Pathophysiology diagnosed with DM, in their late 40’s. Also,

 

Pathophysiology
Assessment of Diabetes Mellitus Type 2

Jenna
Grays, Sharon Okafor, Linda Yonge

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Bowie
State University

Dr.
Obizoba

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.B. is a 48-year old
woman of Indian descent who is significantly overweight and admitted to the
hospital with a chief complaint “My left
foot feels weak and numb. I have a hard time pointing my toes up.” (Bruyere,
2009, p. 258). She has a past medical history of gestational diabetes at 14
years old, hypertension for 10 years, multiple yeast infections during the past
3 years, and a cholesterol level of 225. After her fasting blood glucose was
taken at the state’s annual health screening, reading 141 and upon arrival in
the hospital, her blood glucose reads 168 mg/dL, as well as having a positive
family history of diabetes mellitus type 2, she was diagnose with Diabetes
Mellitus type 2. 

Diabetes mellitus type 2 comes
in two forms: insulin-resistant or insulin-deficient. Insulin deficiency occurs
when insulin not working correctly in the body, followed by a complete lack of
insulin being made in the body. This all occurs when pancreatic beta cells,
which create insulin, dysfunction and there is an impaired production of
insulin. Insulin resistance occurs typically as a result of increased abdominal
body fat and increased weight, when an increase in beta-cells try to compensate
and create more insulin, but are unable to keep up and create sufficient
insulin to overcome insulin resistance. Both of these result in hyperglycemia.

Most of C.B.’s past
medical history can be inter-related to diabetes mellitus type 2. She is
significantly obese, with a BMI of 36, meaning the excess fat has added
pressure on her body to use insulin to control blood glucose levels, likely
resulting in DM. She also had gestational diabetes, meaning high blood sugar
while pregnant, and her 4th and last child weighed 10lbs. 6-½ oz. at
birth. This placed C.B. at a higher risk for DM even though she was not immediately
diagnosed after he daughter was born. Her younger sister and maternal
grandmother both have been diagnosed with DM, in their late 40’s. Also, her
cholesterol level is significantly elevated, 225 mg/dL. “Diabetes tends to lower “good” cholesterol levels and raise
triglyceride and “bad” cholesterol levels, which increases the risk
for heart disease and stroke… This is called diabetic dyslipidemia. Diabetic
dyslipidemia means your lipid profile is going in the wrong direction.” (American
Heart Association, 2017). Further, C.B. smokes 2 packs of cigarettes a day and
has two beers every evening. Lastly, C.B. has hypertension. Her smoking,
weight, cholesterol levels, and diet all contribute to her DM and HTN. Diabetes
affects the arteries, causing them to narrow, and uncontrolled hypertension can
have the same reverse effect- especially with all of the risk factors listed.

As just stated, C.B. has
many risk factors predisposing her to diabetes. Risk factors for developing
diabetes mellitus type 2 include:

·        
Being overweight/obese

·        
Having a positive family history

·        
Being African American, American Indian,
Hispanic/Latino, or an Asian American

·        
Having high blood pressure

·        
Having a high level of triglycerides and
low HDL

·        
A history of gestational diabetes and/or
baby weighing more than 9lbs.

·        
Not being physically active

·        
and history of a stroke/heart disease

A person suffering from diabetes
mellitus will show specific clinical signs and symptoms such as chronic
hyperglycemia due to insulin resistance and the incapability of the pancreas to
secrete a sufficient amount of insulin to counteract the poor use of insulin.
They will also have three major manifestations- polyuria, polydipsia, and
polyphagia, meaning increased urination, increased thirst, and increased
hunger. The reasons for the increased thirst and frequent urination are due to
the blood sugar levels being too high, cause the extra sugar levels get into
the urine (glycosuria), causing the kidneys to release even more water. Since
the kidneys are releasing all this water, it will cause the person to be dehydrated
and that will have the person drinking large amounts of water. As the person is
drinking all this water to cure their increased thirst, this is leading to
increased urine production and frequent urination especially at night. As to my
case study, C.B. stated that they have been getting thirstier lately and has
been making more trips to the bathroom especially more often at night. The
reason why a person has increased hunger is because the cells are starving and
are in a serious urge for energy due to the glucose not being able to enter the
cells and convert the food into energy and because of that a person will always
be hungry, but will never satisfied in hunger. This increased hunger leads to
another clinical sign, which is increased weight. A person who has diabetes
tends to gain weight over time. Other clinical signs and symptoms include
fatigue, recurrent infections, recurrent yeast infections, delayed wound
healing, and vision changes.

