Student Handout for Factors to Consider: Patient Education

DIRECTIONS: As a group, determine how you would address the situation.

Patient Scenarios
1. Maddie, age 16, has type 1 diabetes. She is unwilling to follow proper insulin usage to
maintain glycemic control, because she believes following such protocol “makes her fat.”
Actually, insulin decreases utililzation of fat sores by the body and is considered a fat
sparer. Insulin inhibits to use of fat for energy by enhancing the body’s use of glucose;
insulin also inhibits the action of lipase, the enzyme that causes hydrolysis of fat. It
inbibits liver enzymes that activate gluconeogensis and ihibits the breakdown of
proteins. If you use insulin, it can enhance the use of cell permeability to amino acids
meaning that it prevents muscle tissue from breaking down and promotes tbuilding of
muscle, storage of fat.

2. Donald is a 62-year-old overweight man who was diagnosed with type 2 diabetes 5 years
ago. He has continued gain weight during the past few years. He tells you that he knows he
must exercise, but his feet hurt too much to do anything.

This occurs as a result of lack of blood flow to your peripheral extremities, and as a result
the nerve fibers are damaged. This is called peripheral neuropathy of diabetes, and it most
commonly presents as sensory loss in the feet and progresses up the lower extremity. You
may be experiencing burning, pain and paresthesia of feet.

3. Jack is a young patient, age 12, who was diagnosed with type 1 diabetes 2 years ago. Jack
recently began middle school and has had diabetic ketoacidosis two times since school
began. Jack informs you that he is having difficulty remembering to take his insulin and
modifying his insulin usage to meet his needs.

It is not uncommon for young inividuals to have difficulty remembering to take their insulin.
Jack is suffering from diabetic ketoacidosis because of improper glucose monitoring and
insulin intake. It is important for Jack to follow his insulin regimen and regulate his long
term health condition. He is doing damage to his boy by improper regulation and can have
long term effects such as diabetic neuropathy and blindness. I would make goals for Jack
that can help encourage him to regulate his glucose and to also amintain a daily exercise
regimen.

4. Ian is a competitive cross-country runner who has type 1 diabetes.

You are at risk for hypogylcemic episodes. Exercise is good to have, however, it is important for you
to know htat exercise can move glucose into cells. THe fact that you are type 1 diabetic indicates that
you rely on exogenous insulin. Exogenous insulin and excessive exercise can increase the risk for
hypoglycemia. It is important that you can safely participate in cross country still as long as you learn
how to control your blood glucose levels.

5. Louis has had type 2 diabetes for 10 years. He often forgets to take his medications and
complains he is just “too depressed” to care anymore. He is not motivated to exercise or eat
right. He feels it does not matter because his blood sugar always seems high anyway.

I understand that you are depressed, do you have any support from family or friends? I
understand that it may be hard to do every day activities. We can also educate a family
member that can assist you with your treatment regimen. Hyperglycemia causes major
damage to small and large arterial blood vessels. If you were to leave your diabetes
untreated, prolonged, chronic hyperglycemia without treatment can lead to damage of blood
vessels which can ultimately lead to eye damage, neuronal damage, and kidney damage
which referred to as diabetic retinopathy, neuropathym and nephropathy. ADditionally, you
are at a high risk for infection as T cells and WBC phagocytic function are affect by the
hyperglyemic environment. You can also develop worsening of these complications, such
as with diabetic neuropathy, it can lead to amputation of the lower leg.
Student Handout for Worst Case Scenario: Systemic Complications

DIRECTIONS: Review the body systems affected by diabetes mellitus from the list provided below. For
each body system, follow the progression of the “worst case scenario” of this system being affected by
diabetes mellitus.

Body System “Worst Case Scenario”

stroke, transient ischemic attack
Cerebrovascular

retinopathy (narrowing of retinal arteries, hemorrhages,

Vision exudates)

blindness
nephropathy (damage to glomeruli and renal arterial
Renal circualtion)

Coronary artery disease (coronary artery plaque buildup,

Cardiac narrowing of arteries, with plaque disruption and emboli →
angina pectoris or myocardial infarction)
Accelerated atherosclerosis (arterial plaque buildup, narrowing
Arterial of arteries, possible plaque disruption and thrombotic or
embolic obstruction of arterial blood flow)
peripheral neuropahty; mainly sensory.motor to lesser extent
Peripheral nervous (damage to enoneurial arterial circulation that decreases
system blood flow to nerves, particulary nerves of lower extremity)
peripheral arterial disease of lower extremities (arterial plaque
Peripheral vascular buildup, narrowing of arteries, and obstruction of arterial
blood flow in lower extremities)
Immunosuppresion (WBC dysfunction in high glucose
Immune environment)

Anxiety, depression, eating disorders, “insulin purging”, denial

Psychological/emotional of the disorder “psychological insulin resistance” (stress,
misinterpretation of disease process, ack of appropriate
coping skills)
Candida vaginitis, candida balanitis (glycogen accumulation
Reproductive within vaginal cells, susceptibility to infection)

