Question

60-year-old woman with a medical history of T2DM for 10 years (baseline A1C, 9.8%) hypertension for 15 years, cerebrovascular disease (stroke in 2010), and chronic kidney disease (estimated CrCl, 48 mL/minute; urine albumin:creatinine 100 mcg:mg) is being seen 5 days before routine follow-up as she developed influenza. Her home drugs are insulin glargine 58 units subcutaneously daily, gliclazide 80 mg two times orally daily, lisinopril 40 mg orally daily, and aspirin 81 mg orally daily. The patient tells of a history of frequent, mild hypoglycemia. Fever and chills for one day. She has completed several diabetes self-management education courses and self-monitors blood sugar twice daily. Her current A1C is 9.4% (9.6% 3 months ago), and her blood pressure is 144/86 mm Hg (142/84 3 months ago). The doctor is about to prescribe new medication/review existing medication.

1. List: Relevant information, like key lab values/symptoms from the case.

2. Assessment: Identification of 3 problems in drug therapy.

3. Care Plan: Preparing the most appropriate care plan for the patient considering the patient-specific factors.

4. Monitoring: List the safety and efficacy monitoring required, this could be also monitoring a lab value or a prognostic indicator like a change of a symptom.

Answer 1

1. Lab values :-

- Estimated CrCl 48 mL/minute

- urine albumin:creatinine 100 mcg:mg

- Current A1C is 9.4%

#. Symptoms :-

- fever

- chills

- mild hypoglycemia

3. Nursing interventions :-

- Blood sugar monitoring: Normal range 70-180 mg/dL patient may have a different target blood sugar level, make sure to know what each patient’s target is.

The physician will make a target blood glucose level. Teach the patient that they need to monitor their blood glucose.They need to call their primary care physician if they have blood glucose levels higher than their target for multiple days or if they have 2 readings of greater than 300 mg/dL.

Teach the patient how to use their glucometer and record their results.

- Insulin administration -Rapid Acting: Humalog Novolog -Fast/short Acting: Regular -Intermediate Action: NPH -Long Acting:’ Lantus Levemir

It is important to know which insulin to give and how they work. Each institution has guidelines and each insulin has guidelines. Following the guidelines, make sure you know the onset, peak and duration of each type of insulin.

-Rapid Acting

Onset: 10-30 minutes

Peak: 30 minutes- 3 hours

Duration: 3-5 hours

-Fast/short Acting

Onset: 30 minutes-1 hour

Peak: 2-5 hours

Duration: Up to 12 hours

-Intermediate Action

Onset:1.5-4 hours

Peak: 4-12 hours

Duration: Up to 24 hours

-Long Acting

Onset:1-4 hours

Peak: minimal peak

Duration: Up to 24 hours

To administer insulin, teach the patient to rotate injection sites and to clean the site with alcohol prior to inserting needle.

- Educate about nutritional changes and monitoring

This would be a good time to get the dietician involved. The patient needs to learn at a minimum, how to count carbs and which foods to avoid such as beer.

A patient’s glucose should be checked once when the patient wakes up, before meals, and before going to bed.

If the patient is hypoglycemic, and they are able to eat or drink, give them some OJ and graham crackers with peanut butter.

Increase water intake if the patient has hyperglycemia

- Monitor feet and educate about monitoring feet

Both decreased blood flow to the feet as well as neuropathy occur to make the feet something the patient really needs to watch. Wounds are hard to heal so if they are having a hard time feeling their feet and they become injured, the wounds will be worse than with someone without diabetes.

Teach the patient to check their feet everyday. Washing their feet, cutting their toenails straight across, and scrubbing off calluses gently are a couple of points to make with the patient.

The patient may have a podiatrist involved in their care as well.

As a nurse, you will need to be checking the patient’s feet as well and monitor any wounds.

- Monitor Blood Pressure (BP) Normal Blood Pressure: 120/80 mmHg

It is vital to keep someone with diabetes within normal limits for their blood pressure.

Placing strain on the cardiovascular system wrecks havoc on other organ systems. Being diabetic makes the chances of that system having issues worse. A patient can lose their vision, kidney function, have a stroke or heart attack.

Educate about maintaining a healthy weight and keeping active

With a healthy weight, the patient is likely also implementing a healthy diet as well as implementing more movement. These three things (weight, diet, exercise) can help to manage or even reverse diabetes.

- Healthy weights are calculated based on height and sex of the patient. Other ways to monitor the size of the patient is to use a BMI calculator or measure waist circumference.

4. Safety and efficacy monitoring include :-

- regular blood sugar monitoring

- regular BP monitoring

- regular weight monitoring

- LFT and KFT levels

- feet monitoring

- side effects of medications that require urgent management