Monitoring Glucose Levels and Ketones PDF

11/20/23, 5:27 PM Realizeit for Student Monitoring Glucose Levels and Ketones Blood glucose monitoring is a cornerstone of diabetes management, and selfmonitoring of blood glucose (SMBG) levels have dramatically altered diabetes care. SMBG is a method of capillary blood glucose testing in which th...

11/20/23, 5:27 PM Realizeit for Student Monitoring Glucose Levels and Ketones Blood glucose monitoring is a cornerstone of diabetes management, and selfmonitoring of blood glucose (SMBG) levels have dramatically altered diabetes care. SMBG is a method of capillary blood glucose testing in which the patient pricks their finger and applies a drop of blood to a test strip that is read by a meter. It is recommended that SMBG occurs when circumstances call for it (e.g., before meals, snacks, exercise) for many patients taking insulin (ADA, 2020). Self-Monitoring of Blood Glucose Using SMBG and learning how to respond to the results enable people with diabetes to individualize their treatment regimen to obtain optimal blood glucose control. This allows for detection and prevention of hypoglycemia and hyperglycemia and plays a crucial role in normalizing blood glucose levels, which in turn may reduce the risk of long-term diabetic complications. Various methods for SMBG are available. Most involve obtaining a drop of blood from the fingertip, applying the blood to a special reagent strip, and allowing the blood to stay on the strip for the amount of time specified by the manufacturer (usually 5 to 30 seconds). The meter gives a digital readout of the blood glucose value. The meters available for SMBG offer various features and benefits such as monthly averages, tracking of events such as exercise and food consumption, and downloading capacity. Most meters are biosensors that can use blood obtained from alternative test sites, such as the forearm. There is a special lancing device that is useful for patients who have painful fingertips or experience pain with fingersticks. Because laboratory methods measure plasma glucose, most blood glucose monitors approved for patient use in the home and some test strips calibrate blood glucose readings to plasma values. Plasma glucose values are 10% to 15% higher than whole blood glucose values, and it is crucial for patients with diabetes to know whether their monitor and strips provide whole blood or plasma results. Methods for SMBG must match the skill level and physical capabilities of patients. Factors affecting SMBG performance include visual acuity, fine motor coordination, cognitive ability, comfort with technology and willingness to use it, and cost (Eliopoulos, 2018). Some meters can be used by patients with visual impairments; these meters have audio components to assist in performing the test and obtaining the result. In addition, meters are available to check both blood glucose and blood ketone levels by those who are particularly susceptible to DKA. Most insurance companies, and https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 1/5 11/20/23, 5:27 PM Realizeit for Student programs such as Medicare and Medicaid, cover some or all of the costs of meters and strips. All methods of SMBG carry the risk that patients may obtain and report erroneous blood glucose values as a result of incorrect techniques. Some common sources of error include improper application of blood (e.g., drop too small), damage to the reagent strips caused by heat or humidity, the use of outdated strips, and improper meter cleaning and maintenance. Nurses play an important role in providing initial education about SMBG techniques. Equally important is evaluating the techniques of patients who are experienced in selfmonitoring. Every 6 to 12 months, patients should conduct a comparison of their meter result with a simultaneous laboratory-measured blood glucose level in their provider’s office and have their technique observed. The accuracy of the meter and strips can also be assessed with control solutions specific to that meter whenever a new vial of strips is used and whenever the validity of the reading is in doubt. Candidates for Self-Monitoring of Blood Glucose SMBG is a useful tool for managing self-care for everyone with diabetes. It is a key component of treatment for any intensive insulin therapy regimen (i.e., 2 to 4 injections per day or the use of an insulin pump) and for diabetes management during pregnancy. It is also recommended for patients with the following conditions: Unstable diabetes (severe swings from very high to very low blood glucose levels within a 24-hour day) A tendency to develop severe ketosis or hypoglycemia Hypoglycemia without warning symptoms For patients not taking insulin, SMBG is helpful for monitoring the effectiveness of exercise, diet, and oral antidiabetic agents. For patients with type 2 diabetes, SMBG is recommended during periods of suspected hyperglycemia (e.g., illness) or hypoglycemia (e.g., unusual increased activity levels) and when the medication or dosage of medication is modified (ADA, 2020). Frequency of Self-Monitoring of Blood Glucose For most patients who require insulin, SMBG is recommended two to four times daily (usually before meals and at bedtime). For patients who take insulin before each meal, SMBG is required at least three times daily before meals to determine each dose (ADA, 2020). Those not receiving insulin may be instructed to assess their blood glucose levels at least