Treatment Of Diabetes And Other Conditions With Drugs And Nursing Considerations

Type I Diabetes

Questions:

I: Mrs Joan McNeil is a 64-year-old widower who currently lives with her daughter due to a recent fall and DVT in her left calf.

S: She has presented to your hospital with a DKA after having nausea and vomiting for the past 3 days which she was unable to tolerate anything oral and is dehydrated.

B: Joan has been a type 2 Diabetic on Metformin for 30 years. Recently her GP started her on insulin a.c and nocte. Joan weighs 115 kg and suffers from Osteoarthritis and finds it difficult to mobilise. She also has hypertension in which she is medicated for.

A: After spending the night in ED receiving IV fluids and an insulin infusion, she has been admitted to your ward with uncontrolled Type 2 Diabetes needing re-assessment and management. Joan currently has an intravenous infusion in progress and has a sliding scale, requiring 2/24 BSLs and additional insulin pre meals.

R: Refer to the mediation charts.

Question 1:

a) Explain the aetiology and pathophysiology of Type 1 Diabetes and Type 2 Diabetes.

In your answer compare the differences between Type 1 and Type 2 diabetes. Include: characteristics and treatment.

b) Explain what a DKA is and possible reasons from the history why this would have occurred?

Question 2:

Joan has been a Type 2 Diabetic for 30 years. She has now been commenced on Insulin.

a) Is she now considered a Type 1 diabetic? Explain your answer.

b) Why would Joan’s GP have commenced her on Insulin a.c and nocte? Give a detailed explanation.

Question 3:

a) What are the symptoms of Hypoglycaemia?

b) What is the treatment for Hypoglycaemia?

Question 4:

Mrs McNeils Blood Glucose levels for the past 12 hours are as follows:

0600: 13.5mmol/l; 0800: 14.5mmol/l; 1000: 9.9mmol/l; 1200: 15.0mmol/L; 1400: 7.7mmol/l; 1600: 6.8mmol/l; 1800: 3.2mmol/l; 1900: 10.6 mmol/l; 2100: 16mmol/l;

a) Document these on the attached BGE (Blood Glucose Form).

b) At 1200hrs you documented the BSL as 15.0. What would you do?

Question 5:

Identify 5 other conditions related to diabetes that Joan is at risk of? Choose 1 and explain this in detail including pathophysiology, aetiology, signs and symptoms, medications and treatment options.

Question 6:

On arrival to the ward Joan gives you a bag containing her medications. This bag includes: Metformin, Actrapid, Protaphane, Digoxin, Ventolin Puffer, Coloxyl with Senna, Atenolol.

For each of these medications please explain:

• The pharmacodynamics (how they work) on Mrs McNeils body.

• Why Joan would be taking these medications

• Trade names

• Dosage parameters

• Adverse reactions

• Nursing Considerations

• Patient education

Question 7:

Mrs McNeil was commenced on IV fluids due to dehydration

a) What clinical manifestations would Mrs McNeil exhibited on admission for the Doctor to diagnose this.

b) Outline in detail the Enrolled Nurses role in relation to managing Joan’s IVT.

c) Identify and explain in detail at least 4 possible complications of having an IV Infusion.

You have just completed a set of observations. These are as follows:

BP: 160/96

HR: 98

R: 26

O2 sats: 86%

Joan is having difficulty responding to your questions in full sentences.

d) What is Joan most likely suffering from?

e) What could have caused this and why?

Question 8:

As part of the admission process you complete a patient medical history check. You identify that the patient has had a recent DVT in her left calf.

a) After identifying this, what medication is used in hospital to prevent this from reoccurring?

b) How does this medication work?

c) Outline how you would administer this medication (please include equipment, process and safety precautions)

d) Please sign the medication chart to indicate you have given the morning medications.

Question 9:

You assist Joan to the toilet, on returning to the chair Joan appears to be short of breath and complains of a squeezing sensation (heaviness) in her chest. Please explain your immediate actions in order of priority and provide a rationale for each.

Question 10:

Continuing on from above, you have just completed a set of observations. These are as follows:

BP: 86/38

HR: 46

R: 24

O2 sats: 80%

Joan is sweating profusely

Based on the observations you decide to leave the patient to make a MET call.

a) What is the criteria for making a MET call?

Question 11:

The Doctor diagnosed acute Myocardial Infarction as the troponin level was 0.9.

a) What is the normal range for a troponin level?

