Original Discussion Directions
Discussion – Week 11
In the United States, 25.6 million adults age 20 years or older have diabetes (American Diabetes Association, 2011). If not properly treated and managed, these millions of diabetic patients are at risk for several alterations including heart disease, stroke, kidney failure, neuropathy, and blindness. Proper treatment and management is the key for diabetic patients, and as the advanced practice nurse providing care for these patients, it is your responsibility to facilitate this process. Patient education is critical, as is working with patients to establish a regular pattern for daily activities such as eating and taking medications. When developing care plans for patients, you must keep the projected outcomes of treatment in mind, as well as patient preferences and other factors that might impact adherence to treatment and management plans. In this Discussion, you draw from your Practicum Experience and consider factors that impact the education and treatment of patients with diabetes.
Review Chapter 205 in Part 17 of the Buttaro et al. text.
Reflect on the clinical presentation of diabetes, as well as your Practicum Experiences and observations. Select a case from these experiences that involve a diabetic patient. When referring to the patient, make sure to use a pseudonym or other false form of identification. This is to ensure the privacy and protection of the patient.
Recall the medical details of the patient in the case that you selected including patient history, clinical presentation, physical exams, diagnostics, and the recommended treatment plan.
Select one of the following patient factors: genetics, gender, ethnicity, age, or behavior. Reflect on how this factor might impact the treatment plan and patient education strategies.
Post on or before Day 3 a description of the case that you selected including the diabetic patient?s medical details. Then, explain how the factor that you selected might impact the treatment plan and patient education strategies.
Read a selection of your colleagues? responses.
Respond on or before Day 6 to at least two of your colleagues on two different days who selected different factors than you. Pose questions for your colleagues regarding their treatment plans and/or patient education strategies. Then, expand on your colleagues? postings by providing additional insights based on readings and evidence.
Response #1 to Enrique
Mr. DP is a 45-years-old African-American male patient who visited the clinic for his six months follow-up check-up. He is concern that his diabetic medication is not working due to the persistently elevated finger stick ranging from 160 to 200 which he checks daily before breakfast. He admitted that he have a problem controlling his diet while at work but swore that he skips dinner most of the time to prevent raising his blood glucose level while sleeping. He is also complaining of always being thirsty, frequency of urination and occasional tingling sensations to his hands and feet.
Mr. DP has history of high blood pressure, high cholesterol, and obesity with BMI of 33.9. He is currently taking Metoprolol 50 mg PO daily, Simvastatin 20 mg PO daily at HS, and Metformin 1000mg PO daily. He does not have any surgery in the past and denies any allergies to medications.
Personal/Social History: 25 pack-year smoker. He drinks four to five bottles of beer every weekend. Denied using illicit drugs. Non-compliant with diabetic diet prescribed by dietician.
Significant family history includes: Brother is a 50-years-old with diabetes and hypertension, sister is a 58-years-old with asthma (currently controlled), and DM II. Mother (deceased) had history HTN and father (deceased) had HTN and DM II.
With regards to his lifestyle, Mr. JD is a bus driver for 25 years, married with one healthy son. Owns a house and live in a quiet neighborhood. He admitted that he has been having a problem following the diabetic diet plan provided by his nutritionist due to NATURE of his job. His food is usually from a deli food store or local restaurants which are usually composed of pasta, pizza, burger, fries, chips, and diet soda. He can only eat healthy food when he is at home.
Physical exams revealed an obese 5?6?, 210 lbs., male, not in acute distress, with BP 145/70, left arm, sitting, adult cuff; P 98 and regular; T 98.2 F. orally; RR 18 non-labored; Oxygen saturation: 98% on room air. P/S=0/10
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: Thorax symmetrical; equal breath sounds; no rhonchi;
Heart/Peripheral Vascular: Heart rate regular with good S1, S2; no S3 or S4; no murmur
ABD: Protuberant, with normoactive bowel sounds, auscultated x4 quadrants
Genital/Rectal: not assessed
Musculoskeletal: symmetric muscle development; muscle strengths 5/5 all groups
Neuro: CN II ? XII grossly intact, DTR?s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Patient?s random blood sugar was 220 mg /dl while his A1C is seven which was taken a week prior to his visit. Random blood sugar >200mg /dl is diagnostic for diabetes (Buttaro, et al., 2013). A1C is a representation of patient?s glucose level for the past 2 to 3 months showing how well the glucose level was controlled by patient?s medication (ADA, 2013). Base on the patient?s A1C level, his metformin dosage is not controlling his blood sugar level which is worsened by his diet and health habits.
