diabetes management (presentation slides - ms powerpoint)

seeing beyond vision loss

Webinar 3: Diabetes Management and Vision Loss

Lynn Baughan RN, MN, CDEKathryn MacDonald, RD, CDE 19th November 2012

Welcome to CNIB’s InFocus Webinar Series


Participants will be able to:1.Identify the key components for diabetes

management.2.Describe techniques for teaching clients with vision

loss, blood glucose monitoring, medication and insulin administration, meal preparation and foot examination.

3.Identify resources for ongoing education and support for managing diabetes.

Learning Objectives


• Estimated number of people diagnosed with diabetes will increase to 4.4 million by 2020 if trends continue

Diabetes in Canada….

• Estimated cost for treatment of diabetes in 2010 is 11.7 billion dollars

• 2.7 million Canadians have diabetes

Reference: Canadian Diabetes Association (2010). Diabetes: Canada at the Tipping Point.


• Manage blood glucose, lipids and blood pressure

Management of Diabetes

Healthy Eating• A balance of…

Regular Physical ActivityMonitoringTaking Prescribed

MedicationsSelf Management and Coping Skills


Working as a team with the client at the centreInstead of “No” and “Can’t” it is “How”Connect with a Diabetes Care Team and other available

resourcesProvide self management support

Management of Diabetes


• Use large print materials • High contrast black on white, at least a 16 point bold

serif type (arial) and with lots of white space• Prefer to use 20 point arial font• Use a fine tip black felt marker (CNIB or Sharpie)

General Teaching Tips

• Use models (food, foot, meters)


Next Webinar

Webinar: Supporting your patients

www.cnib.ca/infocuswebinarseries

- Basic etiquette- How to navigate the patient- Communication and education

Practical tips and strategies on how to work with clients in a clinical setting:


Adaptive Diabetes Education

• Must be individualized• Matches techniques and equipment for the person• Provides choices• Must ensure safe, accurate performance of skills• Evaluates skills on a regular basis


Emphasis on high fibre

• Plenty of raw vegetables• Moderate amounts of whole fruits and whole grains

Healthy Eating and Diabetes Individualized approach to meal planningBalanced, regularly spaced meals, consistent

Weight management

• Portion Moderation

Sugar is OK in moderation as part of a balanced intake

Low fat and low sodium


CDA Nutrition Guide - Just The Basics


• Rehabilitation specialist:• Does an in-home assessment• Teaches skills for safe meal preparation• Teaches how to label items • Puts tactile labels on the stove or microwave

Meal Planning Tips

• Strive to maintain enjoyment in food preparation, eating and independence

• Use specific sized serving spoons and dishes to estimate portions


• Special products are available for meal preparation and cooking (i.e. extra long oven mitts, fluid level indicators, audible weigh scales etc.)

Meal Planning Tips

• Use modified visual aids


• www.balancefba.org• www.lowvisionchef.com

Working Safely In The Kitchen

Large print, braille, tactile and audible cuesBright colours and colour contrasts on cooking utensilsTechniques for spreading, measuring, pouring, and

choppingSafe food storageShopping for groceriesOrganizing the kitchen


Carry a fast acting glucose and identification

Physical Activity - Getting Started Safely

Medical check-up firstEyes, heart and feet checkedProper fitting foot wearCheck blood glucose before and afterPlan activity 1 to 11/2 hours after meals

• Work up to goal of 150 minutes per week total


• Potential Deterioration of Glycemic Control in Type 1: through counter regulatory hormone response when blood glucose is above 14 mmol/L and ketones are present

Side Effects of Increased Activity• Risk of Hypoglycemia: for people taking insulin and/or

some oral agents• Potential Aggravation of Complications: such as cardiac,

neuropathy in the feet and retinopathy


• Treat first if unable to test

Hypoglycemia = Low Blood Glucose • Blood glucose less than 4 mmol/L

• Signs and Symptoms:• Tremors• Palpitations• Sweaty• Headache• Mood changes• Irritable• Difficult thinking

• Test blood glucose if able to


• Assess possible causes for the low blood glucose to prevent recurrence.

Treatment of HypoglycemiaRule of 15• Treat with 15 gm glucose• 3 BD glucose tabs OR 4 dextrose tabs OR 175 ml orange

juice• Wait 15 minutes, recheck blood glucose• Repeat treatment until blood glucose is > 4 mmol./L• More than 1 hour to next usual meal or snack?• Give a 15 gm carbohydrate snack (e.g. 4-6 crackers with

cheese, ½ sandwich)


• Education focuses on maximizing use of all available senses

• Conduct assessment under conditions that maximize client’s vision

• Demonstrate various meters to determine best choice

for client• Options for those who cannot read display screen

Blood Glucose Monitoring


Options for Blood Glucose Monitoring


• Meters with large, bold numbers include:• Oracle• Accu-Chek Compact• One Touch Ultra• Ascenia Contour• Ascensia Breeze• Precision Xtra• BG Star

Products For Testing Blood Glucose

• Blood glucose monitors are available at pharmacies and medical supply companies• Prescription required for coverage under most health care plans


• Reinforce over time, until independent in skill

Teaching Tips

• Break skill down into small components• Keep all supplies in consistent location• Use divided container to store supplies• Encourage use of all available senses


Obtain Sample

•Land mark by placing thumb on 1st joint below finger tip

•Poke finger

•Gently pump 4 times


Apply the Sample

• Slowly move strip back and forth across the fingertip • Record results in large print log book or on recording device• Upload results to audio log book


Targets for Glycemic ControlTest Target Fasting Blood Glucose andBefore Meals

4.0 to 7.0 mmol/L

2 hours After Meals 5 to10 mmol/L (if A1C in target)5 to 8 mmol/L (if A1C not at target and can be achieved safely)

A1C Glycated Hemoglobin Less than or equal to 7%

Targets are individualized to the client’s risk factors (age, co-morbidities, duration of diabetes, risk of hypoglycemia etc.)

