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Consider the patient situation

Collect cues/information

1. As a nursing student, your clinical facilitator has allocated you to care for Jarrah. After the morning handover, you are asked to explain the pathophysiology of type 1 diabetes to the clinical facilitator. What is your response?

2. Your clinical facilitator tells you that Jarrah would rather not have multiple daily injections. He wants to know why he cannot just have tablets to manage his type 1 diabetes like his friend who has type 2 diabetes. What is your response?

1. In diabetes type 1, the pancreas, which is a large gland behind the stomach, cannot produce insulin anymore. Insulin is the hormone that is responsible for lowering the blood sugar level. It happens because the cells which form insulin get destroyed by the immune system of the body. The condition is the culmination of lymphocytic infiltration along with the destruction of the insulin-secreting beta cells of the islets of Langerhans of the pancreas. The pathophysiology of this disease involves the concentration of plasm glucose signalling the central nervous system that mobilises the reserves of energy (Saberzadeh-Ardestani et al., 2018). It is dependent on the blood flow to the cerebrum along with the integrity of tissue, arterial plasma glucose, the speed of fall of concentration of plasma glucose along with metabolic fuels.

2. In the case of type 1 diabetes, the patient cannot have only medicines because the medications will work only if the pancreas can produce some amount of insulin. Though insulin is a mandatory part of treatment in the case of type 1 diabetes, it must be provided in the correct amount so that the sugar level of the body can be kept under normal (Dimple, Kumar & Tomer, 2018). However, only medications would not be the solution as it is a chronic disorder and is not curable for most people. Hence, it has to be kept under control through adjustment of lifestyle, proper intake of diet and following other dietary guidelines. Jarrah cannot just rely on medications without the availability of insulin in the correct amount. The blood sugar levels may rise abnormally high leading to serious health consequences.

Process information

Jarrah is disappointed that he has to administer two different types of insulin. Your clinical facilitator asks if you can explain to her how Jarrah’s prescribed regime works to achieve glycaemic control.

1. Explain the ‘time-course’ of formulations of NovoRapid and Optisulin.

2. Explain the principles underpinning a ‘basal-bolus’ regime of insulin (see Bryant & Knights, 2019, p. 682 – 683).

*See also MimsOnline 2022 Full Prescribing Information NovoRapid and Optisulin

3. Explain the mechanism of the action of NovoRapid and Optisulin in attaining glycaemic control.

1. When injected under the skin, NovoRapid makes a quick onset of action than normal and soluble human insulin. The effect of this injection occurs within 10-20 minutes of injecting. Jarrah will be able to see the maximum effect of the medicine within 1 to 3 hours post-injection, while it lasts up to 3 hours. Optisulin, on the other hand, is insulin that lasts in action for up to 24 hours (Van der Hoogt, 2017). But, it has to be consumed regularly at the same time every day to see effective results. Before injecting the formulation of Optisulin, the label of insulin on the cartridge must be checked by the nurse injecting the same to Jarrah to ensure that the current insulin is being used. It should be injected under the skin and not on any muscle or vein.

2. A basal-bolus insulin regime involves intake of a form of insulin that is longer acting for keeping the blood glucose levels under stable conditions through episodes of fasting and separating injections within insulin that is shorter acting with the aim of preventing the abrupt rise in the blood glucose levels after consumption of meals (Priya et al., 2020). The main principle states that the blood sugar level of Jarrah will be regulated by the basal insulin as a result of endogenous production of glucose by the process of glycogenolysis as well as gluconeogenesis, where the bolus insulin will prevent the meal-related rise in the level of blood glucose (Attri et al., 2020).

3. When NovoRapid is injected into the body of Jarrah, clubbed with a lower concentration of blood glucose produces a very rapid action in comparison to that of soluble human insulin. This happens within the first four hours of consumption of a meal. The medicine reduces glycated haemoglobin by a few percentages in the body of the patient in comparison to that of human soluble insulin ("NovoRapid Full Prescribing Information, Dosage & Side Effects | MIMS Malaysia", 2022). This is a very slight difference. Through this mechanism, the blood sugar level that rises after meals in Jarrah shall be reduced to normal. When Optisulin is injected into Jarrah, it will work by promoting the movement of sugar from the blood into the tissues of the body while stopping the production of sugar in the liver. In this way, it will help in attaining glycaemic index (Danne et al., 2018).