The dosage of Metformin was increased to 1000 mg PO BID. Metformin inhibits gluconeogenesis and promotes peripheral glucose uptake, improving glucose sensitivity (Wilmot & Idris, 2014). He was given a health education on the importance of the adherence to diabetic diet to fully control and maintain blood sugar. Maintaining a normal blood sugar level prevents worsening of symptoms that can lead to end organ damage. He was scheduled to return for complete blood count, complete metabolic panel, lipid and hepatic profile.
Mr. DP?s body habitus, sedentary lifestyle, ethnicity, and family history of DM strongly predisposed him to developed DM (Buttaro et al., 2013). However, his diet, smoking habit, and physical inactivity cause him to developed uncontrolled DM (Wilmot & Idris, 2014). According to Wilmot & Idris, (2014) individuals who are high risk of developing DM are those who are obese, lead a sedentary lifestyle, have a strong family history of T2DM, be of black and minority ethnic (BME) origin and come from a less affluent socioeconomic group. Driving several hours a week keeps him from doing any form of exercise and gives him no choice on what food to eat but fast food. Another factor that increases his risk of having DM is his smoking habit. Smokers are 30?40% more likely to develop type 2 diabetes than nonsmokers (CDC, 2014).
MR. DP?s symptoms revealed that he is developing end-organ damage from prolonged uncontrolled DM that can get worst when normal glycemic index is not achieved sooner than later (Wilmot & Idris, 2014). Patient?s numbness to his extremities is due to nerve damage that occurs to almost any nerves in the body which is also called diabetic neuropathy (Buttaro et al., 2013). Diabetic neuropathy is common to 60% to 70 percent of diabetic patients that can be improved if glycemic index is controlled (Buttaro et al., 2013). Other complications that may develop from persistently elevated blood sugar level includes depression, hypoglycemia, hyperglycemia, diabetic ketoacidosis, hyperglycemic hyperosmolar state, diabetic retinopathy, and DM nephropathy (Buttaro et al., 2013). Educating Mr. DP and his family on which of his risk factors can be controlled to help lower his blood glucose and creating a management plan that is aggregable to both parties, empowers him take part in the management of his care (ADA, 2015). Engaging into an active lifestyle, smoking cessation, weight reduction, and adherence to a healthy diabetic diet creates a long term positive result including improvement of self-esteem, body image, prevention of depression, and avoiding the occurrence of DM complications (ADA, 2015).
American Diabetes Association. (ADA). (2015). Classification and diagnosis of diabetes. Retrieved fromhttp://care.diabetesjournals.org/content/38/Supplement_1/S8
American Diabetes Association. (ADA). (2013). A1C and eAG. Retrieved fromhttp://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/a1c/?referrer=https://www.google.com/
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sanberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St Louis, MN: Mosby.
CDC. (2014). Smoking and diabetes. Retrieved from http://www.cdc.gov/tobacco/campaign/tips/diseases/diabetes.html
Wilmot, E., & Idris, I. (2014). Early onset type 2 diabetes: risk factors, clinical impact and management. Retrieved from
Response # 2 to Darinka
Type 2 diabetes mellitus is the most common type of diabetes. Hyperglycemia results because the pancreas is unable to provide enough insulin or the body is unable to respond to insulin efficiently (Valencia, Oropesa-Gonzalex, Hogue, & Florez, 2014). Many modifiable and non-modifiable risk factors impact the development of the disease. Ethnicity and age are contributing risk factors for acquiring diabetes.
Patient J. D. presented to the primary care office for follow-up after completing blood work approximately one week ago for complaints of fatigue and recent weight loss. Ms. D is 83-years-old living with her son and daughter-in-law having moved to the United States from Mexico approximately five months ago. The patient has not had a routine medical follow-up in Mexico, and the family felt it was necessary to have her evaluated. The lab work drawn one week prior were concerning for new onset hyperlipidemia, diabetes, and uncontrolled hypertension. Metabolic syndrome is common among patients diagnosed with type 2 diabetes and predisposes this group of patients to cardiovascular disease (Wood, 2013). Metabolic syndrome is found in patients that are obese, have high triglycerides and low high-density lipoproteins, and hypertension (National Heart Lung and Blood Institute [NIH], 2016).
History is positive for obesity, hypertension, and recently diagnosed gastroesophageal reflux disease. Surgical history includes an appendectomy 20 years ago and left knee fracture in 2015 that limits mobility. The family history is positive for hypertension, elevated cholesterol, and diabetes.
The patient is a never smoker, non-drinker, and she does not abuse drugs. The patient does not take any medications except for occasional tramadol 50mg 1 tablet prn knee pain.
