DIABETES MELLITUS . STATE UNIVERSITY OF NEW YORK AT STONY BROOK 1 YEAR NURSING PROGRAM SUMMER 2008 HNI 364. The story of patient S.S. Case Study: Diabetes Mellitus. Who is S.S.?: Case History. White female, 5’ tall, 87 lbs. Active, thin 14 year-old
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STATE UNIVERSITY OF NEW YORK AT STONY BROOK
1 YEAR NURSING PROGRAM
SUMMER 2008 HNI 364
Case Study: Diabetes Mellitus
What was the most likely cause of S.S.’s polyuria and weight loss before her hospitalization?
Diabetes Type 1
Accumulation of glucose
No uptake of glucose
by body’s cells
Increased solute concentration in
blood due to excess glucose
H20 moves from high
to low solute concentration:
from cells to intravascular space
Body excretes excess
H20, glucose, and
electrolytes in urine
When your body cannot utilize glucose for energy it will begin to breakdown adipose tissue or fat and use that for energy, which explains the weight loss.
What are normal blood glucose levels?
Normal blood glucose levels, before meals, should be less than 100 mg/l.
Normal blood glucose levels, 2 hours after meals, should be less than 140 mg/l.
Realistic target levels for people on medication is 70 – 140 before meals and less than 180 after meals.
Compare and contrast the signs and symptoms of diabetic ketoacidosis and insulin shock. Explain why each occurs.
High blood glucose levels (> 250 mg/dL)
Accumulation of ketones in urine and blood
Low blood glucose levels (< 45 mg/dL)
When the body cannot use glucose for energy due to the lack of insulin, the glucose is converted into fat for energy.
Excess fat is broken down by the liver and produces ketone bodies, which end up in the urine (ketouria).
Polyuria further increases the concentration of ketone bodies in the urine.
Breakdown of protein in the body also produces ketone bodies, contributing to ketoacidosis.
Too much insulin in the blood due to overdose during an insulin shot.
Since insulin is responsible for uptake of glucose into body’s cells, too much insulin results in too little blood glucose.
Immediate intake of sugar will counteract insulin shock.
Both ketoacidosis and insulin shock are severe, emergency situations.
If left unaddressed they can both lead to coma.
The best way to prevent either one is to constantly monitor blood glucose levels.
Question 3: Why must insulin be injected? Discuss the various types of insulin, their time of onset, peak of action and duration of action. Do persons with Type II diabetes ever require insulin injections? If so, when and why?
-NPH (N) or Lente (L)
Onset: 5-15 minutes
Peak of Action: 1 hour after injection
Duration of Action: 3-4 hours
Onset: 30-45 minutes
Peak of Action: 2-3 hours after injection
Duration of Action: 5-8 hours
Onset: 2-4 hours
Peak of Action: 4-10 hours after injection
Duration of Action: 10-16 hours
Onset: 6-10 hours
Peak of Action: has a peak, but top speed looks like its normal speed
Duration of Action: 20 + hours
Onset: 30 minutes
Duration: 16-24 hours
Figure 2. Onset of action, peak, and duration of action of exogenous insulin
preparations. (Neutral protamine Hagedorn = NPH)
Reprinted with permission from the American Diabetes Association's Clinical Education Program
"Insulin Therapy for the 21st Century."
Injections of insulin should mimic normal release patterns of the body
Long-acting insulin is usually injected 1-2x a day
In addition, short-acting or rapid-acting insulin is injected at mealtimes
- > 50% calories from carbohydrates (1300 kcal/day)
- 10-15% calories from protein (260-390 kcal/day)
- 30-35% calories from fats (780-910 kcal/day)
•NPH (intermediate-acting) and regular (shortacting) are commonly mixed to produce differently-timed pharmacologic actions with a single injection.
•The regular insulin is prepared
first to prevent it from becoming contaminated with the intermediate-acting insulin (NPH).
•Check the patient's name, medication, dosage, route and time of administration.
•With the same syringe inject air equal to the dose of insulin to be withdrawn from the short-acting (regular) insulin.
intermediate-acting insulin, which reduces
the action of the faster-acting insulin, administer
the mixture within 5 minutes of preparation.
Since the total amount to be given is 20 units, a low dose 50 unit syringe is appropriate, but a 100 unit syringe may also be used.
