Nurse Protocol For

Division of Public Health

Nurse Protocols for Registered Professional Nurses

for 2008

NURSE PROTOCOL FOR

DIABETES MELLITUS

IN ADULTS

Diabetes 8.1

Division of Public Health

Nurse Protocols for Registered Professional Nurses

for 2008

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TABLE OF CONTENTS

DIABETES / 7
Diabetes Mellitus in Adults / 7.1
Appendix A: / Continuum of Care Visits / 7.13
AppendixB: / Summary of Recommendations / 7.15
Appendix C: / Oral Hypoglycemic Agent and Oral Agent Adjustment Guidelines / 7.17
Appendix D: / Oral Agents for Treatment of Type 2 Diabetes / 7.18
Appendix E: / FDA Approved Indications for Combination Therapy / 7.23
Appendix F: / Insulin Products Available in the United States / 7.24
Appendix G: / Insulin Adjustment Guidelines / 7.26
Appendix H: / Treatment Algorithm of Type 2 Diabetes / 7.28

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Division of Public Health

Nurse Protocols for Registered Professional Nurses

for 2008

NURSE PROTOCOL FOR

DIABETES MELLITUS IN ADULTS

DEFINITIONDiabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. Diabetes is characterized by fasting plasma glucose (FPG) 126 mg/dL or random plasma glucose 200 mg/dL (with testing on two separate days) accompanied by symptoms. Symptoms of diabetes mellitus are frequently due to the osmotic diuresis associated with hyperglycemia. Complications of diabetes may be acute and/or chronic. Acute complications include: hyperglycemia, hypoglycemia, diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic syndrome. The chronic complications of diabetes are most often the result of sustained hyperglycemia and include damage, dysfunction and failure of various organs, such as eyes, kidneys, nerves, heart and vascular system.

ETIOLOGYType 1 Diabetes Mellitus

1.Cause: inadequate or absolute lack of insulin production secondary to destruction of the pancreatic Beta cells. Individuals are dependent on exogenous insulin for survival. Type 1 comprises less than 10% of all cases of diabetes.

2.Contributing factors:

a.Autoimmune mediated response.

Idiopathic (No evidence of autoimmunity is present).

Type 2 Diabetes Mellitus

1.Cause: combination of insulin resistance and/or inadequate insulin production. Individuals may produce excessive amounts of insulin but they are unable to use it effectively. Insulin resistance places increasing demands on the pancreas, which eventually cannot compensate, resulting in a relative, and later an absolute, hypoinsulinemic state.

Risk factors:

Overweight - BMI 25 kg/m2 (see BMI chart in Nutrition Manual). BMI >22 for Asian Americans.
Waist circumference >102cm (40 inches) for men and >88cm (35 inches) for women.
Sedentary lifestyle.

d.Age 45 years old.

e.First degree relative with diabetes.

f.Race – African-American, Latino, Native American, Asian and Pacific Islander at greater risk.

History of large birth-weight babies - >9 pounds or history of diagnosed with gestational diabetes.
History of impaired glucose tolerance or fasting

glucose >100 mg/dL(>100 is impaired fasting glucose with 33% chance to develop diabetes in 6 years).

Hypertensive (blood pressure 140/90 mmHg).
Have HDL cholesterol level 35mg/dL and/or triglyceride level > 250mg/dL.

Pre-diabetes

1.Impaired glucose tolerance

2.Patients are asymptomatic but at high risk for developing cardiovascular disease and diabetes.

3.Impaired fasting glucose is 100-125 mg/dL.

4.Plasma glucose at 2 hour oral glucose tolerance test (75-gram) between 140-199 mg/dL.

SUBJECTIVE1.The client may be asymptomatic. Elevated glucose

levels are often found in routine lab work, during evaluations for surgery or work-up for other conditions.

There may or may notbe a family history or obvious risk factors.

Client history may or may not reveal the following:

Symptoms of hyperglycemia.
Unexplained weight loss or gain.
Previously diagnosed with “borderline diabetes,” gestational diabetes or impaired glucose tolerance.
Past or current symptoms of coronary heart disease, heart failure, cerebrovascular disease, peripheral vascular disease, renal disease, gout or sexual dysfunction.

The following should be investigated and documented in chart:

a.Current diabetesself-management routine, if previously diagnosed, to include:

1)Medications.

2)Diet and eating pattern.

3)Self-management training.

4)Self-monitoring of blood glucose (SMBG) pattern and results.

5)Duration of diabetes.

6)Frequency of usage and indications for OTC medications, prescriptions, and alternative medications, home remedies, nutritional supplements.

Exercise history.

c.Acute complications, emergency room visits and hospitalizations related to diabetes.

d.History of infections.

e.Family history of diabetes.

