Diabetes Game Demo

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This is part 1 of 2 of your clinical requirement for this course. Completion of this online module is necessary for participation in simulation day. In this online learning module, you will encounter 3 scenarios involving patients with diabetes. As you accurately respond to knowledge checks and activities, you will receive a total of 3 clues for each scenario. It is essential to keep track of these clues, as they will be crucial for unlocking the door and get you access to your next patient. Upon completion of the module, you will be awarded a completion certificate that you will print and bring to simulation day.

GlucoGuardian: Nursing Challenge

Can you recognize the signs and symptoms?

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Hypoglycemia and Hyperglycemia

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Can you recognize the signs and symptoms?

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Hypoglycemia and Hyperglycemia

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Can you recognize the signs and symptoms?

Hypoglycemia and Hyperglycemia

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Drag and drop statements into the correct category

Can take years to develop

Often starts in childhood

Requires lifelong insulin therapy

Can develop in a few weeks or months

More common in middle age

Metabolic disorder that occurs when the body is unable to produce enough insulin or use it properly

Caused by immune system reaction your immune system mistakenly attacks and destroys cells in your pancreas that make insulin

Type 2 Diabetes

Type 1 Diabetes

Select from the drop down activity

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Matching game

Types of Insulin

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Click on the areas that could be given subcutaneous insulin injections

INSULIN INJECTION SITES

See Tips

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INSULIN INJECTION SITES TIP

You have been assigned to Patricia Roth. Click on the folder to receive report.

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Enter the code to exit the room

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Vital Signs BP 168/88mmHg, HR 68/min, RR 22/min, 92% on room air, temp 98.8F Weight 62kg Review of Systems Neuro: Alert and oriented to self and intermittently to place, pleasantly confused, reports feeling fatigued HEENT: Wears glasses Cardiac: WNL, well perfused no edema Respiratory: Lungs clear on auscultation, no cough GI: soft non -tender, last BM yesterday, has a poor appetite the past few days GU: voiding appropriately Skin: fragile, red area to the anterior and lateral side of the right lower leg, open area to right great toe and heal Muskeletal: generalized weakness, ambulates with a cane

Home Medications Metformin 600 mg BID Aspirin 81mg once daily Lisinopril 10mg once daily Insulin Lispro/Humalog sliding scale and carb counting

Patricia Roth is a pleasantly confused female who was hospitalized for cellulitis to a chronic right leg ulcer with delayed wound healing

Medical History Hypertension Dementia Type 2 diabetes Peripheral neuropathy

DOB 05/23/1942

Patricia Roth

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Black coffee

Scrambled eggs

Fresh fruit place

Buttermilk pancakes

Patricia Roth's Breakfast

CLUE

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Patricia Roth

After reading the patient report answer the following question to receive your clue!

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"I went to give Mrs. Roth her breakfast tray but she wasn't in her room and I cannot find her anywhere"

Patricia Roth

John the patient care tech

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Medication Admnistration Record

Patricia Roth

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Patricia Roth

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Tips

The correct answer is INSULIN because of the timing between the insulin administration and Mrs. Roth's disappearance.

Patricia Roth

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Diet coke

Baked chips

Tomato soup

Turkey burger

CLUE

Patricia Roth's Lunch

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Drag and drop the statement in the correct category

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Muscle tissue

Pancreas

Liver

Pathophysiology of Type 2 Diabetes

Insulin resistance

Defective insulin production

Inappropriate glucose production

Info

Tips

Biguanide such as Metformin

Drag and drop the class of medication to the target tissue/site of action

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Muscle tissue

Pancreas

Liver

Pharmacology of Type 2 Diabetes

Sulfonylureas such as Glipizide

Thiazolidnediones (TZDs) such as Pioglitazone

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Whole wheat dinner roll

Water

Side carrots and broccoli

Roasted salmon with brown rice

CLUE

Patricia Roth's Dinner

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Insulin to Carb ratio is 1:10 1. Determine number of carbohydrates patient ate 2. Divide this number by 10 to determine the units of insulin 3. if tenths place is 0.5 or greater, round UP to the nearest whole number. For tenths place 0.4 or less, round DOWN Example: Patient had 62 grams of carbs at lunch. 6.2/10=6.2 round down to 6 units

