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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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diabetes mellitus




SUMMER 2008 HNI 364

the story of patient s s
The story of patient S.S.

Case Study: Diabetes Mellitus

who is s s case history
Who is S.S.?: Case History
  • White female, 5’ tall, 87 lbs.
  • Active, thin 14 year-old
  • General good health, occasional cold/flu
  • Never been hospitalized
  • Family history: maternal grandmother has hyperthyroidism
history of present illness hpi
History of Present Illness (HPI)
  • Late fall, Mrs. S. noticed that S.S. was pale and less active
  • S.S. felt tired and began to avoid friends and activities (wanted to resign from cheerleading!)
  • S.S. was constantly hungry, but still thin.
  • S.S. noticed she had to use the bathroom after almost every class.
  • S.S. was irritable, had difficulty concentrating
  • Due to these symptoms, Mrs. S. took S.S. to family physicians
s s s current status
S.S.’s current status
  • S.S. has lost 7 lbs in last week, despite eating 5-6 meals /day.
  • Skin is pale and dry
  • VS are within normal limits, but respirations and ulse rates are higher than on previous physical exams.
  • Voiding lg. amounts of urine q 1-2 hrs
  • Constantly hungry, thirsty, fatigued
  • Fasting glucose level = 396 mg/dl
  • Urine acetone +
  • S.S. and her family demonstrated technical competence and understanding in:
    • Blood glucose monitoring
    • Urine testing
    • Diet activity
    • Sick day management
    • Reason for urine testing
question 1a

Question 1A:

What was the most likely cause of S.S.’s polyuria and weight loss before her hospitalization?


No insulin formed

by pancreas

Diabetes Type 1

Accumulation of glucose

in bloodstream


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

Cell dehydration

why did s s lose weight
Why did S.S. lose weight?

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.

question 1b

Question 1B:

What are normal blood glucose levels?

normal blood glucose
Normal blood glucose

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.

question 2

Question 2:

Compare and contrast the signs and symptoms of diabetic ketoacidosis and insulin shock. Explain why each occurs.

lab tests
Lab tests


High blood glucose levels (> 250 mg/dL)

Accumulation of ketones in urine and blood

Insulin shock

Low blood glucose levels (< 45 mg/dL)



Extreme thirst


Dry mouth

Frequent urination



Difficulty breathing

Difficulty concentrating

Insulin shock


Difficulty concentrating






what s the deal with ketoacidosis
What’s the deal with ketoacidosis?

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.

what causes insulin shock
What causes insulin shock?

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.

similarities between ketoacidosis insulin shock
Similarities between ketoacidosis & 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?

why must insulin be injected
Why must insulin be injected?
  • Insulin is a protein made up of two peptide chains linked together by disulfide bonds.
  • Proteins are broken down and digested by proteases (i.e. pepsin in the stomach & trypsin in the small intestines)
  • If taken orally, insulin will therefore be broken down and deactivated, never reaching the blood stream
  • Insulin must be injected SQ to provide a more direct route of entry into the blood stream
types of insulin
Types of Insulin
  • Rapid (Quick-acting)

-Insulin Lispro

  • Short Acting

-Regular (R)

  • Intermediate-Acting

-NPH (N) or Lente (L)

  • Long-Acting

-Ultralente (U)

  • Pre-mixed
rapid insulin
Rapid Insulin

Onset: 5-15 minutes

Peak of Action: 1 hour after injection

Duration of Action: 3-4 hours

short acting regular insulin
Short-Acting (Regular) Insulin

Onset: 30-45 minutes

Peak of Action: 2-3 hours after injection

Duration of Action: 5-8 hours

intermediate acting insulin
Intermediate-Acting Insulin

Onset: 2-4 hours

Peak of Action: 4-10 hours after injection

Duration of Action: 10-16 hours

long acting insulin
Long-acting Insulin

Onset: 6-10 hours

Peak of Action: has a peak, but top speed looks like its normal speed

Duration of Action: 20 + hours

pre mixed insulin
Pre-mixed Insulin

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."

do persons with type ii diabetes ever require insulin injections if so when why
Do persons with Type II Diabetes ever require insulin injections? If so, when & why?
  • Type II diabetes occurs when the body produces enough insulin, but the ability to process & use this insulin is lost (the body becomes resistant)

