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Helps manage intercurrent illness. Allows for Pattern Management. Evaluates pre-meal and post-meal BG patterns. Coordinates amount and timing of food, activity and meds to reach target BGs. Identifies safe levels to operate equipment. (e.g. driving)
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Assists in achieving and maintaining glycemic goals. Provide immediate blood glucose results to detect, avoid and/or correct: Hyperglycemia. Hypoglycemia Hypoglycemia unawareness.
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In 2006, what percentage of adults with diabetes checked their blood glucose at least once a day?
A.
40% (rate for 1997) B. 63% C. 74% D. 86% (those treated with insulin)
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use
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A1C vs eAG
eAG (mg/dl) 126 140 154 169 183 197 212 226 240
A1c
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or providers office
eAG (Estimated Average Glucose) Linear relationship between A1c and average BG level allowing A1C to be reported in familiar units 28.7 X A1C 46.7
http://professional.diabetes.org/GlucoseCalculator.aspx
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99% lab accuracy Results in 5 minutes 5 uL blood sample (finger, heel, ear) National Glycohemoglobin Standardization program certified Reimbursable www.a1cnow.com
BG Meters
Sensor Meters
Measures
postprandial BG (> 180 mg/dl) over 1-2 wks Post meal hyperglycemia linked to CVD, retinopathy, other complications A1C misses up to 40% of those with near normal levels who are elevated post meal
electronic charge resulting from reaction of strip enzyme and glucose in the drop of blood. meters are plasma calibrated
Newer
Readings are 12% higher than whole blood calibrated meters (older ones)
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AACE2
< 110 mg/dl Within target range < 140 mg/dl Below target range Above target range
< 7%
< 6.5%
Brewer KW et al. Diabetes Care. 1998.
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American Diabetes Association (2010) Clinical Practice Recommendations American Association of Clinical Endocrinologists (2002)
Assessment of Client
Psychosocial concerns
Immediate results
Reduction of anxiety
Hypoglycemia unawareness
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Assessment of Client
Identify
Pain
Assessment of Client
Barriers
perception with finger poke. Elevated or fluctuating readings. Cost: insurance coverage Inconvenience, esp away from home. Dislike of record keeping.
span
Memory Manual
impairment
dexterity
Tremors Age
Assessment of Client
Assessment of Client
Older Adults
Less
Children
Small
markings on strips.
Talking
Provide written and picture reinforcement. Remember: both hyperglycemia and hypoglycemia impair learning and retention.
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Method
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Assessment of Client
Assessment of Client
Assessment of Client
Troubleshooting
Ensure
Meter Problems
Calibration/Coding
Maintenance Other
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Customer
Meter Limitations
Aug 09: FDA reported potential for falsely BG with use of glucose dehydrogenase pyrroloquinoline quinone (GDH-PQQ) test strips
Strips cant distinguish between glucose and other nonglucose sugars found in peritoneal diaylsis solution (Extraneal), certain immunoglobulins, abatacept (Orencia); tositumomab (Bexxar) or products containing maltose, galactose or xylose. Concern: potential for overtreatment with insulin and masking hypoglycemia Strips affected: Accu-Chek, FreeStyle, TRUEtest, . Cozmonitor, OmniPod
Oxygen Uric Acid Acetaminophen Ascorbic Acid Salicylates Maltose* Galactose* Xylose*
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No No No No No No No
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Meter Limitations
AccuChek Aviva Accu-Chek Compact Plus One Touch Ultra 2 Bayer Contour FreeStyle Lite/ Freedom Precision Xtra
Hematocrit Levels
hematocrit (from anemia, some cancers, CKD/dialysis) can give false high reading. hematocrit (from dehydration) will give false low reading. Each meter lists a range of hematocrits for which it is accurate.
Important
No ?? $9.25 $23-39
User Error
User Error
Contaminated Sample
Wash
hands in warm water. Hang hand at side and gently shake. Use appropriate lancet to yield adequate sample. Milk finger gently from base to tip. Best bleeders are thumb and ring finger
hands thoroughly, rinse well and dry completely. Alcohol use is not necessary
Testing Site
Finger
Inadequate sample
Application
of sample to strip.