CHD risk factors.
History of target organ damage.
Psychosocial/economic factors.
Tobacco, alcohol and recreational drug use.
Female reproductive history: menstrual history, method of

contraception, pregnancies and outcomes.

k. Special test results related to the diagnosis of diabetes.

l.Prior HbA1c records.

m.Immunization history.

5.Clients may report sudden, or insidious, onset of one or more of the following symptoms related to diabetes:

a.Frequent urination, bladder dysfunction, impotence.

b.Extreme thirst.

c.Extreme hunger.

d.Weight loss despite normal or increased appetite.

e.Blurred vision.

f.Fatigue, weakness, lethargy.

Nausea/vomiting.
Slow-healing wounds.
Recurrent infections.
Burning, tingling or numbness in extremities.
Sleep apnea.

6.The following are signs and symptoms of complications or target organ damage:

a.Visual disturbances.

b.Chest pain.

Shortness of breath.
Edema.
Dizziness.
Headache.
Confusion or other neurologic symptoms (e.g., difficulty with speech or movement, facial or one-sided numbness).
Nausea and vomiting.

OBJECTIVE 1.Physical examination

Appearance

1)Type 1 = Thin, ill appearance, dehydrated, may have had significant weight loss.

2)Type 2 = Frequently overweight orobese.

b.Height, weight and BMI.

c. Routine assessment of blood pressure (standing and sitting or sitting and lying) to assess fordehydration and autonomic neuropathy. Blood pressure may be greater than 140/90 mmHg.

d.Extremities - assess client extremities for changes in color, deformity, injury, sensation, temperature changes, muscle strength and deep tendon reflexes (use a 128-Hz tuning fork and a monofilament). Shiny spots over tibial bones, loss of hair over lower legs and toes, ulcerations of feet/legs, carbuncles and ulcers, lipohypertrophy or lipoatrophy at insulin injection sites. Mouth - assess for gum problems, tooth decay and oral candidiasis.

e.Optic Fundi – Assess for retinopathy including: microaneurysm, retinal detachment, glaucoma, vitreous hemorrhage, neovascularization, decreased extraocular movement, narrowing, copper-wiring, or AV nicking.

Arterial Pulses – Palpate and auscultate pulses.

g.Neurologic - Perform a complete neurologic exam. Decreased or absent deep tendon reflexes, numbness or burning sensation or sensory loss may be present. Gastrointestinal neurologic manifestation presents a gastroparesis with nausea, vomiting and weight loss.

h.Neck - Palpate the thyroid for an enlarged thyroid. Assess for hoarseness and difficulty swallowing.

i.Skin - Inspect for sites of previous insulin injections, shiny spots over tibial bones, loss of hair over lower legs and toes, ulcerations of feet/legs, carbuncles and ulcers, lipohypertrophy or lipoatrophy at insulin injection sites. Early on in type 2 diabetes hyperinsulinemia may be evidenced by Acanthosis Nigricans around the neck, waist, inguinal and axillary skin folds (dark velvety hyperpigmentation).

j.Cardiovascular – Perform a cardiac exam. Orthostatic hypotension, hypertension, decreased capillary refill, absent pedal pulses, impaired circulation.

k. Abdomen - Perform abdominal exam. Palpate for an enlarged liver.

l.Inspect the hands for mobility and deformities.

2.Diagnostic laboratory findings (Non-Pregnant Adults)

Confirmed fasting plasma glucose level of

126 mg/dL on at least two different occasions (on subsequent days).

Confirmed random plasma glucose level of

200 mg/dL (with classic symptoms of diabetes), on two different occasions.

c.Two-hour oral glucose tolerance test (OGTT) of

>200 mg/dL.

NOTE: The OGTT is done only if diagnostic testing is indicated and client has a normal fasting plasma glucose level. This test is useful only if strict adherence is given to proper OGTT procedure using 75 grams of glucose, and is not recommended for routine clinical use.

ASSESSMENTDiabetes Mellitus (Type 1 or Type 2)

PLANDIAGNOSTIC AND FOLLOW-UP STUDIES

Inform the clientof the importance of abnormal results and follow-up and referrals. If a service is not available in the clinic, the client should be given resource/referral information that must be appropriately documented in the client’s record. The client’s follow-through on the recommendations should be documented at the next visit.

Glycosylated hemoglobin or HbA1c – Every six months for well controlled patients on diet therapy or oral medication. Every three months for patients on insulin, poorly controlled or when medications have been changed. Treatment goal is <7%.
Total cholesterol and lipid profile annually (every 3-6 months if abnormal or if client is taking lipid-lowering agents).
Serum creatinine, potassium, and sodium annually.
ECG annually (or as indicated).
Referral for dilated eye exam annually.
Annual microalbuminuria test.
24-hour urine collection for creatinine clearance annually (if indicated by positive urine protein).
TSH in all type 1 diabetic patients and as indicated in type 2.

