Nursing Case Study Example Diabetes
The prevalence of diabetes varies greatly from population to population and throughout the whole wide world. As much as there is an increase in prevalence of the condition, many people have not had their condition diagnosed and treated. The knowledge about diabetes is essential for prevention and management and therefore people should be educated about complications that are associated with diabetes and how to manage it. With proper treatment and healthy living, many patients can live a long and comfortable life. This article explores the complications, diagnosis, types, treatment, and other questions that help raise awareness.
Identify systemic complications associated with diabetes mellitus.
Retinopathy
Nephropathy
Neuropathy
Cardiovascular disease
Peripheral vascular disease
Periodontal disease
State the diagnostic criteria for diabetes mellitus.
Fasting plasma glucose ≥ 126 b. Oral glucose tolerance after 2 hours ≥ 200 c. HbA1c ≥ 6.5 Random plasma glucose w/ symptoms ≥ 200
Compare and contrast the pathophysiology of diabetes type 1, type 2, and gestational diabetes.
Type 1 – autoimmune destruction of β cells in pancreas → absolute insulin deficiency
Type 2 – insulin resistance → beta cells overproduce insulin → burn out cells → relative
to insulin deficiency
May develop absolute deficiency later in disease
Gestational – similar to type 2, but due to placental hormones → insulin resistance
Predisposes to type 2 later in life
Distinguish the treatment of diabetes type 1 versus type 2.
Type 2 – oral meds to increase insulin release or sensitivity ( to target beta cells) + lifestyle
changes
Type 1 – insulin therapy +/- amylin injections
- State the prevalence of diabetes mellitus in the U.S.
20.8 million people b. 7% of U.S. population
Compare the prevalence of diabetes type 1 and type 2.
Type 1 – 5-10%
Type 2 – 85-90%
Identify oral manifestations of diabetes mellitus.
- Burning mouth syndrome b. Candidiasis c. Dental caries d. Gingivitis e. Glossodynia ( burning of the mouth with no obvious cause) f. Lichen planus g. Neurosensory dysesthesias periodontitis h. Salivary dysfunction i. Taste dysfunction j. Xerostomia
Describe the relationship between diabetes mellitus and periodontitis.
Patients with severe periodontitis are more likely to have uncontrolled diabetes in the future, as
well as increased risk for cardio & renal disease
- Poorly controlled diabetes, → increased occurrence & severity of periodontitis
- Increased blood glucose → formation of advanced glycation end products →
binding to RAGEs on macrophages & endothelial tissue → exaggerated
inflammatory response
- Enhanced apoptosis → reduced wound healing
- Periodontal disease also releases inflammatory cytokines into microcirculation, which can
reach distant sites
- Antagonize insulin ii. Promote inflammation elsewhere
Recognize the common systemic signs and symptoms associated with diabetes mellitus.
New-onset polyuria & nocturia ( night)
Polydipsia ( drink a lot ) c. Unexplained weight loss d. Blurred vision, tiredness
Describe the epidemiology of diabetes mellitus.
20.8 million (7%) of the U.S. population has D.M.
1.5 million new cases in 2005 ii. 10-15% of the U.S. population has prediabetes
Complications take about ten years to develop & occur in 30% of D.M. patients
Identify risk factors for diabetes mellitus.
Type
13% chance if mom has it,
6% chance if dad
30-50% chance b/w monozygotic twins
- Type 2 – stronger than type 1
- 40% have a parent w/D.M. 2. First-degree relative → 5-10x higher risk of D.M. 3. 60-90% chance b/w monozygotic twins
- Type 1
Loss of pancreatic tissue – surgery, infection, cystic fibrosis
Low vitamin D 3. Autoantibodies
- Type 2
Obesity/overweight, inactive, high B.P., high cholesterol
Ethnicity – African-Americans, Hispanic Americans, Native Americans, Asian
Americans, Pacific Islanders @ higher risk
Previous gestational diabetes
Age
PCOS ( Polycystic ovary syndrome )
Discuss issues and precautions associated with dental implant surgery in diabetic patients.
If controlled, a high success rate is possible
If the uncontrolled, increased risk of failure
Hyperglycemia reduces bone formation & remodeling → reduces osseointegration of implants
Hyperglycemia compromises microvasculature → delayed wound healing &
increased infection
Precautions
Use antibiotics ii. Adjust insulin
Monitor glycemic control iv. Use chlorhexidine mouthwash
Communicate w/ physician vi. Caution w/ epi
Treat in the morning & after a meal viii. Hydroxyapatite coated = better success rate
Identify common classes of oral anti-diabetic drugs.
