Case Study of K.W

1

CASE STUDY OF K.W.

Case Study of K.W

Anna Keane

University of New Hampshire

4/26/2016

Scenario

You work in a diabetes mellitus (DM) treatment center located in a large teaching hospital. The first patient you meet is K.W., a 25-year-old Hispanic female, who was just released from the hospital 2 days ago after being diagnosed with type 1 DM. Nine days ago, K.W. went to see the physician after 1-month history of frequent urination, thirst, severe fatigue, blurred vision, and some burning and tingling in her feet. She attributed thosesymptoms to working long hours at the computer. Her random glucose level was 410mg/dL. The next day, her labs, were as follows: fasting glucose 335mg/dL, HbA1C 8.8%. cholesterol 310mg/dL, triglycerides 300mg/dL, HDL 25mg/dL, LDL 160mg/dL, ratio 12.4, creatinine 0.9 mg/dL, and body mass index of 37.6. Her BP is 160/96 mm Hg. She was admitted to the hospital for control for her glucose levels and the initiation of multi-dose injection 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, medical nutrition therapy (MNT) and exercise.

Pathophysiology

Insulin is a hormone secreted by beta cells in the in the islets of Langerhans in the pancreas. When a person eats glucose is released in the blood stream which, triggers insulin to be secreted. Insulin functions to transport and metabolize glucose for energy, stimulates the storage of glucose in the liver and muscle, signals the liver to stop the release of glycogen, enhances storage of fat in adipose tissue, accelerates the transport of amino acids into the cells, and inhibits the breakdown of stored glucose, protein and fat. (Hinkle, Cheever 2014)

Type 1 diabetes (T1D) previous called juvenile diabetes, ketosis prone diabetes, insulin dependent diabetes mellitus, is a metabolic disorder that is characterized by an absence of insulin production and secretion from the autoimmune destruction of beta cells. Further more, glucose that comes from food cannot be broken down into energy and converted to glycogen in the liver. Glucose remains in the blood stream leading to hyperglycemia. If blood glucose exceed 180-200mg/dL the renal threshold, the kidney cannot reabsorb all glucose and it is excreted in the urine. This leads to osmotic diuresis, which causes excess fluid and electrolytes to be excretedas well. Since the body cannot convert glucose from the food being ingested. It breaks down fat as energy that results in highly acid ketone bodies into the body. (Hinkle, Cheever, 2014)

Epidemiology and Prevalence

Endocrinology and metabolism clinics of North America collected data from large epidemiological studies worldwide. In the United States approximately 1 in 300 people will be diagnosis with T1D by the age of 18. People being diagnosed with T1D have increased by 2-5% worldwide. Onset of T1D usually occurs during adolescence. Majority of cases are diagnosed before the age of 20 and the number of cases peaks between the ages of 10-14. However, one fourth of the people diagnosed with T1D are diagnosis as an adult. T1D on average equally effects woman and men. There evidences that T1D is genetically linked. They report that 90-95% of people with T1D carry one or both the halotypes, Human leukocyte antigen complex I or II. These halotypes are now considered the principal susceptibility marker for T1D (Maahs, West, Lawrence, Mayer-Davis, 2010).

The SEARCH for diabetes in youth study looked at the incidence of type 1 and type 2 diabetes in Hispanic American youth and set out to describe the demographic, clinical, and behavioral characteristics of this population. They found that among Hispanic American youth, T1D was more prevalent than type 2 diabetes. Common factors that arose in this population were poor glycemic control, as well as elevated LDL cholesterol and triglycerides. In addition 40% of Hispanic American youth with T1D were overweight or obese. (Lawrenceet al., 2009)

Pharmacotherapy

K.W was started on sliding scale lispro (Humalog) four times daily and glargine (Lantus) insulin at bedtime. K.W states she knows people who take NPH and regular insulin and wants to know why she can’t take them. You as her nurse are to go over with her the most significant difference between these two insulins and explain the advantages of using glarine (Lantus) and lispro (Humalog) insulins, In addition to other important information K.W needs to know about DM1 pharmacology.