Autonomic neuropathy (damage to endoneurial arterial

Autonomic circulation, which decreases blood flow to autonomic nerves;
nervous system dysfunction of sympathetic and parasympathetic nervous
systems)
Skin ulceration, susceptibility to staphylococcal infection, and
Skin poor wound healing. Necrobiosis lipoidcia diabeticorum,
acanthosis nigricans, lipoatrophy and lipohypertrophy,
intertriginous candida infection (skin ulceration)
Student Handout for Where There Is One, There Are Many

DIRECTIONS: Consider the systemic effects of diabetes mellitus covered in the prior activity. In
this activity, discuss the follow-up laboratory tests and treatment strategies that may occur
when managing long-term complications of a patient with diabetes mellitus.

Body System Diagnosis Treatmen

t
CT scan or MRI aspiring or anticoagulant
Cerebrovascular ECG therapy
Carotid artery CT scan
carotid stenosis surgery
(endarterectomy) or tx of Afib
fundoscopic exam photocoagulation therapy
Vision
clinical signs: microaneurysms,
hemorrhage, macular edema ,
exudates, “cotton wool spots”
urinalysis - microalbuminuria, dialysis, hemodialysis
Renal proteinuria

MI: - IV nitrates
Cardiac - elevated cTnI and cTn T - morphine
-elevated CPK-MB fraction - aspirin
-ECG shows ST elevation or ST - oxygen
depression, inverted T waves - heparin or another
-Cardiac catheterization with anticoag
angiography shows Coronary - antiplatelet therapy
artery obstruction - beta blockers if stable,
-Radionuclide angiogram Ca++ antagonists
-Cardiac Ct scam - thrombolytic agent to
-calcium CT scan dissolve clot
-ECG - PCI includes PTCA with
stent placement or CABG
- Cardiac rehab
cardiac catheterization, CT Surgical treatments - CABG
Arterial calcium scan and US surgery and PCI; angioplasty
(stent placement)
Lipid Profile (total cholesterol,
LDL, HDL, triglycerides) - if Same as hyperlipidemia:
hyperlipidemia present - NONpharm: low-fat diet,
additional tests needed; BMI physical activity; fish oil; high
calculated d/t obesity fiber diet

Endothelial function - US of PharmL HMG-CoA reducatase

arm’s brachial artery inhibitors (statins); Bile acid
sequestrants
CRP (C-reactive protein):
produced in response to
atherosclerosis (inflammatory
process)
hs-CRP (blood tests)
 angiograph, homocysteine level,
Intravascular US
- loss of sensation in feet foot care/elevate feet when
Peripheral - paresthesias of foot sitting
nervous system - foot deformities (charcot - eliminate aggravating
joint) drugs
- gait disturbance - -diuretics
- support stockings
PAD: -diet low in fat, low in salt to
Peripheral vascular -elevated hs-CRP diminish formation of cholesterol
-total cholesterol > 200 and decrease BP
- LDL > 140 in most affected -antilipidemic meds
person -folic acid to lower homocysteine
- HDL < 40 - anticoag (aspirin
- elevated blood homocysteine -keep BP low
level - exercise daily to build collateral
- ABI < 1 branch of leg arteries
- vasodialtor meds
PVD: -revascularization treatments
- pain og lower extremity
d/t ischemia
(intermittent claudication
- weak or absent pulses
- paresthesia in feet
- pallor of lower extremity
- coolness on palpation
- poor wound healing

- test for staph aureus on

Immune skin
- WBC panel
- tests for pneumonia, UTI,
TB and fungal infections

signs and symptoms discussion of feelings

Psychological/emotional - powerlessness
- anger - discuss likelihood that
- guilt and discouragement insulin will be needed for
- anxiety - stressful to optimal control of BF as
manage disease disease progresses
- denial - assess psychoscoial
needs
- emotional support
signs and symptoms: antibiotics
Reproductive - candida vulvovaginitis -
pruritis, vaginal dischage antifungal medications -
- candida balanitis - fluconazole
pruritic rash in antifungal cream
uncircumcised males
signs and symptoms: - control BP, glucose, and
Autonomic - postural hypotension lipids
nervous system - gastroparesis - smoking cessation
 - bladder and bowel - RAAS blockade (ACE
dysfunction inhibitor, ARBs)
- lack of sympathetic - nephrologist referal
nervous symptoms in
hypoglycemia
signs and symptoms: - rotate sites between
Skin - prolonged wound healing abdomen, deltoid, and
- skin ulceration thigh to prevent
- pigmented pretibial lipoatrophy and
papules - lipohypertrophy
hyperpigmented areas
on legs
- necrobiosis lipoidica
diabeticorum
- acanthsosis nigracans -
conglomeration of tiny,
pigmented, velvety,
macular lesion on neck,
axilla, extensor surfaces
- dry skin and pruritis