Carb Count

Sliding Scale

Lispro Insulin Order Set

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After gathering all the clues, calculate the total of carbs the patient eats in a day

Breakfast + Lunch + Dinner Total Carb ______________________

Full Day

Total Carbs ____________________

Total Carbs ____________________

Total Carbs ____________________

Dinner

Lunch

Breakfast

Patricia Roth

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Info

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Mrs. Roth is sitting in a chair looking out the window. You call the patient care tech and they start to gather some vital signs for you. You reach for her hand - it's cool and clammy. Mrs. Roth is drowsy but alert. She responds to your questions although she is still pleasantly confused. She does not appear in any distress and says she was just looking for a doughnut.

You found Mrs. Roth!

Patricia Roth

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Patricia Roth

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You check Mrs. Roth blood glucose and it is 54. Use the hypoglycemia protocol to treat Mrs. Roth

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Hypoglycemia Protocol

Patricia Roth

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Info

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Feedback

Using the hypoglycemia protocol, the nurse should prepare to administer 15 grams of carbohydrates. Mrs. Roth is able to take PO treatment. The nurse should look for rapid acting PO treatment that can be quickly and easily consumed Orange Juice is the best option. it is quick and easy to drink providing the patient with about 15 grams of carbohydrates that are readily available for the body to utilize Diet soda does not have enough carbohydrates. An apple contains about 25 grams of carbohydrates. It is not ideal because it cannot be administered quickly Cheese slices contain protein but no carbohydrates Hot chocolates contains about 25 grams of carbohydrates but is not the best choice because it is meant to be sipped rather than administered quickly

hypoglycemic protocol

Patricia Roth

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Info

Mrs. Roth drank the orange juice. You check the clock.

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hypoglycemic protocol

You recheck Mrs. Roth blood glucose at 09:15 and it is 60. Use the hypoglycemia protocol to treat Mrs. Roth.

Info

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hypoglycemic protocol

You recheck Mrs. Roth blood glucose at 09:15 and it is 60. Use the hypoglycemia protocol to treat Mrs. Roth.

Info

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Feedback

Based on the protocol, you should repeat the treatment until the blood glucose is >70mg/dL and then move to the next protocol. You should also notify the provider of the hypoglycemic event. You should not give IV D50 if the patient is able to take PO You should continue to administer fast-acting simple carbohydrates until the blood sugar is greater than 70mg/dL. Once it is greater than 70mg/dL, the patient should be allowed to eat a meal that contains complex carbohydrates. The nurse should first treat the low blood glucose according to the protocol and then update the provider Updating the provider is part of the protocol but you should first administer patient care.

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Congratulations!

After 15 minutes, you recheck Mrs. Roth's blood glucose and it is 97. You notify the provider and he is very impressed with your quick thinking ability! Remember everything you did! You just started at a new unit and assigned a patient who went missing. You located the patient and returned her safely to her room. You then managed the hypoglycemic event and kept your patient safe! You are an awesome nurse! Click return to go back to the room. Enter the full day carb number on the lock to exit the room and to your next assignment!

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Enter the code to exit the room

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Vital Signs BP 100/70mmHg, HR 104/min, RR 24/min, 98% on room air, temp 102.2F Weight 90kg Review of Systems Neuro: slighlty confused HEENT: dry mucous membrane Cardiac: S1S2, no edema Respiratory: rales in right lower chest GI: soft, tender GU: voiding appropriately Skin: poor skin turgor

Home Medications Insulin gargline 24 units at bedtime Rapid-acting insulin analog before each meal

Jose Alvez is a 52 years-old with type 1 diabetes since the age of 14 years old. His wife took him to the ED because of drowsiness, fever, cough, diffuse abdominal pain and vomiting. Fever and cough started 2 days ago and the patient could not eat or drink water. Jose and his wife have limited English language proficiency. Per the interpreter, Jose ran ot of insulin because of his insurance.

