McKenna's Pharmacology for Nursing, 2e

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P A R T 6  Drugs acting on the endocrine system

■■ Blood glucose levels vary with food intake, exercise and stress levels, possibly necessitating a change in insulin dose. ■■ Individuals need to learn to recognise the signs of hypoglycaemia and hyperglycaemia to effectively manage their drug therapy.

■■ Insulin replaces the endogenous hormone when the body does not produce enough insulin or when there are not enough insulin receptor sites to provide adequate glucose control. KEY POINTS

CRITICAL THINKING SCENARIO Type 1 diabetes mellitus

THE SITUATION M.J. is a 22-year-old woman who has newly diagnosed type 1 diabetes mellitus. She was stabilised on insulin while hospitalised for diagnosis and management. One week after discharge, M.J. experienced nausea and anorexia. She was unable to eat, but she took her insulin as usual in the morning. That afternoon, she experienced profuse sweating and was tremulous and apprehensive, so she went to the hospital emergency room. The initial diagnosis was insulin reaction from taking insulin and not eating, combined with the stress of her gastrointestinal upset. M.J. was treated at the emergency room with intravenous glucose. After she had rested and her glucose levels had returned to normal, she was discharged to home. CRITICAL THINKING What instructions should M.J. receive before she leaves? Think about the ways that stress can alter the blood glucose levels. Then consider the stress that a newly diagnosed type 1 diabetic person undergoes while trying to cope with the diagnosis, learn self-injection, and think about complications of the disease that may arise in the future. What teaching approaches could help M.J. to decrease her stress and to effectively plan her medical regimen? What sort of support would be useful for M.J. as she adjusts to her new life? DISCUSSION The diagnosis of type 1 diabetes is a life-changing event. M.J. had to learn about the disease and how to test her blood and give herself injections, manage a new diet and exercise program, and cope with the knowledge that the long-term complications of diabetes can be devastating. Many people who are regulated on insulin in the hospital experience a change in insulin demand after discharge. The SNS is active in the hospital, and one of the effects of SNS activity is increased glucose level—preparing the body for fight or flight. For some people, returning home eases the stress that activated the SNS and glucose levels fall. If the person continues to use the same insulin dose, hypoglycaemia can occur. Other people may feel

protected in the hospital and experience stress when they are sent home. They may feel anxious about taking care of themselves while coping with everyday problems and tensions. These people need an increased insulin dose because their stress reaction intensifies when they get home, driving their blood glucose level up. People are taught how to measure their blood glucose levels before they leave the hospital. After they get used to doing this and regulating their insulin based on glucose concentrations, they usually manage well. The first few days to weeks are often the hardest. The healthcare professional should review with M.J. how to test her glucose, draw up her insulin and regulate the dose. The healthcare professional should also give M.J. written information that she can refer to later. In addition, the healthcare professional should give M.J. a chance to talk and to vent her feelings about her diagnosis and her future. To help decrease M.J.’s stress and to avoid problems during this adjustment period, the healthcare professional can give M.J. a telephone number to call if she has problems or questions. M.J. should return in a few days to review her progress and have any questions answered. In the meantime, the healthcare professional should encourage M.J. to write down any questions or problems that arise so that they can be addressed during the follow-up visit. Support and encouragement will be crucial to helping M.J. adjust to her disease and her drug therapy. She can also be referred to a diabetes association in her community that offers support services to help diabetics.

CARE GUIDE FOR M.J.: TYPE 1 DIABETES MELLITUS Assessment: History and examination

Review the person’s history for allergies to drug products, pregnancy, breastfeeding and other drugs in current use. M.J. denies allergies, pregnancy and breastfeeding. She is taking no other medications. Focus the physical examination on the following: Neurological: orientation, reflexes; M.J. appears shaky and her pupils are dilated. Skin: colouration and/or lesions; M.J.’s appearance (pale, sweaty) is consistent with diaphoresis.