Diabetes Mellitus, Part 2

Exercise 2 - Virtual Hospital Activity

 Sign in to work at Pacific View Regional Hospital for Period of Care 1. (Note: If you are
already in the virtual hospital from a previous exercise, click on Leave the Floor and
then on Restart the Program to get to the sign-in window.)
 From the Patient List, select Harry George (Room 401).
 Click on Go to Nurses’ Station.
 Click on Chart and then on 401.
 Click on Emergency Department.

Exercise 2 - Question 1

What two medications were ordered to control Harry George’s diabetes? Include the dose and
route for each.

Your Answer:

Regular insulin 10 Uni IV and Regular insulin 10 Uni subQ

Regular insulin 10 units IV, followed by 10 units subcutaneously

Question 2
Not yet graded / 1 pts

Exercise 2 - Question 2

How would you give the IV insulin? (Hint: You can access the Drug Guide by clicking on
the Drugicon in the lower left corner of the screen in the Nurses’ Station.)

Your Answer:

Undiluted IV push

Undiluted, IV push

Question 3
Not yet graded / 1 pts

Exercise 2 - Question 3
Find the Emergency Department physician's progress notes for Monday at 1345. What does the
physician plan to order for the sliding scale insulin coverage?

Your Answer:

0 to 150 mg/dl, give 0 uni regular insulin

151 to 200 mg/dl, give 3 uni regular insulin

201 to 252mg/ dl, give 7 uni regular insulin

251 to 300 mg/dl, give 10 uni regular insulin

Above 300 mg/dl, call physician

Blood glucose before meals and at bedtime

0 to 150 mg/dL, give 0 units regular insulin

151 to 200 mg/dL, give 3 units regular insulin

201 to 250 mg/dL, give 7 units regular insulin

251 to 300 mg/dL, give 10 units regular insulin

Above 300 mg/dL, call physician

Blood glucose testing to be done before meals and at bedtime.

Question 4
Not yet graded / 1 pts

 Click on Physician’s Orders.

Exercise 2 - Question 4

Look at the orders for Monday at 1345. What was the actual sliding scale insulin order?

Your Answer:

0 to 150 mg/dl, give 0 uni regular insulin

151 to 200 mg/dl, give 3 uni regular insulin

201 to 252mg/ dl, give 7 uni regular insulin

251 to 300 mg/dl, give 10 uni regular insulin

Above 300 mg/dl, call physician

Blood glucose before meal

0 to 150 mg/dL, 0 units regular insulin

151 to 200 mg/dL, 3 units regular insulin

201 to 250 mg/dL, 7 units regular insulin

251 to 300 mg/dL, 10 units regular insulin

Above 300 mg/dL, call physician

Check blood glucose before meals

Question 5
Not yet graded / 1 pts

 Click on Return to Nurses' Station.

 Click on Kardex and then on 401 to access the correct record.

Exercise 2 - Question 5

According to the Kardex, how often should the capillary blood glucose be tested?

Your Answer:

Four times a day before meal and at bed time

4 times a day; before meals and at bedtime

Question 6
Not yet graded / 1 pts

 Click on Return to Nurses’ Station.

 Click on MAR and then on 401 for Harry George’s records.

Exercise 2 - Question 6

According to the MAR, when should the insulin sliding scale be administered? What was the
time of this order?
Your Answer:

Scale administered before meals. Monday at 1830

Sliding scale to be administered before meals. Order dated Monday at 1830.

Question 7
Not yet graded / 1 pts

Exercise 2 - Question 7

What would you do regarding the inconsistencies identified above?

Your Answer:

Nurse look the order from Monday 1830 and give before meals and at bedtime. Correct the
transcription error on the MAR and hospital policy and fill report for potential medical error

The nurse can always call the physician to verify an order. However, in this case, if the nurse
would go back into the chart and look at the physician’s orders dated Monday 1830, it would be
noted that the physician did update the insulin sliding scale orders to be done before meals and at
bedtime. Therefore, the nurse simply needs to correct the transcription error on the MAR.
According to hospital policy, the nurse might also have to complete a reporting form
documenting an error or potential medication error.

