Assessing the patient PowerPoint Presentation, PPT - DocSlides

Assessing the patient PowerPoint Presentation, PPT - DocSlides

2016-05-08 39K 39 0 0

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Exercise and Type 1 Diabetes. 2nd National . conference. NEC, 15 May 2015. What would you ask?. Age. Duration T1D. Other co-morbidities. Complications. Occupation/current activity level. Medication including insulin regime. ID: 311039

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Slide1

Assessing the patient

Exercise and Type 1 Diabetes

2nd National

conference

NEC, 15 May 2015

Slide2

What would you ask?

Age

Duration T1D

Other co-morbidities

Complications

Occupation/current activity level

Medication including insulin regime

Current approach to managing T1D (CHO counting,

f

requency of glucose testing)

Hypoglycaemia

frequency, and any associated with previous exercise

Hypo aware?

Smoking and alcohol

Planned activity

Slide3

What would you examine/test?

Weight/BMI

HR

BP

Fundoscopy

/retinal screening results

PVD – foot pulses

Neuropathy

Foot ulceration

Urinary ACR / serum

creatinine

HbA1C

(TFT)

(Coeliac screen)

Slide4

1) 29yr old accountant. Diagnosed 3yrs.

Little exercise to date.

Humulin

M3

bd

insulin regime. Abdominal

lipohypertrophy

. No complications. No troubling

hypoglycaemia

. Wants to start cycling at weekends

2) 42yr old shop assistant. Diagnosed 37yrs.

Previous long history of poor control. HbA1c now 73mmol/mol. Had retinopathy previously requiring laser.

Microalbuminurea

. Basal bolus insulin regime. Wants to run the 5K

3) 36yr

old

businessman.

Diagnosed

15yrs

.

Moderate control

. HbA1c now 67mmol/mol.

Basal

bolus insulin regime.

Has recently taken up squash in evenings. Troubled by night hypos following squash.

Slide5

29yr old accountant. Diagnosed 3yrs.Little exercise to date. Humulin M3 bd insulin regime. Abdominal lipohypertrophy. No complications. No troubling hypoglycaemia. Wants to start cycling at weekends

Would you change the insulin regime at outset? If so, to what and why?

Where should she inject and with what needle length?

Do absorption rates differ according to site of injection and if so, how?

What is the recommended technique for insulin injection?

Slide6

Slide7

29yr old accountant. Diagnosed 3yrs.Little exercise to date. Humulin M3 bd insulin regime. Abdominal lipohypertrophy. No complications. No troubling hypoglycaemia. Wants to start cycling at weekends

Would you change the insulin regime at outset? If so, to what and why?

Where should she inject and with what needle length?

Do absorption rates differ according to site of injection and if so, how?

What is the recommended technique for insulin injection?

Slide8

Absorbtion rates

Human insulin

NPH: thighs and buttock because absorption slowest

Soluble: abdomen because absorption fastest

Premixed insulin (human or analogue)

Abdomen in the morning because faster absorption covers breakfast

Thighs/buttocks in evening because slower absorption protects from nocturnal

hypoglycaemia

Analogue

insulins

Site does not affect absorption rates

Massaging site not

recomended

Slide9

29yr old accountant. Diagnosed 3yrs.Little exercise to date. Humulin M3 bd insulin regime. Abdominal lipohypertrophy. No complications. No troubling hypoglycaemia. Wants to start cycling at weekends

Would you change the insulin regime at outset? If so, to what and why?

Where should she inject and with what needle length?

Do absorption rates differ according to site of injection and if so, how?

What is the recommended technique for insulin injection?

Slide10

Insulin injection technique

Resuspend cloudy (NPH and pre-mixed) insulins – how?Disinfection required?Prime needle – how?Single use needleInject through clothing?Count to 10 after pushing in plunger

Slide11

42yr old shop assistant. Diagnosed 37yrs.Previous long history of poor control. HbA1c now 73mmol/mol. Had retinopathy previously requiring laser. Microalbuminurea. Basal bolus insulin regime. Wants to run the 5K

Should he run the 5K?

What advice would you give him if he insisted on participating?

What exercise advice would you give him if he had no complications but wanted to run the marathon?

What exercise advice would you give someone with

Neuropathy

A

utonomic neuropathy

Prevous

MI

Slide12

ADA position statement 2015

Vigorous

or

resistance

exercises may be CI in patients with

proliferative

retinopathy or

severe non-proliferative

retinopathy due to risk of

haemorrhage

or detachment

No evidence that vigorous exercise increases rate of progression of diabetic kidney disease (though watch out for any associated IHD).

Slide13

42yr old shop assistant. Diagnosed 37yrs.Previous long history of poor control. HbA1c now 73mmol/mol. Had retinopathy previously requiring laser. Microalbuminurea. Basal bolus insulin regime. Wants to run the 5K

Should he run the 5K?

What advice would you give him if he insisted on participating?

What exercise advice would you give him if he had no complications but wanted to run the marathon?

What exercise advice would you give someone with

Neuropathy

A

utonomic neuropathy

Prevous

MI

Slide14

Criteria for Recommending Graded Exercise Stress Testing

Age >40

years

with or without cardiovascular disease risk factors other than diabetes

Age >30 years and

:

Type 1 or 2 diabetes of >10 years' duration

Hypertension

Cigarette smoking

Dyslipidemia

Proliferative or

preproliferative

retinopathy

Nephropathy, including

microalbuminuria

Any of the following, regardless of

age

Known or suspected coronary artery disease, cerebrovascular disease, and/or peripheral vascular disease

Autonomic neuropathy

Advanced nephropathy with renal failure

Slide15

42yr old shop assistant. Diagnosed 37yrs.Previous long history of poor control. HbA1c now 73mmol/mol. Had retinopathy previously requiring laser. Microalbuminurea. Basal bolus insulin regime. Wants to run the 5K

Should he run the 5K?

What advice would you give him if he insisted on participating?

What exercise advice would you give him if he had no complications but wanted to run the marathon?

What exercise advice would you give someone with

Neuropathy

A

utonomic neuropathy

Prevous

MI

Slide16

ADA position statement 2015

Peripheral neuropathy.

Risk of skin breakdown, infection,

Charcoat

joint destruction

Daily foot review, good footwear

Non weight bearing exercise if injury/ulcer

Autonomic neuropathy.

Hypo unawareness, impaired thermo regulation, postural hypotension,

HR monitors of exercise intensity unreliable

Higher risk of cardiovascular death - exercise test before increasing physical activity

Slide17

36yr old businessman. Diagnosed 15yrs.Moderate control. HbA1c now 67mmol/mol. Basal bolus insulin regime. Has recently taken up squash in evenings. Troubled by night hypos following squash.

What further information would you need to provide useful advice?

Consider the different scenarios and how you would address them (I will role play during discussion)

Slide18

36yr old businessman. Diagnosed 15yrs.Moderate control. HbA1c now 67mmol/mol. Basal bolus insulin regime. Has recently taken up squash in evenings. Troubled by night hypos following squash.

How does he currently manage his diabetes for exercise? How much CHO does he take?

Does he eat before or after the squash game?

If he eats after sport, does he take his normal or reduced insulin?

Is he troubled by hyper glycaemia after

squashand

if so how does he treat it?

How is he detecting the nocturnal hypo’s? Are these severe or does he wake up?

Slide19

Slide20

Slide21

Slide22

Slide23


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