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.
The three methods used to diagnose DM are, fasting blood glucose blood test,
urinalysis to check for glucose in the urine, and HgbA1C which checks blood sugar
levels over a period of time.
As stated in Ignativicius, D, Workman, M (7th ed., 2013), HbA1C is a test that
measures how much glucose permanently attaches to a specific area of the hemoglobin
molecule. Because glucose binds to a variety of proteins through glycosylation, the
higher the blood glucose is overtime, the more glycosylated hemoglobin becomes.
HbA1C testing is now highly standardized for accuracy and precision.
2. Identify three functions of insulin.
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Three functions of insulin are, to promotes storage of glucose, promotes
conversion of glucose to fat, and enhances protein synthesis.
3. Insulin’s main action is to lower blood sugar levels. Several hormones produced in
the body inhibit the effects of insulin. Identify three.
Out of several hormones that inhibit the effects of insulin, three of them are
cortisone, hormonal growth factor, and epinephrine.
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 most important point to make when teaching the patient about glargine is, to
never mix glargine with another insulin due to the low pH of glargline’s diluent.
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 insulin?
The most significant difference between regular and lispro, is their onset, peak,
and duration of action. Humalog needs to be taken with food (15’) or right before eating.
Taking Y.L.’s busy schedule and that she does not keep up with regular checkups into consideration, it should be emphasized in the teaching plan as to when it is
best to administer insulin, if food needs to be eaten within that time frame, and the signs
and symptoms of hypo- and hyperglycemia. A verification of her understanding of the
regimen and compliance with the treatment plan should be implemented
6. What is the peak time and duration for lispro insulin?
The peak time of lispro is 0.5 -1.5 hours with duration of 3 – 5 hours.
7. Y.L. wants to know why she can’t 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?
The provider is prescribing lispro and glargine over NPH and regular insulin
because given Y.L.’s busy daily schedule lispro will allow her take lispro when she is
able to have a meal due to its rapid onset (15’-30’), placing her at low risk for
hyperglycemia and better control over postprandial blood glucose level. At the same
time, taking glargine will cover a full day (20-24 hours) and does not peak, so will not
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place her at risk of hypoglycemia. Lispro and glargine are often used in combination for
treatment of DM.
From an ethical point, if Y.L. chose not to accept the provider’s recommendation
to switch from NPH and regular insulin to lispro and glargine, the provider can explain
the pros and reasons for the switch in regimen or can adjust her diet to accommodate
Y.L.’s preferred medication regimen. As a nurse, I know that patients have the right to
choose their treatment or refuse it altogether. I understand that she may be used to the
old regimen she was last on and that is why she prefers to go back to it, not realizing
that her routine and diet may have changed since then. The provider may allow her to
go back to NPH and regular insulin if Y.L. is aware of the consequences of her choice
and will accept to make other lifestyle adjustments to fit her preferred regimen.
8. Y.L.’s culture prefers foods high in carbohydrates. What is carbohydrate counting and
why would this method work well for Y.L.?
Carbohydrate counting is counting the amount of carbs in grams eaten per day.
A registered dietician and possibly your primary care physician will determine the
amount of carb intake per day that should be eaten.
This method works well for Y. L. because she prefers to eat food high in carbs it
does not take away what carbs she likes to eat or the fact that she likes to eat carbs,
just minimizes amount of carbs she is able to eat in a day.
An RN that specializes in diabetes can also assist with diet and management of
care if a registered dietitian is not available.
9. What symptoms did Y.L. report today that led you to believe she has some form of
neuropathy?
Symptoms reported today that indicate she may have a form of neuropathy is
that her feet often feel, “burn of feel like pins are in them.”
10. What findings in Y.L.’s history place her at increased risk for the development of
other forms of neuropathy?
Other findings that place Y.L. at increased risk for the development of other
forms of neuropathy is one, now being diagnosed with DM; two, smoking; three, weight
gain; four, increased BP, and lastly hyperlipidemia.
Once patient is diagnosed with diabetic neuropathy, patient can be referred to a
neurologist to assist in the care and management of the neuropathy. A clinical assistant
may assist in preventative screening for diabetic neuropathy then report any
abnormality to the physician.
11. What are some changes that Y.L. can make to reduce the risk or slow the
progression of both macrovascular and microvascular disease?
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Some changes that Y.L. can make to reduce the risk/slow progression of both
macrovascuar and microvascular disease are, having proper foot care, quit smoking,
get yearly eye exams, exercise, diet, stress management, and DM medication
compliance.
Informing Y.L. to immediately contact her provider when she begins to
experience blurry vision, numbness and tingling in her lower extremities, constant
headaches, and chest pain can prevent her from experiencing diabetic complications of
retinopathy, neuropathy, CVA, HTN or CAD from occurring.
12. Y.L. is enrolled in a smoking cessation class. Why is it so important that she stop
smoking?
Smoking raises BG levels and increases insulin resistance, causes CAD that
increases HTN that increases risk of DM. Stopping smoking will lower the risk of DM
complications.
13. Reflection: Carefully considered two components learned and identified at least one
learning need.
What I have learned from this case study are that there are both microvascular
and macrovascular complications associated with unmanaged DM, and the functions of
insulin. What I have yet to understand is the difference between the different types of
insulin, the mechanism of action, and why or when to prescribe which type of insulin to
a diabetic that will best fit them.
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