* syringe measuring cc's or mL's cannot be used*
abdomen, posterior arms, anterior and lateral thighs and posterior hips
Teach the patient what treatments are used, how the treatments work and how to administer the drugs
The patient should be aware of the effects of continuously injecting into the same site
They should know that it is important to rotate the injection site
They shouldn’t inject into a limb that is to be exercised because it will be absorbed faster and may result in hypoglycemia.
Researchers: J Strasheim & M. Valerio
Ppt. Preparer: Stefany Cimino
Presenter: Nancy Yang
Causes: Not Rotating Insulin Injection Sites
Physical education classes
Exercise is an important part of any diabetes treatment plan.
Exercise can actually increase your body’s insulin sensitivity, which means your body requires less insulin to guide sugar into your cells.
Check glucose levels
You're good to go.
For most people, this is a safe pre-exercise blood sugar range.
Eat a healthy meal
100-200 mg /dL
If blood sugars are low try:
½ cup of juice or
few pieces of candy
Take a break
Eat and drink something to bring up glucose levels
Check glucose levels after
if planning on exercising long
You need support and cushion
Check feet daily, especially plantar surface (bottom of foot)
Illness e.g. colds and the flu, episodes of diarrhea and vomiting?
Having diabetes only adds to your concerns.
These hormones raise your blood sugar by preventing insulin from working effectively.
In people without diabetes, the additional sugar promotes healing.
But when you have diabetes, the fluctuations can result in potentially serious diabetes complications.
make a sick-day plan
part of your diabetes
Talk to your doctor and other members of your diabetes care team about your sick-day plan.
Make sure your sick-day plan includes:
What medications to take
How often to measure your blood sugar and urine ketones
How to adjust your insulin dosage, if you need insulin
How to manage any other conditions you may have
When to call your doctor
Also identify a loved one or friend who can contact your doctor or help you seek emergency care if you experience diabetes complications.
Continue taking your diabetes medication when you're sick, and remember to test your blood sugar often. You may need to adjust your insulin doses or other medications. Here are some general guidelines:
Type 1 diabetes. Check your blood sugar and urine ketone levels every four hours.
Excessively high blood sugar can lead to ketoacidosis, especially in people who have type 1 diabetes. e conditions can be fatal.
These conditions can be fatal.
With a minor illness such as a cold, you may be able to stick to your diabetes meal plan — which will help ensure blood sugar stability. Remember to check the sugar content of any over-the-counter medications you take. Many cough syrups and other liquid cold preparations are high in sugar.
If you have nausea, vomiting or diarrhea, you may not be able to eat your regular foods. But it's still important to get enough carbohydrates. Try these foods, which contain about 10 to 15 grams of carbohydrates each:1 double-stick frozen fruit pop
1 cup milk
1/2 cup fruit juice
1/2 cup regular (not diet) soda
6 saltine crackers
3 graham crackers
1 slice dry toast
1/2 cup regular (not artificially sweetened) gelatin
If you're not able to keep anything down, it's especially important to monitor your blood sugar closely.
Diabetes complications can quickly become dangerous.
Contact your doctor if:
Your blood sugar level is higher than 300 mg/dL
Your blood sugar level is higher than 240 mg/dL for more than 24 hours
Your urine ketone level is moderate to high
You feel sleepier than usual or can't think clearly
You're unable to keep fluids down or vomit for more than six hours
You have diarrhea for more than six hours
You feel confused and can't think clearly
Your lips and tongue appear dry and cracked
High blood sugar can weaken your immune system. This makes you more likely to get a cold or the flu — and more vulnerable to serious effects of common illnesses. To reduce the risk of getting sick, wash your hands often and avoid crowds during flu season.
Ask your doctor about
vaccination for flu
feel confident in your ability
to manage your diabetes by following
your sick-day plan.
People with diabetes face a higher risk for influenza and its complications, including pneumonia, possibly because the disorder neutralizes the effects of protective proteins on the surface of the lungs. In fact, deaths among people with diabetes increase by 5 - 15% during flu epidemics, and they are six times more likely to be hospitalized with complications from flu than non-diabetic patients who have flu. Everyone with diabetes should have annual influenza vaccinations and a vaccination against pneumococcal pneumonia.
Urinary Tract Infections
Women with diabetes face a significantly higher risk for urinary tract infections, which are likely to be more complicated and difficult to treat than in the general population.
*especially true if the glycosylated hemoglobin remains high for a long period