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1.     As a nursing student, your clinical facilitator has allocated you to care for Jarrah. After the morning handover, you are asked to explain the pathophysiology of type 1 diabetes to the clinical facilitator. What is your response?

2.     Your clinical facilitator tells you that Jarrah would rather not have multiple daily injections. He wants to know why he cannot just have tablets to manage his type 1 diabetes like his friend who has type 2 diabetes. What is your response?

1.     Diabetes type 1 is a condition that has a rapid onset but one whose development takes a long process that involves progressive immunological damage. The condition is characterized by the invasion of the pancreatic islets by the T-lymphocytes destroying the beta cells (Kahanovitz et al., 2017). The antigen-presenting cell (APCs) travel to the pancreatic lymph nodes and interact with the autoreactive CD4+ T lymphocytes resulting in the activation of the autoreactive CD8+T cells. The destruction of the B-cells is amplified by the release of the pro-inflammatory cytokines as well as reactive oxygen species from the innate immune cells such as the neutrophils, macrophages, and the natural killer cells (DiMeglio et al., 2018). T cells, which are activated in the lymph nodes, stimulate the B-lymphocytes into producing antibodies against the b-cell proteins.

2.     Individuals diagnosed with type 1 diabetes need insulin shots and not insulin pills. Type 1 diabetes patients cannot take insulin as pills since the digestive enzymes would break the insulin down before it is used in the body. Insulin injections on the subcutaneous layer of the skin are effective as it enables the continuous infusion of the insulin into the body to manage diabetes (Akil et al., 2021). The insulin injections are therefore most effective in enabling the patients to achieve better glycaemic control without necessarily increasing the risk for hypoglycaemia.

Jarrah is disappointed that he has to administer two different types of insulin. Your clinical facilitator asks if you can explain to her how Jarrah’s prescribed regime works to achieve glycaemic control.

1.      Explain the ‘time-course’ of formulations of NovoRapid and Optisulin.

2.      Explain the principles underpinning a ‘basal-bolus’ regime of insulin (see Bryant & Knights, 2019, p. 682 – 683).

*See also MimsOnline 2022 Full Prescribing Information NovoRapid and Optisulin

3.      Explain the mechanism of the action of NovoRapid and Optisulin in attaining glycaemic control.

1.     NovoRapid is usually injected subcutaneously. The action of the medicine begins within 10 to 20 minutes after injection. The patient is able to feel the maximum effect of the drug 1 to 3 hours after injection. The drug remains active after 3 to 5 hours of injection. Optisulin is a long-acting diabetes drug, which is only administered subcutaneously once a day (Hemmingsen et al., 2019). The drug can be administered any time of the day but the patient must maintain the same time every day.

2.     The Basal-bolus insulin regimen means the use of one or two doses of either intermediate or long-acting insulin, and three or four doses of short-acting insulin (Attri et al., 2020). Basal insulin works by regulating a rise in the blood glucose attributed to endogenous glucose production from the process of gluconeogenesis and glycogenolysis. On the other hand, bolus insulin works by preventing a rise in blood glucose levels that is related to meals.

3.     The basal-bolus regimen should be used when, a patient has suboptimal blood glucose control with oral blood glucose drugs, when the use of oral blood glucose-lowering drugs is linked with organ dysfunction, during a transition from intravenous insulin infusion to a subcutaneous insulin regimen, and when a patient was already using the regimen before hospitalization.

4.      Novarapid works by regulating glucose metabolism. It facilitates the storage while inhibiting the breakdown of glucose, amino acids, and fats. It lowers the blood glucose by increasing the peripheral uptake in the skeletal muscle and fat (Rubin et al., 2021). The drug also inhibits gluconeogenesis, proteolysis, and lipolysis. Optisulin (Insulin glargine) acts by regulating glucose metabolism (Cunningham & Freeman, 2021). The drug lowers the blood glucose levels through the stimulation of the peripheral glucose uptake by the skeletal fat and muscle. It also acts by inhibiting hepatic glucose production. Insulin hinders proteolysis, lipolysis in the adipocyte as well as enhances protein synthesis.

You are on a night shift and Jarrah rings his bell at 0200hrs and states he feels unwell. You take his blood glucose level (BGL) and find it to be 3.0mmol/L. This is the second consecutive night this has happened.

1.    What are the registered nurse’s responsibilities relating to the Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice in providing safe care to Jarrah? Identify one standard and apply it to your responsibility in this situation.