Medical History Type 1 diabetes Hypertension

DOB 02/13/1972

Jose Alvez

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Click on the statements describing DKA

DKA vs HHS

Feedback

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DKA vs HHS

• Childhood environmen: supportive familmy
• Socio-economic status:

• Community-based organizaion: diabetes education
• Policy: financial support
• Healhcare system: insurance coverage, affordability, physician-patient relatioship
• Biologic: genetics
• Behaviors: diet, medication adherence
• Physical: age, race, obesity

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Placeholder for activity

Social Determinant of Health

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CLUE 1: write Jose's initial BG down. You may need it to unlock the door

Jose Alvez

The provider orders labs, EKG, chest x-ray. Fingerstick glucose shows 455 and urine test reveals ketonuria.

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Jose Alvez

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Jose Alvez

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Lab for Jose resulted as followed

Jose Alvez

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FEEDBACK

• hypokalemia is a common complication in DKA
• It can be life-threateing and can lead to cardiac arrhythmias and death.
• Hypokalemia occurs in DKA due to osmotic diuresis, inadequate oral intake, vomiting, renal clearance of ketone bodies
• Insulin therapy also induces hypokalemia therefore, potassium monitoring and replacement is required

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CLUE 2: write the BG number down. You will need it to unlock the door code

Jose Alvez

IJose is placed on IV insulin, IV maintenance fluid. An hour later you recheck Jose's blood glucose. It is now 333.

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The provider orders 2 IVs, patient to be kept NPO, blood glucose POC hourly check, BMP q2 hours, VBG every 2 hours, and a NS 0.9% 10-20 ml/kg IVF bolus, along the following orders.Select the rationale for each order

Jose Alvez

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Matching drop down activity

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Fluid resuscitation is the first priority.Patients with DKA typically lose 6–9 liters of fluid. Half of the fluid replacement should happen within the first 8–12 hours.

• Start with 0.9% Normal Saline (NaCl) at 15–20 mL/kg/hr.
• Later transition to 0.45% NaCl depending on sodium levels.
• As blood glucose falls to 200–250 mg/dL, switch to a dextrose-containing fluid (e.g., D5 0.45% NaCl) to prevent hypoglycemia while continuing insulin.

Potassium Management:

• DKA patients often have low potassium due to acidosis and fluid loss.
• Always check potassium levels before starting insulin.
• If potassium < 3.3 mEq/L, delay insulin therapy and start potassium replacement first to avoid severe hypokalemia, which can cause muscle weakness and life-threatening cardiac arrhythmias.

Insulin Therapy:

• Insulin should be started after adequate fluid resuscitation and only if potassium is > 3.3 mEq/L.

• Insulin drives potassium into cells, which can worsen hypokalemia if not corrected first.

DKA Management Overview

Jose Alvez

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Jose Alvez

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Jose Alvez

CLUE 3: write this BG number down. You will need it to unlock the code

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Jose has been placed on IV insulin infusion with IVF with potassium. on the next hour, his BG is 189 but his anion gap has not closed, his bicarbarb is 10 and pH 7.26

Jose Alvez

Jose Alvez

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Twelve hours later, Jose's labs resulted. His anion gap has closed.

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• DKA is resolved when the following criteria are met
• BG less than 200 mg/dL
• Serum bicarbonate at least 15 mEq/L
• pH: greater than 7.3
• Anion gap: less than or equal to 12 mEq/L
• Patient is able to eat
• Once DKA has resolved, a patient can transition to a standard subcutaneos insulin regimen if he is eating. If the patient is unable to eat, the IV insulin could be continued alon with the dextrose infusion
• The IV insulin infusion should be continued for two to four hours after initiating the short- or rapid-acting subcutaneous insulin because abrupt discontinuation of IV insulin acutely reduces insulin levels and may result in recurrence of hyperglycemia and/or ketoacidosis

FEEDBACK

Jose Alvez

What do you do next?

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Before discontinuing the IV insulin infusion, a subcutaneous insulin injection should be given, and the IV insulin should continue for an additional 2–4 hours. This overlap ensures that insulin levels remain stable, preventing rebound hyperglycemia and recurrence of ketoacidosis. Careful timing during the transition from IV to subcutaneous insulin is a critical final step in safely managing DKA.

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"Don't worry if this feels new — this exercise is meant to build your confidence!"