Question 8
Not yet graded / 1 pts

Exercise 2 - Question 8

What problems might occur if Harry George does not receive insulin at bedtime?

Your Answer:

Elevated fasting blood glucose. Can cause electrolyte imbalance, polydipsia and polyuria

Elevated fasting blood glucose. If high enough, could result in fluid and electrolyte imbalances
as well. Clinical manifestations might include polydipsia and polyurea. Elevation would also
cause HbA1c to rise.

Question 9
Not yet graded / 1 pts
  Click on Return to Nurses' Station.
 Click on 401 at the bottom of the screen.
 Click on Clinical Alerts.

Exercise 2 - Question 9

What is the clinical alert for 0730?

Your Answer:

Fasting morning glucose of 206

Fasting morning glucose of 206

Question 10
Not yet graded / 1 pts

Prepare and administer the sliding scale insulin for this glucose level by following these steps:

 Click on Medication Room on the bottom of the screen.

 Click on MAR or on Review MAR at any time to verify how much insulin to administer
based on sliding scale. (Hint: You must click on the correct room number within the
MAR. Remember to look at the patient name on the MAR to make sure you have the
correct patient's records.) Click on Return to Medication Room after reviewing the
correct MAR.
 Click on Unit Dosage and then on drawer 401 for Harry George’s medications.
 Select Insulin Regular, put medication on tray, and then close the drawer.
 Click on View Medication Room.
 Click on Preparation and choose the correct medication to administer. Click on Prepare.
 Click on Next, choose the correct patient to administer this medication to, and click
on Finish.
 You can click on Review Your Medications and then on Return to Medication
Room when ready. Once you are back in the Medication Room, you may go directly to
Harry George’s room by clicking on 401 at the bottom of the screen.
 Click on Patient Care.
 Click on Medication Administration and follow the steps in the Administration Wizard
to complete the insulin administration.

Exercise 2 - Question 10

How much insulin should be administered?

Your Answer:

7 uin
7 units, or 0.07 mL

Question 11
Not yet graded / 1 pts

Exercise 2 - Question 11

What is the preferred site of administration for fastest absorption?

Your Answer:

Abdomen

Abdomen

Question 12
Not yet graded / 1 pts

Exercise 2 - Question 12

List the expected onset, peak, and duration for the insulin you just administered. What actual
times would you expect the onset, peak, and duration for Harry George, based on giving the
insulin at 0730?

Expected length of time:

 Onset
 Peak
 Duration

Actual Time After 0730 Dose:

 Onset
 Peak
 Duration

Your Answer:

Expected:

Onset-0.5 to 1 hr
Peak – 2 to 4 hr

Duration- 5 to 7 hr

After 0730:

Onset -0800 to 0830

Peak-0930 to 1130

Duration-1230 to 1430

Expected Length of Time:

 Onset—0.5 to 1 hour
 Peak—2 to 4 hours
 Duration—5 to 7 hours

Actual Time After 0730 Dose:

 Onset—0800 to 0830
 Peak—0930 to 1130
 Duration—1230 to 1430

Question 13
Not yet graded / 1 pts

Exercise 2 - Question 13

At what time would Harry George be at most risk for hypoglycemia? Describe the signs and
symptoms that would indicate this acute complication.

Your Answer:

Before eating breakfast, before the patient has eaten any food. He would also be at risk for
hypoglycemia midmorning if he does not eat his breakfast as ordered. Hypoglycemia include
shakiness, tremor, sweating, tachycardia, clamminess, hunger, nausea.

Just before eating breakfast, when the insulin’s action is beginning before the patient has eaten
any food. He would also be at risk for hypoglycemia midmorning to late morning if he does not
eat his breakfast as ordered. Signs and symptoms of hypoglycemia include shakiness, tremor,
sweating, nervousness, anxiety, irritability, impatience, tachycardia, palpitations, chills,
clamminess, lightheadedness, pallor, hunger, nausea, headache, tiredness, drowsiness, weakness,
warmth, dizziness, faintness, blurred vision, nightmares, crying out in sleep, paresthesias,
difficulty concentrating, difficulty speaking, incoordination, behavior change, confusion, coma,
and seizures.