Liver function studies (LFTs) if clients are on lipid-lowering drugs and/or metformin. If on plioglitazone or rosiglitazone, LFTs monthly for 8 months then periodically thereafter.

Complete foot exam (vascular, neurologic) initially and annually to identify high-risk feet (peripheral neuropathy with loss of protective sensation, evidence of increased pressure, bony deformity, peripheral vascular disease, history of ulceration or amputation, severe nail pathology). Foot inspection for dryness, corns, calluses and ulcers and inquire about pain, burning, tingling, and/or numbness at each visit.
Referral for dental exam annually.
Weight and calculation of BMI on each visit; height annually.
Referral to other specialties and services as needed.
Urine cultures as indicated. Urinalysis for ketones, protein and sediment.
Refer to Family Planning for women of reproductive age.

THERAPEUTIC

NON-PHARMACOLOGIC

For clients with newly-diagnosed Type 2 Diabetes, a random blood glucose <250 mg/dL OR a fasting blood glucose (FBG) <200 mg/dL, initiate/instruct in diet modification and increased physical activity for 4-8 weeks, and then evaluate client status. A recent position statement from the American Diabetes Association and European Diabetes Association recommends starting pharmacologic agents if the HbA1c is greater than 7%. In addition, if the client presents with three or more symptomsof hyperglycemia, or has signs of an infection, proceed directly to pharmacologic intervention.

Medical Nutrition Therapy goals are to: (See Client Education/Counseling Section)

a.Maintain near-normal glucose levels.

b. Attain and maintain desirable body weight.

c.Decrease fat/cholesterol intake, if needed to achieve optimal lipid levels. Fat percentage recommendation is dependent on desired lipid outcomes.

d.Promote meal pattern consistency.

e.Prevent and treat acute and chronic complications of diabetes.

Recommend increased physical activity as indicated to:

a.Promote weight and lipid control.

b.Individualize with consideration for existing medicalconditions such as cardiovascular disease, peripheral neuropathy, arthritis, age and diabetes medications, if any.

Reduce cardiovascular risk factors.
Decrease insulin resistance and increase metabolism.

Self-Monitoring of Blood Glucose (SMBG):

a.Assess effectiveness of meal plan, exercise and medication.

b. Determine frequency of SMBG. Consider type of diabetes andhypoglycemic agent. Assess client’s willingness, financial resources and level of diabetes control

c.Patients with Type 1 diabetes check 3 or more times a day.

d.Pregnant women taking insulin for gestational diabetes should check 3 or more times a day.

e.Patients with Type 2 diabetes who are being treated with insulin should check 2 or more times per day. However, it is recommended that they check as often as needed until they reach blood glucose targets. Once 50% of blood glucose values are within target blood glucose range, SMBG frequency can be modified to treatment (e.g., diet only, 2-3 times per week; oral medications, daily; insulin therapy 3-4 times per day).

f.Frequent monitoring is essential for those on intensive insulin therapy or pump therapy.

g. Individualized target blood glucose range based on treatment regimen and age. Recommended target: pre-meal glucose between 90-130 mg/dL, random glucose less than 180mg/dL. Occasionally a 2-hour post-prandial blood glucose may be useful in evaluating control (target <180mg/dL).

h.When medication, diet or medical treatment changes, increase frequency of SMBG until 50% or more of BG values are within target range.

i.Additional testing is needed during times of stress, especially infection/illness.

PHARMACOLOGIC

NOTE: Before initiating oral agents, assess alcohol intake, baseline liver functions and renal function.

Type 2 clients with persistently elevated blood glucose level (200 mg/dL random or >140 mg/dL fasting), or if HbA1c 7% after 8 weeks:

a.Initiate oral agents at the lowest starting doseto prevent or minimize side effects. Instruct on SMBG and the need of maintaining a glycemic record (see Appendix A).

NOTE: Consider initial insulin therapy for patients who are not adequately controlled by diet, who are symptomatic, or have ketonuria, ketonemia, or present with severe hyperglycemia (glucose greater than 350 mg/dL).

Be aware that insulins lispro (Humalog), aspart (Novolog) and glulisine (Apidra) are fast-acting insulins and should be taken 5-10 minutes before meals. Regular insulin shouldbe taken 30 minutes before meals. Insulin glargine (Lantus) should never be mixed with other insulins.

b.Oral agents for the treatment of type 2 diabetes - dosing may be increased every 1-2 weeks until maximum dose is reached or a second agent from a different class may be added as combination therapy. (See Appendix D.)

c.If blood glucose is controlled except for morning hyperglycemia, consider combination therapy of an oral agent with insulin. Add insulin at bedtime (0.1- 0.2 U/kg NPH or glargine) subcutaneously. Dose may be adjusted, up or down 2-4 units, every week based on fasting morning blood glucose levels and client’s target blood glucose range. (See Appendix E.)

d.If unable to achieve target blood glucose range on oral agent therapy or combination therapy, begin insulin therapy with two or more injections/day:

NOTE: See Appendix F for types of insulin by category.