As future nurses, you will likely encounter DKA insulin nomograms in clinical practice. These nomograms help guide safe and effective insulin drip adjustments based on blood glucose levels during DKA treatment. To give you a preview of how these calculations work, we've created a short exercise based on Mr. Alvez’s case. Use the provided information to practice adjusting an insulin infusion rate — an important skill you will use in real patient care! Complete the calculation to unlock the final code and exit the room.

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How to Adjust an Insulin Drip Rate in DKA

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A patient is 90kg with an initial BG is 350. Initiate insulin drip at 9 unit/hr (0.1 unit x 90kg). On the next hourly recheck, BG is 300, which is a drop in glucose by 50 mg/dL. On the nomogram, look at the "Drop in Glucose" column under "40 to 100" and the "Glucose Q1H" column under "240-300", it says to decrease by 1 unit/hr. The new rate is 8 unit/hr.

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New Rate (unit/hr) ____________________

Initiate BG at 0.1 unit/kg/hr or 9 units/hr

Clue 2 : 333

nomogram

Clue 1: 455

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Using the clues you have gathered, calculate the insulin infusion rate for Jose Alvez, who weighs 90 kg, based on the DKA insulin nomogram

New Rate (unit/hr) ____________________

Clue 3: 189

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New Rate (unit/hr) 4.5 units/hr

Initiate BG at 0.1 unit/kg/hr or 9 units/hr

nomogram

Clue 2 : 333

Clue 1: 455

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Using the clues you have gathered, calculate the insulin infusion rate for Jose Alvez, who weighs 90 kg, based on the DKA insulin nomogram

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Enter the code to exit the room

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Home Medications Prenatal multivitamins

Brooke Walters is a 35-year old female, G3T2P0A0L2 and currently at 26 weeks gestation. She works as a computer programmer.Previous babies were large. First child was 9lbs (4kg), second child 10 lbs (4.5kg). Pre-pregnancy weight 175lbs (79.3kg); height 5'2" (157cm). BMI 32%. No other significant history or medications. She is being seen for her prenatal visit in the outpatient clinic. She has gained 2 lbs ince her last visit. She continues to take prenatal vitamins.

Medical History None

DOB 10/24/**

Brooke Walters

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Brooke Walters

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RIsk factors for GDM includes

• Being overwieght or obese, a BMI above 30
• Family history of T2DM
• History of GDM in previous pregnancy
• Maternal age >25
• Gaining too much weight too quickly during pregnancy
• Being African American, Hispanic or Latino, AMerican Indian, Alaska Native ,Native Hawaiian or PAcific Islander, Having polycystic ovary syndrome, high blood pressure or prediabetes

FEEDBACK

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Brooke Walters

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https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/gestational-diabetes

• Unlike T1DM, gestational diabetes is not caused by lack of insulin but by other hormones produced during pregancy. During pregnancy, a hormone made by the placenta prevents the body from using insulin effectivel, a condition called insulin resistance.
• All pregnant women have some insulin resistance during late pregnancy. However some women have insulin resistance even before getting pregnant so they start pregnancy with an increased need for insulin and are more likely to develop GDM
• If the body cannot produce enough insulin during pregnancy, glucose remains in the blood leading to high blood glucose
• Gestational diabetic symptoms disappear after delivery.
• High BMI and weight gain can persist or worsen after pregnancy increasing risk for developing type 2 DM

FEEDBACK

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Brooke Walters

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• If a pregnant patient has risk factors for GDM, she will be offered blood tests to diganose for GDM that include the glucose challenge test or oral glucose tolerance test (OGTT), either a 1-hour OGTT or 3-hour OGTT. The tests show how well the body uses glucose.
• The 1-hour OGTT does not require fasting, the 3-hour OGTT requires fasting at least 8 hours
• The 1-hour OGTT involves taking a blood sample to measure the blood glucose level. The patient then drinks 50g of oral glucose solution. One hour later, another blood sample is taken to check for the glucose level. If the blood glucose level is 130 or higher, a more complex 3-hour glucose tolerance test is done.
• The 3-hour OGTT measures glucose concentration over 3 hours. A blood sample is taken to measure blood glucose level after fasting. Then, the patient drinks 100 g of oral glucose solution. The blood glucose is tested again one, two, and three hours after drinking the solution.
• Two abdnormal results in the 3-hour OGTT are diagnostic for GDM

• The tests are usually performed between 24 and 28 weeks of pregnancy or at the first prenatal visit for a patient at high risk fo diabetes.

