Scenario

Y.L. makes an appointment to come to the clinic where you are employed. She has been
complaining of chronic fatigue, increased thirst, constantly being hungry, and frequent urination.
She denies any pain, burning, or low back pain on urination. She tells you she has a vaginal yeast
infection that she has treated numerous times with OTC (over-the-counter) medication. She
admits to starting smoking since going back to work full time as a clerk in a loan company. She
also complains of having difficulty reading numbers and reports making frequent mistakes. She
says by the time she gets home and makes supper for her family, then puts her child to bed, she is
too tired to exercise. She reports her feet hurt; they often burn or feel like there are pins in
them. She reports that after her delivery, she went back to her traditional eating pattern, which
you know is high in carbohydrates. In reviewing Y.L.s chart, you notice she has not been seen
since the delivery of her child 6 years ago. She has gained a considerable amount of weight; her
current weight is 173 lb. Today her BP is 152/97 mm Hg and her plasma glucose is 291 mg/dL.
The PCP (primary care provider) orders the following labs: UA, HbA1c (hemoglobin A1c),
fasting CMP, CBC, fasting lipid profile, and a baseline
24-hour urine collection to assess creatinine clearance. The lab values are as follows:

fasting glucose 184 mg/dL

A1c 10.4
UA glucose, ketones
cholesterol 256 mg/dL
triglycerides 346 mg/dL,
LDL (low-density lipids) 155 mg/dL
HDL (high-density lipids) 32 mg/dL,
diagnosed with type 2 diabetes.

After meeting with Y.L. and discussing management therapies, the PCP decides to start
insulin therapy and have the patient count carbohydrates. Y.L. is scheduled
for education classes and is to work with the diabetes team to get her blood sugar under control.

1. Identify the three methods used to diagnose DM. Research evidence-based practice relating to
what are the recent diagnostic tests for diabetes.

According to Ignatavicius & Workman (2016), DM can be diagnosed by:

1. Assessing the blood glucose levels three ways to get an accurate diagnosis
a. Fasting blood glucose test
i. Normal: <100 mg/dL
ii. Abnormal
1. >100-126 mg/dL impaired fasting glucose
2. >126 mg/dL on two occasions are diagnostic f diabetes
b. Glucose tolerance test (2-hr ost-load result)
i. Normal: <140 mg/dL
ii. Abnormal
1. >140 mg/dL but lower than 200 mg/dL impaired glucose
tolerance
2. >200 mg/dL indicate provisional diagnosis of diabetes
1
 c. Glycosylated hemoglobin (A1C)
i. Normal: 4-6%
ii. Abnormal:
1. 5.7-6.4% indicate increased risk for evelopment of diabetes
2. >8% indicates poor diabetes control and need for adherence to
regimen or changes in therapy.
(pp. 1308)

2. Identify three functions of insulin.

1. Promotes storage of glycogen in the liver (glycogenesis)

2. Inhibits glycogen breakdown into glucose (glycogenolysis)
3. Inhibits conversion of fats to acids (ketogenesis)

3. Insulins main action is to lower blood sugar levels. Several hormones produced in the body
inhibit the effects of insulin. Identify three.

According to Kennedy (2016),

1. Epinephrine (adrenaline) acts directly on the liver to promote sugar production
(via glycogenolysis). Epinephrine also promotes the breakdown and release of fat
nutrients that travel to the liver and that are converted into sugar and ketones.
2. Cortisol is a steroid hormone. It makes fat and muscle cells resistant to the
action of insulin, and enhances the production of glucose by the liver. Under normal
circumstances, cortisol counterbalances the action of insulin. Under stress cortisol levels
become elevated and you become insulin resistant.
3. Growth Hormone like cortisol, growth hormone counterbalances the effect of
insulin on muscle and fat cells. High levels of growth hormone cause resistance to the
action of insulin.

4. Y.L. was started on lispro (Humalog) and glargine (Lantus) insulin with carbohydrate
counting. What is the most important point to make when teaching the patient about
glargine?

