Question

Chapter 57 Case Study

You are working as a nurse in an outpatient clinic as the diabetic educator. Your patient has recently
been diagnosed with type 2 diabetes and you will be developing a teaching plan. Your patient is a 50-
year-old male with a history of hypertension, vital signs are stable, hemoglobin A 1C is 7.5%, and the
patient has a body mass index (BMI) of 28.

1. What are the main goals of therapy for all patients with diabetes in terms of both symptom control and
quantitative targets for fasting blood glucose levels and for the hemoglobin A 1c ?

2. You prepare a teaching plan to include glargine [Lantus] for your patient. What information will you
include in your teaching plan?

Answer 1

Case Scenario

My patient is a 50year old male with a history of hypertension. He has been recently diagnosed with type II diabetes mellitus. His vitals are stable, hemoglobin A 1C is 7.6 and patients' body mass index is 28.

1. Diabetes mellitus is a chronic disease, characterized by high levels of glucose in the blood. There are four major types of diabetes mellitus:

1. Type 1 diabetes mellitus: It is usually diagnosed in childhood and occurs because the insulin-producing cells of the pancreas that is Beta cells are damaged therefore there is little or no insulin prepared by the beta cells. Patients with type 1 diabetes mellitus require insulin injections to control their blood sugar levels.
2. Type 2 diabetes mellitus: it also referred to as adult-onset diabetes. In this type, the pancreas does not produce enough amount of insulin or either the insulin produced is not that effective in controlling the blood sugar levels. This type of diabetes can sometimes be controlled by lifestyle modifications and its treatment includes oral glucose-lowering medications or insulin injections

Goals of the therapy

• To maintain blood glucose levels within the normal limits
• To avoid acute decomposition, prevent or delay the appearance of late disease complications
• Reduce the risk of end-organ failures
• Reduce the risk of cardiovascular events such as myocardial infarction and cardiovascular deaths
• Delay or prevent the progression of heart failure
• To prevent hypoglycemia
• Weight control
• Maintain a good quality of life
• Glycemic control :
  • HbA1c should be <7.0
  • Preprandial capillary plasma glucose should be between 80-130 mg/dL
  • Peak postprandial capillary plasma glucose should be < 180 mg/ dL

• Blood pressure should be < 140/90mm Hg
• Lipids:
  • Low-density lipoprotein should be, 100 mg / dL
  • High density lipoprotein should ber > 40 mg/dL
  • Triglyceride should be < 150 mg /dL

2. Teaching plan to include Glargine( Lantus) for my patient

What is Glargine or Lantus insulin?

Injection glargine is used to control blood glucose levels in adults with type 2 diabetes and in children (6years or older) with type 1 diabetes. It is long-acting insulin, which starts acting after several hours of administration and its effects remains for a long time.

What are the possible side-effects of insulin glargine?

Common side effects are:

• Low blood sugar levels
• Itchy red rash on the site of injection
• Thickening of the skin where injection is administered

Call for medical health if you have

• Signs of an allergic reaction: itchy skin rash in entire body, wheezing, tightness of chest, swelling in throat or tongue
• Signs of infection: fever, chills, bad sore throat
• Very low or high blood sugar
• rapid weight gain
• shortness of breath

What are the important safety informations to consider?

• Check the insulin every time before use. It is colorless and should not be cloudy.
• You a single needle only once
• Regularly check your blood glucose levels
• Store the insulin in the refrigerator
• The insulin should never be freezed
• Do not share you insulin needle or pen with others
• Rotate the injection sites daily

What arte the sites for glargine insulin administration?

• Abdomen: this is the most commonly used site of injection. Select a site between the below ribs and above the pubic region, but avoid the 2 inch area surrounding the navel
• Thighs: between 4 inches below your thigh joint and 4 inches above the knee joint.
• Arms: at the back of your arm ( in the fatty area) between the shoulder joint and the elbow

How to take insulin injection?

Step1: Collect all the required materials

• Insulin pen or syringe
• Fresh needles
• Gauze
• Alcohol pads
• Puncture proof containers for sharps disposal

Step 2: Wash hands thoroughly

If you are using a vial and syringe

Step 3 a. hold the syringe in an upright position and pull the plunger till the required dose level

Step3 b. Remove the cap from the vial and clean the stopper of the vial with an alcohol swab

Step 3 c insert the needle into the vial and push the air into the vial

Step 3 d. Turn the vial upside down keeping the needing inside the vial and pull the plunger till it reaches the correct dosage

Step3e. Remove the needle from the vial and remove any air bubbles present

If using an insulin pen

Step3 a. rotate the back of the pen the, the dose selector according to the dose of insulin ordered

(Common for open and syringe)

Step 4. Clean the site of injection with an alcohol swab. Pinch 1-2 inch of the skin fold and insert the needle in a 90-degree angle and push the plunger and wait for 10 seconds. Release the pinched skin fold and remove the needle

Step 5. Discard the syringe or needle in the puncture proof container

Step 6. Place the insulin back in the refrigerator