Case Study: Type 1 Diabetes Management Plan For Ben

Medical history and social history of Ben

Case study

You are a Registered Nurse working in the emergency department caring for Ben Summer who is 19 years of age.

Medical history

Ben visited his local doctor after experiencing increased appetite and excessive thirst. He has been unusually tired when playing football and hasn’t been able to perform at his best. He has lost 10 kilograms of weight over a two week period and has been frequently urinating at night. The doctor suspected type 1 diabetes and tested his urine, which was positive for glucose and ketones. A random capillary blood glucose level was 25.0mmol/L and blood ketone level was 1.5mmol/L. Ben was advised to attend the hospital emergency department immediately.

Social history

Ben lives with his mother (Susan), father (John) and 12 year old brother (Jacob). He attends university full time, studying engineering and works at McDonalds on a casual basis. Ben plays football on the weekends and trains two days during the week. He has a girlfriend Rachel and they both enjoy surfing at the beach.

Emergency department review

Two hours after review by the local doctor, Ben’s capillary blood glucose level (BGL) was 26.0mmol/L and blood ketone level was 1.6mmol/L. Other vital signs were within normal limits. After review by the endocrinologist, Ben was given a provisional diagnosis of type 1 diabetes based on his symptoms and family history of autoimmune disease (His mother has hyperthyroidism, Graves’ disease). His blood test confirmed that he did not have ketoacidosis.

Treatment plan

Ben was prescribed subcutaneous insulin; Aspart (NovoRapid) Flexpen 10 units TDS and Glargine (Lantus) Solostar 30 units nocte. He was referred to the diabetes service for ongoing care.

1.Explain the 11 components of a valid routine subcutaneous insulin medication order and why this is important. Support your answer with academic or clinical guideline references. 

2.Explain why Ben has been prescribed this medication. Relate to pathophysiology of type 1 diabetes and the mechanism of action of NovoRapid insulin. Support your answer with academic references. 

3.What is the onset, peak and duration of action for NovoRapid insulin according to Bullock and Manias (2017)? Explain when NovoRapid should be administered in relation to food intake and why. Support your answer with academic references. 

4.Discuss the definition, causes, symptoms and treatment of hypoglycaemia, a common adverse effect of NovoRapid. Support your answer with academic references.

5.Discuss the importance of understanding the medication prior to administration. Support your answer with academic references. 

6.Discuss the 5 rights of medication administration and why it is important for nurses to follow this procedure. Support your answer with academic references. 

7.What is the most appropriate insulin pen needle length for Ben and why? Support your answer with academic references. (5 marks)

8.What diabetes specific nursing assessment would you conduct prior to administration of NovoRapid insulin to Ben and why? Support your answer with academic references. 

9.Identify the site and angle you would inject the NovoRapid insulin and explain why this was selected for Ben. Discuss infection control considerations. Support your answer with academic references. (5 marks)

10.What would you document and where? Why is documentation important? Support your answer with academic or clinical guideline references. 

11.Explain the diabetes specific nursing assessment you would provide for Ben post administration of insulin, when you would provide it and why. Support your answer with academic references. 

1.Discuss the potential impact of type 1 diabetes on Ben.

Discuss the daily physical challenges of living with type 1 diabetes that Ben may face. Support your answer with academic references. (5 marks)

2.Discuss potential emotional impacts of living with type 1 diabetes that Ben may face. Support your answer with academic references. (5 marks)

1.Firstly, the nurse will need to Ben’s name in full and the date he received the insulin dose. The nurse will also specify the insulin name (NovoRapid insulin) and the dosage. The time and frequency of medication administration should also appear in the medication order. In addition, Ben’s residence and his contact information should be indicated. Lastly, the nurse should write his or her name. All these components, according to Rossetti, Porcellati, Bolli & Fanelli (2008) enhance Ben’s safety.

2.Ben was prescribed NovoRapid because his beta cells cannot synthesize enough insulin and hence his system needs to be supplemented with artificial insulin that can perform similar function as normal insulin. Novorapid is almost similar to the insulin released by the pancreas of a person without diabetes (Goldman-Levine & Lee, 2005). They begin to be active 10-15 minutes after being punctured. Its activity peak is at 30-90 minutes and last between 3 and 4 hours.