Biguanides – metformin
Keep liver from making more glucose
Sulfonylureas
Increase insulin release from the pancreas
Meglitinides
Increase insulin release from the pancreas
Thiazolidinediones
Increase glucose uptake by fat & muscle
α-glucosidase inhibitors
Prevent carb digestion
where is the pancreas located
the head of the pancreas nestles into the curve of the duodenum, the first portion of the small intestine
what are the exocrine functions of the pancreas
digestive enzyme production
what are the endocrine functions of the pancreas
insulin and glucagon production
what cells produce glucagon
alpha cells: raise blood glucose levels
which cells produce insulin
beta-cells: lowers blood glucose levels
normal blood pH level
7.35-7.45
pH scale
0-7 acidic (more H+)
Seven neutral
8-14 alkaline (more O.H.-)
what is a chemistry panel
groups of tests that are ordered to determine a person’s general health status
urinalysis
examination of urine (checks for WBC, RBC, glucose, etc.) also detects kidney and other organ functions
which results from the chemistry panel would be abnormal with diabetes
K (potassium)
glucose
BUN
results of the chemistry panel
k = 5.9 (3.5-4.9)
glucose = 659 (70-110)
BUN = 29 (7-24)
why are the chemistry panel results abnormal
k= electrolyte imbalance
glucose= high Blood sugar
BUN= stress on the kidneys
systolic pressure
the force of blood pushing against the walls of arteries as the heart pumps blood
diastolic pressure
when the heart is at rest
what can cause hypertension
age, family history, genetics, unhealthy lifestyle
hypertension
high blood pressure
hypotension
low blood pressure
why are CO2 levels low in patients in DKA
hyperventilating blows off CO2 to try to lower acidity levels in the blood
why do patients with DKA hyperventilate
to blow off extra CO2
stages of DKA
no insulin
the body can’t use sugar for energy
use fat for energy instead
waste products for breaking down fat is ketons
- buildup of ketons leads to high blood acidity
what is DKA
diabetic ketoacidosis
diabetes
conditions where blood glucose levels are elevated
type 1 diabetes
a chronic disease where cells in the pancreas that make insulin are destroyed, and the body is unable to produce insulin
type 2 diabetes
the cells have stopped responding to insulin. the body struggles to move glucose from the blood to the cells
symptoms of untreated diabetes
excessive hunger
excessive thirst
blurred vision
fatigue
frequent urination
dramatic weight loss
complications of diabetes
increased heart attack risk
eye problems, including blindness
nerve damage
infections on skin
kidney damage
what is diabetic ketoacidosis
when there is not enough insulin, the body can’t use sugar for energy, so it uses fat instead
symptoms of hyperglycemia
increased thirst/hunger, frequent urination, glucose in urine, headache, fatigue, blurred vision
symptoms of hypoglycemia
shaky/jittery, sweaty, hungry, headache, blurred vision, sleepy/tired, dizzy/lightheaded
ways you can become hyperglycemic
overeating sugar or not taking enough insulin
ways you can become hypoglycemic
taking too much insulin for what you’re eating
what is a complication of hypoglycemia
DKA
what is a complication of hyperglycemia
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
why is a dietician important to a patient with diabetes
to have healthy eating habits and the amount of insulin you need depends on how much/what you’re eating
who performs an arterial blood gas test
respiratory therapist
what does the arterial blood gas test detect
acid-base imbalance
pancreatic islets/islets of Langerhans
pancreatic tissue that contains beta cells that produce insulin
orangomegaly
enlargement of visceral organs
Risk Factors – Diabetes
Obesity
Advanced Age
Glucose Intolerance
Family history
Gestational diabetes
Sedentary lifestyle
Pancreatitis or pancreatic cancer
Certain infections
Signs and Symptoms – Diabetes
Glycosuria
Polyuria
Prolonged wound healing
Polyphagia
Ketoacidosis
Fatigue
Polydipsia
Recurrent infections
Weight loss
What is the main sign/symptom of diabetes?
Hyperglycemia
Diabetic Foot Complications
Edema
Infection
Ischemia
Ulcers
Fallen arches
Hammer’s toe
Charcot’s joints
Type 2 diabetes definition
Insufficient insulin production/resistance
Type 1 diabetes definition
Total insulin deficiency
Complication – Glycosylation definition
Glucose is deposited into the basement membrane of blood vessels and neurons
Complication – How does excess glucose cause polyuria?
Glucose transporters become saturated, remaining infiltrated. This glucose causes an osmotic gradient, drawing more water into the filtrate
What are the consequences of polyuria?
