Case study for Diabetes—Insulin March 2, 2009

George Marshall, a 25-year-old manual laborer, visits his physician to have the stitches removed form a
wound on his right arm. Dr. Geer notes that the incision is not healing well. He also observes that Mr. Marshall
seems lethargic, so he decides to do a physical examination and some routine laboratory work. Mr. Marshall’s
history reveals a recent weight loss of 8 pounds, lethargy, polydipsia, and polyuria. His fasting blood glucose is
elevated (425 mg/dL) and the urine is positive for ketones. There is a family history of diabetes mellitus.
Dr. Geer admits Mr. Marshall to the hospital to control his diabetes. The client is started on 10 units of
U-100 regular insulin and 25 units of NPH U-100 insulin before breakfast. A sliding scale of U-100 regular
insulin dosage based on the results of the QID blood glucose testing is established.

< 150 mg 0 units

150-200 mg 4 units
200-250 mg 6 units
250.300 8 units
300.350 10 units
The nurse checks Mr. Marshall’s Accucheck at 7:30AM. The reading was 230mg/dl.
How much insulin and types will receive (in total) this morning?

U-100 Regular – 6 Units (per MD order, sliding scale)

NPH U-100 – 25 Units

In addition to this treatment, Mr. Marshall receives instruction concerning a 2,200-calorie diabetic diet.
After several days, his fasting blood glucose is approaching normal value (150 mg/dL). He reports feeling
better. A client education program is begun, with individual sessions 4 days a week and group sessions once a
week. Mr. Marshall seems to be doing well and is able to administer his own insulin, but one day, a setback
occurs. At about 4:00 pm he begins to perspire profusely, develops a headache, and experiences a tremor in
his hands. In addition, he feels nauseated.

1. What type of diabetes (type 1 or 2) does Mr. Marshall appear to have? Are his initial symptoms
characteristic of this type of diabetes mellitus?

Mr. Marshall has Type 1 DM. Yes, the typical symptoms include polydipsia, polyuria, weight
loss, lethargy.
Signs include: FBG: 425mg/dL & urine positive for ketones – is this indicative of type 1.
Type 1 key signs: Age – 25, Type 1 is usually discovered in pts under 40. Family history of DM.
(Type 1 is not as strongly tied to family history). Also, s/s of type 1 are generally rapid
development, and weight loss in a matter of days.
Dr. Geer started him immediately on Insulin (NOT on lifestyle management, also no mention of
his weight status).

2. Why is Mr. Marshall placed on two types of insulin? Can the regular insulin and the NPH insulin
be mixed in the same syringe? What skills and knowledge about diabetes must Mr. Marshall
acquire to care for himself adequately?

Mr. Marshall is on two types of insulin because 1 is for meal time (faster acting) and one is for
sustained DM maintenance.
Regular: onset = 30 – 60 minutes, peak 1-5 hours, Duration 6-10 hours
NPH: 60-120 minutes, peak 6-14 hours, duration 16-24 hours [provides glycemic control
between meals, 2x/day admin. NPH ONLY longer acting that you can mix with short acting
insulins! NPH = cloudy, t/f draw up REGULAR 1st, then NPH.

TEACH:
• Maintain education re: diabetes
• Exercise & maintain diet control
• Tighter glycemic control lessens the complications
o t/f SMBG very important
• s/s of DKA (may develop quickly):
o * Excessive thirst

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Case study for Diabetes—Insulin March 2, 2009

o * Frequent urination
o * Nausea and vomiting
o * Abdominal pain
o * Loss of appetite
o * Weakness or fatigue
o * Shortness of breath
o * Fruity-scented breath
o * Confusion

o * High blood sugar level

o * High ketone level in your urine
• s/s Hypoglycemia:
o * nervousness,
o * sweating,
o * intense hunger,
o * trembling,
o * weakness,
o * palpitations, and
o * often have trouble speaking.
• Storage of insulin:
o UNOPENED vials in refrigerator (not frozen), then will be good until
expiration date
o Current use vial: room temp for up to 1 month & still be effective. No
direct sunlight or excess heat
o Mixtures in vials: stable = 1 month @ room temp, 3 mos refrig
 Store w/ needle up
o Prefilled mixtures: 1-2 weeks okay store
• Do not rotate injection site, only vary w/n site by ~ 1 inch.
• If travel pack enough insulin (out of country)
• Restrict exercise if BS <250, esp if ketonuria
• SICK DAY education!
• Mix: clear before cloudy, roll NPH in palms
• Foot care / caution