Type II Diabetes Insulin Requirements

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

question 4 goal for a nutrition program for children with type 1 diabetes
Question #4Goal for a nutrition program for children with Type 1 Diabetes
  • Maintain blood glucose levels without causing excessive hypoglycemia
  • When hypoglycemia occurs bring levels up to 80 mg/dl
  • Foods low on glycemic index do not produce drastic changes in blood glucose levels; i.e. whole grains, oranges and peanuts

- > 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)

tips to help when eating out
Tips to help when eating out
  • keep a count of calorie intake
  • eat slowly
  • eat same portions as you would at home
  • order foods that are not breaded or fried
  • choose healthy alternatives
  • carry diabetes kit with you.
  • if rapid acting insulin is taken, try to delay injection until meal is served
  • talk to doctor about how to adjust insulin regimen when eating out
5a how do you prepare the injection why

#5A How do you prepare the injection? Why?

•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).

steps to preparing injection
Steps To Preparing Injection
    • •Carefully verify insulin labels.
  • •Roll the NPH vial between hands to resuspend the insulin preparation.
  • •If vial did not have cap on top, wipe off with an alcohol swab.
  • •Verify dosage a second time.

•Check the patient's name, medication, dosage, route and time of administration.

steps to preparing injection cont
Steps To Preparing Injection (Cont.)

•With the same syringe inject air equal to the dose of insulin to be withdrawn from the short-acting (regular) insulin.

  • Take insulin syringe and aspirate volume of air equivalent to the dose of insulin to be withdrawn from the intermediate-acting (NPH) insulin first.
  • Remove syringe from vial without aspirating the insulin.
steps to preparing injection cont1
Steps To Preparing Injection (Cont.)
  • Withdraw the correct dose into the syringe (10 units of regular). Verify again that the correct dose has been withdrawn.
  • Place the needle of the syringe back into the NPH vial and withdraw the correct dose (10 units). Verify that the correct dose has been withdrawn.
  • The total amount of insulin in the syringe should be the sum of the two types (20 units).
  • Because short acting insulin was mixed with

intermediate-acting insulin, which reduces

the action of the faster-acting insulin, administer

the mixture within 5 minutes of preparation.

what type of syringe would you use
What Type of Syringe would you use?

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.

  • A 50 or 100 unit Insulin syringe would be used
  • Insulin is measured in units (check the insulin bottle)

* syringe measuring cc's or mL's cannot be used*

what sites could you use for the injection
What sites could you use for the injection?
  • Insulin should be administered subcutaneously
  • There are 4 main sites:

abdomen, posterior arms, anterior and lateral thighs and posterior hips

  • The insulin is absorbed faster in the abdomen and the rate of absorption decreases in the arms, thighs and 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.


Question #5: Lipodystrophy and What are some of the long term complications of diabetes and why do they occur?

Researchers: J Strasheim & M. Valerio

Ppt. Preparer: Stefany Cimino

Presenter: Nancy Yang

lipodystrophy localized disturbance of fat metabolism below skin surface
Lipodystrophy: Localized Disturbance of Fat Metabolism Below Skin Surface