You are on a night shift and Jarrah rings his bell at 0200hrs and states he feels unwell. You take his blood glucose level (BGL) and find it to be 3.0mmol/L. This is the second consecutive night this has happened.

1. What are the registered nurse’s responsibilities relating to the Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice in providing safe care to Jarrah? Identify one standard and apply it to your responsibility in this situation.

2. Identify two possible causes of his hypoglycaemia.

3. What are the appropriate nursing actions after taking Jarrah’s BGL? Give a rationale for the nursing actions.

4. If Jarrah appears to have altered consciousness, explain the nursing actions you would take and provide a rationale.

1. According to the NMBA standards, a nurse should render the safe, appropriate and responsive nursing practice of great quality to a patient in time of need. They should appropriately delegate the various aspects of practice that have been enrolled to them as nurses and render effective as well as timely direction as well as supervision while ensuring the fact that the practice which has been delegated is sound and safe as well as correct ("Nursing and Midwifery Board of Australia - Registered nurse standards for practice", 2022). In the case of Jarrah, a proper nursing practice that is timely and effective should be provided to bring him out of the hypoglycemic condition.

2. Two reasons why the situation of hypoglycaemia might arise for Jarrah are the administration of excessive insulin or medication. It may also occur if he has not eaten properly after the medication and injection.

3. In the case of Jarrah, a blood glucose level of 3mmol/L indicates that his blood sugar level is falling. Under such a condition, the registered nurse shall feed the patient with glucose tablets or juice containing carbohydrates or honey. This will raise the blood sugar level of Jarrah, and thus the situation of threat may subside. Moreover, the nurse can also inject glucagon injection or any other forms of intravenous glucose into Jarrah. Glucagon facilitates sugar levels from dropping too low (Isaacs et al., 2021). This will result in restoring of glucose level to normal in Jarrah.

4. In case Jarrah faces unaltered consciousness, proper nursing management shall be undertaken by optimum intravenous access, and at the same time, the nurse should conduct the administration of dextrose in a quantity of around 50%. Glucagon administration can also be done. This needs to be done so that the sugar level can be restored back to the normal range (Shea, Gerard & Krinsley, 2019). There should be proper air circulation in Jarrah's ward so that he can breathe well to regain consciousness. The nurse should make effective participation and communication with the primary care physician and the concerned specialist doctor so that the patient can be brought to consciousness soon.

Integrate the ACQHS Quality Use of Medicines principles into any of your responses below

Jarrah and his father require information and education about diabetes and medication management before discharge. Standard 3.2 of the NMBA Registered Nurse Standards for Practice requires nurses to ‘provide the information and education required to enhance people’s control over health’ (2016, p. 4).

Take time to educate

1. Jarrah is struggling to come to terms with his type 1 diabetes diagnosis and the need to have multiple daily injections. What information would you give him about the long-term benefits of having the insulin and closely monitoring his BGL?

2. What information would you provide to Jarrah and his father about recognising symptoms of hypoglycaemia?

3. What education would you provide regarding techniques around self-administration of insulin?

4. Identify one aspect that you would have to consider in relation to social justice. How could this impact Jarrah’s ongoing health needs? What solution might you offer to address this?

5. What issues could affect Jarrah’s ongoing glycaemic control in relation to a) his age and b) engagement in sport once he is discharged?

1. In terms of long-term benefits, by taking multiple injections of insulin daily, one blood-sugar level of Jarrah would remain under control, and it would further reduce the chances of any kind of complications in the future, such as kidney failure and disruption of vision. The pancreas is spared from facing the load of producing excessive insulin to lowering the blood sugar level. Also, the symptoms of diabetes, such as frequent urge of urinating and feeling of fatigue, shall also become subside.

