PathophysiologyAssessment of Diabetes Mellitus Type 2JennaGrays, Sharon Okafor, Linda YongeBowieState UniversityDr.Obizoba C.B. is a 48-year oldwoman of Indian descent who is significantly overweight and admitted to thehospital with a chief complaint “My leftfoot 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 14years old, hypertension for 10 years, multiple yeast infections during the past3 years, and a cholesterol level of 225. After her fasting blood glucose wastaken at the state’s annual health screening, reading 141 and upon arrival inthe hospital, her blood glucose reads 168 mg/dL, as well as having a positivefamily history of diabetes mellitus type 2, she was diagnose with DiabetesMellitus type 2. Diabetes mellitus type 2 comesin two forms: insulin-resistant or insulin-deficient. Insulin deficiency occurswhen insulin not working correctly in the body, followed by a complete lack ofinsulin being made in the body. This all occurs when pancreatic beta cells,which create insulin, dysfunction and there is an impaired production ofinsulin. Insulin resistance occurs typically as a result of increased abdominalbody fat and increased weight, when an increase in beta-cells try to compensateand create more insulin, but are unable to keep up and create sufficientinsulin to overcome insulin resistance.
Both of these result in hyperglycemia. Most of C.B.’s pastmedical history can be inter-related to diabetes mellitus type 2. She issignificantly obese, with a BMI of 36, meaning the excess fat has addedpressure on her body to use insulin to control blood glucose levels, likelyresulting in DM. She also had gestational diabetes, meaning high blood sugarwhile pregnant, and her 4th and last child weighed 10lbs. 6-½ oz. atbirth.
This placed C.B. at a higher risk for DM even though she was not immediatelydiagnosed after he daughter was born. Her younger sister and maternalgrandmother both have been diagnosed with DM, in their late 40’s. Also, hercholesterol level is significantly elevated, 225 mg/dL.
“Diabetes tends to lower “good” cholesterol levels and raisetriglyceride and “bad” cholesterol levels, which increases the riskfor heart disease and stroke… This is called diabetic dyslipidemia. Diabeticdyslipidemia means your lipid profile is going in the wrong direction.” (AmericanHeart Association, 2017). Further, C.B. smokes 2 packs of cigarettes a day andhas two beers every evening. Lastly, C.B.
has hypertension. Her smoking,weight, cholesterol levels, and diet all contribute to her DM and HTN. Diabetesaffects the arteries, causing them to narrow, and uncontrolled hypertension canhave the same reverse effect- especially with all of the risk factors listed. As just stated, C.B. hasmany risk factors predisposing her to diabetes.
Risk factors for developingdiabetes 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 andlow HDL· A history of gestational diabetes and/orbaby weighing more than 9lbs.· Not being physically active· and history of a stroke/heart diseaseA person suffering from diabetesmellitus will show specific clinical signs and symptoms such as chronichyperglycemia due to insulin resistance and the incapability of the pancreas tosecrete a sufficient amount of insulin to counteract the poor use of insulin.They will also have three major manifestations- polyuria, polydipsia, andpolyphagia, meaning increased urination, increased thirst, and increasedhunger. The reasons for the increased thirst and frequent urination are due tothe blood sugar levels being too high, cause the extra sugar levels get intothe urine (glycosuria), causing the kidneys to release even more water. Sincethe kidneys are releasing all this water, it will cause the person to be dehydratedand that will have the person drinking large amounts of water. As the person isdrinking all this water to cure their increased thirst, this is leading toincreased urine production and frequent urination especially at night. As to mycase study, C.B.
stated that they have been getting thirstier lately and hasbeen making more trips to the bathroom especially more often at night. Thereason why a person has increased hunger is because the cells are starving andare in a serious urge for energy due to the glucose not being able to enter thecells and convert the food into energy and because of that a person will alwaysbe hungry, but will never satisfied in hunger. This increased hunger leads toanother clinical sign, which is increased weight.
A person who has diabetestends to gain weight over time. Other clinical signs and symptoms includefatigue, recurrent infections, recurrent yeast infections, delayed woundhealing, and vision changes. When having a patient with diabetesmellitus type 2, there are certain things a nurse will monitor for such as thepatient’s blood glucose levels, their weight, their blood pressure, theirkidney function, and infections of skin, vagina, and urinary tract, and theinput and output of urine. If the blood glucose levels are extremely high, thena nurse should monitor for HHNS (hyperosmolar hyperglycemic nonketoticsyndrome). This is a life-threatening complication of diabetes mellitus type 2in which the glucose levels are greater than 600. When this happens, the bodyis trying to get rid of the extra blood glucose by excreting it in the urineand as a result the body loses large amounts of water leading to dehydrationthat can cause seizures, coma, and even death. It’s very imperative to monitorthe patient’s feet to decrease the risk of amputation and ulcers.