3.Novorapid insulin has a shorter duration of action compared to human soluble insulin after subcutaneous injection. According to Bullock & Manias (2017), NovoRapid begin to be active 10-15 minutes after being punctured. Its activity peak is at 30-90 minutes and last between 3 and 4 hours. NovoRapid ® has a faster onset of action and a shorter duration than soluble human insulin. Because of the faster onset of action, NovoRapid ® should usually be administered immediately before a meal (Rossetti, Porcellati, Bolli & Fanelli, 2008).

4.Hypoglycemia in an adult is defined as a blood glucose level below 40 mg / dl, even in the absence of symptoms (Skyler, 2004). It is caused by inadequate intake of glucose or food rich in glucose. The common symptoms include sweating, palpitations, anxiety, changes in the pupillary size and increase in the secretion of saliva by the parotid. Hypoglycemia is treated by intravenous administration of glucose. It is not advisable to administer NovoRapid to hypoglycemic individuals because NovoRapid increase the uptake of blood glucose yet hypoglycemic patients have low level of blood glucose.

5.Since Ben is suffering from type 1 diabetes, it is important to choose medication whose pharmacodynamic properties fit’s Ben’s condition. Ben needs medication that act first. Different medications have different pharmacodynamic properties (Goldman-Levine & Lee, 2005). These properties dictate the time, dosage and frequency. For example, NovoRapid ® produces a faster onset of action compared and hence stands out as the best replacement for insulin deficiency (Florence, 2015). The replacement insulin acts in the same way as naturally produced insulin and helps glucose to enter the blood in the cells (Bullock & Manias, 2013).

Emergency department review of Ben

6.The first right is the right patient, for our case, Ben is the right patient. The second right is right drug, for this case, NovoRapid. The third right is right of medication. Right of medication describes the right for Ben to be treated. Another right is the right route. For Ben’s case, the right route is subcutaneous route because NovoRapid can be absorbed immediately into blood vessels located in subcutaneous layer. Lastly, the right dose is another key right of medication (Fogarty & McKeon 2006).

7.Needles of 5 and 6 mm in length for an insulin pen or injector are recommended for Ben. This is because Ben can be categorized as an adult patient with reduced body weight or for standard injection into a reduced layer of subcutaneous tissue (Gibney, Arce, Byron & Hirsch 2010). The needles of 5 to 6 mm will ensure that the insulin is delivered to the right point where it can get into blood stream as soon as possible.

8.Some of the assessment to conduct before administering insulin is to determine whether Ben could be having other illness. If it is determined that Ben have another condition, then nurse will have to evaluate the effectiveness of medication and determine the right dosage (Wallace & Matthews 2004).  In addition, nurse will have to assess whether Ben is agitated or stressed, whether he is taking various medications, and his level of physical activity. These assessments will enable nurses choose the best medication and determine the right dosage.  

9.The recommended injection sites for Ben is the anterior wall of the abdomen and the external surface of the thigh. The angle of the injection should be 45 °, and a skin fold should be formed (Gibney, Arce, Byron & Hirsch 2010). Pathogens can enter through the broken skin. Hence it is advisable to use sterilize cotton, sterilized needle and remove the needle in the angle at which it penetrated the injection site in order to avoid infections (Gibney, Arce, Byron & Hirsch 2010).

10.The first thing to document is the name of medication. Based on the diagnosis made, Ben should receive NovoRapid insulin, medication designed to address insulin deficiency (Masse, et al 2018).. NovoRapid is an insulin replacement that is very close to insulin produced by the body. The second thing to document is the amount of dose given (In Qureshi & In Maxwell, 2014). The usual dose is between 0.5 and 1.0 units per kilogram of body weight per day. The third thing to document is route used and site for injection. NovoRapid is given by subcutaneous injection into the abdominal wall, thighs, arms, shoulder or shoulder. Other aspects to document include time administered, initials and signature. Documentations help in ensuring ongoing care is done efficiently (Aitken, Manias & Dunning 2006).