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poke vs. alternate site testing. best for suspected hypoglycemia or rapid changes in BG, post meal or within 1 hour of rapid acting insulin Alternate sites (palm, forearm, thigh, upper arm) are affected by food, activity, stress, illness, meds
Finger:
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Test Strips
When to use:
Fasting or 2+ hours since last meal/snack 2+ hours since last insulin dose 2+ hours since any activity
Bayer
Storage
Avoid
If suspect a low reading Within 2 hours of eating After exercise During illness Before driving
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Coding/Calibration
Failure to calibrate meter Encourage client to get in habit of calibrating
meter with each new box/bottle of strips.
Improper Coding
An improperly coded meter can provide a BG reading that is off by up to 30% If meter correctly coded
Probability Probability
Code chip Check strip Enter code on box of strips into meter
of 2 unit insulin dosing error: 7.1% of 3 unit insulin dosing error: 0.49%
If meter is miscoded:
probably probably
of a 2 unit insulin dosing error: up to 50% of a 3 unit insulin dosing error: up to 22.3%
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Calibration
Maintenance
control solution with each new bottle of strips, if meter was dropped or whenever meter accuracy is questioned. strip viability, technique accuracy and correct functioning of meter.
Verifies
with water dampened Q-tip/cloth only. outer surface with gentle disinfectant. Dont use alcohol, cleaners with ammonia, glass cleaners or abrasive cleaners.
Clean
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Other
Frequency of SMBG
Factors Raising BG
Dehydration Hypoxia Anemia High
Factors Lowering BG
Hypotension Trauma/shock High High Low
Determined by how the data will be used monitoring during insulin adjust. Postprandial monitoring for glycemic effects of food portion Dependent on:
Medications Type
(low Hct)
pH
Mannitol Maltose
used
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of diabetes
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At target BG: at least 3 times daily Not at target: pre/post meal + occasional 2-3 am Additional times
always
At target BG (on insulin): at least 3 times daily At target BG (no insulin): at least once daily Not at target: pre/post meal + occasional 2-3 am Additional times
Anytime Before
check BG before administering insulin or changing insulin rates by pump suspected hypoglycemia
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suspected hypoglycemia
Anytime Before
driving
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driving
Insulin Resistance
Liver
BG contribute 70%
in middle of night
Dawn Phenomenon
Early
BG contribute 30%
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Between
3-8 am, body releases counterregulatory hormones that make insulin less effective
Type 2: Cause: cells resistant to insulin, liver producing too much sugar and/or pancreas not making enough insulin What Helps? Exercise, wt loss, meds
1st Phase: within 10 minutes after glucose reaches bloodstream 2nd Phase: sustained release (~30 minutes post meal); lasts several hours Type 2s often lose 1st phase insulin release early in the disease
Type 1: Cause: not enough basal insulin What Helps? May need to increase dose
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Monitoring Tips
Use words like blood sugar checks, readings or measurements test has pass-fail interpretation Refer to results as: in target range or out of target range avoid good or bad Never use results to judge but to change treatment plan. Always praise for doing SMBG.
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Problem solve with client any questionable data. Verify technique. How neat and tidy is the book? Is more than 1 type of ink used?
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LifeScan
microliter blood sample in 5 seconds Can flag pre and post meal readings 500 test memory Can download to computer
Results
LifeScan
OneTouch UltraLink
Uses
same One Touch test strips Wirelessly transmits BG reading to MiniMed Paradigm Insulin Pump Similar meter features as One Touch Ultra 2
No coding meters Upgrade of Flash and Freedom meters 0.3 microliter sample; 5 second testing 400 test memory
Precision Xtra
in one
No coding 0.6 microliter sample, 5 second test Can also test blood ketones (separate strip)
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Roche Diagnostics
Roche Diagnostics
AccuCheck Advantage
contained strips: 17 strip drum Automatic strip handling and coding 1.5 microliter sample; 5 second test 300 test memory Computer download capability
Must use code chip 4.0 microliter sample; 26 second test 480 test memory Computer download capability
Accu-Chek Aviva
Large readout Must use code chip 0.6 microliter sample; 5 second test 500 test memory Computer download capability
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Bayer Diagnostics
Bayer Diagnostics
Ascencia Breeze 2
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Ascencia Contour
The
strip autodisc No coding Large display 420 test memory 1.0 microliter sample 5 second test Computer download capability
