Staged diabetes management a systematic approach - part 10 pps

392 APPENDIX Check all that apply 7 9. At which point are patients referred for diabetes education? Who provides diabetes education? CDE CHR NP/PA Pharm RD RN Newly Diagnosed type 1 Newly Diagnosed type 2 Type 1 Continuing Education Type 2 Continuing Education Impaired Glucose Tolerance Inpatient Gestational Diabetes At Onset of Complications Pre-conception Counseling Other SECTION FOUR: DIABETES EDUCATION SERVICES 1. Do you have a diabetes education curriculum in place in your facility? Yes No. 1. If yes, please describe or attach summary. 2. What diabetes patient education materials do you use?: ADA Drug Co IDC 1 IHS In House Ministry of Health Other Figure A.1 (continued) APPENDIX 393 SECTION FIVE: SYSTEM ASSESSMENT 1. Is there a diabetes committee or team? Yes No Chairperson: ______________________________________________________ Members: (by discipline and role) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Will this committee/team be responsible for the implementation of SDM? 2. How will you evaluate success of the SDM program? ______________________________________________________________ ______________________________________________________________ a) What process/outcome inidcators will you use? ______________________ b) How often will you measure outcomes? _____________________________ 3. Are you currently auditing diabetes care? No 8 Yes Yes No Figure A.1 (continued) 394 APPENDIX What strengths does your community bring to the diabetes program? ________________________________________________________________ ________________________________________________________________ Do you have the following processes to enhance your diabetes care in place? How will you involve/inform others of the SDM program, its content and implementation process 5. Medical staff and employees: __________________________________________ Health care professionals outside the facility: ______________________________ Patients and their families: _____________________________________ Community and/or community agencies: ____________________________ a. b. c. d. 6. 7. What barriers to improved diabetes care do you have, or expect to experience? ________________________________________________________________ 4. 9 Yes No Comments Diabetes Flowsheet on chart Case Reviews/Grand Rounds Diabetes Support Group(s) Patient Satisfaction Survey Rapid HbA 1c available at time of patient visit Foot Care Clinic Community Awareness Program Figure A.1 (continued) APPENDIX 395 8. What questions do you have to assist you with the Site Preparation or training for SDM? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Thank you for your assistance. 10 Figure A.1 (continued) 396 APPENDIX 1. Site Name ________________________________ 2. Abstraction Date:(mm/dd/yy) ________________________________ 3. Abstractor Name: _________________________________ 4. Abstractor Title: _________________________________ 5. Patient Gender: 1 ؍ Female 2 ؍ Male 6. Patient Date of Birth:(mm/dd/yy) ________________________________ 7. Pre-Diabetes: Type of glucose abnormality diagnosed 1 ؍ Impaired Glucose Tolerance 2 ؍ Impaired Fasting Glucose 3 ؍ Other 8. Diabetes Type: 0 ؍ Not documented 1 ؍ Type 1 Diabetes 2 ؍ Type 2 Diabetes 3 ؍ Gestational Diabetes 4 ؍ Prior Gestational Diabetes 5 ؍ Other 9. Year Diabetes Diagnosed: _________________________________ 10. Race: 1 ؍ Asian 2 ؍ American Indian/Alaska Native 3 ؍ Black/African-American 4 ؍ Native Hawaiian/ Other Pacific Islander 5 ؍ White 6 ؍ Other 7 ؍ Unknown 11. Ethnicity: Does patient self-identify as Spanish, Hispanic, or Latino? 1 ؍ No 2 ؍ Yes 12. Visit Date: (mm/dd/yy) _______________________________ 13. Blood Pressure Date: (mm/dd/yy) _______________________________ 14. Most Recent Blood Pressure Systolic _________________________________: 15. Most Recent Blood Pressure Diastolic _________________________________: 16. Most Recent HbA 1c Date:(mm/dd/yy) ________________________________ 17. Most Recent HbA 1c Value: _______________________________ 18. HbA 1c Lab Normal Range: ______________ 19. Total Serum Cholesterol Date: (mm/dd/yy) _______________________________ 20. Total Serum Cholesterol Value: ________________________________________________________________ 21. LDL Date: (mm/dd/yy) _______________________________ 22. LDL Value: _______________________________ SDM Patient Chart Audit Form Figure A.2 SDM patient chart audit form APPENDIX 397 23. HDL Date: (mm/dd/yy) _______________________________ 24. HDL Value: ________________________________ 25. Serum Triglyceride Value: (mm/dd/yy) _______________________________ 26. Serum Triglyceride Value: _________________________________ 27. Gross Protein Present: 0 ؍ Not