Question 14
Not yet graded / 1 pts

Exercise 2 - Question 14

While you are preparing to administer Harry George’s insulin, he asks you why he is taking this
because he did not use insulin at home. How would you answer this?

Your Answer:

Stress of hospitalization increases his blood glucose. Check the patient's blood glucose four
times a day and for elevations with Regular insulin.

The stress of his current illness and hospitalization increases his blood glucose more than at
home. Therefore it is common to check the patient's blood glucose four times a day and cover the
elevations with Regular insulin. It does not mean that he will have to take insulin once he is
recovered.

Question 15
Not yet graded / 1 pts

Exercise 2 - Question 15

For what side effects should you monitor Harry George related to his insulin regimen?

Your Answer:

Hypoglycemic, dawn phenomenon, and Somogyi.

Hypoglycemic reactions, dawn phenomenon, and Somogyi phenomenon.

Question 16
Not yet graded / 1 pts

Exercise 3 - Virtual Hospital Activity

 Sign in to work at Pacific View Regional Hospital for Period of Care 4. (Note: If you are
already in the virtual hospital from a previous exercise, click on Leave the Floor and
then on Restart the Program to get to the sign-in window.)
  Click on Chart and then on 401 for Harry George's chart. (Remember: You are not able
to visit patients or administer medications during Period of Care 4. You are able to review
patient records only.)
 Click on Nurses' Notes.

Exercise 3 - Question 1

Read the notes for Wednesday at 1730. What does the patient say regarding glyburide?

Your Answer:

Refused the glyburide, because he just got insulin, he doesn’t need the insulin pill.

Harry George refused the glyburide. He states that because he just got insulin, he doesn’t need
the insulin pill.

Question 17
Not yet graded / 1 pts

Exercise 3 - Question 2

How would you respond to the patient's demands?

Your Answer:

Explain the medications to the patient. The goal of medication therapy is to achieve blood
glucose levels at near normal with just the use of glyburide so that the patient will not need to
use insulin at home.

The nurse needs to explain the medications to the patient. He should be told that the insulin is
active for only a short period of time and is given to cover his high blood glucose in conjunction
with the use of glyburide. Glyburide is still needed to maintain a more constant, normal level of
blood glucose. The goal of medication therapy is to achieve blood glucose levels at near normal
with just the use of glyburide so that the patient will not need to use insulin at home. The action
of glyburide can be explained more fully once the patient is more cooperative.

Question 18
Not yet graded / 1 pts

Exercise 3 - Question 3

How often did Harry George take the glyburide at home?

Your Answer:
One time per day.

Once daily

Question 19
Not yet graded / 1 pts

Exercise 3 - Question 4

Why do you think this was increased in the hospital? What concerns might you have regarding
this increase? (Hint: This patient is also receiving insulin.)

Your Answer:

Patient needs to increase in his oral medication. Nurse needs to be watchful for signs and
symptoms of hypoglycemia, the most common side effect of oral hypoglycemic.

Harry George’s blood glucose levels may not have been controlled on the once-daily dose. When
he was admitted, his glucose level was 380 mg/dL, necessitating an increase in his oral regimen.
However, the patient states that he was unable to take his medication for a week because he did
not have it. Therefore the nurse needs to be watchful for signs and symptoms of hypoglycemia,
the most common side effect of oral hypoglycemic agents.

Question 20
Not yet graded / 1 pts

Exercise 3 - Question 5

What classification of oral hypoglycemic does glyburide belong to? (Hint: For help, click on
the Drug Guide located on the counter in the Nurses' Station.)