first system to automatically correct for common variables that affect accuracy
Automatic Hematocrit
No
coding required microliter sample, 5 second test 480 test memory; computer download capability Flag pre and post meal readings 2 hour post meal test alarm
0.6
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WaveSense
(AgaMatrix)
KeyNote, Presto, Jazz
More
Stores 2000 readings Uses contour test strips Plugs directly into computer usb port
Flags pre/post meal Set up individual goals View personal trends Set up testing reminders/alarms
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accurate readings: corrects for common errors (hematocrit, altitude, temp, user error) 0.5 microliter sample; ~ 4 second test Computer download capability FREE logbook application on Apple iPhone Keynote: requires coding; strips ($17.95 for 50) Presto: no coding; 300 test memory; 14, 30 and 90 day averages; Meter ($20-25); strips (~$25 for 50) Jazz: for data management; 1865 test memory www.wavesense.info/
ReliOn (Wal-Mart); www.relion.com ` Ultima: 0.6 ul sample, results in 5 sec; 450 test memory; meter ($9); strips ($9 for 20, $20 for 50, $39 for 100) ` Micro: No coding; 0.3 ul sample; 50 test memory; meter ($12); strips ($21.94 for 50) Prodigy Pocket (Diagnostic Devices, Inc) www.prodigymeter.com No coding; small sample; results in 7 sec; 120 test memory free computer download at their website Meter ($15-20); strips ($20-25 for 50)
Works with AccuChek Advantage meter (code chip) 15 sec test; 480 test memory; Insulin vial label id ~$470-480 www.accu-chek.com
TRUE Track (Home Diagnostics) www.presitgesmartsystem.com No coding , 1.0 ul sample; 10 sec test Sold under Rite Aid, Walgreens 55 Meter + strips ($22.99 w/50 strips, $47.99 w/100 strips)
Audible no-coding meter with tactile features on buttons and earphone jack for privacy Approved by the National Federation of the Blind and the American Foundation for the Blind 0.6 microliters; 7 second test; 450 test memory $75-85 (meter, 10 strips, 10 lancets) Prodigy AutoCode: talking meter (English/Spanish) www.prodigymeter.com
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Advocate meters (Diabetic Supply of Suncoast) Talking meters with large display screen 0.7 microliters, 7 second test, 450 test memory www.dsosi.com Advocate Redi-Code No coding Advocate Duo Also checks blood pressure
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meters with large display screen microliters, 7 second test, 450 test memory www.foracare.com/usa
Fora V10: talking meter For a V12: No coding For a V20 and V22 Advanced talking functions
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Meter/Strip Combos
DIDGET
Disposable meter, 0.5 microliter sample, 4 second test 99 test memory; $10 for meter, $35 for 50 strips www.cvs.com
BG meter attached to the Nintendo DS and DS Lite Positively reinforces consistent BG testing habits by awarding points that kids can use to unlock new game levels and customize their gaming experience. Currently available at stores or online at CVS Pharmacy and Walgreens
Disposable meter with 50 strips; 1.0 microliter sample 10 second test; ~$30-35 www.presitgesmartsystem.com
Investigational device combining test strips, lancets and lancing devices in a convenient cartridge system No handling/disposing of supplies www.intuitymedical.com
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Skin Patches
Univ of Calgary: size of a deck of cards with 4 microneedles; penetrate skin to draw blood but not deep enough to hit a nerve; BG data sent to a wireless remote Sandia National Labs:
sensing car sound an alarm if BG starts to dip glucose monitor chip worn & wirelessly transmits readings to a microchip in dashboard
ElectroNeedles and Posts (micron sized electrodes or posts that painlessly measure proteins and macromolecules)
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color based on BG: purple (low), orange (good), yellow (high) www.draper.com
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solution with radioisotope (carbon 13) analyzer measures amount of exhaled carbon dioxide
GlucoPhone
& receive BG results in real time text alerts to any cell phone
with Verizon LG 5200 phone meter (results in < 10 seconds), 25 GlucoPack test strips, 25 lancets , 1 lancing device, 1 bottle control solution Test stips: $10 for 50
www.glucophone.com
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iPhone Applications
Manual input of BG data, carbs and insulin doses (creating an electronic logbook and reports) which can be shared with others
Diabetes
Log
UTS
Diabetes (www.utracksys.com)
WaveSense
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meter with iphone via wireless Bluetooth or a cable (no manual input) BG data; send readings & message to others a meal builder, insulin scheduler, BG graphs
Health Website
http://www.diabeteshealth.com/charts/
BG Meters comparison Continuous Glucose Monitoring comparison
Estimate Not
how much insulin is needed with meals (based on food intake) available yet
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Final Thoughts
Personalize each SMBG plan. Always praise client for any readings. Never use results to pass judgement. Dont expect perfect control.
Work