Since people with T1D no longer produce their own insulin they must get their insulin exogenously through insulin injections. There are many different forms that insulin can come in, they main difference is their onset, peak and duration of action. Lispro (Humalog) is a rapid acting insulin with a onset of action of less than 15 minutes and peaks 30 minutes to an hour after injection. The effects of Humalog last for 3-4 hours. This insulin is expected to cover the increase in glucose post meals so this insulin is to be given multiple times a day, prior to the patient eating a large meal. Glargine (Lantus) is long acting insulin with an onset of an hour and duration of 24hours. This insulin is peakless, its function is to keep a constant level of glucose through out the day. This insulin is given once a day at the same time. The biochemistry of this insulin makes it acidic so it cannot be mixed with other insulin or it will cause precipitation of the medication and make it ineffective. The advantage of this regimen is that it more closely mimics a normal pancreas. Lantus maintaining a basal insulin level where Humalog would mimic the extra insulin that a pancreas would have to produce after the consumption of a meal. In addition each pre-meal dose of Humalog can be adjusted to more or less depending on the patients blood glucose level. This allows the patient to have more flexibility with their life. Use of NPH and regular insulin would not allow a patient to have as much flexibility, it is recommended that that people who take these insulin’s should not vary their meal patterns and activity levels (Hinkle, Cheever 2014).

When on insulin therapy it is important for a person to properly know how to store insulin, how to properly and safely administer insulin and know the signs and symptoms of hypoglycemia. For proper injection you should inject the insulin into a fatty area, example would be on the stomach or any area where you can “pinch an inch”. Sites of injection should be rotated to prevent irritation. Also the site should be cleaned prior to injection with an alcohol pad. To store current vial of insulin it can be kept at room temperature out of light for up to one month. If insulin is discolored in any way do not use. An adverse effect of hypoglycemia, signs and symptoms of this are Sweating, chills, clamminess, irritability, confusion, rapid heartbeat, lightheadedness, dizziness, nausea blurred vision, tingling or numbness, headaches, fatigue. If a person experiences any of these symptoms that should have a fast acting carbohydrate and test their blood sugar.

Glucose Monitoring

Self-Monitoring of Blood Glucose (SMBG) measures a person’s blood glucose at that moment. This allows for detection and prevention of hypoglycemia. It is important for a person to normalize blood glucose to prevent diabetic complications such as s retinopathy, nephropathy, neuropathy and cardiovascular disease. (Hinkle, Cheever, 2014)

To see how a patient is controlling their blood glucose over a long period of time HgbA1C monitoring is done to see how a person in managing their blood glucose level over a period of 120 days. When blood glucose is elevated in the blood, the excess glucose attaches to the hemoglobin of the red blood cell. The longer amount of time there is an elevation of glucose the more glucose attaches to the red blood cells. This results in in an increase result of HgbA1C. (Hinkle, Cheever, 2014)

National Institute for Health and Care Excellence (NICE) for adults with type 1 diabetes publishednew recommendations in August of 2015 that offers approaches to care in T1D. NICE has the goals to keep the patient at the center of their care, minimize complication of T1D and promoting education for T1D. The current NICE recommendations for blood glucose monitoring and blood glucose management are as follows.HbA1c levels should be taken every 3–6months in adults with T1D and a tighter target of 6.5% should be managed tominimize the risk of longterm vascular complications, however, factor such as the person's daily activities, risk for complications, their comorbidities, occupation and history of hypoglycemia, should be considered to come to a individualized HbA1c target. NICE guideline also recommends that adults with T1D SMBG testing at least 4times a day, including before each meal and before bed. They only recommend using fingertips as sites for selfmonitoring of blood glucose. Also at this time they cannot recommend real-time continuous blood glucose as a way of routinely monitoring their blood glucose levels. (NICE, 2015)

Medical Nutrition Therapy

K.W states her diet is mostly fast foods and the foods cooked at home are high in starch and fat. She also states that because of her work schedule, meal times often vary from day to day. She asks what is CHO counting and why would this method work well for her?

Medical Nutrition Therapy (MNT) is prescribed by a registered dietician to help manage T1D. The goals of MNT are to achieve and maintain normal healthy range of blood glucose, lipid, lipoprotein, blood pressure levels, to prevent or slow chronic complications by modifying nutrient intake and lifestyle. To address the individual needs of patient, Consider personal and cultural preferences, all while trying to maintain the pleasure of eating. CHO counting consists of counting the grams of carbohydrates an individual eats. (Hinkle, Cheever, 2014) A person can mange this by reading food labels and using recourses like the United States Department of Agriculture website to find nutrition facts for food that tend not to have labels for example fruit and vegetables. When working with a registered dietician a person can come up with a “carb balance” that will suit their needs and lifestyle. A carb balance is the amount of a carbs a person can eat per meal to keep their blood sugar a consistent level (Hinkle, Cheever, 2014). This allows for flexibility and individualization of their own diet.

Exercise and Lifestyle

K.W states that she currently doesn’t exercise at all. What benefits will K.W receive from participating in an exercise program? What do you need to teach K.W. regarding exercise precautions.

