Chapter 11: Endocrine System Medications: anti-diabetic medications answer key

11.5 Diabetic Case Study

1. Type 1 diabetes is an autoimmune disease affecting the beta cells of the pancreas so they do not produce insulin; synthetic insulin must be administered by injection or infusion.

Type 2 diabetes is acquired, and lifestyle factors such as poor diet and inactivity greatly increase a person’s risk for developing this disease. In type 2 diabetes, the body’s cells become resistant to the effects of insulin. In response, the pancreas increases its insulin secretion, but over time, the beta cells become exhausted. In many cases, type 2 diabetes can be reversed by moderate weight loss, regular physical activity, and consumption of a healthy diet. However, if blood glucose levels cannot be controlled with these measures, oral diabetic medication is implemented and eventually insulin may be required.

1. Surgery and hospitalization often stimulate a client’s stress response, which includes the release of cortisol.  Cortisol increases blood glucose levels, so the client may require insulin to control blood sugar levels while hospitalized.
2. The nurse should administer 6 units of Humalog insulin along with the scheduled 20 units of Humulin-N insulin at breakfast.
3. Metformin may be discontinued because it is contraindicated in clients with kidney disease (e.g., serum creatinine levels ≥115 umol/L [males] or ≥ 94 umol/L [females]).
4. The client is displaying signs of hypoglycemia. A supplementary carbohydrate, such as 250 mL of orange juice, should be administered as soon as possible. However, if the client seems confused or unable to swallow, glucagon should be administered.
5. The client has hypoglycemia because the peak effect of Humulin-N is about 6 hours. Because the medication is peaking between meal times, the client’s blood sugar continues to decrease.  On the other hand, the onset of Humalog insulin is 15-30 minutes, with the peak effect in 1-3 hours, so the food eaten during meal time maintains a normal blood sugar as long as the meals and the insulin administration are matched.
6. The hemoglobin A1C test indicates the client’s average level of blood sugar over the past 2 to 3 months. It is also referred to as HbA1c, glycated hemoglobin test, or glycohemoglobin.  Normal hemoglobin A1C is less than 5.7%.  In clients with diabetes, the goal is to maintain hemoglobin A1C levels less than 7%.   The client’s recent lab result of 10% indicates the need for additional diabetes medication, as well as client education regarding diabetes management, to avoid the development of long-term complications of diabetes.
7. Lantus is a long-acting insulin that has a duration over 24 hours. It does not have a peak and should be administered once daily at the same time each day.  Lantus should only be administered subcutaneously and should not be mixed with other insulin.

11.7 Diabetic Case Studies

1. a. sulfonylurea requires consistent meals to avoid hypoglycemia. If the client does not eat regularly, then they should be switched to a different oral anti-diabetic med.

1. b. Metformin is typically the first line treatment for type 2 diabetes. It has the benefit of no risk of hypoglycemia and no weight gain and is generally well-tolerated. If the client was switched off of metformin, perhaps they did not tolerate the GI side effects, or they had renal impairment or did not tolerate the medication. Most often overt time, metformin is tolerated but less effective, so a second med is added not replacing metformin.
2. Alcohol can cause hypoglycemia the following day and cause dehydration. To avoid the drop in blood sugars, before the party: Eat a regular, carbohydrate-rich meal before the party, and bring treatment (glucose tablets, a can of pop) for low blood glucose levels to the party.   At the party: take blood sugars more regularly.  Between each drink, have a non-alcoholic drink and carbohydrate-rich food.

After the party: up to 24 hours after the party, have a responsible adult know the signs of hypoglycemia and monitor your blood sugars every few hours if the client is not able to.  Get back into normal routine the next morning with eating food and taking insulin.

3. a. The addition of insulin is to prevent the hyperglycemic episodes that contribute to an increased CV complications over time. Insulin will improve glycemic control. The plan to keep the other oral medications will provide better glycemic control than just switching to insulin. It will also allow a lower dose of insulin and ultimately less risk of hypoglycemia. With SGLT-2 inhibitors, it also has cardioprotective effects such as lowering blood pressure and decreasing fluid through increased urination.
4. There are a number of important teaching points when starting on insulin therapy. The client should be referred to a diabetic outpatient clinic for ongoing education. Some teaching points include: understanding the rationale for insulin and the different types (bolus vs basal). They should know when to check blood sugars and signs of hypoglycemia. They should understand the onset, peak and duration of their insulins and when they need to eat. They also need to know how to administer the insulin, including site rotation and storage of the vials.

4.a. Lipodystrophy is a potential complication of repeated use of the same injection site. It can occur as lipoatrophy (fat loss) or lipohypertrophy (lumpy, raised, rubbery fat accumulation).

4.b. The complication with lipodystrophy is that the insulin will not be properly absorbed, leading to delayed or reduced insulin absorption, glycemic instability and unexplained hypoglycemia. Some clients have limited mobility and use the same site repeatedly, and some clients need further information of the importance of rotating sites. For this client, the nurse should find out more about any challenges with injecting their insulin and together look for a solution to avoid further issues. Prevention includes rotating sites and daily inspections of the sites. The lipodystrophy will eventually subside.