documented 1 ؍ Yes, or previously diagnosed OR 28. Microalbumin Test Date (mm/dd/yy) ___________________________ OR 29. Urine Albumin Creatinine Ratio Date (mm/dd/yy) ________________________________ AND 30. Urine Albumin Creatinine Ratio (mg/g): ________________________________ 31. Self-Management Education: 0 ؍ Not documented 1 ؍ Yes 32. Nutritional Education: 0 ؍ Not documented 1 ؍ Yes 33. Self-Monitoring Blood Glucose: 0 ؍ Not documented 1 ؍ Yes 34. Foot Exam Date: (mm/dd/yy) _______________________________ 35. Tobacco Status Documented: 1 ؍ Not documented 3 ؍ Previous tobacco user 2 ؍ Yes, documented in chart 36. If smoker, was referral for Tobacco Cessation made?: 0 ؍ Not documented 1 ؍ Yes 37. Retinal Exam Date: (mm/dd/yy) _______________________________ 38. Metabolic syndrome: is patient diagnosed with any type of Metabolic Syndrome in addition to the above diabetes types? 1 ؍ No 2 ؍ Yes Figure A.2 (continued) 398 APPENDIX Set short- and long-term goals (weight control, exercise, food plan, medications, monitoring) Determine SMBG and HbA 1c targets Record current medications Address lifestyle changes such as activity level and smoking cessation Educate about preventive care (foot, eye, dental) Plan contraception and pregnancy with women of childbearing age Refer patient to registered dietitian for nutrition recommendations (exercise plan) and instruction Refer patient to diabetes educator for self-management training, BG and urine ketone monitoring and record-keeping instructions Plan follow-up schedule with patient Refer patient for special services as necessary Medical History Symptoms/laboratory tests at diagnosis Previous and current diabetes therapy and control (SMBG and HbA 1c ) Weight history/especially previous diets Nutrition and exercise pattern assessment Medications: assess those that may affect BG (b -blockers, steroids, thiazides) Growth and development in children and adolescents Acute or chronic complications including hypoglycemia/hyperglycemia; neuropathy; sexual dysfunction; retinopathy; nephropathy; foot problems; cardiovascular disease; gastrointestinal symptoms Prior or current infections including skin, dental, genitourinary History of other conditions, including endocrine and eating disorders Smoking and/or alcohol use Lifestyle, cultural, psychosocial, abuse, occupational, and economic issues Previous education about diabetes • • • • • • • • • • • • Physical Exam Determine body mass index (BMI ϭ weight/height 2 ϭ kg/m 2 ) BP (sitting and standing) Examinations: funduscopic; dental; thyroid; cardiovascular; abdominal; neuro/vascular; feet; insulin injection sites Growth and development in children (plot on growth charts) Sexual maturation in children • • • • • Laboratory Evaluation Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results or for meter quality assuarance Hemoglobin A 1c (HbA 1c ) Fasting lipid profile within 6 months of diagnosis Urinalysis (urine culture if sediment) Urine microalbumin (timed or random albumin/creatinine ratio) if dip stick negative for proteinuria; after 5 years of duration in postpubertal type 1; at diagnosis and then annually in type 2 Serum creatinine in adults; in children if proteinuria present Thyroid functions in all type 1, in type 2 when thyroid disease is suspected Other lab assessments as indicated by history (chem profile, CBC) EKG (adults) Management Plan • • • • • • • • • • • • • • • • • • • Figure A.3 Medical Visit/Initial DecisionPath APPENDIX 399 Follow-up Visit Every 1–2 months during adjust phase; every 3–4 months during maintain phase Interim History Note current stage (food plan, oral agent, etc., particularly self-adjustment of insulin/oral agent) Review current medications and illnesses Review SMBG and HbA 1c targets Discuss episodes of hypoglycemia/hyperglycemia (frequency, cause, severity, symptoms, treatment) Address presence of intercurrent illness/ketonuria Assess nutrition; exercise; lifestyle changes; psychosocial issues; complications Evaluate patient’s adherence issues Assess sexual activity beginning with puberty Birth control/pregnancy planning for women of childbearing age Review record book Assess frequency of monitoring; SMBG ranges; patterns of hypoglycemia/hyperglycemia; validate meter accuracy annually; response to exercise; illness If memory meter used, compare with record book or download into computer for analysis • • • • • • • • • • • • Physical Exam Determine body mass index (BMI ϭ weight/height 2 ϭ kg/m 2 ) BP (sitting and standing) Examinations: funduscopic; dental; thyroid; cardiac; abdominal; neuro/vascular; feet; injection sites for patients on insulin Growth and development in children (plot on growth charts) Sexual maturation in children Examine previous abnormal findings • • • • • • Laboratory Evaluation Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results or for meter quality assurance HbA 1c • • Management Plan Refer patient to diabetes educator and/or regisitered dietitian for review of self-management and/or medical nutrition therapy as indicated Consult with specialists as indicated (ophthalmologist, nephrologist, neurologist, podiatrist) Yearly Check-Up • • Complete eye examination with dilation by ophthalmologist: annually after 5 years duration in post-pubertal type 1; at diagnosis and then annually in type 2 Lipid profile: every 5 years if normal; annually if abnormal Albuminuria: each visit Urine microalbumin (time or random albumin/creatinine ratio) if dip stick negative for proteinuria: after 5 years duration in postpubertal type 1; at diagnosis and then annually in type 2 Thyroid: age Ͻ18 if growth problems, enlarged thyroid, or symptoms; age у18 if suspected problem s EKG: all adults Foot examination (pulses, nerves and inspection) • • • • • • • Figure A.4 Medical Visit/Follow-up DecisionPath 400 APPENDIX Weight (lb) Height 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 245 250 255 260 265 270 275 280 285 290 295 300 305 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16 26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16 27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23 38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24 39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 25 25 41 40 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 43 42 40 39 38 37 36 34 33 32 32 31 30 29 28 27 27 44 43 41 40 39 37 36 35 34 33 32 31 31 30 29 28 27 45 43 42 41 39 38 37 36 35 34 33 32 31 30 30 29 28 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29 47 45 44 43 41 40 39 38 36 35 34 33 33 32 31 30 29 48 46 45 43 42 41 40 38 37 36 35 34 33 32 31 31 30 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 50 48 47 45 44 42 41 40 39 38 37 36 35 34 33 32 31 51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32 52 50 48 47 45 44 43 42 40 39 38 37 36 35 34 33 32 53 51 49 48 46 45 44 42 41 40 39 38 36 36 35 34 33 54 52 50 49 47 46 44 43 42 41 39 38 37 36 35 34 33 55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34 56 54 52 50 49 47 46 45 43 42 41 40 39 38 37 36 35 57 55 53 51 50 48 47 45 44 43 42 40 39 38 37 36 35 58 56 54 52 51 49 48 46 45 44 42 41 40 39 38 37 36 59 57 55 53 51 50 48 47 46 44 43 42 41 40 39 37 37 60 58 56 54 52 51 49 48 46 45 44 43 41 40 39 38 37 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" Patients with BMI Ͼ 25 kg/m 2 have a higher risk of adverse effects on health BMI is defined as body weight (kg) divided by height squared (m 2 ) (BMIϭ kg/m 2 ) 1 meter ϭ 39.37 inches, 1 kilogram ϭ 2.2 pounds Figure A.5 BMI chart APPENDIX 401 Patient experiencing hypoglycemia BG Ͻ70 mg/dL (3.9 mmol/L) with symptoms Is patient unconscious or having a seizure? NO Is patient confused or combative, requiring assistance in treatment? Patient usually able to self-treat Eat 15 g carbohydrate SMBG, if possible, immediately following treatment If no response, repeat treatment and continue SMBG • • • Follow-up Assess cause and determine level of hypo- glycemia; identify individual symptoms; discuss preventive measures and review annually with patient and significant others Sypmtoms Mild: shaking; sweating; tachycardia; dizziness; hunger; blurred vision; irritability Moderate: confusion; tiredness; yawning; poor coordination; headache; double vision; combativeness Occurrence Most common in type 1 diabetes with variable glucose levels or on intensive treatment program In type 2 diabetes, hypoglycemia can occur with oral hypoglycemic agent, combination therapy, or insulin In gestational diabetes, hypoglycemia occurs rarely and generally only in those treated with insulin (lower threshold to Ͻ60 mg/dL [3.3 mmol/L]) • • • • • Treatment for Severe Hypoglycemia Subcutaneous or IM glucagon: ½ cc (0.5 mg) for age Ͻ5; 1 cc (1.0 mg) for age у5 If glucagon not available, call 911 for emergency assistance; health professionals may administer 50% D/W; 5–25 cc IV Follow-up Assess cause of hypoglycemia; make appropriate adjustments in treatment plan; report episode to clinician Treatment for Moderate Hypoglycemia Fruit juice or glucose gel (30 g) If patient refuses or is unable to swallow, administer subcutaneous or IM glucagon Treatment for Mild to Moderate Hypoglycemia (15 g carbohydrate) 3–4 glucose tablets 3 tsp honey ½ cup fruit juice 6 saltine crackers 1 slice bread 1 cup milk 15 g glucose gel ¾ cup regular soda pop • • • • • • • • If next meal or snack is more than 1 hour away, eat additional snack of 1 carbohydrate and 1 protein exchange: If patient is on a-glucosidase inhibitor, use glucose tabs or milk (not sucrose) to treat hypoglycemia NO YES YES Figure A.6 Hypoglycemia/Treatment DecisionPath [...]