The patient should know the side effects of hypoglycemia (cold sweats, pale skin,
drowsiness, excessive hunger, and headache), and hyperglycemia (flushed dry skin, fruit-like
breath, polyuria, confusion, and N&V). The patient should always carry candy if hypoglycemia
was to occur. Advise the patient to not mix glargine with any other insulin or medication, and to
use a different site as the lispro. Make sure that the pateitn heck the blood sugar every 6 hours
Advise the patient that the onset of glargine is 3-4 hours and the duration is 24hr, so there
shouldnt be any excessive exercising or skipping a meal, because that can cause severe
hypoglycemia (Vallerand, &Sanoski, 2013).

2
5. Because Y.L. has been on regular insulin in the past, you want to make sure she understands
the difference between regular and lispro. What is the most significant difference between these
two insulins?

The most significant difference is that lispro is a rapid-acting insulin, which means that
lispro has a rapid onset and shorter duration than regular inulin.

6. What is the peak time and duration for lispro insulin? Why is it important to know?

Lispro has an onset of 15 min and duration of 3-4 hours (Vallerand, &Sanoski, 2013).
This is important to know because patient needs to know that they need to immediately after
administration of lispro to avoid hypoglycemia. According to Noble, Johnston, & Walton
(2016), Because insulin lispro begins to exert its effects within 15 minutes of administration,
patients must eat within this time period.

7. Y.L. wants to know why she cant take NPH and regular insulin. She is more familiar with
them and has taken them in the past. Explain why the provider chose lispro and glargine insulin
over NPH and regular insulin?

I believe the provider chose to change Y.L. from NPH and regular insulin lispro and
glargine because Y.L.s blood glucose was still not under control with NPH and regular insulin,
which may have been due to NPH and regular insulins long onset and short duration. Regular
insulins onset is 30-60 minutes and duration of 5-7 hours, and NPHs onset is 2-4 hours and
duration is 10-16 hours (Vallerand, &Sanoski, 2013); Y.L.s pancreas over the years was
deteriorating causing the beta cells to decrease the release of insulin (Timby & Smith, 2014), so
this regimen of NPH and regular insulin was not giving Y.L. enough insulin coverage with the
long onset and short duration.
Lispro has a rapid onset of 15 minutes and short duration of 3-4 hours, but if taken with a
long acting insulin like glargine, which has a slow onset of 3-4 hours, but longer duration of 24
hours. Lispro and glargine will work together to lower Y.L.s blood sugar quickly (lispro), so she
can eat quicker without experiencing hypoglycemia and keep her blood sugar down for a long
time (glargine) so that she does not experience hyperglycemia throughout the day. This regimen
will help Y.L. control her blood sugar under control (Vallerand, &Sanoski, 2013).

8. Y.L.s culture prefers foods high in carbohydrates. What is carbohydrate counting and why
would this method work well for Y.L.?

According to Timby & Smith (2013), carbohydrate counting is a dietary management

that involves an individualized meal pattern that specifies the number of carbohydrate choices,
which is one choice = 15 carbohydrate for each meal and snack. Most adults are allowed 3-5
carbohydrate choices per meal and 1-2 for each snack, depending on their caloric needs (pp.
863). Y.L. doesnt have to completely get rid of the carbohydrates that her culture consumes she
just has to properly count the carbohydrates that she consumes in each meal and snack and keep
3
it within her dietary limit she will be able to consume those carbohydrates. The only difference
is she will be eating those carbohydrates in the correct portion sizes per meal or snack.

9. What symptoms did Y.L. report today that led you to believe she has some form of
neuropathy? What type of teaching would you initiate?

The symptoms that Y.L. reported that led me to believe that she has some form of
neuropathy is when she said she that her feet hurt; they often burn or feel like there are pins in
them.
I would instruct Y.L. to inspect her feet daily for blisters, corns, calluse, long or ingrown
nailes, or any reddedned areas; use mirror to visualize all aspects of the foot. Wash the feet daily
in warm (not hot) water. Dry the feet thoroughly, being carful to dry between the toes. Keep
toenails short and cut straight across. Do not use razor, abrasive, or commercial products to
remove corns or calluses. Use lambs wool between toes that overlap. Wear well-fitting shoes
that fit comfortably when first worn; do not wear rubber, plastic, or vinyl shoes that cause the
feet to perspire. Never go barefoot. Visit a podiatrist regularly for foot care. Wash, dry and
cover any injuries with sterile gauze (Timby & Smith, 2013).

10. What findings in Y.L.s history place her at increased risk for the development of other forms
of neuropathy? If Y.L. chose not to conform with diabetic teaching, what are some of the legal,
ethical consequences related to caring for this patient?

