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P A R T 6
Drugs acting on the endocrine system
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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
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Blood glucose levels vary with food intake, exercise
and stress levels, possibly necessitating a change in
insulin dose.
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Individuals need to learn to recognise the signs of
hypoglycaemia and hyperglycaemia to effectively
manage their drug therapy.
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.