... type 2 diabetes risk, 83, 89, 169 aspart, 56, 57 gestational diabetes, 283 Staged Diabetes Management: A Systematic Approach (Revised Second Edition)  2006 Matrex ISBN: 0-4 7 0-8 6576-X R.S Mazze, E.S Strock, G.D Simonson and R.M Bergenstal 422 aspirin cardiovascular disease, 314 diabetic retinopathy, 336 pain management, 341 atherosclerotic disease dyslipidemia, 299 hyperinsulinemia, 123–124 athlete’s... nutrition therapy • Do not delay meals or snacks • Eat extra food or adjust insulin for planned exercise • Be aware of warning signs and treat promptly • Always carry food to treat hypoglycemia • Anticipate schedule changes • Always eat carbohydrates when consuming alcohol • Make sure friends, co-workers, teachers, and room-mates are aware of causes, symptoms and treatment • Have glucagon available for... Ancillary DecisionPaths, 13, 44–45 angiotensin II receptor blockers, 202, 299, 303, 305 annual comprehensive review, 420 anorexia, metformin, 52 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), 304 antioxidants, cardiovascular disease, 314 Appropriate Blood Pressure Control in Diabetes Trial, 329 Asian-Americans, type 2 diabetes, 80, 169 Asians gestational diabetes, ... Boys add for activity (23 kcal/lb very active, 18 kcal/lb normal, 16 kcal lb inactive); girls calculate as adult Children/Method 2 First year: 100 0 kcal Ages 1–3: add 40 kcal/inch Age Ͼ3: Boys 125 kcal ϫ age; girls 100 kcal ϫ age; add up to 20% kcal for activity Figure A. 11 Nutrition Education/Initial DecisionPath 407 APPENDIX Follow-up nutrition education indicated Obtain Referral Data • Type of diabetes. .. food plan? Assess patient’s ability to • identify problem areas • self-adjust goals and behaviors • take deliberate action to change behaviors • self-monitor behavior change actions NO Consider referral to diabetes educator or licensed psychologist for counseling YES Follow-Up Evaluate food plan goals at each visit Figure A. 20 Food Plan Adherence DecisionPath 416 APPENDIX Patient with medication adherence... (BMI), 103 , 400 children and adolescents, 159, 161, 162 breastfeeding, see lactation C-peptide, 92, 169 C-reactive protein, macrovascular disease, 296 calcium channel blockers, 202, 205, 303, 304, 306 call to action, 36 caloric requirement, 104 , 105 , 277 Calories, 106 candidiasis, 363 capsaicin creams, 341 carbarnazepine, 343 carbohydrate counting, 105 , 176, 246, 409 cardiovascular disease antioxidants,... 162 See also exercise/activity adherence assessment, 414–418 gestational diabetes, 289, 290 type 1 diabetes, 250–252 type 2 diabetes, 148–149 adhesive capsulitis, 362 Adjust DecisionPath, 12–15, 44 adjust phase, 7 adolescents, see children and adolescents advanced glycosylation end products (AGEs), diabetic neuropathy, 338 African-Americans acanthosis nigricans, 360 gestational diabetes, 257, 263 hypertension,... interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment Obtain Referral Data • Type of diabetes (diagnosis data) • Diabetes treatment regimen (medications, medical nutrition therapy) • Medical history (HTN, lipids, complications) • HbA1c/ketones/SMBG data • SMBG/HbA1c targets • Prescription for BG testing, if needed Diabetes Education Goals • SMBG/HbA1c in target • Achieve self -management. .. prevalence, 20 undertreatment, 34 diabetes care, changing perspective, 19–22 diabetes care system, current health care system, 28 diabetes care team, 17–18 Diabetes Control and Complications Trial (DCCT), 7, 19–21, 223, 320, 338 diabetes education, 403–405 type 1 diabetes, 228, 241–244 type 2 diabetes, 145–146 diabetes educator, 18 diabetes management current health care system, 28 improvement initiatives,... office every work-day morning for the next two weeks Re-set goals as necessary Is patient taking an active role in changing exercise behaviors? NO YES Is patient exercising adequately and consistently? NO Assess patient's ability to • identify problem areas • self-adjust goals and behaviors • take deliberate action to change behaviors • self-monitor behavior change actions Assist patient with problem . 2 Diabetes 3 ؍ Gestational Diabetes 4 ؍ Prior Gestational Diabetes 5 ؍ Other 9. Year Diabetes Diagnosed: _________________________________ 10. Race: 1 ؍ Asian 2 ؍ American Indian/Alaska Native 3. rewards for progress • • • • Figure A. 8 Diabetes Education/Initial DecisionPath 404 APPENDIX Follow-up diabetes education indicated Obtain Referral Data Type of diabetes (diagnosis data) Diabetes. signs and treat promptly Always carry food to treat hypoglycemia Anticipate schedule changes Always eat carbohydrates when consuming alcohol Make sure friends, co-workers, teachers, and room-mates