Transcript Carb Counting and Insulin Administration

Carb Counting and Insulin
Administration Module
Georgia Hospital Association
Diabetes Special Interest Group
1
Program Objectives
 Define
basal bolus insulin therapy
 Define
carbohydrate (CHO)
 Identify
the carb content of various
food groups
2
Program Objectives (cont.)
 Calculate
carb content by reading a food
label
 Calculate
the carb load in a sample meal
 Calculate
meal insulin dosage using
carb/insulin ratio
 Calculate
initial Total Daily Insulin (TDI)
3
BASAL BOLUS INSULIN THERAPY
 Calculate

initial Total Daily Insulin (TDI):
Adjust Pre-Admission TDI considering for
change in diet, stress, meds, etc.
OR

Calculate Weight (kg) x 0.5 units = TDI for
Type 2 (consider using 0.3 for renal impaired
or 0.4 for Type 1)
4
Next

Give 50% as Glargine or Detemir (This is the
BASAL insulin.)

Give 50% divided in thirds or 17% per meal as
rapid-acting insulin analog (This is the MEAL
BOLUS insulin to cover the carbs consumed at
the meals.)

Give in proportion to CHO consumed at meal if
patient is carb counting or give divided equally in
thirds for consistent carb meals.
5
Another way to calculate the
meal bolus insulin is to estimate
the carb to insulin ratio.
6
Calculating the Carb to Insulin Ratio
 If
previously on insulin, divide the total
daily dose of insulin into 600. This will
estimate the CHO ratio or how many
grams of CHO 1 unit of rapid acting insulin
will cover.
Example:
600/60 = 10
Therefore, 1 unit will cover about 10 grams
of CHO
7
Calculate the Correction Factor “CF”



If BG >140 mg/dL: (BG-100) / CF = units of rapid acting
insulin
(This is the Correction Bolus.)
If the Total Daily Insulin is known, then
CF = 1700 / Total Daily Insulin
OR
If the Total Daily Insulin is not known then
CF = 3000 / Wt (kg)
Do Not Use Correction (Sliding Scale) Insulin as the Only
Diabetes Management Tool
8
Insulin Administration Guidelines
 Test
capillary blood glucose before meals,
bedtime and when appropriate at 3 AM.
 If
BG is in target range at meal time give
the meal bolus within 15 minutes of the
start of the meal
 If
the BG is above target range at meal
time give the meal bolus plus the
correction bolus
9
Guidelines continued
 The
basal insulin is administered whether
the patient is eating or not.
 Corrections
are given whether the patient
is eating or not.
 The
meal bolus is held if the patient is not
eating or is adjusted based on the amount
of carb consumed at the meal.
10
Carbohydrate Counting
 Counting
just the carbohydrate in the food
eaten is one method for meal planning that
works well for many people with diabetes
 Carbohydrate
counting focuses the
attention on food choices that most affect
blood glucose levels
11
Fixed or Flexible Meal Plans
 The
carbohydrate at each meal or snack
may be consistent from day to day or
flexible, depending on the type of
carbohydrate counting meal plan used.
 Carbohydrate
affects blood glucose more
than any other nutrient.
12
Carbohydrate Facts
 One
of three major energy sources in
foods
 Most
common carbs are sugars and
starches (chains of sugar)
 Carbs
are primarily found in milk, fruit,
starch and starchy vegetables
 Carbs
are also in honey, molasses, syrup
and sugar
13
Food and Blood Glucose
VISUAL #2
Nutrients inNutrients
Food
in Food
Nutrient
Carbohydrate
Protein
Fat
Vitamins
Minerals
Water
Contains Calories
CHO has the greatest effect
on post meal blood glucose