Reference: Adapted from Canadian Diabetes Association. (2008). Clinical Practice Guidelines for Prevention and Management of Diabetes 1n Canada.


• Memory aids

Oral Medication

• Assess current ability in safe administration of oral medications

• If difficulties encountered, consider:• Personal markings on container lids• Different shaped container for each type of pill• Blister pack prepared by pharmacy• Individual dosettes


• Preloaded syringes• Filled by community pharmacist

Options for Preparation of Insulin• Ensure safe accurate measurement

• Maximize vision with magnifiers:• Syringe (i.e. BD, Truhand, Insuleze etc.)• Pen dosage dial (i.e. Novolin)• Hand held with or without light source

• Disposable prefilled insulin pens


• Re-useable Insulin Pens• HumaPen® Luxura, HD, Memoir• Novolin ® Pen 4, Echo

• Disposable Insulin Pens• HumaMix ® 25 prefilled• Lantus ® Solostar

• Syringe Magnifiers

• Count-a-dose

Devices For Insulin Measurement


• Clearly label pens• Store supplies in a consistent area• Record instructions on a recorder• Confirm priming of needle by flushing on tactile

area of hand or arm• Carefully count audible clicks for dosage• Teach how to reset pen to zero

Tips For Teaching Insulin Pens


• Follow-ups to check equipment

Tips For Teaching Insulin Pens

• Frequent return demonstrations of skills• Method for recording amount remaining in insulin

cartridge, when to change cartridge and injection sites used

• Extra pen available


• Feel for changes such as breaks in the skin, blisters, corns, calluses, swollen areas

Adaptive Foot Care

• If touch is reliable, teach the client how to check the feet• Use the fingertips and thumb to check the feet each

day

• Examine the top and bottom of both feet including the surface of each toe


• Arrange for a sighted person to do regular foot checks

Foot Care

• Use the back of the hand to feel for temperature changes

• Advise client to see doctor immediately if: • A warm or unusually cold area is felt • Other changes such as skin breakdown are felt• A foul odour may indicate infection

• Suggest a foot care specialist to cut or file the nails


E Eye

Complication Prevention

A Hemaglobin A1C

B Blood Pressure

C Cholesterol

D Dental Check

F Foot Care


Move from story telling to problem solving

Successful Behavior Change

Gradual small stepsMatch strategies to stage of readiness to change

Use diabetes friendly approaches ie healthy eating not diet


Ask questions – shift the responsibility/decision making to the client

Helping Clients Change Behavior

Determine client’s key concerns and address them firstGather information and use itReview the data with the client

Support skills training and knowledge building


Inter-professional Team of Health Care Professionals•Diabetes Education Program•Centers for Complex Diabetes Care•Community Care Access Centres•Community Pharmacist•Eye Care Specialists•Foot Care SpecialistsPeer Support•Support Groups•Self Management Programs

Diabetes and Self Management Services


www.cnib.ca/dr

Eye Connect: Diabetic Retinopathy

- Diabetic retinopathy basics- Prevention- Diagnosis and treatment- Living with diabetic retinopathy- For Health Care Professionals- “Your Guide to Diabetic Retinopathy” Patient Guide


Production of materials has been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.

•CNIB Website: www.cnib.ca•Toll-free CNIB Helpline: 1-800-563-2642 •Email: [email protected]

CNIB Contacts & Resources


Helpful Links for Resources

• Canadian Diabetes Association www.diabetes.ca

• Stand Up To Diabetes www.ontario.ca/diabetes

• The Diabetes Care Community www.diabetescarecommunity.ca

• Eat Right Ontario www.eatrightontario.ca

• Dietitians of Canada www.dietitians.ca


• Lynn Baughan RN, MN, CDECentral West Diabetes Regional Coordination [email protected]: 905-494-6752

• Kathryn MacDonald RD, CDECentral West Diabetes Regional Coordination [email protected]

Presenters


1. Bernbaum, M. et. Al. (1985). “A model clinical program for patients with diabetes and vision impairment” .(1989). The Diabetes Educator, 15: 325-30.

2. Cleary, M. (1985). “Aiding the person who is visually impaired from diabetes”.The Diabetes Educator, Winter Ed.

3. CNIB website, retrieved July 26, 2012. http://www.cnib.ca/en/your-eyes/eye-conditions/eye-connect/DR/Pages/default.aspx

4. Haire-Joshu, D., (Ed.), Herman, W., & Greene, D. (1996). Management of diabetes mellitus perspectives of care across the life span. “Microvascualar complications of diabetes ”. P-239-46. Chapter 7.

5. Jones, H., (Ed.) & Opsteen, C. (2010) 2nd Ed. Building Competencies in Diabetes Education; Advancing Practice. Chapter 7. Management of Chronic Complications, p. 7-56-64.

6. Wagner, H., Pizzimenti, J., Daniel, K., Naushira, P., & Hardigan, P. (2008). “Eye on diabetes a multicultural patient education intervention ”. The Diabetes Educator, Vol. 34., (1), p. 84-89.

References

diabetes management (presentation slides - ms powerpoint)

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