            When having a patient with diabetes
mellitus type 2, there are certain things a nurse will monitor for such as the
patient’s blood glucose levels, their weight, their blood pressure, their
kidney function, and infections of skin, vagina, and urinary tract, and the
input and output of urine. If the blood glucose levels are extremely high, then
a nurse should monitor for HHNS (hyperosmolar hyperglycemic nonketotic
syndrome). This is a life-threatening complication of diabetes mellitus type 2
in which the glucose levels are greater than 600. When this happens, the body
is trying to get rid of the extra blood glucose by excreting it in the urine
and as a result the body loses large amounts of water leading to dehydration
that can cause seizures, coma, and even death. It’s very imperative to monitor
the patient’s feet to decrease the risk of amputation and ulcers. Patients
should “avoid going barefoot, and wear shoes that are supportive and
comfortable. If cuts, scrapes, or burns occur, they should be treated
promptly…” (Lewis, Bucher, Heitkemper, & Dirksen, 2014, p.1173). Nurses
should monitor for decreased sensation of the lower extremities because if a
patient loses sensation of the lower extremities, it gives them the inability
to protect their feet. If something were to happen, such as a cut to their foot,
they wouldn’t be able to feel it, which would consequently increase the risk of
serious foot infection. That’s why making sure the patient doesn’t go barefoot
is critical in the decrease of infections. Nurses should also monitor for gangrene,
which can cause amputation of limbs. Nurses need to monitor the eyes especially
the retina, optic disc, and the macula for signs of hemorrhage and exudates.
Constant hyperglycemic states can cause injury and obstruction to large and
small blood vessels. A nurse should monitor the arteries for atherosclerosis.
Since there is an increasing blood pressure and serum lipid concentrations,
diabetes mellitus speeds up the process of atherosclerosis. Atherosclerosis is
the hardening and narrowing of the arteries and this hardening and narrowing
causes a decrease in blood flow and a decrease in supply of oxygen to the
cells. Atherosclerosis can cause several diseases such as myocardial
infarction, coronary artery disease, stroke, and peripheral artery disease.

            Procedures that can help nurse
monitoring are vital signs, giving a physical exam, giving a foot exam, an
ankle-brachial index (if PAD is indicated), obtaining weight of patient daily,
looking at blood tests such as the fasting blood glucose, postprandial blood
glucose, A1C, lipid profile, blood urea nitrogen and serum creatinine,
electrolytes, etc. To monitor the eyes, a funduscopic examination should be
performed. If presence of hemorrhage and exudates are present, then that is an indicative
sign of retinal degeneration. Also, give a neurologic examination using the
monofilament test, vibratory testing with a tuning fork, and the light touch
test, to test for sensation of lower extremities. To help monitor urine, a
urinalysis should be done and as well as obtaining the values of the urine
input and output.

            Reportable changes in the patient’s
status should include increased thirst, frequent urination, increased hunger,
increase or decrease of weight, fatigue, dark discoloration and ulcers of the
extremities, decreased sensation of lower extremities, blurred vision, repeated
yeast infections, weakness of the lower extremities, rashes on the skin, and
wound healing that is prolonged.