Patientsshould “avoid going barefoot, and wear shoes that are supportive andcomfortable. If cuts, scrapes, or burns occur, they should be treatedpromptly…” (Lewis, Bucher, Heitkemper, & Dirksen, 2014, p.1173). Nursesshould monitor for decreased sensation of the lower extremities because if apatient loses sensation of the lower extremities, it gives them the inabilityto 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 ofserious foot infection. That’s why making sure the patient doesn’t go barefootis critical in the decrease of infections.
Nurses should also monitor for gangrene,which can cause amputation of limbs. Nurses need to monitor the eyes especiallythe retina, optic disc, and the macula for signs of hemorrhage and exudates.Constant hyperglycemic states can cause injury and obstruction to large andsmall 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 isthe hardening and narrowing of the arteries and this hardening and narrowingcauses a decrease in blood flow and a decrease in supply of oxygen to thecells. Atherosclerosis can cause several diseases such as myocardialinfarction, coronary artery disease, stroke, and peripheral artery disease. Procedures that can help nursemonitoring are vital signs, giving a physical exam, giving a foot exam, anankle-brachial index (if PAD is indicated), obtaining weight of patient daily,looking at blood tests such as the fasting blood glucose, postprandial bloodglucose, A1C, lipid profile, blood urea nitrogen and serum creatinine,electrolytes, etc. To monitor the eyes, a funduscopic examination should beperformed. If presence of hemorrhage and exudates are present, then that is an indicativesign of retinal degeneration. Also, give a neurologic examination using themonofilament test, vibratory testing with a tuning fork, and the light touchtest, to test for sensation of lower extremities. To help monitor urine, aurinalysis should be done and as well as obtaining the values of the urineinput and output.
Reportable changes in the patient’sstatus should include increased thirst, frequent urination, increased hunger,increase or decrease of weight, fatigue, dark discoloration and ulcers of theextremities, decreased sensation of lower extremities, blurred vision, repeatedyeast infections, weakness of the lower extremities, rashes on the skin, andwound healing that is prolonged. C.B.
‘s lab values include: Na 139meq/L, K 400 meq/L, Cl 102 meq/L, HCO3 22 meq/L BUN 14mg/dl, Cr 0.9 mg/dl, Ca9.8 mg/dl, PO4 3.
3mg/dl, Mg 1.9 mg/dl, AST 19 IU/L, ALT 13 IU/L, Alk phos 43IU/L, T. bilirubin 1.0 mg/dl. C.B.’s abnormal lab values include: Glu 168mg/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 abnormalvalues is as follows; C.B.’s elevated deposits of triglycerides and cholesterolare because she is obese with a body mass index of more than 30. According toHuether & McCance (2012, p.
463), this elevation of triglycerides andcholesterol interferes with intracellular insulin signaling thereforedecreasing the response of the tissue to insulin and contribute to beta cellapoptosis, which is cell death that occurs as a normal and controlled part ofthe growth or development of an organism. Hyperglycemia, leads to an increasein LDL, by reducing the inability of the body to remove cholesterol. When theblood glucose is elevated, LDL and the receptor for LDL in the liverglycosylated that is coated with sugar, impairing the ability of the liver toremove cholesterol from the blood stream.
Obesity is correlated with highinsulin and decreased insulin receptor density. The clinical appearance ofdiabetes is prevented by compensatory hyperinsulinemia. Beta cell dysfunctionprogresses and lead to a deficiency of insulin activity. Glucose concentrationis elevated in Diabetes Mellitus 2 because pancreatic alpha cells becomes lessresponsive to the inhibition of glucose leading to an increase in glucagonsecretion. The abnormal high levels of glucagon increase blood glucose levelsthrough the processes of glycogenolysis and gluconeogenesis (Huether , 2012).
Thevalues that require close monitoring and identification of reportableconditions 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 theabnormal lab values include; high blood glucose level and HbA1c can be improvedby dietary interventions, blood glucose monitoring, and engaging in an exercise program and medicationsmay also be used to lower blood glucose levels. The nurse can work togetherwith the client, physician, dietician, and physical therapist in deliveringcare. Elevated triglycerides can be lowered by participating in regularexercise, maintaining a healthy weight, eating healthy, stopping to smoking andlimiting alcohol use to 1 drink a day if drinking. The diet therapy should aimat having serum lipid levels, LDL cholesterol below 100 mg/dl, HDL cholesterolabove 40mg/dl, and triglyceride level below 150 mg/dl.
