Posts Tagged ‘type 1 diabetes’

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Youth with T1 Diabetes Not Meeting A1c Targets: What Can Nurses Do?

February 13, 2013

By Jeniece Trast, MA, RN, CDE, clinical research nurse manager, certified diabetes educator, Children’s Hospital at Montefiore, Montefiore Medical Center, Bronx, NY

bloodglucosetestingDiabetes Care recently published an article showing that our youth with type 1 diabetes, especially those in adolescence, are not meeting glycosylated hemoglobin (HbA1c) clinical guidelines. The HbA1c is a blood test done every two to three months that shows how well controlled the glucose levels were over that time period. As much as this news is disappointing, I am not shocked by it. Type 1 diabetes is a challenging disease to live with at any age; however, the adolescent years definitely intensify the challenge.

As a nurse and certified diabetes educator (CDE), I take on many roles when caring for a teenager with type 1 diabetes: educator, team member, moderator, blood glucose assessor, advocate, cheerleader, and even role model (yes, I have type 1 diabetes also).

Challenges and responsibilities. When caring for these patients, keep in mind that type 1 diabetes is a difficult disease to live with on a day-to-day basis. People with type 1 have lots of important responsibilities just to stay alive: multiple insulin administrations each day; constant blood glucose checking; understanding the effects of exercise on glucose level both during and after exercise; balancing exercise, stress, food, and insulin; providing sick day care; assessing for and treating hypoglycemia; troubleshooting when things go wrong; carrying supplies at all times; and worrying about the disease’s future possible complications—just to name of few!

Particular stresses for teens. These obligations require education, clinical and psychological support, and motivation. Nurses can play a vital role in all of that. Additionally, teenagers want to feel “normal,” puberty occurs, growth spurts happen, peer pressures influence them, erratic lifestyles dictate their lives, they long for independence, and many other potentially difficult situations occur during adolescence. All of this contributes to the fact that these teens are not achieving optimal control.

What can nurses do? There are many things we can do with our teenage patients to help them achieve both their goals and our goals. Read the rest of this entry ?

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Forward or Back? Some Personal Notes on Why the Affordable Care Act Matters

June 28, 2012

By Jacob Molyneux, senior editor/blog editor

So today the U.S. Supreme Court did something a little surprising in upholding the individual mandate provision in the Affordable Care Act (here’s the text of the full decision). It was the right thing to do, given judicial precedent, but it still comes as a surprise that Chief Justice Roberts was the swing vote rather than Kennedy, or that they actually did this. Justice Roberts must have looked to his conscience and seen how history would judge him. Or it’s nice to think so.

This is good for many reasons: those under 26 on their parents’ plans can now stay there. A bunch of money earmarked for nurse education will not suddenly disappear. Health care exchanges holding insurance companies to minimum standards will be implemented. Accountable care organizations can continue to experiment in an effort to replace the disastrously expensive fee-for-service model with one tied more closely to outcomes. And a great deal more.

But now we should ask ourselves: Do we go forward or back? This is the real question when it comes to the American health care system. Going back isn’t an option, though many are sure to go on pretending it is (the Republicans will make repealing the Affordable Care Act a centerpiece of their campaign promises, no doubt, a rallying cry against the Democrats). Ignoring reality is something humans are very good at, though it doesn’t always end well, if history is a guide.

And in truth it will take an increasingly powerful act of will to ignore the medical bankruptcies, medical tourism for affordable care to Mexico and further afield, the emergency rooms crowded with the uninsured seeking care for minor and major ailments, the yearly statistics that tell us our health care system is the most expensive per capita and yet has outcomes worse than those of many far poorer countries.

Still, some will surely rise to the occasion as they intone mantras about the free market’s ability to solve all problems for the good of all. Meanwhile the one percent who own an increasingly large percentage of the nation’s wealth will simply avert their eyes, able to afford the best surgeons, concierge care, home visits, brand name drugs.

This matters to me for personal (among other) reasons. At age 27 I left my job working with abused and neglected children and their caregivers and went to graduate school in North Carolina. Living on a tight budget, I opted out of the university’s health care coverage. That is, I chose not to purchase health care . . . it wasn’t mandated, and I didn’t need it.

That fall, as I immersed myself in following my creative dream, I found myself losing touch with reality. My clothes hung off me, I had a thirst that drove me nearly insane (at one point I sat in a bathtub all afternoon sucking on ice cubes just to stop myself from buying and guzzling random selections of liquids at the store—Yoo-hoo, of all things, and orange juice, and Guinness, seltzer, Coke, milk, chocolate milk, etc., etc.). I felt disoriented. One day I saw double as I drove my used pickup truck along the lush parkway. When I went out for a run I found myself barely able to complete a mile, let alone my usual five or six.