Flash Glucose Monitoring is a tool with immense potential for the management of diabetes type 1, and it helps to bring about improvements in metabolic control as well as improvement in the quality of life (Mancini et al., 2018). If Jarrah monitors his BGL on a long-term basis, then he can keep his blood sugar under control while understanding if the level goes abruptly high or falls suddenly low. Moreover, he will be able to figure out what foods are making his blood sugar level go high or fall down.

2. Since Jarrah has had episodes of hypoglycaemia in the hospital quite often, he and his father must always be alert about this condition as it may arise at any time. They have to be careful about noticing the symptoms associated with hypoglycaemia, such as excessive sweating, feeling trembling, hungry, feeling of dizziness, palpitations, tingling sensation in the lips and thirst as well. If any such symptoms are observed, Jarrah's father or Jarrah himself must administer some food item which is sweet such as fruit juice, chocolate bars, candies and other things, so that sugar levels are increased, and any mishap can be avoided.  

3. Jarrah and his father must be careful that they are not using expired insulin. The vial of insulin injection must be resuspended by rolling in the palm of hands before injection. Jarrah and his father must be careful that the insulin must not be injected into the muscle or any vein. It should be injected into a subcutaneous area; hence, the region of the lower abdomen can be chosen. The skin of the area should be pinched and raised, followed by insertion of the injection at an angle of 45 degrees. The needle has to be pushed all the way into the skin and left for 5 seconds, and then pulled out (Ahmed, Marzouk & Mahmoud, 2018). During self-administration, Jarrah and his father must be aware of the dosage, and high doses may increase complications.

4. One of the principles of social justice in healthcare is proper access to all resources by the patient (Dukhanin et al., 2018). As a nurse, I would have considered the fact that Jarrah gets uninterrupted and complete access to all the resources which are needed for the treatment of his diabetes. This includes medicines, injections, doctor check-ups, guiding nurses, a well-developed diet and any other things which would keep him healthy. Without the availability and accessibility to proper resources, the quality and flow of treatment for Jarrah may get interrupted and eventually aggravate health complications further. To avoid such issues, unbiased and equal treatment must be provided to Jarrah while they will be required to cooperate with the hospital authorities by abiding by the policies and regulations of the organisation. This will ensure abundant access to all resources of treatment for Jarrah.

5. (a) The age of Jarrah is less as he is a teenager. It has been found that children and adolescents with diabetes have poor glycaemic control clubbed by high chances of complications. It has been found that the release of growth hormone in the growing age of a teenager often acts as an anti-insulin agent, which makes blood sugar levels hard to be controlled (Chia, Egan & Ferrucci, 2018). Also, an active teenager like Jarrah, when diagnosed with diabetes, has certainly faced quite a lot of emotions and reactions like fear and shock, which have chances of aggravating the glycaemic control beyond normal limits.

(b) Physical activity is supposedly considered to increase and improve glycaemic control while reducing the chances of complications of acute type 1 diabetes mellitus (Tornese et al., 2020). When Jarrah gets engaged in sports after discharge from the hospital, he will be into physical activity, which shall decrease abdominal fat while improving peripheral sensitivity of insulin. Being engaged in sports will help Jarrah to keep their physical and mental health improved while reducing the spikes in glucose level after every meal. However, engaging in sports rigorously may lead to an abrupt fall in blood glucose levels as the body will lose the reserves of glucose while using them from the muscle.

References:

Ahmed, F. A., Marzouk, S. A., & Mahmoud, S. R. (2018). Effectiveness of Video-assisted Training on Insulin Self-Administration Level among Adolescents with Type 1 Diabetes. International journal of Nursing Didactics, 8(07), 30-39. https://doi.org/10.15520/ijnd.v8i07.2224

Attri, B., Goyal, A., Gupta, Y., & Tandon, N. (2020). Basal-bolus insulin regimen for hospitalised patients with COVID-19 and diabetes mellitus: a practical approach. Diabetes Therapy, 11(9), 2177-2194. https://doi.org/10.6084/m9.figshare.12533291

