Question

You work in the diabetes mellitus (DM) center at a large teaching hospital.  The first patient you meet is K.W., a 25-year-old Hispanic woman, who was just released from the hospital 2 days ago after being diagnosed with type I DM.

            Nine days ago K.W. went to see the physician after a 1-month history of frequent urination, thirst, severe fatigue, blurred vision and some burning and tingling in her feet. She attributed those symptoms to working long hours at the computer. Her random glucose level was 410 mg/dL. The next day her laboratory values were as follows: fasting glucose 335 mg/dL, hemoglobin A_1c(HBA_1c) 8.8%, cholesterol 310 mg/dL, triglycerides 300 mg/dL, high-density lipoprotein (HDL) 25 mg/dL, low-density (LDL) 160 mg/dL and creatinine 0.9 mg/dL. Her body mass index is 37.6. Her blood pressure is 160/96. She was admitted to the hospital for control of her glucose levels and the initiation of insulin therapy with carbohydrate (CHO) counting. After discharge, K.W. has been referred to you for comprehensive education. You are to cover four basic areas: pharmacotherapy, glucose monitoring, medication nutrition therapy and exercise.

Case Study Progress: K. W. calls the clinic several days later complaining of having the “flu”. She says that she has been nauseated and vomited once during the night. She sats she has had two loose stools. On questioning she states she does have a few hills and might have a low grade temperature but does not have a thermometer to check her temperature. She states she did not check her glucose level this morning or take her insulin because she has not eaten.

12. Describe the instruction that you need to give K.W. regarding the management of her illness and DM.

13. Write below how you would document the phone call with K.W. in progress note format.

Answer 1

12. Goals of management :-

- decrease symptoms

- promote well being

- prevent complications

- delay onset and progression of long term complications

- maintain normal blood glucose levels

#. Patient-centered education for blood glucose monitoring :-

Self monitoring of glucose monitoring-SMBG assists in reaching target blood glucose levels and in prevention of hypoglycemia

-Home meters measure whole blood, which is 10-15% lower than lab samples

-Multiple times a day is often required for multiple insulin injections-3-4x a day

-talking meters for the visually impaired

2) Nutritional management for diabetes with carbohydrate counting and use of exchange lists :-

total carbohydrates 45-65% and include fruits, vegetables, whole grains, legumes and low fat milk, min. of 130g per day

-protein intake 15-20%, less with kidney disease

-fiber to 14g per 1000 calories-monitor for hypoglycemia, AHA recommends 26 g/day

-limit saturated fat to less than 7%

-monitor alcohol use-2 fat exchanges, only with meals

-one food group equally exchanges for another in the same group. 1 slice of bread=1/2 cup of pasta

carb. counting-1 unit of rapid acting insulin covers 15g of carbohydrates-useful for insulin pumps

-2 slices of toast=32g carbs

-1/2 OJ is 1 exchange

3) Patient teaching to identify and treat peripheral neuropathy, and foot care

-cleanse and inspect feet daily for redness, check bathwater temperatures, optimal 95 degrees F, wear proper shoes, no open toe, well-fitting, avoid walking bare-foot, get a doctor to trim toe-nails properly, cream on feet but not btw toes, report any nonhealing breaks in the skin to the health care provider

4) Teaching about the medication ,their actions and side effects . What are the signs of emergency ,when to reach the physician.

5. Teaching about insulin administration ,the sites , timings , different types of insulin etc.

13) Documentation of the phone call :-

The patient named K.M called to the clinic complaining of having the “flu”. She says that she has been nauseated and vomited once during the night. She had two loose stools. On questioning she states that she does have low grade temperature but does not have a thermometer to check her temperature. Also she states that she did not check her glucose level in the morning and have't take her insulin because she has not eaten.

Signature of the staff nurse

Date