As must be clear by now, my immune system had decided to attack my own body, wiping out the insulin-producing cells in my body. It was nothing I did, nothing I could have averted. I was strong, young, healthy, fit. And now, after some blood tests, I learned I had type 1 diabetes and would need to be my own nurse for the rest of my life, checking my blood glucose level many times a day, injecting myself before meals and when the blood glucose level was too high. From then on in I’d need to be attentive to every permutation of exercise, diet, medication as I tried to achieve the “tight” glucose control that would keep me from losing limbs, sight, nerve endings, organs, and eventually my life.

But at the time, in the midst of the initial confusion and struggles, I had a very simple problem on top of all the others: how do I afford this meter to test my blood glucose level, the strips that cost almost a dollar each, the syringes, the two types of insulin, an endocrinologist to monitor the condition? I borrowed some money from an older relative and scraped by. I was lucky enough to have that option. I applied for free medications from a state program. Until I got on my feet a bit more, I spent a lot of time being anxious, broke, and a little scared, skimping on test strips when it was dangerous to do so, regretful that I had decided to go back to graduate school for something unlikely to make me wealthy.

Later still, working as an adjunct university lecturer and a freelance editor, I found what it’s like to be denied access to affordable coverage on the open market. That was upsetting, and it’s one of the things the ACA intends to remedy. Now I’m lucky to get insurance through my job, but the medications are still expensive. I now have two other autoimmune conditions that require medications and specialists. I’m fine, overall, high functioning, but much of my “extra” money is used for medications, tests, physician visits. Without being part of a group plan at work, I’d never be able to afford insurance and all of the medications I need. A full-time job at a large company is a requirement.

So I know why health care reform matters, even if the ACA doesn’t go nearly far enough to control costs, even if it still cedes too much power to the marketplace, to drug companies and insurance companies. Read the rest of this entry ?

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What Nurses Need to Know About Continuous Glucose Monitoring

March 30, 2010

Case 1. A 27-year-old man has had type 1 diabetes for 19 years. His hemoglobin AIc level prior to starting RT-CGM [real-time continuous glucose monitoring] was 9.4%. . . . Over the 15 months of RT-CGM use, he was able to decrease his hemoglobin AIc level to 7.7% and maintain it at that level for several months. After he stopped using RT-CGM because his insurance didn’t cover sensors, his hemoglobin AIc level rose to 8.5%. When he got a new job and was able to resume use of RT-CGM, after three months his hemoglobin AIc level had once again decreased, this time to 7.9%.

Case 2. A 10-year-old girl has had type 1 diabetes for almost three years. Her hemoglobin AIc level before starting RT-CGM was 9.8%. By five months after starting RT-CGM her hemoglobin AIc level had decreased to 7.2%. After discontinuing sensor use because of the high cost of RT-CGM supplies and a lack of insurance coverage, her hemoglobin AIc level rose to 8.2%.

The above are composite cases of patients with type 1 diabetes who used real-time continuous glucose monitoring devices as a tool to improve their blood sugar control. They’re from an article in the April issue of AJN that gives a balanced overview of this technology, including how it works, its current uses (as a diagnostic tool, a warning system for hypo- and hyperglycemia, and a way to improve long-term glycemic control), its coverage and costs—and its advantages and disadvantages, as described here:

The advantages of using a sensor include

* the availability of glucose values every few minutes.

* a possible reduction in the frequency of hypo- and hyperglycemia.

* tighter glycemic control and a possible decrease in long-term complications.

* a possible reduction in the frequency of finger-sticks.

The challenges to using a sensor are that

* it requires its own insertion site in the body, and the receiver must be within five to 10 feet of the transmitter, depending on the product, for glucose values to be detected.

* it often requires the patient to carry the receiver around, in addition to the other supplies. (Medtronic currently has a product on the market that’s both an insulin pump and CGM receiver in one unit, and Abbott’s CGM receiver also functions as a glucose meter. Other companies are also working on creating integrated products that deliver insulin and measure glucose values. Currently, two insertion sites, one for the insulin pump and one for the RT-CGM sensor electrode, are needed in the sensor-enhanced pump. Several companies are at work on combining insulin delivery and glucose measurement at a single injection site.)

* patients may need to actually do more frequent glucose testing.

* some patients will have difficulty understanding the difference between finger-stick glucose values and sensor values. There is a learning curve here

This technology is right for some, not so right for others. Nurses caring for people with diabetes will need to know more about it as it becomes more common.

Patients who decide to use RT-CGM devices may initially face frustration while getting used to the system, especially when adjusting to the differences that can occur in either direction between blood glucose and sensor values. Many will need encouragement from nurses. It’s nurses’ responsibility to give their patients the most updated information about the advantages and disadvantages of new tools that may help them better manage their diabetes.

We hope you’ll read the article, and let us know your experiences with continuous glucose monitoring, either as patients or nurses…or both.

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