Nursing: Overview

Case Study Type 2 Diabetes Mellitus Y. L. makes an appointment to come to the clinic where you are employed. She has been complaining of (C/O) chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination. She tells you she as a vaginal yeast infection that she has treated numerous times with the over-the-counter (OTC) medication. She admits to starting smoking since going back to work full time as a clerk in a loan company essay writer world.

She also complains of having difficulty reading numbers and reports making frequent mistakes. She also says, “By the time I get home, and make supper for my family, then put my child to bed, I am too tired to exercise. ” She reports her feet hurt, they often “burn or feel like there are pins in them. ” She reports that, after her delivery, she went back to her traditional eating pattern, which is high in carbohydrates (CHO). In reviewing Y.

L’s chart, you notice she has not been seen since the delivery of her child 6 years ago. You note that in her 26th week of pregnancy she was diagnosed with gestational diabetes mellitus (GDM). You also note that she is 5’3” and her pre pregnancy BMI was 25. Her father has type 2 diabetes mellitus and both paternal grandparents had type 2 DM. She has gained considerable weight; her current weight is 173 pounds. Today, her blood pressure is 152/97 mm Hg, and her plasma glucose is 291 mg/dl.

Her primary care provider (PCP), which of course is a Family or Adult Nurse Practitioner, orders the following labs: urinalysis, hemoglobin A1C, fasting complete metabolic panel (CMP), CBC, fasting lipid profile, and glomerular filtration rate (GFR). The lab values are as follows: fasting glucose 184 mg/dl, Hb A1C 10. 4, UA +glucose, -ketones, cholesterol 256 mg/dl, triglycerides 346 mg/dl, LDL 155 mg/dl, HDL 32 mg/dl, ratio 8. 0. A subsequent fasting glucose is also elevated and Y. L is diagnosed with type 2 diabetes mellitus.

After meeting with Y. L. and discussing management therapies, the PCP decides to start multiple-dose injection (MDI) insulin therapy and have the patient count CHO. Y. L. is scheduled for education classes and is to work with the diabetes team to get her blood glucose under control. You may use your text book and you must also use 2 additional references (not Wikipedia). List your references at the end. Refer to the rubric for guidance. Double space and make sure your name is on the attachment. 1. Identify the three methods used to diagnose DM.

The recommended screening and diagnostic test for diabetes is to measure fasting plasma glucose, oral glucose tolerance test, and use of the glycated hemoglobin A1c measurement (A1C). The American Diabetes Association provides criteria for diagnosing diabetes and are as follows: In nonpregnant adults: symptoms of diabetes and casual plasma glucose greater than or equal to 200 mg/dl, or fasting plasma glucose greater than or equal to 126 mg/dl, or 2-h plasma glucose greater than or equal to 200 mg/dl during an oral glucose tolerance test.

Certain individuals should be screened more often (every 1-2 years) than others when they have any of these following issues: overweight (BMI greater than 25), history of gestational diabetes, history of vascular disease, first-degree relative with diabetes, high-risk ethnic group, previously found to have impaired glucose tolerance or impaired fasting glucose, and signs of insulin resistance, such has acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome. The patient Y. L. has many of these issues that qualify her for screening. She is overweight, (BMI 30. ),she is hypertensive, she has a history of gestational diabetes, her father has diabetes. Y. L. was diagnosed with DM with an A1C of 10. 4, fasting glucose of 184 mg/dl, and a subsequent fasting glucose that was also elevated. 2. Explain Type 2 DM. Type 2 DM has a complex pathology. Most individuals with Type 2 DM have insulin resistance combined with varying degrees of insulin deficiency (according to the American Diabetic Association). Later in diabetes, insulin deficiency is often more pronounced. . When there isn’t enough insulin or the insulin is not used as it should be, glucose can’t get into the body’s cells.

When glucose builds up in the blood (hyperglycemia) instead of going into cells, the body’s cells are not able to function properly. Other problems associated with the buildup of glucose in the blood include: damage to the body such as damaged nerves and small blood vessels of the eyes, kidneys, and heart. High levels of glucose also predispose a person to atherosclerosis of the large arteries that can cause cardiac arrest and strokes. The build up of glucose in the blood can also cause an increase in urination. Most patients with Type 2 DM are overweight with increased abdominal adipose tissue.

It’s most commonly seen in adults. The onset of Type 2 DM is usually slow and progressive. Early symptoms of Type 2 DM include bladder, kidney, skin, or other infections that are more frequent or heal slowly, fatigue hunger, increased thirst, increased urination, blurred vision, erectile dysfunction, and pain or numbness in the feet or hands. The patient Y. L. presents with all of the symptoms, with the exception of erectile dysfunction. Treatment for T2 DM should include modifying lifestyle with monitoring and controlling blood glucose levels, appropriate diet changes, weight control and exercise.