Causes: Not Rotating Insulin Injection Sites

2 Forms:

  • Lipoatrophy
  • Lipohypertrophy
lipoatrophy loss of subcutaneous fat under the skin surface resulting in small dents
Lipoatrophy: Loss of Subcutaneous Fat Under the Skin Surface Resulting in Small Dents
  • Appears as Slight Dimpling
  • Appears as Pitting (more serious)
lip hypertrophy buildup of fat below the skin surface causing lumps
Lip hypertrophy: Buildup of Fat Below the Skin Surface Causing lumps
  • Appears as Fibro-Fatty Masses.
  • Absorption is Delayed at these Sites.
  • Avoid these Sites Until Hypertrophy Disappears.
question 5d
Question 5d:
  • What are Some of the Long Term Complications of Diabetes and Why Do They Occur?
diabetes long term complications
Diabetes: Long Term Complications
  • Affects the Metabolism of Every Cell in the Body
  • Adversely Affects the Body’s Blood Supply
  • Can Lead to Life-Threatening and Disabling Complications Over Time
  • Therapeutic Management can Prevent or Delay the Onset of Various Complications
3 general categories of long term diabetes complications
3 General Categories of Long Term Diabetes Complications
  • Macrovascular Disease
  • Microvascular Disease
  • Neuropathy
macrovascular disease
Macrovascular Disease
  • Atherosclerotic Changes in Larger Blood Vessels
  • Diabetics are more Prone to Develop than non-diabetics, but No clear-cut explanation Why
  • There is No Direct Link Between Hyperglycemia and Artherosclerosis
  • Diabetes is Seen as an Independent Risk Factor
coronary artery disease
Coronary Artery Disease
  • Artherosclerotic Changes in Coronary Arteries
  • Leads to MI and an Increased Chance of a 2nd MI
peripheral vascular disease
Peripheral Vascular Disease
  • Atherosclerotic Changes in Large Blood Vessels of Lower Extremities
  • Decreased Peripheral Pulses
  • Intermittent Claudication
  • Increased Chance of Gangrene, Amputation
microvascular disease
Microvascular Disease
  • Changes Unique to Diabetics
  • Characterized by Capillary Basement Membrane Thickening
  • Increased Blood Glucose Levels React through a Series of Biochemical Responses to Thicken the Basement Membrane
diabetic retinopathy
Diabetic Retinopathy
  • Changes in Small Blood Vessels in Retina
neuropathy conditions affecting the nerves
Neuropathy: ConditionsAffecting the Nerves
  • Renal Disease
  • Foot and Leg Problems
renal disease
Renal Disease
  • Diabetics comprise 25% of the patients with End-Stage Renal Disease (ESRD) requiring dialysis or transplantation
  • Diabetics have a 20-40% chance of developing Renal Disease
  • Type I Diabetics show signs after 15-20 years
  • Type II Diabetics show signs within 10 years of diagnosis
renal disease after onset
Renal Disease: After Onset
  • The Kidney’s filtration mechanism is stressed, allowing blood proteins to leak into urine
  • Kidney Blood Vessel Pressure Increases-thought to serve as the stimulus for development of Nephropathy
  • As Renal failure progresses, catabolism of insulin decreases, and frequent hypoglycemic episodes result, requiring a change in insulin


foot and leg problems
Foot and Leg Problems
  • 50-75% of all Lower Extremity Amputations are performed on Diabetics
  • Increased risk of foot infections
three contributing factors
Three Contributing Factors
  • Neuropathy
  • PVD
  • Immunocompromised Status
  • Loss of pain and pressure sensation, increased dryness and fissuring due to decreased sweating
  • Poor Circulation in lower extremities, causes poor wound healing and increased risk of gangrene
immunocompromised status
Immunocompromised Status
  • Hyperglycemia Impairs the ability of specialized Leukocytes to destroy bacteria
  • Decreased Resistance to Infections
  • Daily Foot Checks
question 6a
Question #6A.

Physical education classes


cheerleading practice

physical education classes and cheerleading practice
Physical education classes and cheerleading practice

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.

before and after physical education cheerleading practice
Before and after physical education/ cheerleading practice:

Check glucose levels

You're good to go.

For most people, this is a safe pre-exercise blood sugar range.

Eat a healthy meal

Hydrate yourself

100-200 mg /dL

bring snacks and enough water or gatorade type drinks to physical education or cheerleading
Bring snacks and enough water or Gatorade-type drinks to physical education or cheerleading

If blood sugars are low try:

½ cup of juice or

few pieces of candy

if you feel lightheaded or dizzy at any time
If you feel lightheaded or dizzy at any time

Take a break

Eat and drink something to bring up glucose levels

always take breaks to hopefully avoid feeling lightheaded dehydrated or dizzy
Always take breaks to hopefully avoid feeling lightheaded, dehydrated or dizzy

Check glucose levels after

if planning on exercising long

30 minutes

wear appropriate footwear i e no flip flops or sandals
Wear appropriate footwear(i.e. no flip flops or sandals)

You need support and cushion

Check feet daily, especially plantar surface (bottom of foot)

question 6b
Question 6B.