The following day, you are doing a ward round. You notice Mrs McNeil walking to the toilet on her own. You ask if she is ok and she responds “yes”. You continue your round. 20 minutes later you walk past Mrs McNeils room and notice she has not returned from the toilet. As you walk closer you see Mrs McNeil collapsed on the floor in the doorway of the toilet.

b) What is your next response?

c) Joan has No Pulse and is not breathing. You know you need to commence CPR, what does this involve. Give a detailed explanation of the resuscitation process. Ratio, depth of compression, frequency, checking of pulse, timing of interventions, other assistance etc.

d) What medications are used in the management of a cardiac arrest. Explain the pharmacodynamics, dosage parameters and timing for these medications

Question 12:

After a long stay in hospital recovering from her MI, Joan is finally ready for discharge to a rehabilitation facility.

a) Develop a discharge plan and a written handover to the facility. Using the ISBAR handover format ensure you include all information, events and medication pertaining to Joan’s stay hospital.

Type II Diabetes

1. a) Type I Diabetes: in this condition the immune system of the body that fights against viruses and bacteria incorrectly demolishes the islet cells within the pancreas. Pathophysiology of this condition includes beta cells destruction within the pancreas in spite of which causative agent or risk factors are present (Schatz, Haller and Atkinson, 2010). Risk factors include autoimmune response towards the beta cells within the pancreas, consisting expansion of autoantibody-generating beta cells, CD8+ T cells, CD4+ T helper cells and innate immune system activation.

Type II Diabetes: in this condition human system becomes insulin resistant or the pancreas may stop producing adequate amount of insulin. Insulin resistance that is the cell inability to respond properly to normal insulin levels takes place initially within fat tissue, muscles and liver (Taylor, 2012).

	Type I Diabetes	Type II Diabetes
Characteristics	beta cells destruction within the pancreas in spite of any causative agent or risk factors	In case of insulin resistance, liver inadequately releases proper amount of glucose in the blood stream
Treatment	Immunosupressive drugs: Cyclosporine A.	Proper nutrition, regular exercise, lifestyle modification (Karlsen and Bru, 2000).

b) DKA is considered as a life threatening illness among the sufferers of diabetes mellitus. This takes place mainly with those who are suffering from type I diabetes. It results from insulin shortage, and because of insulin insufficiency body switches to burn fatty acids and generates acidic ketone bodies which cause mainly the complications and symptoms (Egred, 2005). In this case study Mrs. Joan is a diabetic patient and suffering from this condition since last 30years. DKA most often takes place in those patients who previously have diabetes. Apart from that she is obese. From various researches it is seen that DKA may takes place among those who have features of diabetes type II and features include obesity and family history.

2. a) No, she is not considered as Type I diabetic. This is because both features of these conditions are entirely different. Type II diabetes is characterized by increased glucose levels within the blood stream but in type I diabetes immune system destroys the production of insulin by the pancreatic cells (Hassanein, Ewins and Worth, 2000).  In this case body generates insulin but is not capable to identify and utilize it appropriately and that is why insulin therapy is given to the patient to control her blood sugar level. Her immune system does not destroy the insulin producing beta cells within the pancreas.  

b) Joan’s GP have commenced her on insulin dosages because Type II diabetes is completely curable and preventable. The recommendation is justified as Joan is diabetic for last 30years and consuming Protaphane and Metformin (Drugbank.ca, 2015). Yet her blood sugar level is not under control. Therefore commencement of insulin therapy prior meal and during the night time will help Joan to control her elevated blood sugar level.

3. a) The symptoms of hypoglycemia includes fatigue, pale skin, heart palpitations, anxiety, shakiness, hunger, irritability, sweating, blurry vision, nervousness, mood swing, sleeping difficulty, skin tingling, loss of alertness, trouble in concentrating (Park et al., 2010).

b) The treatment of hypoglycemia includes drinking juice or consuming glucose tablets or chewing sugary food (Bellenir, 2008). GP can also give a glucagon shot as for immediate purpose, because this raises the level of blood sugar.

4. a) Blood Glucose Form:

Characteristics

TIME	BSL
0600	13.5mmol/l
0800	14.5mmol/l
1000	9.9mmol/l
1200	15.0mmol/l
1400	7.7mmol/l
1600	6.8mmol/l
1800	3.2mmol/l
1900	10.6mmol/l
2100	16mmol/l

b) When it is documented that the BSL is 15.0 at 1200hrs, the responsible care provider should focus on her hyperglycemia treatment. It is also mentioned in this case study that she has diabetic keto acidosis, so taking care of this factor is of utmost important. Joan weighs 115kg so she should be administered with 6units of insulin.