Polydipsia
With prolonged fluid deprivation, plasma osmolarity will cause a fluid shift = cellular dysfunction
Glycosylation effects
Affects transportation of substances in and out of blood = Tissue ischemia, Poor inflammatory response. Poor wound healing, Recurrent infection, Affects action potential conduction
Glycosylation complications
Neuropathies
Retinopathies
Nephropathies
Macular oedema definition
Fluid leaks into the retina, creating swelling and blurred vision
Proliferative retinopathy definition
Fragile, abnormal blood vessels form but break quickly, causing hemorrhages, scarring, retinal detachment
Nephropathy definition
Microvascular damage affects glomeruli
Autonomic neuropathy definition
Nerve damage in autonomic N.S., caused by glycosylation affecting action potentials
Autonomic neuropathy complications
G.I. issues – delayed gastric emptying, diarrhea, constipation
Erectile dysfunction
Postural hypotension
Urinary problems – infections, incontinence
Peripheral neuropathy complications
Decreased wound healing
Numbness in peripheries
Increased risk of infection/injury
Diabetic Foot Complications
Edema
Infection
Ischemia
Ulcers
Fallen arches
Hammer’s toe
Charcot’s joints
Autonomic neuropathy complications
G.I. issues – delayed gastric emptying, diarrhea, constipation
Erectile dysfunction
Postural hypotension
Urinary problems – infections, incontinence
Discuss issues and precautions associated with dental implant surgery in diabetic patients.
If controlled, a high success rate is possible
If the uncontrolled, increased risk of failure
Hyperglycemia reduces bone formation & remodeling → reduces osseointegration of implants
Hyperglycemia compromises microvasculature → delayed wound healing &
increased infection
Management of diabetes
Medication
Lifestyle changes – physical activity, smoking cessation
Dietary changes
What is the HbA1c test?
Glycosylated Hemoglobin levels. Measures average plasma glucose concentration over the past three months.
What is the normal (non-diabetic) blood glucose range?
3-8 mmol/L
Metformin action, effect, route
biguanide hypoglycemic medication
decreases gluconeogenesis and increases peripheral uptake/utilization of glucose
Oral
Humulin (human neutral insulin) action, effect, route
Long-acting insulin
Facilitates glucose uptake into cells, converts the excess into fat, inhibits lipolysis, enhances protein synthesis
Subcut
Humalog (insulin lispro) action, effect, route
Rapid onset, short-acting insulin
Facilitates glucose uptake into cells, converts the excess into fat, inhibits lipolysis, enhances protein synthesis
Subcut
Glipizide action, effect, route
Stimulates insulin production by the pancreas
Lowers blood glucose level
Describe the pathogenesis and pathophysiological changes associated with diabetes.
The pathophysiology of type 2 diabetes mellitus is characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production, and declining β-cell function, eventually leading toβ -cell failure.
Describe the principles behind monitoring physiological parameters and sampling for laboratory tests as they relate to the diagnosis of diabetes and controlling blood glucose.
In decentralized screening, fasting blood glucose is the appropriate analyte, followed by retesting FPG and/or by urine glucose. The comparability of glucose analyses must be verified by internal and external quality control. HbA1c may also be used in decentralized screening, although the results may vary when different chromatographic methods are used. The OGTT is not recommended as the first screening step but rather as a confirmation test.
Explore some of the pharmacological agents used in Carol’s care.
Insulin pump-she describes the benefits of getting very small, continuous doses of insulin from a pump as opposed to larger doses through pen injections.
mixed dose and mixed type insulin regime- one is rapid-acting insulin while the other is long-acting insulin
Demonstrate knowledge of the principles of preventative measures and therapeutic interventions in acute and complex care.
Assessment
Rationale
Vital signs
Assess heart rate, breathing, and temperature to compare with
Glucose levels
to assess whether carol is worse from the previous check
Abdominal assessment
due to pain being indicate in this area
funduscopic examination
check eyes
limited vascular and neurologic examinations
alertness and comprehensiveness
foot assessment.
circulation
Demonstrate a comprehensive knowledge of nursing practice management for clients experiencing hypo/hyperglycemia
Hyperglycemia Fruity-smelling breath. Nausea and vomiting. Shortness of breath. Dry mouth. Weakness. Confusion. Coma. Abdominal pain.
Hypoglycemia symptoms include sweating, shakiness, tachycardia, anxiety, and a sensation of hunger
Analyze issues related to health education for adults experiencing diabetes.
On how to improve their blood glucose control without a record.
Inconvenience to have to monitor their blood glucose levels
Discuss issues and precautions associated with dental implant surgery in diabetic patients.
If controlled, a high success rate is possible
If the uncontrolled, increased risk of failure
Hyperglycemia reduces bone formation & remodeling → reduces osseointegration of implants
Hyperglycemia compromises microvasculature → delayed wound healing &
increased infection