Chia, C. W., Egan, J. M., & Ferrucci, L. (2018). Age-related changes in glucose metabolism, hyperglycemia, and cardiovascular risk. Circulation research, 123(7), 886-904. DOI: 10.1161/CIRCRESAHA.118.312806

Danne, T., Phillip, M., Buckingham, B. A., Jarosz?Chobot, P., Saboo, B., Urakami, T., ... & Codner, E. (2018). ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatric diabetes, 19, 115-135. DOI: 10.1111/pedi.12718

Dimple, K. A., Kumar, V. I. K. A. S., & Tomer, V. I. D. I. S. H. A. (2018). Traditional medicinal systems for treatment of diabetes mellitus: a review. Int J Pharm Pharm Sci, 10(5), 7-17. https://dx.doi.org/10.22159/ijpps.2018v10i5.25374

Dukhanin, V., Searle, A., Zwerling, A., Dowdy, D. W., Taylor, H. A., & Merritt, M. W. (2018). Integrating social justice concerns into economic evaluation for healthcare and public health: A systematic review. Social Science & Medicine, 198, 27-35. doi: 10.1016/j.socscimed.2017.12.012

Isaacs, D., Clements, J., Turco, N., & Hartman, R. (2021). Glucagon: its evolving role in the management of hypoglycemia. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 41(7), 623-633. https://doi.org/10.1002/phar.2534

Mancini, G., Berioli, M. G., Santi, E., Rogari, F., Toni, G., Tascini, G., ... & Esposito, S. (2018). Flash glucose monitoring: a review of the literature with a special focus on type 1 diabetes. Nutrients, 10(8), 992. https://www.mdpi.com/2072-6643/10/8/992/pdf

NovoRapid Full Prescribing Information, Dosage & Side Effects | MIMS Malaysia. Mims.com. (2022). Retrieved 9 April 2022, from https://www.mims.com/malaysia/drug/info/novorapid?type=full.

Nursing and Midwifery Board of Australia - Registered nurse standards for practice. Nursingmidwiferyboard.gov.au. (2022). Retrieved 9 April 2022, from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx.

Priya, G., Kalra, S., Silver Bahendeka, F. J., Aye, T. T., Shahjada, S., Sehgal, A., ... & Chaudhary12, S. (2020). Initiation of basal bolus insulin therapy. JPMA, 2020. https://vlibrary.emro.who.int/?goto=Q04jBjQNRBtEPjNfCxJARQYeNjhVTj4UTkUfUBlSC0YwehIWPCkgAWpYA0UGbHAZUSVNKAIwGiM2OSwzVF9oHBsXYEZqD0YFEXhxHlNFFwZCFDYsVVs3AA

Saberzadeh-Ardestani, B., Karamzadeh, R., Basiri, M., Hajizadeh-Saffar, E., Farhadi, A., Shapiro, A. J., ... & Baharvand, H. (2018). Type 1 diabetes mellitus: cellular and molecular pathophysiology at a glance. Cell Journal (Yakhteh), 20(3), 294. doi: 10.22074/cellj.2018.5513

Shea, K. E., Gerard, S. O., & Krinsley, J. S. (2019). Reducing hypoglycemia in critical care patients using a nurse-driven root cause analysis process. Critical care nurse, 39(4), 29-38. https://aacnjournals.org/ccnonline/article-abstract/39/4/29/22073

Tornese, G., Ceconi, V., Monasta, L., Carletti, C., Faleschini, E., & Barbi, E. (2020). Glycemic control in type 1 diabetes mellitus during COVID-19 quarantine and the role of in-home physical activity. Diabetes technology & therapeutics, 22(6), 462-467. DOI: 10.1089/dia.2020.0169

Van der Hoogt, M. (2017). The effect of protein and fat meal content on the insulin requirement of type 1 diabetic children (Doctoral dissertation, North-West University (South Africa), Potchefstroom Campus). https://repository.nwu.ac.za/bitstream/handle/10394/26370/Van_der_Hoogt_M_2017.pdf?sequence=

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