5. 5 other conditions related to diabetes are: amputation, vision loss, nerve damage; kidney disease and stroke and heart complication.

Amputation: the main two reasons associated with amputations of legs or feet include narrowing down of blood vessels, obstruction in adequate amount of blood circulation to the lower body portion. Sores or cuts in the legs or feet take time to heal properly and can get bad instead of getting healed. If a problem of damaged nerve is also present then the patient might not feel the ache because of foot problem (Healey and Healey, 2007). Sores if left untreated or ignored then the sores can become rapidly infected that leads to an emergency for amputation (Akram, Kerr and Mclennan, 2008). Treatment includes proper foot care, inspection of sores; avoid wearing badly fitting shocks and proper follow up with doctors.

6.

DRUGS	PHARMACODYNAMICS	REASON	TRADE NAMES	DOSAGE PARAMETERS	ADVERSE REACTIONS	NURSING CONSIDERATION	PATIENT EDUCATION
Metformin	Improves glucose tolerance, lowers basal and postprandial plasma glucose	She is hyperglycemic	Glucophage	1gm, twice Daily	Stomach discomfort, lower back pain, cough, decreased appetite	History of allergy and physical assessment like: skin color, lesions, liver evaluation	Avoid alcohol consumption while administering with this drug
Actrapid	Helps glucose to enter the body cells from blood	To manage the condition of diabetes	Actrapid	4units/8hrs	Excessive reduction all of blood glucose level sudenly	Correct dosage should be prepared	Education need to be given on lifestyle modification, proper diet
Protaphane	Helps glucose to enter the body cells from blood	To control elevated level of blood sugar	Protaphane	14units	Excessive reduction all of a blood glucose level sddenly	Correct dosage should be prepared	Education need to be given on lifestyle modification, proper diet
Digoxin	A cardiac glycoside, treat congestive cardiac complication and arrhythmias because of reentry mechanism	Control the rate of ventriculation in atrial fibrillation, manage congestive cardiac failure	Digacin	62.5mcg/day	Fainting, dizziness	Need to be administered undiluted	Patient should complain if any adverse effect initiates
Ventolin Puffer	A bronchodilator to control the condition of asthma	To treat asthma or COPD	Asthavent	2mg 3-4times/day	Headache, flushing, hypokalaemia	Assess lung sound, observe fore paradoxical spasm	Patient should complain if any adverse effect initiates (Nhs.uk, 2015)
Coloxyl with Senna	Sennosides which are obtained from senna leaves, irritates bowel lining causing laxative effect	Recommended for constipation	Coloxyl	II daily	Weight loss, stomach pain	As digoxin, blood thinner and diuretic tablets  can affect  Coloxyl, nurses should monitor if any adverse reaction arise	Patient should complain if any adverse effect initiates (Aspenpharma.com.au, 2015)
Atenolol	It has lowest solubility in lipid and does not have membrane stabilizing activity	She is hypertensive, so it is used to control her hypertension	Normiten	Daily	Cold hand, feet, confusion	History of sinus bradycardia and physical assessment: urine glucose, blood glucose, cholesterol	CConsume drug with food id gastrointestinal upset takes place (Mayoclinic.org, 2015)

7. a) The clinical manifestations include extreme thrust, confusion, dry skin, mucous membranes, mouth, no urination and sunken eyes (Simmons, 2010).

b) Nurses should have a good amount of knowledge about intra venous therapy. Many technical modifications are now in place those are time saving and innovative. This increases the therapy efficacy. The nurses need to be well equipped with these techniques.

c) The complications may include hematoma infiltration, air embolism and phlebitis (Wittstock, Benecke and Zettl, 2003).

d) Her blood pressure is at higher side, her heart rate is also increased and from her oxygen saturation measurement it is clearly understood that she is suffering from hypoxia.

e) She could have suffering from loss of consciousness and increased palpitation because of dehydrated condition.

8. a) Heparin is used to prevent this from reoccurring.

b) Heparin binds to antithrombin III and leads to instant inactivation of factors Xa and IIa. This heparin bound complex can inactivate plasmin (Drugbank.ca, 2015). Heparin’s antithrombotic effect is related well with the factor Xa inhibition. Heparin prevents formation of existing clots by diminishing further clotting and not a thombolytic agent.

9. Immediate actions: support with oxygen mask as she is suffering from breathing shortness.

The squeezing pain in the heart might represent a change of heart attack, so Digoxin can be administered or any other sublingual tablets can be immediately placed.