According to Ignatavicius & Workman (2016), risk factors for neuropathy is poor blood
sugar, smoking, physical inactivity, obesity, hypertension, and high blood fat and cholesterol
levels (pp. 1303).
Y.L. risk factors is she was newly diagnosed with DM type 2, overweight (173 lbs), does
not exercise, has Bp of 152/97 mmHg, poor control of blood glucose (fasting glucose=184
mg/dL, A1C= 10.4%, plasma glucose 291mg/dL), cholesterol 251mg/dL, triglycerides
346mg/dL, LDL 155mg/dL, and HDL 32mg/dL. All these risk factors can damage the nerve
endings causing neuropathy if not corrected immediately and managed coorectly.
If Y.L. does not comply with the diabetic teacing then the legal ethical consequences we
would be facing is knowing that the diabetic neuropathy will only get worse to the point she will
not feel her feet and having complications of multiple wounds that does not heal properly, which
leads to infection, then to amputation. We as nurses can only inform the patient of the
consequences that will occur and the worst possible outcome if they do not comply with the
teaching, and it is the patients decision if they want to follow it or not.

11. What are some changes that Y.L. can make to reduce the risk or slow the progression of both
macrovascular and microvascular disease? Which community diabetic organizations would you
make referrals to in order to help Y.L.? (give two examples) Which interdisciplinary team
members would be appropriate to incorporate in her care? (give two examples)
According to Ignatavicius & Workman (2016), intensive therapy to maintain blood
glucose levels as close to normal as possible delays the onset and progression of retinopathy,

4
neuropathy. The macrovascular complications can be reduced by through aggressive
management if hyperglycemia, hypertension, and hyperlipidemia, and lifestyle modifications
(pp.1303). If Y.L. follows the strict management of her diabetes she will be able to avoid the
complications that come with microvascular and macrovascular diseases.
The two community diabetic organizations that I would recommend Y.L. to reach out to
is American Diabetes Association, and the Queens Medical Center West Oahus diabetes
education program. The American Diabetes Association is an online website that gives a variety
of information of diabetes and also people you can contact in your community to talk to about
your diabetes. The Queenss Medical Center West Oahus diabetes education program that helps
people with diabetes manage their disease in multiple ways.
The two interdisciplinary team members that I would consult to help with the care of Y.L.
is a podiatrist and social worker. The podiatrist is a team member that will help manage the foot
care that Y.L. will have to perform in order to minimize any complications that might occur with
her neuropathy. The social worker will help Y.L. find ways that will help Y.L. quit smoking in
order to decrease the risks of developing macrovascular and microvascualr complications.

12. Y.L. is enrolled in a smoking cessation class. Why is it so important that she stop smoking?

It is important for Y.L. to quit smoking because smoking narrows and hardens your
arteries, reducing blood flow to your legs and feet. This makes it more difficult for wounds to
heal and damages the integrity of the peripheral nerves (MayoClinc, 2016). If Y.L. continues to
smoke it will increase her chances in developing a macrovasuclar or microvascular disease
because of its of affects of damaging the arteries.

References
Ignatavicius, D.D., & Workman, M.L. (2016). Medical-surgical nursing: Patient-centered

collaborative care (8th ed.). St. Louis, MO: Elsevier.

Kennedy, M.N. (2016). Blood sugar & other hormones. Diabetes teaching center at the

5
 University of California, San Francisco. Retrieved May 26, 2016 from

http://dtc.ucsf.edu/types-of-diabetes/type2/understanding-type-2-diabetes/how-the-body-
processes-sugar/blood-sugar-other-hormones/

Mayo Foundation for Medical Education and research (2016). Diabetic neuropathy. Retrieved

May 28, 2016 from http://www.mayoclinic.org/diseases-conditions/diabetic-

neuropathy/basics/risk-factors/con-20033336.

Timby, B.K., & Smith, N.E. (2014). Introductory Medical-Surgical Nursing (11th ed.,

pp. 213). St. Louis, MO: Elsevier.

Vallerand, A.P., Sanoski, C.A., Deglin, J.H. (2013). Daviss Drug Guide for Nurses (13th ed.,

pp. 678, 999). Philadelphia, PA: F. A. Davis Company.