C.B.’s lab values include: Na 139
meq/L, K 400 meq/L, Cl 102 meq/L, HCO3 22 meq/L BUN 14mg/dl, Cr 0.9 mg/dl, Ca
9.8 mg/dl, PO4 3.3mg/dl, Mg 1.9 mg/dl, AST 19 IU/L, ALT 13 IU/L, Alk phos 43
IU/L, T. bilirubin 1.0 mg/dl. C.B.’s abnormal lab values include: Glu 168
mg/dl, T. Cholesterol 246 mg/dl, LDL 168 mg/dl, Trig 458 mg/dl, HbA1C 8.2 %,
Insulin 290 u/ ml, and low HDL 28 mg/ dl. The interpretation of these abnormal
values is as follows; C.B.’s elevated deposits of triglycerides and cholesterol
are because she is obese with a body mass index of more than 30. According to
Huether & McCance (2012, p.463), this elevation of triglycerides and
cholesterol interferes with intracellular insulin signaling therefore
decreasing the response of the tissue to insulin and contribute to beta cell
apoptosis, which is cell death that occurs as a normal and controlled part of
the growth or development of an organism. Hyperglycemia, leads to an increase
in LDL, by reducing the inability of the body to remove cholesterol. When the
blood glucose is elevated, LDL and the receptor for LDL in the liver
glycosylated that is coated with sugar, impairing the ability of the liver to
remove cholesterol from the blood stream. Obesity is correlated with high
insulin and decreased insulin receptor density. The clinical appearance of
diabetes is prevented by compensatory hyperinsulinemia. Beta cell dysfunction
progresses and lead to a deficiency of insulin activity. Glucose concentration
is elevated in Diabetes Mellitus 2 because pancreatic alpha cells becomes less
responsive to the inhibition of glucose leading to an increase in glucagon
secretion. The abnormal high levels of glucagon increase blood glucose levels
through the processes of glycogenolysis and gluconeogenesis (Huether &
McCance, 2012).

The
values that require close monitoring and identification of reportable
conditions for client C.B include Glucose 168 mg/dl, Trig 458 mg/dl, HBA1c 8.2
%, HDL 28 mg/dl, LDL 168 mg/dl and Insulin 290 u/ml. The interventions for the
abnormal lab values include; high blood glucose level and HbA1c can be improved
by dietary interventions, blood glucose monitoring, and engaging in an exercise program and medications
may also be used to lower blood glucose levels. The nurse can work together
with the client, physician, dietician, and physical therapist in delivering
care. Elevated triglycerides can be lowered by participating in regular
exercise, maintaining a healthy weight, eating healthy, stopping to smoking and
limiting alcohol use to 1 drink a day if drinking. The diet therapy should aim
at having serum lipid levels, LDL cholesterol below 100 mg/dl, HDL cholesterol
above 40mg/dl, and triglyceride level below 150 mg/dl. The nurse should provide
resources for nutrition, exercise programs, weight control and stress
reduction. The nurse should prevent or minimize injury or discomfort in the
client`s left foot that is numb and weak, apply lotion, inspect skin for
irritation, cracking lesions, and monitor hydration level and arterial
insufficiency (Ignatavicius & Workman, 2015).

            The
major treatments for type 2 diabetes mellitus are diet, exercise, medication
and insulin therapy as mentioned above. Diagnosis of type 2 diabetes mellitus
is confirmed if any of the following three conditions is met. Fasting plasma
glucose level less than 100 mg/dl, a random blood glucose testing of equal to
or greater than 200 mg/dL with polyuria, polydipsia, and polyphagia suggests
diabetes and an Oral Glucose Tolerance Test of less than 140 mg/dL after 2
hours. These tests must be confirmed on a subsequent day. Diabetes = AIC of
6.5% or higher on 2 separate occasions. The patient is taking the following
medications; Lisinopril 20 mg po QD an ace inhibitor to treat her high blood
pressure. Acetaminophen 500 mg with hydrocodone bitartrate
5 mg 1 tablet po Q HS and Q 4h PRN a narcotic to treat pain, Naproxen 500 mg po
BID for mild-to-moderate osteoarthritis, Omeprazole 20
mg po QD to decrease the amount of acid in the stomach, Docusate sodium 100 mg
po TID to treat occasional constipation and Loratadine 10 mg po QD PRN to treat
allergy symptoms.