3. What was the nature of the setback that Mr. Marshall experienced?
What should the nurse do?

Hypoglycemia.
• Nursing Interventions:
o Check BS <70 = assessment
o Give 15 grams simple CHO, wait 15 minutes, then re-check
 If still < 70 repeat until 70-110 range.
o Give oral CHO’s if can swallow ONLY.
o Glucagon SQ or IM and 50% IV if NOT able to swallow. (glucagon converts
liver glycogen to glucose, but not effective in severe starvation clients)
o Continue to monitor BS for several hours

4. Mr. Marshall begins to lose consciousness. What interventions should the nurse begin?

Glucagon if lose consciousness.

• 1 mg glucagons IM or SQ
• 2nd dose in 10 minutes if still unconscious

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Case study for Diabetes—Insulin March 2, 2009

• CALL PCP IMMEDIATELY

• To ED
• Small meal when pt wakes up & is no longer nauseated.

5. Indicate the sites that can be used for insulin injections. What would you teach Mr. Marshall
regarding insulin administration and site rotation?

Sites for insulin injection:

• Site affects speed of absorption
o Abdomen = fastest (outside 2inch radius from navel)
o Deltoid = 2nd fastest
o Thigh & butt
• Rotating sites reduces lipohypertrophy (inc fat deposits in skin) & lipoatrophy
(loss of fatty tissue, making tissue look uneven – lumpy)
• Rotate w/n one anatomic site (prevents variances in insulin absorption)
• Depth – subcutaneous, 90 degree angle. If thin, may need 45 degree angle to
avoid IM injection.
• Regular = 30 minutes b/4 meals

6. During this hospitalization, Mr. Marshall is started on an intensive insulin therapy regimen with
insulin glargine and Humalog. Explain this regimen in terms of its benefit, dosing schedule,
possible adverse effects and patient teaching.

Intensive Insulin Therapy

Benefits:
• Provides tight glucose control
• Adaptability – doses adjusted to match calories of meals. Therefore patient able
to have a greater degree of dietary flexibility and glycemic control that is not
possible w/ conventional insulin therapy.

Dosing Schedule:
• Glargine (long acting) is for sustained glycemic control. Generally taken at
bedtime, provides basal level of insulin through out the night and the following
day.
• Humalog (lispro) – is used at meal time (15 min prior) in order to adjust based
on caloric content of meal. Generally injected 4 times / day.

Adverse Effects:
• Hypoglycemia (BG <50) [possibly insulin OD, vomit, diarrhea, etoh, xs exercise,
childbirth & sick day issues.
• If rapid:
o Tachy
o Palpitations
o Sweating
o Nervous
• If gradual:
o Headache
o Confusion
o Drowsiness
o Fatigue
• SEVERE:
o Convulsions

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Case study for Diabetes—Insulin March 2, 2009

o Coma
o Death
• HYPO unawareness is BIG problem in pts w/ TIGHT CONTROL, t/f VERY
FREQUENT SMBG.
• Lipoatrophy - lumpy skin @ injection sites
• Lipohypertrophy – fat accumulation at injetion site.
• Allergic rxtns – RARE.

Patient Teaching:
• Must pay extra careful attention to diet, exercise & insulin therapy.
• Be aware of glycemic target
• SMBG 3-5 x / day
• Requires HIGH degree of pt motivation & extensive education
• Thorough understanding of Diabetes!
• Importance of tight glucose control
• Major components of routine:
o Insulin replacement
o SMBG
o Diet
o Exercise
• How to acquire insulin & supplies
• DO NOT change insulin manufacturers
• Insulin storage
• Mixing procedures
• Dosage calculation / adjustments
• Techniques & locations of injections & why
• How to monitor BG.
• Educate family & SO on hypo/hyper s/s.
• Keep oral CHO at all times (candy, glucose tablet etc)
• Medic alert bracelet
• s/s allergic rxtn:
o local:
 red / hard site, several hrs to develop (generally contaminated
insulin preparation, not insulin itself) very uncommon b/c so
purified now.
o Systemic:
 Rapid, widespread appearance of red, itchy welts. Breathing
difficulty possible. In response to insulin itself, not contaminant!
 Less likely w/ human insulin (BEEF / PORK no longer in U.S.)
 If severe rxtn & pt must continue, then desensitize, small doses
progressing to larger doses.

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