Intermediate-acting + short-acting insulin

before breakfast

AND

Intermediate-acting + short-acting insulin before evening meal.

For initiation of therapy, the total daily dose of insulin units is calculated by multiplying 0.3U x kg (current weight).

a.m.p.m.

Distribution of total units2/31/3

Short/Intermediate ratio1:2 1:1

Insulin doses may be titrated weekly until blood glucose control is achieved (see Appendix G, Insulin Dose Adjustment Guidelines). Consider using 70/30 or 50/50 insulin for individuals unable to mix insulins.

e.Clients taking short-acting insulin must be instructed to take it prior to meals.

f.Instruct on signs, symptoms and treatment of hypoglycemia, SBGM and frequency, record-keeping, target blood glucose range and emergency contact in case of questions or problems.

2.Type 1 clients will likely already be taking insulin injections. Evaluate their existing insulin regimen and level of blood glucose control with target blood glucose range and, if indicated, consider insulin dose adjustment using Insulin Dose Adjustment Guidelines in Appendix G. If newly diagnosed, initiate insulin therapy with two injections/day with:

Short-acting + intermediate-acting before breakfast

AND

Short-acting + intermediate-acting before dinner

To calculate total daily dose of insulin units, multiply 0.3 unit x kg (current weight).

Morning Evening

Distribution of total units2/31/3

Short-acting/

intermediate-acting ratio1:21:1

Insulin dose may be titrated weekly until blood glucose control is achieved (see Appendix G, Insulin Dose Adjustment Guidelines.) Consider using 70/30 or 50/50 insulin for individuals unable to mix insulins.

CLIENT EDUCATION/COUNSELING

The client and/or family participation is key to successful management of diabetes and should be involved in decisions and goal-setting. Prioritize information to prevent overwhelming the client. Important factors in achieving blood glucose control are client education, behavior change, and consistent follow-up. If goals are not being met, the management plan needs to be revised and/or goals need to be reassessed.

The overall goals of education are: effective self-management skills, enhanced clinical outcomes, and optimal quality of life. Assessment should include the client’s educational needs, readiness to learn, and preferred learning style. While some aspects of diabetes self-management should be on an individual basis (one-on-one), group classes can address topics appropriate for most clients (e.g., dining out, reading labels, and physical activity) and allow clients to share and learn from others’ experiences and recognize that others face similar challenges.

1.Determine mutually agreed upon blood glucose, HbA1c and lipid goals.

2.Address lifestyle changes:

Nutrition

Use an individualizedapproach appropriate for the person’s lifestyle and diabetes management goals. No single approach has proven to be most effective. Refer all clients to the nutritionist for assessment and selection of an appropriate meal-planning approach. May use one of the following basic instruction tools:

1)“The First Step on Diabetes Meal Planning,” a basic pamphlet based on the Food Guide Pyramid.

2)“Healthy Food Choices,” a pamphlet with guidelines for healthy food choices, what to eat and timing of meals and snacks.

3)“Idaho Plate Method,” a poster focusing on portion control and appropriate food choices for meals and snacks.

b.Physical activity.

c.If smoker or tobacco user, refer to local cessation program and/or the Georgia Tobacco Quit Line, 1-877-270-STOP (7867).

d.Reduce/control weight - focus on reaching reasonable weight.

e.Control blood pressure <130/80 mmHg.

f.Reduce/control hyperlipidemia(LDL <100mg/dl).

g.Less than 2 alcohol containing beverages/day if male;

1 alcoholic beverage/day if female.

(One alcoholic beverage/day is defined as 12 oz beer, 5 oz wine, 1.5 oz distilled spirits. Each contains approximately 15 grams alcohol). Patients should be counseled that most mixers contain large amounts of sugar and/or fats and should be avoided.

3.Instruct on survival skills:

a.Insulin injection technique (if appropriate), proper preparation, insulin storage, timing of injections and site rotation.

b.Self-monitoring of blood glucose.

c.Causes, signs, symptoms, and appropriate corrective actions for hypoglycemia and hyperglycemia.

d.When to call health care provider and who to call in case of emergency.

e.Sick-day management.

4.Teach preventive care of feet, eyes and mouth/teeth.

5.Address long-term neurological, kidney, retinal and cardiac complications.