two or three times per week, including a 2-hour postprandial test. For all https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 2/5 11/20/23, 5:27 PM Realizeit for Student patients, testing is recommended whenever hypoglycemia or hyperglycemia is suspected; with changes in medications, activity, or diet; and with stress or illness. Responding to Self-Monitoring of Blood Glucose Results Patients are asked to keep a record or logbook of blood glucose levels so that they can detect patterns. Testing is done at the peak action time of the medication to evaluate the need for dosage adjustments. To evaluate basal insulin and determine bolus insulin doses, testing is performed before meals. To determine the need for bolus doses of regular or rapid-acting insulin (lispro, aspart, or glulisine), testing is done 2 hours after meals. Patients with type 2 diabetes are encouraged to test daily before and 2 hours after the largest meal of the day until individualized blood glucose levels are reached. Thereafter, testing should be done periodically before and after meals. Patients who take insulin at bedtime or who use an insulin infusion pump should also test at 3 am once a week to document that the blood glucose level is not decreasing during the night. If the patient is unwilling or cannot afford to test frequently, then once or twice a day may be sufficient if the time of testing is varied (e.g., before breakfast one day, before lunch the next day). Patients are more likely to discontinue SMBG if they are not instructed how to use the results to alter the treatment regimen, if they receive no positive reinforcement, and if testing costs increase. At the very least, the patient should be given parameters for contacting the primary provider. Patients using intensive insulin therapy regimens may be instructed in the use of algorithms (rules or decision trees) for changing the insulin doses based on patterns of values greater or less than the target range and the amount of carbohydrate to be consumed. Baseline patterns should be established by SMBG for 1 to 2 weeks. Using a Continuous Glucose Monitoring System A continuous glucose monitoring (CGM) system is an advanced way that people living with diabetes can use to monitor blood glucose levels. A CGM can be used with or without an insulin pump (see Fig. 46-2A). A sensor attached to a transmitter is inserted subcutaneously in the abdomen or back of the arm and connected to a wireless monitoring device, where the glucose levels are displayed in real time (see Fig. 46-2B). Sensors are replaced every 7 to 14 days. The data from the CGM device are downloaded, and blood glucose readings are analyzed. The newest CGM is implantable and can be worn for 90 days (Kropff, Choudhary, Neupane, et al., 2017). Although the CGM cannot be used for making decisions about specific insulin doses, it can be used https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 3/5 11/20/23, 5:27 PM Realizeit for Student to determine whether treatment is adequate over a 24-hour period. This device is most useful in patients with type 1 diabetes (ADA, 2020). Testing for Glycated Hemoglobin Glycated hemoglobin (also referred to as glycosylated hemoglobin, HgbA1C, or A1C) is a measure of glucose control for the past 3 months (ADA, 2020). When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes. This complex (hemoglobin attached to the glucose) is permanent and lasts for the life of an individual red blood cell, approximately 120 days. If near-normal blood glucose levels are maintained, with only occasional increases, the overall value will not be greatly elevated. However, if the blood glucose values are consistently high, then the test result is also elevated. If the patient reports mostly normal SMBG results but the glycated hemoglobin is high, there may be errors in the methods used for glucose monitoring, errors in recording results, or frequent elevations in glucose levels at times during the day when the patient is not usually monitoring blood sugar levels. Normal values typically range from 4% to 6% and indicate consistently near-normal blood glucose concentrations. The target range for people with diabetes is less than 7% (53 mmol/mol) (ADA, 2020). Testing for Ketones Ketones (or ketone bodies) are by-products of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal that there is a deficiency of insulin and control of type 1 diabetes is deteriorating. When there is almost no effective insulin available, the body starts to break down stored fat for energy. The patient may use a urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple when ketones are present. (One of the ketone https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 4/5 11/20/23, 5:27 PM Realizeit for Student bodies is called acetone, and this term is frequently used interchangeably with the term ketones.) Other strips are available for measuring both urine glucose and ketones (KetoDiastix or Chemstrip uGK). Large amounts of ketones may depress the color response of the glucose test area, meters that text the blood for ketones are available. Urine ketone testing should be performed whenever patients with type 1 diabetes have glycosuria or persistently elevated blood glucose levels (more than 240 mg/dL or 13.2 mmol/L for two testing periods in a row) and during illness, in pregnancy with preexisting diabetes, and in gestational diabetes (ADA, 2020). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 5/5