An insulin regimen is also used to treat T2 DM. 3. Discuss the lab results and how they relate to or impact DM. The patient’s A1c was 10. 4. In terms of her history, take a look at her Hemoglobin A1c. This indicated that her blood glucose level has been elevated consistently of an extended period of time. The A1c is an indication of glycosylation in the body which is damaging to the blood vessels and peripheral nerves. It causes thickening of the basement membrane which will impair oxygen transport to the tissues and carbon dioxide removal. Oxygen is the source of all life to all living tissues.

Any pathologic condition that affects the delivery of oxygen will eventually result in cell damage and ultimately death if not corrected. This is why you will see poor wound healing and necrotic lesions in diabetics. The circulation to distal tissues is impaired because of glycosylation. Her high HgbA1c is an indication of increased risk for neuropathy and micro/macrovascular damage. This correlates with her complaints of pain in her feet. Her blood pressure is elevated, 152/97. A high blood pressure is damaging to organs, because constricted blood vessels will decrease tissue perfusion.

This patient’s fasting lipid profile is also elevated. Her HDL was 32 mg/dl, LDL 155, ration 8. 0. These elevated levels are probably resulting in plaque accumulation in her vascular system, which will further impede circulation and tissue perfusion. Her high triglycerides are probably resulting from her excessive carbohydrate consumption. Her fasting blood glucose level of 184 mg/dl is also damaging, because elevated blood glucose indicates the body’s poor performance of utilizing glucose. This can be a result of an insufficient amount of produced or the body’s resistance to nsulin. Regardless, without insulin, the body is unable to carry glucose into the cells. The elevated blood glucose decreases tissue perfusion, further damaging organs. 4. Discuss hemoglobin A1C. Use of the glycated hemoglobin A1c measurement is a standardized test for monitoring glucose in patients with diabetes. A markedly elevated A1C is virtually diagnostic of diabetes. Hemoglobin A1c provides an average of your blood glucose control over a six to 12 week period and is used in conjunction with home blood glucose monitoring to make adjustments in your diabetes medicines.

Hemoglobin is a substance within red blood cells that carries oxygen throughout your body. When your diabetes blood glucose is not controlled), sugar builds up in your blood and combines with your hemoglobin, becoming “glycated. ” Therefore, the average amount of glucose in your blood can be determined by measuring a hemoglobin A1c level. If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher. For people without diabetes, the normal range for the hemoglobin A1c test is between 4% and 5. 6%. Hemoglobin A1c levels between 5. 7% and 6. 4% indicate increased risk of diabetes, and levels of 6. % or higher indicate diabetes. Because studies have repeatedly shown that out-of-control diabetes results in complications from the disease, the goal for people with diabetes is a hemoglobin A1c less than 7%. The higher the hemoglobin A1c, the higher the risks of developing complications related to diabetes. 5. Identify three functions of insulin. Three functions of insulin are to allow glucose to pass into the cell where it can be used for energy, to “turn off” excess production of glucose in the liver, and to “turn off” fat breakdown which results in the breakdown of ketones. . Insulin’s main action is to lower blood glucose levels. Several hormones produced in the body inhibit the effects of insulin. Identify three and explain. 7. Y. L. was started on lispro (Humalog) and glargine (Lantus) insulin with CHO counting. Explain the action of both. What is the most important point to make when teaching the patient about glargine? 8. Because Y. L. has been on regular insulin in the past, you want to ensure she understands the difference between regular and lispro. What is the most significant difference between these two insulins? . What is the peak time and duration of lispro insulin? 10. Y. L. wants to know why she can’t take NPH and regular insulin. She is more familiar with them and has taken them in the past. Explain the advantages of glargine and lispro over NPH and regular insulin. 11. Y. L. ’s culture prefers foods high in CHO. What is CHO counting, and why would this method work well for Y. L.? 12. Which of the symptoms that Y. L. reported today led you to believe she has some form of neuropathy? 13. Discuss foot care in DM. 14. What findings in Y. L. s history place her at increased risk for the development of other forms of neuropathy? 15. What are some changes that Y. L. can make to reduce the risk or slow the progression of both macrovascular and microvascular disease? Explain macrovascular and microvascular disease. 16. Y. L. is enrolled in a smoking cessation class. Why is it so important that she stop smoking? 17. Discuss the financial impact of DM (include cost of insulin, strips, meters, etc. ) 18. What additional medication (other than DM medication) might the PCP prescribe and why? 19.

Discuss 2 different classes of oral medication for DM. 20. Discuss nephropathy in DM. 21. Discuss yeast infections in the patient with DM. 22. Discuss how exercise benefits a patient with DM. 23. Y. L. has questions about the injection. She states she developed a “large knot in her leg when she took insulin injections during her pregnancy”. What instructions will you give Y. L.? 24. Discuss 2 alternative therapies that have been used in the treatment of diabetes. 25. How does acute and chronic stress impact DM? Adapted from a Mosby Critical Thinking case study.