2.     Identify two possible causes of his hypoglycaemia.

Take action

3.    What are the appropriate nursing actions after taking Jarrah’s BGL? Give a rationale for the nursing actions.

4.    If Jarrah appears to have altered consciousness, explain the nursing actions you would take and provide a rationale.

1.     The nurse would apply Standard 1: ‘Thinks critically and analyses nursing practice.’ This standard requires that the registered nurse uses diverse thinking strategies as well as the best available evidence to provide safe, quality, and person-centered care (Nursing and Midwifery Board, 2022). The nurse would therefore think critically through the patient’s medical history and clinical manifestation and come up with a plan that is based on the best evidence available in the management of patients with type 1 diabetes. She would comply with the legislation, develop practice that is reliant on my experiences, and most importantly shape practice based on the patient’s unique needs.

2.     Hypoglycemia refers to a condition characterized by a low plasma glucose level of below 4.0mmol/L for people with diabetes who are treated with insulin (Yale et al., 2018; Mathew & Thoppil, 2021). Two possible causes for Jarrah’s hypoglycaemia would be intensive insulin therapy and a history of hypoglycaemia (Muche & Mekonen, 2020). Jarrah has been put on ‘basal-bolus’ regime of insulin aspart (Novorapid) before each meal, and insulin glargine (Optisulin) before bedtime. The combined insulin therapy above is intensive and could have caused the hypoglycemia. The second cause is recurrent hypoglycemia. The patient’s medical history indicates that this is the second night that his plasma glucose levels have gone that low.

3.     The nursing actions that would be appropriate after taking the patient’s BG levels would be to provide 15 g glucose (a monosaccharide) that is supposed to facilitate an increase in the BG levels by 2.1 mmo/L within 20 minutes of administration. The monosaccharide would be the most effective as compared to others such as milk, orange juice, and even glucose gel, which are quite slow in increasing the BG levels. They would therefore not be appropriate choices due to their slow action that would increase the patient’s risk of injury.

4.     If the patient was unconscious, severe hypoglycaemia should be treated with 10-25 g (20-50 Ml of D50W) of glucose given intravenously for over 1-3 minutes. In case of no intravenous means, the patient should be given 1 mg glucagon subcutaneously or intramuscularly (Yale et al., 2018). The patient should be closely monitored to record progress or any developments.

1.     Jarrah is struggling to come to terms with his type 1 diabetes diagnosis and the need to have multiple daily injections. What information would you give him about the long-term benefits of having the insulin and closely monitoring his BGL?

2.     What information would you provide to Jarrah and his father about recognising symptoms of hypoglycaemia?

3.     What education would you provide regarding techniques around self-administration of insulin?

4.     Identify one aspect that you would have to consider in relation to social justice. How could this impact Jarrah’s ongoing health needs? What solution might you offer to address this?

5.     What issues could affect Jarrah’s ongoing glycaemic control in relation to a) his age and b) engagement in sport once he is discharged?

1.     It would be of paramount importance for the patient to accept his diabetes 1 diagnosis that would help him comply with the regular monitoring of the blood glucose levels as well as adherence to the insulin injections. The information that Jarrah would need to receive regarding his condition would include the need to keep his blood glucose levels within the target range to lower his risk for long-term health complications. It would be vital to mention to the patient that diabetes management aims at keeping the blood glucose levels between 4 to 6 mmol/L (Mathew & Tadi, 2021). The patient would need to understand that having either too high or too low blood glucose levels is likely to impair cellular function.

2.     Jarrah and his father would need to look out for the symptoms of hypoglycaemia to avoid health complications. Some of the signs and symptoms that they should look out for include shakiness, sweating, dizziness, confusion, a fast heartbeat, going pale, blurred vision, inability to concentrate, hunger and irritability or moodiness (Cardona et al., 2018). Recognizing the signs of hypoglycaemia would facilitate the adoption of an immediate intervention, which would stabilize the blood glucose levels hence preventing adverse health outcomes.

3.     Patient education that I would give to the patient regarding self-administration of insulin would include details like the need to rotate the site daily. The patient should pinch some skin and insert the needle at a 90 degrees angle. He should ensure to keep the skin pinched to avoid the insulin from going into the muscle. Afterwards, he should push the plunger down, hold the needle and syringe in place for approximately 5 seconds.