FEEDBACK

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Brooke Walters

The 26 week laboratory report returns. Complete the following sentence by choosing from the list of options

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CLUE 1

The 1-hour OGTT is positive. Brooke is asked to return to the clinic the next day for the 3-hour OGTT test. For this test, Brooke is asked to fast for at least 8 hours. Write down Brooke's 1-hour OGTT blood glucose result. You will need it for the code to unlock the door.

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The results are listed below.

Brooke Walters

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Brooke Walters

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https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational/tests-diagnosis

• If a pregnant patient has risk factors for GDM, she will be offered blood tests to diganose for GDM that include the glucose challenge test, the oral glucose tolerance test (OGTT) or both. The tests show how well the body uses glucose.

• The tests are usually performed between 24 and 28 weeks of pregnancy or at the first prenatal visit for a patient at high risk fo diabetes.
• Glucose challenge test
• For the initial glucose challenge test, the patient will drink a sweet liquid containing glucose and have lab drawn 1 hour after the drink. There is no need to fast for this test. If the BG level is 140 or hight, the patient may need to come back for the oral glucose tolerance test (OGTT). If the BG is 200 or more, the patient may have T2DM

• The OGTT requires fasting for 8 hours. The blood is first drawn for lab, the patient will drink the sweet liquid containing glucose and have blood drawn every 2-3 hours. High BG levels at any 2 or more blood test times (fasting, 1 hour, 2 or 3 hours) means the patient has GDM.

FEEDBACK

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birth trauma

obesity

preterm birth

Stillbirth

perinatal depression

postpartum hemorrhage due to baby's shoulder dystocia

Shoulder dystocia or other birth injuries

congenital anomalies

Breathing difficulties

jaundice

low blood sugar

Macrosomia (baby weight >8lbs)

future diabetes

C-section

Preeclampsia

Baby

Mother

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Drag and drop the complications that could occur for mother and baby if GDM is left untreated

Brooke Walters

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• https://www.marchofdimes.org/find-support/topics/pregnancy/gestational-diabetes

FEEDBACK

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Brook takes the 3 hour OGTT and receiveds the diagnosis of GDM. You begins to develop the plan of care

Brooke Walters

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• Stabilizing the blood glucose is the priority since it is abnormal and consistent glucose levels within the target range promote the best fetal and maternal outcomes (ACOG, 2018). Slowing weight gain is desirable but cutting calories can lead to ketoacidosis. Macrosomia (large baby) is best prevented by stabilizing blood glucose levels. The client will have to come back for a 3 hour Glucose Tolerance Test(GTT) since the client failed the 1 hour GTT. The 1 hour GTT is for screening, whereas the 3 hour GTT is diagnostic for this client. (ACOG, 2018)

FEEDBACK

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Brooke Walters

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• : Lifestyle changes, like diet and exercise, are successful in 70-85% of all individuals diagnosed with gestational diabetes. (Johns, et al , 2018). Knowledge of glycemic index and complex carbohydrates is important for revising diet for a person with gestational diabetes. Additionally, social determinants of health are imperative to examine in this client related to their diet, physical activity and issues that pertain (CDC, 2022). Although transportation is necessary to participate in prenatal visits, it is not a major concern. Additionally, kitchen location and vitamin K rich foods are also not the highest concern for a nurse to assess.

FEEDBACK

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CLUE 2

Write down Brooke's blood glucose level after 3 hours of the OGTT. You will need it for the code to unlock the door

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Brooke Walters

Medical nutrition therapy (dietaty changes and lifestyle modification) is the primary treatment for the management of GDM. In addition to referring Brooke to a Registered Dietitian, you provdie Brooke with some dietary teaching

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• : Lifestyle changes will be the first step in intervening with a client with gestational diabetes. The correct diet plan is key. A dietician consultation would provide the best guidance in promoting a client – centric diet. Carbohydrates should not exceed 40% of calories, protein should be approximately 20% of calories (ADA, 2021). Ideally, the pregnant individual should plan 3 small- moderate meals with 4 snacks. Other things that should be included in the educational plan is how to perform finger sticks for blood glucose monitoring and when to report results to your nurse midwife or practitioner. Controlling glucose levels can also be achieved via fostering exercise. This plan should be coordinated with the provider or nurse midwife.

