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Case study for Diabetes—InsulinMarch 2, 2009George Marshall, a 25-year-old manual laborer, visits his physician to have the stitches removed form awound on his right arm. Dr. Geer notes that the incision is not healing well. He also observes that Mr. Marshallseems lethargic, so he decides to do a physical examination and some routine laboratory work. Mr. Marshall’shistory reveals a recent weight loss of 8 pounds, lethargy, polydipsia, and polyuria. His fasting blood glucose iselevated (425 mg/dL) and the urine is positive for ketones. There is a family history of diabetes mellitus.Dr. Geer admits Mr. Marshall to the hospital to control his diabetes. The client is started on 10 units of U-100 regular insulin and 25 units of NPH U-100 insulin before breakfast. A sliding scale of U-100 regular insulin dosage based on the results of the QID blood glucose testing is established.< 150 mg0 units150-200 mg4 units200-250 mg6 units250.3008 units300.35010 unitsThe nurse checks Mr. Marshall’s Accucheck at 7:30AM. The reading was 230mg/dl.How much insulin and types will receive (in total) this morning? U-100 Regular – 6 Units (per MD order, sliding scale)NPH U-100 – 25 UnitsIn addition to this treatment, Mr. Marshall receives instruction concerning a 2,200-calorie diabetic diet.After several days, his fasting blood glucose is approaching normal value (150 mg/dL). He reports feelingbetter. A client education program is begun, with individual sessions 4 days a week and group sessions once aweek. Mr. Marshall seems to be doing well and is able to administer his own insulin, but one day, a setbackoccurs. At about 4:00 pm he begins to perspire profusely, develops a headache, and experiences a tremor inhis hands. In addition, he feels nauseated.1.What type of diabetes (type 1 or 2) does Mr. Marshall appear to have? Are his initial symptomscharacteristic of this type of diabetes mellitus?Mr. Marshall has Type 1 DM. Yes, the typical symptoms include polydipsia, polyuria, weightloss, lethargy.Signs include: FBG: 425mg/dL &
urine positive for ketones
– is this indicative of type 1.Type 1 key signs: Age – 25, Type 1 is usually discovered in pts under 40. Family history of DM.(Type 1 is not as strongly tied to family history). Also, s/s of type 1 are generally rapiddevelopment, and weight loss in a matter of days.Dr. Geer started him immediately on Insulin (NOT on lifestyle management, also no mention of his weight status). 2.Why is Mr. Marshall placed on two types of insulin? Can the regular insulin and the NPH insulinbe mixed in the same syringe? What skills and knowledge about diabetes must Mr. Marshallacquire to care for himself adequately?Mr. Marshall is on two types of insulin because 1 is for meal time (faster acting) and one is for sustained DM maintenance.Regular: onset = 30 – 60 minutes, peak 1-5 hours, Duration 6-10 hoursNPH: 60-120 minutes, peak 6-14 hours, duration 16-24 hours [provides glycemic controlbetween meals, 2x/day admin. NPH
ONLY
longer acting that you can mix with short actinginsulins! NPH = cloudy, t/f draw up REGULAR 1
st
, then NPH.TEACH:
•
Maintain education re: diabetes
•
Exercise & maintain diet control
•
Tighter glycemic control lessens the complications
o
t/f SMBG very important
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s/s of DKA (may develop quickly):
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* Excessive thirstPage
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Case study for Diabetes—InsulinMarch 2, 2009
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* Frequent urination
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* Nausea and vomiting
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* Abdominal pain
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* Loss of appetite
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* Weakness or fatigue
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* Shortness of breath
o
*
Fruity-scented breath
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* Confusion
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* High blood sugar level
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* High ketone level in your urine
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s/s Hypoglycemia:
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* nervousness,
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* sweating,
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* intense hunger,
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* trembling,
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* weakness,
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* palpitations, and
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* often have trouble speaking.
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Storage of insulin:
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UNOPENED vials in refrigerator (not frozen), then will be good untilexpiration date
o
Current use vial: room temp for up to 1 month & still be effective. Nodirect sunlight or excess heat
o
Mixtures in vials: stable = 1 month @ room temp, 3 mos refrig
Store w/ needle up
o
Prefilled mixtures: 1-2 weeks okay store
•
Do not rotate injection site, only vary w/n site by ~ 1 inch.
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If travel pack enough insulin (out of country)
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Restrict exercise if BS <250, esp if ketonuria
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SICK DAY education!
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Mix: clear before cloudy, roll NPH in palms
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Foot care / caution3.What was the nature of the setback that Mr. Marshall experienced?What should the nurse do?Hypoglycemia.
•
Nursing Interventions:
o
Check BS <70 = assessment
o
Give 15 grams simple CHO, wait 15 minutes, then re-check
If still < 70 repeat until 70-110 range.
o
Give oral CHO’s if can swallow ONLY.
o
Glucagon SQ or IM and 50% IV if NOT able to swallow. (glucagon convertsliver glycogen to glucose, but not effective in severe starvation clients)
o
Continue to monitor BS for several hours4.Mr. Marshall begins to lose consciousness. What interventions should the nurse begin?Glucagon if lose consciousness.
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1 mg glucagons IM or SQ
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2
nd
dose in 10 minutes if still unconsciousPage
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Case study for Diabetes—InsulinMarch 2, 2009
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CALL PCP IMMEDIATELY
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To ED
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Small meal when pt wakes up & is no longer nauseated.5.Indicate the sites that can be used for insulin injections. What would you teach Mr. Marshallregarding insulin administration and site rotation?Sites for insulin injection:
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Site affects speed of absorption
o
Abdomen = fastest (outside 2inch radius from navel)
o
Deltoid = 2
nd
fastest
o
Thigh & butt
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Rotating sites reduces lipohypertrophy (inc fat deposits in skin) & lipoatrophy(loss of fatty tissue, making tissue look uneven – lumpy)
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Rotate w/n one anatomic site (prevents variances in insulin absorption)
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Depth – subcutaneous, 90 degree angle. If thin, may need 45 degree angle toavoid IM injection.
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Regular = 30 minutes b/4 meals6.During this hospitalization, Mr. Marshall is started on an intensive insulin therapy regimen withinsulin glargine and Humalog. Explain this regimen in terms of its benefit, dosing schedule,possible adverse effects and patient teaching.Intensive Insulin Therapy
Benefits:
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Provides tight glucose control
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Adaptability – doses adjusted to match calories of meals. Therefore patient ableto have a greater degree of dietary flexibility and glycemic control that is notpossible w/ conventional insulin therapy.
Dosing Schedule:
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Glargine (long acting) is for sustained glycemic control. Generally taken atbedtime, provides basal level of insulin through out the night and the followingday.
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Humalog (lispro) – is used at meal time (15 min prior) in order to adjust basedon caloric content of meal. Generally injected 4 times / day.
Adverse Effects:
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Hypoglycemia (BG <50) [possibly insulin OD, vomit, diarrhea, etoh, xs exercise,childbirth & sick day issues.
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If rapid:
o
Tachy
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Palpitations
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Sweating
o
Nervous
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If gradual:
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Headache
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Confusion
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Drowsiness
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Fatigue
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SEVERE:
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ConvulsionsPage
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