4.     Social justice in the health system relates to the provision of equal healthcare services to all individuals despite their personal characteristics (Wallack, 2019). An aspect of social justice would need to be looked into with relation to the patient study is diversity. From the patient’s subjective information, we learn that Jarrah is of the Aboriginal descent and lives with his father in Cherbourg. Therefore, he comes from a minority group. The social justice principle of diversity requires that the healthcare practitioners understand diversity and appreciate cultural differences among patients. Some groups especially the minority groups are more likely to face barriers in the society, which would hinder them from achieving optimal health outcomes. The healthcare practitioners would need to demonstrate cultural competency, awareness and sensitivity while at the same time incorporating their advocacy skills in the patient case.

5.     a. Nursing studies indicate that among the adolescent population, there is a huge decline in diabetes management. Issues have been noted in the treatment adherence as well as glycaemic control. Some of the issues that have associated with the challenges include non-compliance, biological changes, and psychosocial changes that are associated with puberty and young adulthood (Khadilkar & Oza, 2022). Hormonal changes among the adolescents could result in insulin resistance. Non-compliance with diabetes treatment is caused by family functioning, perception of ailment, and the complexity of therapy. Psychosocial barriers relate to the cognitive, behavioural and cognitive changes during adolescence.

b.     After discharge, Jarrah should aim at getting approximately 150 minutes of moderate intensity of aerobic exercise weekly. He should therefore engage in aerobic exercise for approximately 30 minutes for five days. Being active makes a person more sensitive to insulin, which helps in the management of blood glucose levels.

Akil, A. A. S., Yassin, E., Al-Maraghi, A., Aliyev, E., Al-Malki, K., & Fakhro, K. A. (2021). Diagnosis and treatment of type 1 diabetes at the dawn of the personalized medicine era. Journal of Translational Medicine, 19(1), 1-19.

Attri, B., Goyal, A., Gupta, Y., & Tandon, N. (2020). Basal-Bolus Insulin Regimen for Hospitalised Patients with COVID-19 and Diabetes Mellitus: A Practical Approach. Diabetes therapy : research, treatment and education of diabetes and related disorders, 11(9), 2177–2194. https://doi.org/10.1007/s13300-020-00873-3

Cardona, S., Gomez, P. C., Vellanki, P., Anzola, I., Ramos, C., Urrutia, M. A., … & Umpierrez, G. E. (2018). Clinical characteristics and outcomes of symptomatic and asymptomatic hypoglycemia in hospitalized patients with diabetes. BMJ Open Diabetes Research and Care, 6(1), e000607.

Cunningham, A. M., & Freeman, A. M. (2021). Glargine Insulin. In StatPearls [Internet]. StatPearls Publishing.

DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. Lancet (London, England), 391(10138), 2449–2462. https://doi.org/10.1016/S0140-6736(18)31320-5

Hemmingsen, B., Metzendorf, M. I., & Richter, B. (2021). (Ultra‐) long‐acting insulin analogues for people with type 1 diabetes mellitus. Cochrane Database of Systematic Reviews, (3).

Kahanovitz, L., Sluss, P. M., & Russell, S. J. (2017). Type 1 Diabetes – A Clinical Perspective. Point of care, 16(1), 37–40. https://doi.org/10.1097/POC.0000000000000125

Khadilkar, A., & Oza, C. (2022). Glycaemic Control in Youth and Young Adults: Challenges and Solutions. Diabetes, metabolic syndrome and obesity : targets and therapy, 15, 121–129. https://doi.org/10.2147/DMSO.S304347

Mathew, P., & Thoppil, D. (2021). Hypoglycemia. StatPearls [Internet].

Mathew, T. K., & Tadi, P. (2021). Blood glucose monitoring. In StatPearls [Internet]. StatPearls Publishing.

Muche, E. A., & Mekonen, B. T. (2020). Hypoglycemia prevention practice and its associated factors among diabetes patients at university teaching hospital in Ethiopia: Cross-sectional study. PloS one, 15(8), e0238094.

Nursing and Midwifery Board. (2022). Nursing and Midwifery Board of Australia – Registered nurse standards for practice. Nursingmidwiferyboard.gov.au. Retrieved 31 March 2022, from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx.

Rubin, R., Khanna, N. R., & McIver, L. A. (2020). Aspart Insulin. In StatPearls [Internet]. StatPearls Publishing.

Wallack, L. (2019). Building a social justice narrative for public health. Health Education & Behavior, 46(6), 901-904.

Yale, J. F., Paty, B., & Senior, P. A. (2018). Hypoglycemia. Canadian journal of diabetes, 42, S104-S108.