Exercise is an important part in management of T1D. Exercising increases the uptake if glucose in the body by the muscles which in turns lowers blood glucose levels and improves insulin utilization of the body. This is important with people with T1D to reduce cardiovascular complications of hyperglycemia. In addition to lowering blood glucose levels exercising improves circulation, muscle tone, eases stress. Also an increase in the patient’s metabolism can result in weight reduction as well. Exercise can also lower blood lipid concentration, increase HDL, lower total cholesterol and triglycerides. These are also important to reduce the rick for cardiovascular complications.

The benefit of the reduction of blood sugar during exercise also can become dangerous if the person becomes hypoglycemic. It is recommendedpreventing episodes of hypoglycemia by eating 15 grams of a CHO source in combination with a source of protein before moderate exercise. If a person is planning on exercising for long periods at a time they may

Require blood glucose monitoring before, during, after exercise and bring CHO snacks with them. It is also important to wear a wear a medical alert bracelet to alert other people if you become unconscious do to a hypoglycemia episode. (Hinkle, Cheever, 2014)

K.W states that she and her husband were planning to have another child in a year or two. She wants to know how her DM will affect a pregnancy. In persons with DM is a complex issue. What basic information can you share with K.W today without overwhelming her.

It is important woman who have T1D to start planning early. Women should monitor HbA1c, thyroid-stimulating hormone, creatinine, and urine albumin-to-creatinine ratio

testing preconception and through out to assure good health for mother and baby. During pregnancy a woman’s HbA1c levels are recommended to be < 6%. In patients with T1D

maintaining constant blood sugar control allows them to have a normal pregnancy and can lead to a healthy baby. Since a pregnant woman needs to maintain a tighter glycemic control she may require more daily monitoring and more frequent HbA1c testing as as well to avoid complications from uncontrolled glucose such as a baby large for their gestational age, preterm deliveries, pre-eclampsia, and neonatal low blood sugar. (Jolley, 2015)

Case Study Progress

K.W calls the clinic several days later complaining of the “flu”. She has been nauseated and vomited once during the night. She says she has had to lose stools. Upon questioning she states that she does not have a few chills and might have a low-grade fever but does not have a thermometer to check her temperature. She did not check her glucose level this morning or take insulin because she has “not eaten”Describe the instructions that you need to give K.W regarding the management of her illness and DM.

When a person with T1D becomes sick it is important to keep monitoring glucose even if they are not eating. They should be monitoring their blood sugar every 3 to 4 hours. They should continue to take insulin as needed. As for nutrition, it is recommended that they try to meet their carbohydrate needs through soft food or liquids 6 to 8 times a day. Also they should consume sugar free fluids to prevent dehydration. Also rest is important as well. When sick a person with T1D should call the provider if blood glucose is greater than 240mg/dL and their urine test for ketones, or if they become disoriented or confused, have rapid breathing, continue to vomiting and diarrhea occurring more than 5 times a day or longer than 24hr. (Hinkle, Cheever, 2014)

Summary

K.W. is newly diagnosed with T1D, it is important to provide education for this patient so she will be able to control her diabetes. Since this is a life altering diagnosis it is important as healthcare providers to be patient, reeducation may have to be taken. Priority right now is for K.W. to learn how to properly monitor and normalize her blood sugar. Once she has some control of that, it is important to then focus on reducing her other risk factors that can contribute to cardiovascular problems down the line. Weight reduction, lowering her triglycerides, LDL cholesterol and total cholesterol and raising her HDL cholesterol with exercisewill furthermore reduce her risk for diabetic complications down the road.

References

Brunner, L. S., & Smeltzer, S. C. (2010). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Lawrence, J., Mayer-Davis, E., Reynolds, K., Beyer, J., Pettitt, D., D'Agostino RB, J., & ... Hamman, R. (2009). Diabetes in Hispanic American youth: prevalence, incidence, demographics, and clinical characteristics: the SEARCH for Diabetes in Youth Study. Diabetes Care, 32S123-32 1p. doi:10.2337/dc09-S204

Jolley, D. (2015). Type-1 Diabetes and Pregnancy. International Journal Of Childbirth Education, 30(2), 84-86 3p

Maahs, D. M., West, N. A., Lawrence, J. M., & Mayer-Davis, E. J. (2010). Chapter 1: Epidemiology of Type 1 Diabetes. Endocrinology and Metabolism Clinics of North America, 39(3), 481–497.

National Institute for Health and Care Excellence (2015b) Type 1 diabetes in adults: diagnosis and management [NG17].