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D ia b e te s E x c h a n g e L is ts
V IS U A L # 3
N u tr ie n ts in F o o d E x c h a n g e G r o u p s
Nutrients in Food Groups
C a r b o h y d r a te
(g m )
P r o te in
(g m )
Fat
(g m )
C a lo r ie s
S ta rc h
15
3
1 o r le s s
80
F ru it
15
—
—
60
F a t-fre e (s k im )
12
8
0–3
90
L o w -fa t (1 % )
12
8
5
120
W h o le
12
8
8
150
5
2
—
25
V a r ie s
V a r ie s
V a rie s
V a r ie s
V e r y le a n
—
7
0–1
35
L ean
—
7
3
55
M e d iu m fa t
—
7
5
75
H ig h f a t
—
7
8
100
—
—
5
45
M o n o u n s a tu r a te d
—
—
5
45
P o ly u n s a tu ra te d
—
—
5
45
S a tu ra te d
—
—
5
45
H y d ro g e n a te d
—
—
5
45
G roup
C a r b o h y d r a te
M ilk
N o n s ta rc h y
V e g e ta b le s
O th e r
C a rb o h y d ra te s
M e a t/M e a t
S u b s titu te
Fat
15
“Diabetes Food Lists”
Food Groups
Starchy Vegetables
&
CHO
CHO
CHO
16
Starch Group
Approximately 15
grams of CHO per
serving
Reference: Life with Diabetes Third Edition, American Diabetes Association
17
Fruit Group
Approximately 15
grams of CHO per
serving
Reference: Life with Diabetes Third Edition, American Diabetes Association
18
Milk Group
Approximately 12
grams of CHO per
serving
Reference: Life with Diabetes Third Edition, American Diabetes Association
19
Other Carbohydrate Group
Approximately 15
grams of CHO
per serving
Reference: Life with Diabetes Third Edition, American Diabetes Association 20
Vegetable Group
Approximately
5 grams of CHO
per serving
Reference: Life with Diabetes Third Edition, American Diabetes Association21
Sample Meal Plan 1800 Calories
Breakfast (60 grams CHO)
 4 CHO x 15 g = 60 g
2 Starches
1 Fruit
1 Milk
• Protein (1 ounce)
 1 Fat
 Free Foods or Beverages totaling
less than 20 calories
Dinner (60 g of CHO)
 4 CHO x 15 g =45 g
2 Starches
1 Fruit
3 Vegetables x 5 grams per
serving = 15 g
 Protein (3 ounces)
 1 Fat
 Free food or beverage totaling
less than 20 calories
Lunch (60 g of CHO)
 4 CHO x 15g = 60 g
3 Starches
1 Fruit
 2 servings of Vegetables
• Protein (3 ounces)
 1 Fat
 Free foods or beverages totaling
less than 20 calories
Bedtime Snack (15 g of CHO)
• 1 CHO = 15 g
1 Starch, fruit or milk
 Protein (1 ounce)
 Free food or beverage totaling
less than 20 calories
22
“Carbohydrate Counting”
Shredded Wheat
Nutrition Facts
1. Look at the “Serving size”
Serving Size 2 biscuit (1.6 oz.)
Servings per container: 10
Total Calories: 155 Calories from fat: 9
Fat
Saturated
Trans Fat
Cholesterol
Sodium
Total Carbohydrate
Dietary Fiber
Sugars
Protein
Vitamin A
Calcium
0%
2%
1g
0.2 g
0g
0mg
3mg
36.2g
5.5g
0.4g
5.2g
2. Look at the “Total
Carbohydrate” in grams
3. Subtract half the fiber (if
greater than 5 grams) and
half the sugar alcohol (if any
listed) from the “Total
Carbohydrate”
4. This is the amount you will
Cover with insulin
Vitamin C 0%
Iron
6%
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Count the CHO in This
Sample Meal Plan









2/3 cup pasta
1 oz. slice garlic bread
Meat tomato sauce
1 small salad
½ cup cooked broccoli, cauliflower
1 cup unsweetened tea
1 packet of low cal dressing (3 grams of CHO)
1 packet of sweetener (1 gram of CHO)
½ cup lite fruit
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Answer
This meal is approximately 60 grams of
CHO:



2/3 cup pasta = 30 grams of CHO
1 oz. slice of bread = 15 grams of CHO
½ cup lite fruit = 15 grams of CHO
 We
count the CHO in the fruit, milk and
starch groups.
 We do not count the vegetables unless
there are at least three servings.
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Practice Carb/Insulin Ratio

If patient weighs less than 150 lbs:
Total CHO in grams divided by 15 = number of
units of insulin for meal bolus
Example:
60 grams = 4 units of insulin
15
 If patient weighs 150 lbs or more divide total
CHO in grams by 10 to find the units of insulin
for meal bolus
Example:
60 grams = 6 units of insulin
10
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Estimating Meal Insulin Dose

If patient is on 1800 calorie diet he/she usually
receives about 60 grams (4 carbs) at each meal
at a hospital.



If the patient plans to eat all of the meal, give the meal
bolus as ordered by physician.
If the patient eats half the meal or more exactly half
the carb, give half the meal bolus
If the patient skips the meal, do not give the meal
bolus, but do give the correction bolus if BG is above
target and you have orders for correction insulin.
27
Nursing Judgment

The nurse may give the meal bolus within 15 minutes of
the start of the meal if the patient is not a reliable eater.

If the patient is a reliable eater the nurse should give the
meal bolus with the meal.

If the meal bolus has been given and the patient failed to
eat adequate CHO load consider substituting liquid CHO
for the solid CHO that was not consumed.
Example: 1/2 cup apple juice = 15 grams of CHO
This should be done as soon as possible to prevent
hypoglycemia.
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Summary
 Up
to 100% of the carbohydrate can be
changed into BG in your body
 You
can estimate the carb load for your
patient’s meal by adding the grams of carb
found in fruit, milk, and starch on the tray
 You
can also use the food label to find out
how much carb is in a serving size by
reading the total carb and subtracting half
the fiber and half the sugar alcohol.
29
Summary (continued)
There are three components to
subcutaneous insulin therapy:



Basal insulin to control blood glucose
between meals
Meal or prandial insulin to cover the CHO load
at the meal
Correction insulin to bring a high blood
glucose into target range.
30