Your Answer:

Second-generation sulfonylureas

Second-generation sulfonylureas

Question 21
Not yet graded / 1 pts

Exercise 3 - Question 6

For what side effects of glyburide should you assess Harry George?
Your Answer:

Dizziness, weight gain, constipation, diarrhea, altered taste sensation, heartburn, nausea,
vomiting, headache, photosensitivity, peeling skin, rash, itching,

Altered taste sensation, dizziness, drowsiness, weight gain, constipation, diarrhea, heartburn,
nausea/vomiting, stomach fullness, headache, photosensitivity, peeling skin, rash, itching

Question 22
Not yet graded / 1 pts

Exercise 3 - Question 7

What specific patient teaching points should you give this patient regarding glyburide?

Your Answer:

Carry quick source of sugar for immediate response to hypoglycemia.

Notify provider about any increased stress, illness, infection, trauma, heavy physical activity.

Wear sunscreen and protective eyewear.

Demonstrate correct method for blood glucose monitoring.

Watch for symptoms of hypoglycemia and hyperglycemia

Medical alert bracelet with information.

Do not skip or delay meals.

Watch for signs/symptoms of hypoglycemia and hyperglycemia.

Carry candy, sugar packets, or other quick source of sugar for immediate response to
hypoglycemia.

Wear medical alert bracelet with information.

Notify provider of any changes that would affect blood glucose levels, such as increased stress,
illness, infection, trauma, heavy physical activity.

Wear sunscreen and protective eyewear.

Demonstrate correct method for blood glucose monitoring.

Question 23
Not yet graded / 1 pts

 Click on EPR.
 Select 401 from the Patient drop-down menu and Vital Signs from the Category drop-
down menu.
 Click on Exit EPR.
 Click on Chart and then on 401.

Exercise 3 - Question 8

List the date and time, blood glucose levels, and insulin doses received since Harry George's
admission. (Hint: There are eight. You will need to access the chart and review the expired
MARs to obtain the sliding scale doses.)

Your Answer:

Monday 2035; 253 mg/dL; 10 units

Tuesday 0735; 180 mg/dL; 3 units

Tuesday 1135; 201 mg/dL; 7 units

Tuesday 1735; 220 mg/dL; 7 units

Tuesday 2305; 179 mg/dL; None

Wednesday 0720; 206 mg/dL; 7 units

Wednesday 1120; 226 mg/dL; 7 units

Wednesday 1735; 218 mg/dL; 7 units

Monday 2035; 253 mg/dL; 10 units

Tuesday 0735; 180 mg/dL; 3 units

Tuesday 1135; 201 mg/dL; 7 units

Tuesday 1735; 220 mg/dL; 7 units

Tuesday 2305; 179 mg/dL; None

Wednesday 0720; 206 mg/dL; 7 units

Wednesday 1120; 226 mg/dL; 7 units

Wednesday 1735; 218 mg/dL; 7 units

Question 24
Not yet graded / 1 pts

Exercise 3 - Question 9

Based on Harry George’s pattern of blood glucose levels, would you evaluate his current therapy
as effective? If not, how might the physician further treat his diabetes?

Your Answer:

Glucose levels are not optimally controlled. Blood glucose are above 200 mg/dL The physician
may consider the addition of another oral hypoglycemic agent or increase the insulin coverage.

Somewhat, but his glucose levels are not optimally controlled. The blood glucose levels are
remaining consistently above 200 mg/dL The physician may consider the addition of another oral
hypoglycemic agent and/or increase the insulin coverage.

Question 25
Not yet graded / 1 pts

Exercise 3 - Question 10

If you were reviewing the chart orders and the EPR on Wednesday evening and found the
information recorded in the table in question 8, what would you be ethically and legally bound to
report?

Your Answer:

The medication omission error, no insulin coverage given on Tuesday at bedtime would need to
be reported. With a glucose level of 179, patient should have received 3 uni of regular insulin,
but he did not receive it because the order was transcribed

The medication omission error related to the lack of insulin coverage given on Tuesday at
bedtime would need to be reported. With a glucose level of 179, the patient should have received
3 units of regular insulin, but he did not receive it because the order was transcribed inaccurately.