FEEDBACK

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After diagnosing GDM, you instruct Brooke to initiate home glucose monitoring, specifying the times for blood glucose checks and the target goals. Brooke is scheduled weekly visits. Since Brooke does not have history of diabetes or taking medications for diabetes before the pregnancy, she only needs to check her blood glucose before meals and 2 hours after meals.

Brooke Walters

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When should you instruct Brooke to monitor and log her blood glucose level?

Brooke Walters

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A week later, Brooke shows her blood glocose log which shows levels are within target range

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Brooke Walters

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You instruct Brooke to continue to monitor her blood glucose level and to bring the results back in 2 weeks at her follow-up appointment.

Brooke Walters

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Write down Brooke's blood glucose level of 2 hour postpandrial of 150. You will need this for the code to unlock the door

Clue 3

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Despite stable blood glucose level during the first week after dietary modification and regular exercise, Brooke's log shows that her blood glucose levels have not been stable for the past 2 weeks. The provider is prescribing Brooke with insulin. Brooke is concerned because she heard that people with diabetes take insulin. She is also concerned that insulin may hurt her baby.

Brooke Walters

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Brooke Walters

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• Insulin remains the "gold standard" for the pharmacological management of GDM. The use of oral hypoglyemic agents has traditionally been avoided in pregnancy because of concfersn over fetal teratogenesis and prolonged neonatal hypoglycemia. However, recent studies suggest that second-generation hypglycemic agents such as glyburide and glipizide do not cross the placenta and are sfae in pregnancy, achieving glycemic control in 85% of pregnancies complicated by GDM.
• Insulin does not cross the placenta
• Both insulin and physical activity lower the blood glucose level and when combined they can cause blood glucose level to drop very quickly. The client should test blood sugar level before any physical activity. If the level is low, the client should eat something and test again to make sure the level is higher before starting an activity.
• Physical activity is an importnat part of any healthy pregnancy. For women with GDM, it also helps their bodies' insulin work better, which is an effective way to help control blood sugar levels.

FEEDBACK

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Brooke is at her 30 week prenatal visit and here are the results of her labs,

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Brooke Walters

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• The client had elevated serum glucose presence of glucose in urine at 26 weeks gestation. All other factors were normal. The serum glucose is now acceptable and there is no glucose in the urine

FEEDBACK

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Brooke states that she plans to have another child and asks you if she will develop GDM with that pregnancy.

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Congratulations!

Brooke delivers a healthy 8 lbs 9 oz baby boy at 39 weeks without complications. She is monitored for GDM during the postpartum period. Add the numbers from the 3 clues together. Click return to go back to the room and enter the calculated number to unlock the door.

Name:

You have completed all the challenges. Your patients shared they received the best of care! Print this certificate and bring it on the simulation day

Congratulations!

Insulin to Carb ratio is 1:10 1. Determine number of carbohydrates patient ate 2. Divide this number by 10 to determine the units of insulin 3. if tenths place is 0.5 or greater, round UP to the nearest whole number. For tenths place 0.4 or less, round DOWN Example: Patient had 62 grams of carbs at lunch. 6.2/10=6.2 round down to 6 units

Carb Count

Liver: instead of its normal ability to release glucose as the body needs it, in type 2 diabetes the liver haphazartly releases glucose. Glucose is not released according to the body's needs Pancreas: Due to insulin resitance throughtout the body, the pancreas becomes fatigued. Initially, this insulin resistance may cause increased insulin secretion as the body tires to compensate. Eventually, the B-cells become tuckered out and do not produce enought or any insulin on their own. Muscle Tissue: Insulin receptors become unresponsive or disappear. When the body does not respond to insulin, the movement of glucose into the cells is altered and leads to hyperglycemia.