabetes and exercise: When to monitor your blood sugar. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-and-exercise/art-20045697. Accessed February 24, 2015.http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-and-exercise/art-20045697 B

10. US.NMH.15.01.105 1.Living Healthy with Diabetes: a guide for adults 55 and up. American Diabetes Association website. http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living-healthy-with-diabetes-guide.pdf. Updated September 27, 2013. Accessed February 23, 2015.http://main.diabetes.org/dorg/PDFs/living-with-diabetes/living-healthy-with-diabetes-guide.pdf 2.Stretching and Balance Exercises. American Diabetes Association website. http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/stretching-and-balance-exercises.html. Accessed February 26, 2015.http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/stretching-and-balance-exercises.html 3.What We Recommend. American Diabetes Association website. http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/what-we-recommend.html. Accessed February 26, 2015.http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/what-we-recommend.html How Patients With Diabetes Can Exercise Walking Strength or resistance activities Swimming Lifting light weights Taking the stairs or step exercises Stretching Flexibility exercises Important: Patients should never exercise without the prior approval of a health care provider. 10

11. US.NMH.15.01.105 Be Aware of Hypoglycemia (Low Blood Sugar) Low blood sugar occurs when a patient’s blood sugar level drops too low to provide enough energy for the body’s activities. Low blood sugar is most often caused by 1 : –Taking your insulin or diabetes medication at the wrong time or taking too much –Meals or snacks that are too small, delayed, or skipped –Increased activity or exercise –Excessive drinking of alcohol Hypoglycemia can occur without symptoms and can be difficult to recognize in patients, so be sure to regularly check blood sugar levels. 1.National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed February 25, 2015.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. 11

12. US.NMH.15.01.105 Symptoms of Hypoglycemia 1 1. National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed February 25, 2015.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia Hunger Nervousness Dizziness Shakiness Drowsiness Feeling anxious Weakness Confusion Sweating What to Do for Hypoglycemia If you suspect a patient has low blood sugar, notify the health care team right away. 12

13. US.NMH.15.01.105 1.American Diabetes Association. Hyperglycemia. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html. Accessed February 25, 2015.http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html Be Aware of Hyperglycemia (High Blood Sugar) High blood sugar occurs when a patient’s body has too little insulin or when the body can’t use insulin properly. 1 Causes 1 : –Type 1 – patient may not have received enough insulin –Type 2 – patient may not have an adequate level of medication –Too much food –Too little exercise –Stress of an illness, such as a cold or flu 13

14. US.NMH.15.01.105 Symptoms of Hyperglycemia The signs of hyperglycemia are often difficult to detect but include: Blurred vision 1 Frequent hunger 1 Increased thirst 1 Frequent need to urinate 1 Fatigue 1 Weight loss 1 Headaches 1 What to Do for Hyperglycemia If you suspect a patient has high blood sugar, contact a nurse right away. 1. Hyperglycemia in diabetes. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795. Accessed Accessed February 26, 2015.http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795 14

15. US.NMH.15.01.105 Medication for Type 1 Diabetes – Insulin There are several ways your patients may take insulin 1 : By injection –Using a vial and syringe or an insulin pen New delivery methods –Including injectors, pumps, etc 1.National Diabetes Information Clearinghouse. What I need to know about diabetes medicines. http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez. Accessed February 25, 2015.http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez 15

16. US.NMH.15.01.105 Medication for Type 2 Diabetes People with type 2 diabetes may take medication in the following ways 1 : Pills Insulin 1.National Diabetes Information Clearinghouse. What I need to know about diabetes medicines. http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez. Accessed February 25, 2015.http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez 16

17. US.NMH.15.01.105 Have Your Patients Protect Their Skin 1 Remind patients to keep their skin clean and dry Use moisturizing soaps when bathing patients Moisturize skin to prevent chapping, especially in cold or windy weather Treat cuts right away Important: Make sure your patients have cuts, burns, or infections treated right away. 1. Skin Care. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/skin-care.html. Accessed February 26, 2015.http://www.diabetes.org/living-with-diabetes/complications/skin-care.html 17

18. US.NMH.15.01.105 Protect Your Patients’ Feet 1 Check your patients’ feet every day Make sure your patients’ shoes fit well and protect their feet Wash your patients’ feet regularly Rub lotion over the tops and bottoms of your patients’ feet but not between their toes Trim patients’ toenails when needed Protect from hot and cold. Don’t use hot water bottles, heating pads, or electric blankets on their feet Encourage patients to elevate their feet when sitting Important: Tell a nurse immediately if you notice that a patient has pain or less sensitivity in their feet, and/or if they have cuts, blisters, corns, ingrown toenails, color or shape changes, or calluses. 1 18 1.Foot care. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html. Accessed February 26, 2015.http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html

19. US.NMH.15.01.105 You Play an Important Role in the Health of Your Patients With Diabetes Remind your patients about: Nutrition Know-How Exercising appropriately Recognizing the warning signs of low blood sugar and high blood sugar Knowledge of their medication needs Care of their skin and feet 19 Knowledge of their medication needs

20. US.NMH.15.01.105 Thank you for your participation. Are there any questions? 20

21. 21 Self-Assessment Quiz Please print copies of the following slide and distribute to all attendees after the presentation. The quiz answers are provided on the last slide. © 2015 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.15.01.105.

22. 22 © 2015 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.15.01.105

23. 23 © 2015 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.15.01.105