10. a) The criteria here that can be considered to give a MET call includes her sudden chest pain and raised heart rate and elevated blood pressure that indicate her chance to get a heart attack.

11. a) Normal range of troponin: 0-0.2ng/ml.

b) The next response is a call to the medical emergency team.

c) Turn patient onto her back, open airway using chin lift and head lift, keeping this passage open the personnel should look, feel, and listen to identify whether the patient is normally breathing and should take less than 10seconds. Listen at patient’s mouth for breathing sounds, look or movement of chest, feel for air on cheek. Chest decompression can be given and 2ventilations.

d) ACE inhibitors can be used in this condition. Generic name: benazepril; Trade name: Lotensin

This drug inhibits ACE in human (Nlm.nih.gov, 2015). This enzyme catalyzes conversion of angeotensin I to vasoconstrictor substance. Dosage: 20mg/day.

12. Joan’s discharge plan should be focused on her physiological conditions: DVT, DKA, diabetes and dehydrated condition. As the doctor has started insulin therapy, the patient should be educated properly regarding insulin administration. If help is required the hospital should arranged for nurse aide along with her.  She should be provided with a template mentioning dos and don’ts, so that she can follow proper medication and its timing.  

References

Akram, A., Kerr, R. and Mclennan, A. (2008). Amputation of lower left lip following dental local anaesthetic. Oral Surgery, 1(2), pp.111-113.

Aspenpharma.com.au, (2015). Coloxyl – docusate | Aspen Pharmacare Australia. [online] Available at: https://www.aspenpharma.com.au/products/details/index/id/448/product/Coloxyl [Accessed 19 Feb. 2015].

Bellenir, K. (2008). Diabetes sourcebook. Detroit, MI: Omnigraphics.

Drugbank.ca, (2015). DrugBank: Heparin (DB01109). [online] Available at: https://www.drugbank.ca/drugs/DB01109 [Accessed 19 Feb. 2015].

Drugbank.ca, (2015). DrugBank: Heparin (DB01109). [online] Available at: https://www.drugbank.ca/drugs/DB01109 [Accessed 19 Feb. 2015].

Drugbank.ca, (2015). DrugBank: Metformin (DB00331). [online] Available at: https://www.drugbank.ca/drugs/db00331 [Accessed 19 Feb. 2015].

Egred, M. (2005). Diabetic keto-acidosis and hyperkalaemia induced pseudo-myocardial infarction.Heart, 91(9), pp.1180-1180.

Hassanein, M., Ewins, D. and Worth, R. (2000). Case presentation: An unusual cause of severe peripartum hypoglycaemia in type I diabetes. Diabetes Research and Clinical Practice, 50, p.215.

Healey, J. and Healey, J. (2007). Diabetes. Thirroul, N.S.W.: Spinney Press.

Karlsen, B. and Bru, E. (2000). Coping among adults with type I and type II diabetes. Diabetes Research and Clinical Practice, 50, p.231.

Mayoclinic.org, (2015). Atenolol (Oral Route) Description and Brand Names – Drugs and Supplements – Mayo Clinic. [online] Available at: https://www.mayoclinic.org/drugs-supplements/atenolol-oral-route/description/drg-20071070 [Accessed 19 Feb. 2015].

Nhs.uk, (2015). Ventolin – Asthma medicines and drugs – NHS Choices. [online] Available at: https://www.nhs.uk/Conditions/Asthma/Pages/MedicineOverview.aspx?condition=Asthma&medicine=Ventolin [Accessed 19 Feb. 2015].

Nlm.nih.gov, (2015). Benazepril: MedlinePlus Drug Information. [online] Available at: https://www.nlm.nih.gov/medlineplus/druginfo/meds/a692011.html [Accessed 19 Feb. 2015].

Park, M., Freund, G., Donovan, S., Freund, G., Johnson, R. and Woods, J. (2010). Neuroendocrine mechanisms of behavioral changes induced by hypoglycemia. Urbana, IL.: University of Illinois.

Schatz, D., Haller, M. and Atkinson, M. (2010). Type I Diabetes. Philadelphia: Saunders.

Simmons, S. (2010). Acute dehydration. Nursing, 40(1), p.72.

Taylor, R. (2012). Insulin Resistance and Type 2 Diabetes. Diabetes, 61(4), pp.778-779.

Wittstock, M., Benecke, R. and Zettl, U. (2003). Therapy with Intravenous Immunoglobulins: Complications and Side-Effects. Eur Neurol, 50(3), pp.172-175.