Treatment plan for Ben

11.One of the post administration assessment is to determine potential side effects. Improper dosing, in most cases, may lead to hyperglycaemia and diabetic ketoacidosis. Ketoacidosis does not occur immediately (George, Byun & Howard-Thompson, 2018). The first symptoms develop slowly over hours or days. Consequently, it is a role of nurse to follow up and assess the effects of every drug administered so as to intervene accordingly in case of contraindication.  It is also important to note that the NovoRapid may cause hypoglycaemia (low blood sugar). The nurse should therefore be ready to assess Ben in order to determine whether he developed hypoglycemia or hyperglycemia (Skyler, 2004).  

1.Firstly, it is important to note that the common symptoms of type 1 diabetes include constant thirst, frequent urge to urinate, weakness and drowsiness, blurred vision, sensation of goosebumps, numbness and tingling in the palms and soles, skin problems, poorly healing cuts and scratches, sudden weight loss and severe hunger with proper and full nutrition (Brazeau, Rabasa-Lhoret  & Strychar  et al. (2008). These symptoms may make it inconvenient for Ben to engage in daily activities. If Ben used to go out the whole day, he will have to change his behavior and schedule. In other words, diabetes type 1 will force Ben to live relatively restricted lifestyle.

2.Diabetes mellitus is a physical illness, but it puts our psychological world in check. After the diagnosis can appear compatible pictures with: anxiety, social withdrawal, depression, anger, feelings of guilt and disability and a series of feelings and situations that can worsen the general state of mind of the patient (Wallace & Matthews 2004). Ben has a risk of social isolation or emotional disorders that affect their more social sphere, so it is important to address these aspects. This is why psychologists stress the importance of taking care of internal emotional world by supporting our loved ones, going to group therapy with people suffering from the same condition and / or asking for advice from psychologists who are experts in chronic diseases.

References

Aitken R., Manias E. & Dunning T. (2006). Documentation of medication management by graduate nurses in patient progress notes: a way forward for patient safety. Collegian. 13(4):5–11

Brazeau A. S., Rabasa-Lhoret R. & Strychar I, et al. (2008). Barriers to physical activity among patients with type 1 diabetes. Diabetes Care. 31:2108–9. [PMC free article] [PubMed]

Bullock, S & Manias, E. (2017). Fundamentals of Pharmacology (8e). Pearson.

Bullock, S., & Manias, E. (2013). Fundamentals of Pharmacology. Melbourne: P.Ed Australia.

Florence, A. T. (2015). Physicochemical principles of pharmacy: In manufacture, formulation and clinical use. London: Pharmaceutical Press.

Fogarty G. J. & McKeon C. M. (2006). Patient safety during medication administration: the influence of organizational and individual variables on unsafe work practices and medication errors. Ergonomics. 49:444–56.

George, C. M., Byun, A., & Howard-Thompson, A. (2018). New Injectable Agents for the Treatment of Type 2 Diabetes Part 1 - Injectable Insulins. The American Journal Of Medicine, 131(7), 752-754. doi:10.1016/j.amjmed.2018.01.049

Gibney M. A., Arce C. H., Byron K. J. & Hirsch L. J. (2010). Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: Implications for needle length recommendations. Curr Med Res Opin. 26(6):1519-1530. 3.

Goldman-Levine, J. D. & Lee, K. W (2005). Insulin Detemir--A New Basal Insulin Analog. The Annals of Pharmacotherapy 39: 502-507.

In Qureshi, Z., & In Maxwell, S. R. J. (2014). The Unofficial Guide to Prescribing e-book. Churchill Livingstone

Masse, M., Maton, M., Genay, S., Blanchemain, N., Barthélémy, C., Décaudin, B., & Odou, P. (2018). In vitro assessment of the influence of intravenous extension set materials on insulin aspart drug delivery. Plos One, 13(8), e0201623. doi:10.1371/journal.pone.0201623

Rossetti, P., Porcellati, F., Bolli, G. B., Fanelli, C. G. (2008). Prevention of Hypoglycemia While Achieving Good Glycemic Control in Type 1 Diabetes: The role of insulin analogs. Diabetes Care 31: S113-S120 .

Skyler, J. S. (2004). Effects of Glycemic Control on Diabetes Complications and on the Prevention of Diabetes. Clin. Diabetes 22: 162-166

Wallace T. M. & Matthews D. R. (2004). Recent advances in the monitoring and management of diabetic ketoacidosis. QJM. 97:773–80. [PubMed]