Illness e.g. colds and the flu, episodes of diarrhea and vomiting?

diabetes management
Diabetes management:

Creating your

sick-day plan

Diabetes management can be especially challenging when you're struggling with a cold or other illness.
You don't feel well. Your temperature is high, you're tired and you've lost your appetite.

Having diabetes only adds to your concerns.

When you're sick, your body produces hormones to help fight the illness.

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.

To prevent complications,

make a sick-day plan

part of your diabetes


start with your health care team
Start with your health care team

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.

keep close track of your blood sugar and urine ketone levels
Keep close track of your blood sugar and urine ketone levels:

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.

Excessively high blood sugar can lead to ketoacidosis, especially in people who have type 1 diabetes.  

These conditions can be fatal.

stick to your diabetes meal plan
Stick to your diabetes meal plan

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

In addition to sipping fruit juice or sweetened beverages, drink at least 8 ounces of water or other calorie-free liquid every hour you're awake.

If you're not able to keep anything down, it's especially important to monitor your blood sugar closely.

know when to contact your doctor
Know when to contact your doctor

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

think prevention
Think prevention

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.

think prevention1
Think prevention

Ask your doctor about

vaccination for flu


pneumococcal pneumonia.

If you do get sick,

feel confident in your ability

to manage your diabetes by following

your sick-day plan.


Respiratory Infections

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.

  • Hemoglobin on red blood cells combine with blood glucose to make glycosylated hemoglobin
  • Red blood cells store glycosylated hemoglobin slowly over their 120-day life span
what is it
What is it?
  • A laboratory test also known as the Hemoglobin A1C
  • Analyzes the concentration of glycosylated hemoglobin within the body’s circulation
  • Determines blood glucose levels
High blood glucose levels
    • Result in red blood cells storing large amounts of glycosylated hemoglobin
  • Normal or near normal blood glucose levels
    • Result in normal or near normal amounts of glycosylated hemoglobin
why is it important
Why is it important?
  • High Glycosylated Hemoglobin puts you at risk for:
    • eye disease
    • kidney disease
    • nerve damage
    • heart disease and stroke

*especially true if the glycosylated hemoglobin remains high for a long period

how is the glycosylated hemoglobin test used
How is the glycosylated hemoglobin test used?
  • Diagnostic tool used by doctors for diabetic patients since 1976
  • Offers a good estimate of disease management over a 2 to 3 month period, in contrast to other tests that give a onetime snapshot
Used in the routine monitoring of patients with diabetes mellitus
  • How well patient is responding to treatment
    • Low test values reduce risk for having complications from diabetes mellitus
how is the test performed
How is the test performed?
  • Venipuncture
  • Some may feel moderate pain, or only a prick or stinging sensation.
  • Afterward, there may be some throbbing
examples of glycosylated hemoglobin
Examples of glycosylated hemoglobin
  • A glycosylated hemoglobin level of 7% is considered to be good
          • 6% Very Good
          • 8% Not too bad
          • 10% Not good
          • 13% Dangerous
benefits s s will derive from having the test done
Benefits S.S. will derive from having the test done
  • safely monitor her blood glucose levels
  • newly diagnosed pt’s may have to monitor levels closely over several 2-3 week periods
disadvantages to using this test
Disadvantages to using this test
  • Results require interpretation by a physician with knowledge of person’s clinical condition
  • False high or low may result
    • Some medical conditions such as splenectomies falsely increase levels
  • Potter, P.A., & Perry, A.G. (2009). Fundamentals of Nursing (7th edition). St. Louis, MO: Mosby, INC.
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  • McCance, Huether et al. Pathophysiology. 4th Edition.
  • Abraham , E.C., Schwartz, M.K., (1985) Glycosylated Hemoglobins – Mehtods of Anmalysis and Clinical Applications..
  • http://www.fda.gov/diabetes/glucose.html
  • http://www.endocrinologist.com
  • http://healthlibrary.epnet.com
  • http://www.healthatoz.com
  • http://www.labtestsonline.org/understanding/analytes/a1c/test.html
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  • http://www.mdconsult.com/
  • http://mayoclinic.com/