Assessments and implementations of
medications are as follows: lisinopril, monitor for blood pressure and pulse
frequently during dose adjustment and frequently during the therapy, assess for
signs of angioedema (dyspnea and facial swelling). Implementation of lisinopril
include correct volume depletion if possible before the initial therapy. Quick
drop of blood pressure during the first 1-3 hours after first dose may need
volume expansion with normal saline. The teachings for this medicine include
the patient should take the medication same time each day as prescribed and
take missed doses as soon as they remember but not if the time is close to the
next dose. The patient should also avoid salt substitutes that contain
potassium or foods that have high sodium and potassium unless directed by
health care professional. The patient needs to change positions slowly to
minimize orthostatic hypotension and that drinking alcohol may also increase
orthostatic hypotension. Assessment needed for acetaminophen with hydrocodone
bitartrate include the risk for opioid addiction, misuse or abuse, check blood
pressure, pulse and respiration during administration. Pain assessment
including location, intensity prior to and 1 hour after administration
Implementations for this medication include an overdose can lead to fatalities.
Explanation of the therapeutic value of the medicine should be done before administration.
The medicine should also be stopped gradually after long use to prevent
withdrawal symptoms. The teaching for this medication is that it should be
taken as prescribed and not more than the recommended amount (Burchum et al. (2016)).

For naproxen, assessments include
pain and range of motion prior to and 1-2 hours following administration. Pain
location, intensity and type should be noted. Implementation for naproxen
include; higher doses may cause more side effects, and it may be administered
with food, milk or antacids to decrease the risk of GI irritation. Abdominal
pain and occult blood in the stool should be assessed for omeprazole. Bowel
function is also an important assessment while taking this medicine.
Implementations for omeprazole are: the medicine should be taken before meals
preferably in the morning and capsules should be swallowed whole without
crushing or chewing. The patient should be taught that the medicine can cause
dizziness, and they should avoid driving or activities that require alertness.
The patient should avoid alcohol products that contain aspirin or foods that
may cause GI irritation. Patient should report onset of tarry stools, diarrhea,
abdominal pain or headaches. For docusate sodium the assessments to be done include
checking for distention of the abdomen, bowel sounds and function, including
pattern, color and stool consistency. Implementation of docusate sodium include
that it does stimulate peristalsis, and it should be administered with a full
glass of water or juice if possible in the evening. Patients should be educated
that docusate should be used for a short period of time, and the patients to
increase fiber intake in the food, drink 6-8 glasses of liquids a day and
increase mobility. Assess for allergy symptoms for loratadine before and during
therapy and for lung sounds. Implementation is that loratadine should be taken
once daily. Teaching includes, the medication should be taken as prescribed and
it may cause dizziness or drowsiness. The patient should avoid taking alcohol
with loratadine, Burchum et al. (2016).

All in all, diabetes mellitus type
2 is a progressive, irreversible disease process. If left untreated, it can
cause serious complications from amputations, to sepsis (if foot becomes
infected), to death. While a positive family history and being of a certain
ethnicity can cause you to be more susceptible, some treatment/prevention
includes lifestyle changes. Again, modifiable lifestyle changes include:
managing weight, managing high blood pressure, lowering triglycerides and
raising HDL, and staying physically active.

 

 

 

 

References

American
Heart Association. (2017, April 14). Cholesterol abnormalities & diabetes.
Retrieved from: http://www.heart.org/HEARTORG/Conditions/More/Diabetes/WhyDiabetesMatters/Cholesterol-Abnormalities-Diabetes_UCM_313868_Article.jsp#

Bruyere,
H.. (2009). 100 case studies in pathophysiology. Philadelphia: Walters
Kluwer/Lippincott Williams & Wilkins. (p. 258-

Burchum, J. R., Rosenthal, L. D., Jones, B. O.,
Neumiller, J. J., & Lehne, R. A. (2016). Lehnes
pharmacology for nursing care. St. Louis, MO: Elsevier/Saunders.

Huether, S. E., &
McCance, K. L. (2012). Understanding pathophysiology. St. Louis,
MO: Elsevier/Mosby.

Ignatavicius,
D. and Workman, M. (2015). Medical-surgical
nursing. Philadelphia: Elsevier Saunders.

Lewis,
S., Bucher, L., Heitkemper, M., Dirksen, S. (2014) Medical-Surgical Nursing. (9th
edition). St. Louis, MS: Elsevier Mosby.