Assignment
A. R. is a 50-year old Native American college professor (medical anthropology) with a history of Type II diabetes mellitus (NIDDM) for the past 10 years. He has been controlling his glucose by taking glyburide (Diabeta, Micronase) and using a 2000 calorie ADA (American Diabetes Association) diet. He is aware of the higher incidence of type II DM in his people and is open to anything he can learn about it. His blood glucose level had been fairly consistent with an average AM reading of 200 mg/dL. He is 74" and weighs 220 lb. having lost 10 lbs. over the last month. Six months after hospitalization for viral pneumonia, A. R. is readmitted for hyperglycemia. He has been running higher blood glucose levels (280 to 300 mg/dL) and has lost 10 lbs. He is currently on a medical leave of absence from work. His medical history includes a myocardial infarction, hypertension, and renal insufficiency.
I. Dr. J., A. R.'s physician, determines that A. R. requires insulin for glucose control and orders regular human insulin per sliding scale before breakfast and supper; NPH human insulin 20 units before breakfast and supper. When would you expect the regular insulin to have its peak effect compared to NPH?
II. You are aware of the new American Diabetic Association (ADA) nutrition recommendations and principles for people with diabetes mellitus. A. R.'s physician does not appear aware of these guidelines. You would like to try these guidelines on A. R. to see if he can obtain better glucose control. You know A. R.'s physician has been open to new ideas in the past as long as they have a sound, scientific basis. What collegial strategy might you use to approach him about a change in the A. B.'s treatment plan?
III. What other health care professionals may be helpful to you in working out a strategy for A. R.'s care?
IV. None of the other nurses on your unit knows about the more recent developments in diabetes management. Many of the patients on your floor are diabetics. What are 3 activities you can undertake to promote professional growth and development on your unit? (Be creative!)
V. A. R. says, he isn't too keen on "jabbing himself with a needle a couple times a day." He wants to know why he can't keep on taking the oral insulin he has been using (glyburide). What is the basis for your response?
A. R.'s revised care plan calls for tighter glucose control with glucose levels of 80 to 120 mg/dL being the recommended range. Dr. J. has discussed with him the importance and benefit of keeping his glucose below 140 mg/dL, and you are going to talk to him about administering his insulin.
VI. While you are teaching A. R. how to administer the insulin, he asks why it is necessary to prepare the regular insulin first. Offer a meaningful reason for this procedural step.
VII. At 0300, A. R. calls you into his room complaining of sweating, nausea and "shakiness." What would you do first?
It is determined that A. R.'s blood glucose is 65 mg/dL.
VIII. Of the following choices, indicate which item(s) would be appropriate to give A. R. to immediately treat hypoglycemia.
½ cup pure orange juice
1 slice of bread
2 graham cracker squares
1 glass of milk
Half a bagel
½ cup soda pop (not diet or sugar-free)
IX. Of the following statements, which one(s) indicate that A. R. requires further teaching regarding self-care?
My wife and I enjoy soaking in our hot tub.
My feet get cold, and the heat pad I use sure helps.
I'll have to have my wife help me look at my feet since I can't see as well as I used to.
Sometimes I can't even feel my feet, especially if I've been sitting for a long time.
These thick toenails should probably be cut by a doctor.
This file I have works great for these calluses on my feet.
X. A. R. says he has read that exercise can help people with diabetes. Outline the benefits and risks of exercise for the diabetic patient in general. State how the risks can be minimized.
XI. Develop a teaching plan that addresses the special needs of A. R. as he embarks on an exercise program. Include at least 8 points.
XII. The dietitian evaluates A. R.'s eating pattern and determines his frequent hyperglycemic episodes are related to eating candy or sweet rolls during these periods and lack of knowledge regarding the difference between simple and complex carbohydrates. Offer an analogy that would help A. R. comprehend this concept.