Blood pressure 171/85, heart rate 68 beats per minute, respiratory rate 16 per minute and regular, weight 110 lbs, body mass index 22
The physical exam revealed a deconditioned, elderly, and thin female in non-acute distress. Pupils were equal, round, reactive to light and accommodation. The neck was supple, non-tender, without masses or tenderness. No lymphadenopathy was appreciated. The oral mucosa was dry, without lesions or exudate. Skin was thin, without lesions, ulcers, rashes, or bumps. Heart sounds distant, regular rate and rhythm, S1S2 without murmurs or rubs. No lower extremity edema. Chest was clear to all, without wheezes, rales, or rhonchi. Abdomen was soft, non-tender, with active bowel sounds. Extremities with full range of motion.
An office glucose finger stick was 276 mg/dL. Laboratory studies done one week previously indicate:
Hemoglobin A1C ? 7.6
Sodium 136 mEq/l, potassium 4.0 mEq/l, chloride 96 mEq/l, carbon dioxide 24 mEq/l, blood urea nitrogen 18 mg/dl, creatinine 1.0 mg/dl, fasting blood sugar 210. A complete blood count was normal.
Fasting lipids ? cholesterol 250 mg/dL, LDL 175 mg/dL, HDL 42 mg/dL, triglyceride 162mg/dL.
The treatment plan was as follows:
1. Start Metformin ER 500 mg 1 tablet PO daily with evening meal.
2. Start Atorvastatin calcium 20 mg 1 tablet PO daily.
3. Increase Ramipril 10 mg 1 tablet PO daily.
4. Add Atenolol 50 mg 1 tablet PO at bedtime for systolic blood pressure > 130.
The Centers for Disease Control and Prevention (CDC) (2014) report age as being a major contributing factor to acquiring diabetes. Twenty-six percent of the population aged 65 and older have the disease (CDC, 2014). The decline in B-cell function and insulin secretion is associated with aging (Cornell, 2015). Ethnicity is also a major factor, and 13% of Hispanics have diabetes. Dietary preferences among the Hispanic population alone may impact the treatment plan. Hispanics typically eat high starch foods with a high carbohydrate load affecting glycemic control. It will be IMPORTANT to provide dietary teaching to stress the importance of following recommendations to help lower glucose levels and decrease the risk of complications. The aged also have limited resources to which may impact the patients ability to purchase healthful foods.
Along with diet, exercise is an important component in lower blood sugar levels and the elderly often do not have the motivation or the support necessary to perform daily activity (Tomlin & Asimakopoulou, 2014). Frailty and reduced mobility are associated with aging affecting the elder patient?s ability to exercise independently. Much like children, the elderly often depend on family support for their daily needs, and if the family is not engaged and actively involved in the patient?s care, it may be difficult for the elder to be compliant with recommendations (Tomlin & Asimakopoulou, 2014).
Authors Tomlin and Asimakopoulou (2014) discuss cognitive function and its decline seen in both the aged and those with diabetes. When age and diabetes are combined, memory and the ability to problem-solve is impaired affecting the patient?s ability to successfully self-manage the complexity of disease states such as diabetes (Tomlin & Asimakopoulou, 2014). Meal planning, monitoring glucose levels, and medication management are areas that are impacted (Tomlin & Asimakopoulou, 2014).
Centers for Disease Control and Prevention. (2014). National diabetes statistics report 2014. Retrieved from http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
Cornell, S. (2015). Continual evolution of type 2 diabetes: an update on pathophysiology and emerging treatment options. Therapeutics & Clinical Risk Management, 11621-632. doi:10.2147/TCRM.S67387
Tomlin, A., & Asimakopoulou, K. (2014). Supporting behaviour change in older people with type 2 diabetes. British Journal Of Community Nursing, 19(1), 22-27. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=f9f6cb4b-f78e-4369-b9ab-b1ea128cbf20%40sessionmgr105&vid=19&hid=124
Valencia, W. M., Oropesa-Gonzalez, L., Hogue, C., & Florez, H. J. (2014). Diabetes in Older Hispanic/Latino Americans: Understanding Who Is at Greatest Risk. GENERATIONS 38(4), 33-40. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=b2f7ac32-a771-4783-a99a-9b9b845bb00b%40sessionmgr104&vid=4&hid=124
National Heart Lung and Blood Institute. (2016). What is metabolic syndrome. Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/ms
Wood, M E. (2013). Diabetes mellitus. In T. M. Buttaro, J. Trybulski, P. Polgar Bailey, & J. Sandberg-Cook (Eds).Primary care: A collaborative practice (4th ed., pp. 1062-1083). St. Louis, MO: Mosby