Yvonne Quidilla

NURS 220
1/22/14
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,

glycosylated hemoglobin (HbA1c), and postprandial blood glucose which is also
known as oral glucose tolerance test. In a fasting blood glucose test the patient is
to fast 8 hours prior to the test (water is permitted). A reading of 70-100 mg/dl is
considered normal. A person would be diagnosed with DM should they have
results greater than 126mg/dl at two separate testing times. When taking a OGTT
a person is diagnosed with DM when their result is or greater than 200mg/dl. A
level of 6.5% or greater is the HbA1c test is diagnostic for DM.
2. Identify three functions of insulin.
Insulin stimulates the uptake of glucose in skeletal muscles, it keeps the
blood lipid levels within the normal range, suppresses the production of glucose
and LDL in the liver, promotes glycogenesis, and inhibits glycogenolysis,
ketogenesis, and gluoneogensis.

3. Insulins main action is to lower blood sugar levels. Several hormones produced in the
body inhibit the effects of insulin. Identify three.
Three hormones that inhibit the effects of insulin are epinephrine,
thyroxine, and growth hormone.

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 a patient about glargine,
also known as Lantus, is that it should never be mixed with another insulin.
Glargines pH is 4 and will cause precipitation when it is mixed with another
insulin.

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 insulins?
2

Lispro is a rapid acting insulin, which means its effects are immediate, so
food needs to be there when it is administered. Regular insulin is short acting
and takes about 0.5- 1 hour to take effect.

6. What is the peak time and duration for lispro insulin?

Lispros peak time is 0.5 1.5 hours and it lasts between 3-5 hours.

7. Y.L. wants to know why she cant 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 chose lispro and glargine insulin over NPH and regular insulin
because with NPH and regular insulin there is less flexibility for dosing.

8. Y.L.s culture prefers foods high in carbohydrates. What is carbohydrate counting and
why would this method work well for Y.L.
Since Y.L.s culture prefers foods high in carbohydrates a meal planning
system called carbohydrate counting is ideal for Y.L. In carbohydrate counting,
regardless of the food source, the total grams of carbohydrates is what is
considered. Y.L.s dietician will determine her daily allowance of carbohydrates in
grams ad a meal plan including snacks can be compiled based on that.

9. What symptoms did Y.L. report today that led you to believe she has some form of
neuropathy?
The symptoms that Y.L. reported that led me to believe she may have some
form of neuropathy is her statement of her feet hurting and describing it as
burning or like having pins in them.

10. What findings in Y.L.s history place her at increased risk for the development of
other forms of neuropathy?

Because Y.L. has a history of hypertension, hyperglycemia, is overweight,

and smokes she is at risk for developing other forms of neuropathy.

11. What are some changes that Y.L. can make to reduce the risk or slow the
progression of both macrovascular and microvascular disease?
Y.L. should incorporate exercising into her weekly routine. About 120
minutes or more a week. Exercising will help her to manage her weight along with
changing her eating habits. Y.L. should consult with a dietician so that they can
create a customized meal plan for her that is to her liking but healthier. Her eating
habits and exercising will also assist in decreasing her LDL and increasing her
HDL levels as well as lowering her high blood pressure. Since she has pain in her
feet she can possibly speak with a physical therapist or trainer who can help her
create a workout that she is comfortable doing.

12. Y.L. is enrolled in a smoking cessation class. Why is it so important that she stop
smoking?
Smoking increases Y.L. risk of developing a macrovascular or
microvascular disease. The nicotine in the smoke also increases her HbA1c by
about 35%. It is important that she stops smoking for these reasons. Her HTN,
DM, and being overweight places her at risk for a number of disease and smoking
increases the chances of those diseases developing.

Resources
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patientcentered collaborative
care (7th ed.). St. Louis: Elsevier.