The RN is caring for a 30-year-old violinist who makes his living as a touring c

Question

The RN is caring for a 30-year-old violinist who makes his living as a touring concert artist. While on a concert tour, he fainted on stage, was taken to a hospital and subsequently diagnosed with Type I Diabetes Mellitus. The RN is teaching the patient about self-monitoring of blood glucose, dietary considerations and insulin injections. The patient tells the RN that he cannot possibly manage this regimen, since he spends a lot of his life “on airplanes and on stages.”

Initial Discussion Post: Address the following:

Discuss an approach the RN can take to assist this patient to understand his disease and comply with treatment.

What factors would the RN need to consider?

How might the regimen need to be adapted, based on this patient’s lifestyle?

Explanation / Answer

Patients with type 1 diabetes mellitus (DM) require lifelong insulin therapy. Most require 2 or more injections of insulin daily, with doses adjusted on the basis of self-monitoring of blood glucose levels. Long-term management requires a multidisciplinary approach that includes physicians, nurses, dietitians, and selected specialists.

recommends unimpeded access to glucose test strips for blood glucose testing and use of continuous glucose monitoring.

Using Continuous glucose monitors

Continuous glucose monitors (CGMs) contain subcutaneous sensors that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pagerlike device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia.

Artificial pancreas

Closed-loop systems, also known as artificial pancreases, are in development for use in improving glycemic control in type 1 diabetes. These systems include a CGM that is in constant communication with an infusion pump, with a blood glucose device (eg, a glucose meter) utilized for CGM calibration. An external processor, such as a cell phone, runs control algorithm software, receiving data from the CGM. The data is used to perform a series of calculations, producing dosing instructions that are sent to the infusion pump.

Insulin Therapy

For patients on intensive insulin regimens (multiple daily injections or insulin pumps), the preprandial dose is based on the carbohydrate content of the meal (the carbohydrate ratio) plus a correction dose if their blood glucose level is elevated

Common insulin regimens include the following:

Insulin is sensitive to heat and exposure to oxygen. Once a bottle of insulin is open, it should be used for no more than 28 days and then discarded; even if there is still some insulin in the bottle, it may have lost its clinical effectiveness. Insulin kept in a pump reservoir for longer than 3 days may lose its clinical effectiveness (though insulin aspart has now been approved for use for as long as 6 days in a pump).

Sometimes, insulin distributed from the pharmacy has been exposed to heat or other environmental factors and therefore may be less active. If a patient is experiencing unexplained high blood sugar levels, new insulin vials should be opened and used.

Diet

One of the first steps in managing type 1 DM is diet control. Dietary recommendations should take into account the patient’s eating habits and lifestyle.

Diet management includes education about how to adjust the timing, size, frequency, and composition of meals so as to avoid hypoglycemia or postprandial hyperglycemia. All patients on insulin should have a comprehensive diet plan, created with the help of a professional dietitian, that includes the following:

Caloric distribution is an important aspect of dietary planning in these patients. A recommended distribution consists of 20% of daily calories for breakfast, 35% for lunch, 30% for dinner, and 15% for a late-evening snack.

The minimum protein requirement for good nutrition is 0.9 g/kg/day (usual range, 1-1.5 g/kg/day), but a reduced protein intake is indicated in cases of nephropathy. Fat intake should be limited to no more than 30% of the total calories, and a low-cholesterol diet is recommended. Patients should minimize consumption of sugars and ensure that they have adequate fiber intake. In some cases, midmorning and midafternoon snacks are important to avoid hypoglycemia.

Activity

Exercise is an important aspect of diabetes management. Patients should be encouraged to exercise regularly.

Educate the patients about the effects of exercise on the blood glucose level. If patients participate in rigorous exercise for more than 30 minutes, they may develop hypoglycemia unless they either decrease the preceding insulin injection by 10-20% or have an extra snack. Patients must also make sure to maintain their hydration status during exercise.

Management of Hypoglycemia

Hypoglycemia may result from a change in insulin dose, a small or missed meal, or strenuous exercise. Regular insulin doses may cause hypoglycemia if the patient becomes anorectic or has another cause for reduced food intake, has gastroparesis, or is vomiting.

Common symptoms of hypoglycemia are light-headedness, dizziness, confusion, shakiness, sweating, and headache. Patients should be made aware of these symptoms and educated to respond rapidly with sugar intake. They should be advised to carry candy or sugar cubes. Family members can be taught to administer a subcutaneous injection of glucagon. In an emergency situation, initial treatment consists of a bolus injection of 25 mL of 50% glucose solution followed by a continuous glucose infusion.

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