The nurse should provideresources for nutrition, exercise programs, weight control and stressreduction. The nurse should prevent or minimize injury or discomfort in theclient`s left foot that is numb and weak, apply lotion, inspect skin forirritation, cracking lesions, and monitor hydration level and arterialinsufficiency (Ignatavicius & Workman, 2015). Themajor treatments for type 2 diabetes mellitus are diet, exercise, medicationand insulin therapy as mentioned above. Diagnosis of type 2 diabetes mellitusis confirmed if any of the following three conditions is met. Fasting plasmaglucose level less than 100 mg/dl, a random blood glucose testing of equal toor greater than 200 mg/dL with polyuria, polydipsia, and polyphagia suggestsdiabetes and an Oral Glucose Tolerance Test of less than 140 mg/dL after 2hours. These tests must be confirmed on a subsequent day. Diabetes = AIC of6.5% or higher on 2 separate occasions.
The patient is taking the followingmedications; Lisinopril 20 mg po QD an ace inhibitor to treat her high bloodpressure. Acetaminophen 500 mg with hydrocodone bitartrate5 mg 1 tablet po Q HS and Q 4h PRN a narcotic to treat pain, Naproxen 500 mg poBID for mild-to-moderate osteoarthritis, Omeprazole 20mg po QD to decrease the amount of acid in the stomach, Docusate sodium 100 mgpo TID to treat occasional constipation and Loratadine 10 mg po QD PRN to treatallergy symptoms. Assessments and implementations ofmedications are as follows: lisinopril, monitor for blood pressure and pulsefrequently during dose adjustment and frequently during the therapy, assess forsigns of angioedema (dyspnea and facial swelling). Implementation of lisinoprilinclude correct volume depletion if possible before the initial therapy. Quickdrop of blood pressure during the first 1-3 hours after first dose may needvolume expansion with normal saline. The teachings for this medicine includethe patient should take the medication same time each day as prescribed andtake missed doses as soon as they remember but not if the time is close to thenext dose.
The patient should also avoid salt substitutes that containpotassium or foods that have high sodium and potassium unless directed byhealth care professional. The patient needs to change positions slowly tominimize orthostatic hypotension and that drinking alcohol may also increaseorthostatic hypotension. Assessment needed for acetaminophen with hydrocodonebitartrate include the risk for opioid addiction, misuse or abuse, check bloodpressure, pulse and respiration during administration. Pain assessmentincluding location, intensity prior to and 1 hour after administrationImplementations 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 preventwithdrawal symptoms. The teaching for this medication is that it should betaken as prescribed and not more than the recommended amount (Burchum et al.
(2016)).For naproxen, assessments includepain and range of motion prior to and 1-2 hours following administration. Painlocation, intensity and type should be noted. Implementation for naproxeninclude; higher doses may cause more side effects, and it may be administeredwith food, milk or antacids to decrease the risk of GI irritation. Abdominalpain and occult blood in the stool should be assessed for omeprazole. Bowelfunction is also an important assessment while taking this medicine.
Implementations for omeprazole are: the medicine should be taken before mealspreferably in the morning and capsules should be swallowed whole withoutcrushing or chewing. The patient should be taught that the medicine can causedizziness, and they should avoid driving or activities that require alertness.The patient should avoid alcohol products that contain aspirin or foods thatmay cause GI irritation. Patient should report onset of tarry stools, diarrhea,abdominal pain or headaches. For docusate sodium the assessments to be done includechecking for distention of the abdomen, bowel sounds and function, includingpattern, color and stool consistency.
Implementation of docusate sodium includethat it does stimulate peristalsis, and it should be administered with a fullglass of water or juice if possible in the evening. Patients should be educatedthat docusate should be used for a short period of time, and the patients toincrease fiber intake in the food, drink 6-8 glasses of liquids a day andincrease mobility. Assess for allergy symptoms for loratadine before and duringtherapy and for lung sounds. Implementation is that loratadine should be takenonce daily. Teaching includes, the medication should be taken as prescribed andit may cause dizziness or drowsiness. The patient should avoid taking alcoholwith loratadine, Burchum et al. (2016).
All in all, diabetes mellitus type2 is a progressive, irreversible disease process. If left untreated, it cancause serious complications from amputations, to sepsis (if foot becomesinfected), to death. While a positive family history and being of a certainethnicity can cause you to be more susceptible, some treatment/preventionincludes lifestyle changes. Again, modifiable lifestyle changes include:managing weight, managing high blood pressure, lowering triglycerides andraising HDL, and staying physically active.
ReferencesAmericanHeart 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: WaltersKluwer/Lippincott Williams & Wilkins. (p.
258-Burchum, J. R., Rosenthal, L. D., Jones, B. O.
,Neumiller, J. J., & Lehne, R. A.
(2016). Lehnespharmacology for nursing care. St. Louis, MO: Elsevier/Saunders.
Huether, S. E., , K. L. (2012). Understanding pathophysiology. St.
Louis,MO: Elsevier/Mosby. Ignatavicius,D. and Workman, M. (2015).
Medical-surgicalnursing. Philadelphia: Elsevier Saunders.Lewis,S., Bucher, L., Heitkemper, M., Dirksen, S. (2014) Medical-Surgical Nursing.
(9thedition). St. Louis, MS: Elsevier Mosby.