NURS2100 Acute Care Nursing Assignment - RMIT University, Australia

Questions -

Discuss the pathophysiology of type 2 diabetes as it relates to the chronic symptoms the patient is experiencing.

Analyse the potential management approaches (medical and nursing) for a hypertensive diabetic patient.

Develop an education plan for Bill based on support resources available in Australia, particularly his learning and treatment/care needs associated with his disease progress.

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Answer -

Title: Nursing interventions for a hypertensive and diabetic patient

Introduction:

Diabetes mellitus (DM) is a worldwide epidemic affecting 350-million people with a high economic burden. DM demographics suggest a relation between the socio-economic status, diet, age, genetics, environment, geography, ethnicity and the prevalence of DM (Skyler et al., 2017). DM is a complex metabolic disorder characterized by impairment of insulin secretion, glucose uptake by the cells in the body is manifested as chronic hyperglycaemia due to insulin resistance. Etiology of DM is classified based on the insulin sensitivity and secretion in the body. Type 1 DM is due to insulin sufficiency, and Type 2 DM is due to insulin resistance where the cells of body secrete insulin, but it is not recognised(Goyal & Jialal, 2018). DM systemically affects the body systems from microvascular to macrovascular components leading to life-threatening health complications Retinopathy, neuropathy etc. Obesity and sedentary lifestyle are major contributors of this disease(Kahn, Cooper, & Del Prato, 2014). The risk of T2DM is higher than T1DM, and it increases with age with a higher occurrence in individuals older than 45 years. Elderly are prone to chronic illness in the later part of their life due to the natural biological degeneration. These diseases negatively affect the quality of life, physical mobility, emotional state and psychology(Somrongthong, Hongthong, Wongchalee, & Wongtongkam, 2016)

Case history and Diagnosis:

Mr. Bill Lever is a 58-year-old male with a medical history of T2DM; Recent diagnosis revealed hypertension. His Lifestyle is sedentary with reduced physical activity. His pulse rate across the body is stable with a respiratory rate of 18. Any visible skin complications were absent. Mr. Bill had no blurred vision. Body temperature was normal at 37. His chief complaints were extreme fatigue.

Diagnosis of T2DM has been made through various methods with a golden standard of Oral glucose tolerance test, fasting blood sugar analysis and glycated haemoglobin.

Laboratory findings showed a 7.2 % HBA1C, indicating consistently high glucose levels. Pitting oedema in the legs represents a dysregulation of body fluid circulation and peripheral vascular disease. In support to this observation, a Urine analysis revealed higher levels of urea and albumin a protein, decreased glomerular filtration rate, indicative of kidney disease.

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Pathophysiology of the disease:

Homoeostasis of glucose in the body is dependent upon the insulin secretion system and the sensitivity of the cells for the uptake of glucose according to the altered concentrations in the blood. Glucose disposal in the body is regulated through many mechanisms that regulate the glucose breakdown, stimulate the absorption of glucose by the gastrointestinal tract, utilization of glucose by muscular tissue. Increase in the concentration of plasma glucose, pancreatic beta cells produce insulin. Post-ingestion of, a major portion of glucose 50% is absorbed by brain and liver.

Adipose tissue contributes through the conversion of excess glucose into fat through the process of lipogenesis (Cersosimo, Triplitt, Solis-Herrera, Mandarino, & DeFronzo, 2018)

A high BMI value is a major risk factor for the development of T2DM(Skyler et al., 2017). Increase in the fat deposition in liver and muscle results in the inflammation of the liver reduces the sensitivity of liver cells to absorb the glucose from the blood further developing insulin resistance. This process promotes hyperglycaemia and thereby T2DM.

Chronic obesity damages the beta cells in the pancreas through autoimmune reactions in the body, that decreases the overall insulin secretion and the disease progresses into T1DM.

Co-morbidities of T2DM include bacterial and fungal infections. Abrasions in the skin are prone to bacterial and fungal infections; wound healing is delayed due to the excess availability of glucose in the peripheral blood circulation.

Ketoacidosis is another metabolic complication ketoacidosis characterised by the excess breakdown of fat due to unavailability of glucose in the cells. This pathway produces acidic compounds known as ketones(Gosmanov, Gosmanova, & Kitabchi, 2018).

Treatment and Nursing interventions in Self- management of Medication:

Nursing interventions include the detection of early signs and symptoms to design an individualised care plan for the patient. Diabetes is a complex disease with short term and long-term complications in metabolism and physiology. Elderly patients often experience higher levels of disease-associated stress due to the symptoms and lifelong alterations in their lifestyle. Mr. Bill exhibited anxiety and distress regarding his familial medical history on the onset of disease. Disease and symptom management to improve the quality of life is the primary goal of nursing intervention.

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A treatment plan for Mr. Bill included medication and lifestyle changes. Self-management of glucose levels involved regular checks of blood glucose levels, hypertension recording the energy levels during the day. His sedentary lifestyle and imbalanced diet lead to obesity. To maintain an optimum BMI and prevent the cardiovascular issues, a balanced diet for the patient with low carbs to protein ratio was suggested. To improve the circulation and the uptake of glucose by the cells physical activity is crucial. Walking at least 60 minutes is recommended.

Medication prescribed included Oral anti-hyperglycaemic agents such as 1000mg-Metformin. Hypertension is treated with Eplerenone 50mg an aldosterone antagonist.(Nguyen, Dominguez, Nguyen, & Gullapalli, 2010). Renal function failure is evident through the physical examination of urine albumin concentration. Angiotensin-converting enzyme regulators are prescribed to control the renal disease (Turner, Bauer, Abramowitz, Melamed, & Hostetter, 2012).

The usual pattern for insulin administration is by having multiple injections. The dose varies and is tailored to the individuals' nutritional intake, activity levels, and glycaemic goals; Nursing interventions include teaching Mr.Bill about his insulin, administration and BGL monitoring technique, adjustment to BGL monitoring.

Mr. Bill's blood work showed a stable-high HBA1C and blood glucose levels indicating the little effect of oral medication on the disease indicating the need of external insulin administration. A new treatment regimen was proposed with 10 units of insulin at night. Along with the medication, there is a need to inspire trust and motivation to self-manage the disease.

Along with the medication diet with less saturated fats, refined sugars, restricted consumption of banana and high fibre foods like vegetables are recommended. Aerobic Exercise s for at least 30minutes a day are included in the treatment plan.

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Patient education:

Co-morbidities of T2DM complicate the prognosis of the disease. Acute and chronic complications may result in blindness, kidney failure, cardiovascular disease, peripheral vascular disease that may lead to amputation of limbs. Active participation and self-management by patients is crucial in regulating Diabetes. The goal of diabetes management involves the formulation of patient centred diet plan, daily foot care regimen, scheduled physical exercises, strict monitoring of self-administration of Diabetic medication, regular follow-up visits to Clinician.

Awareness on the importance of glucose levels in the body in causing the complications plays a key role in the success of the treatment plan. Identification of symptoms of hyperglycaemia (such as profuse sweats, dizziness, and confusion) and an action plan to alleviate the symptoms is ideal.

In the current case, Bill's has a T2DM with co-morbidities renal failure, hypertension exist. Regular monitoring of blood pressure and recording the pattern of symptoms is suggested.

Conclusion:

Self-management interventions for adults with type 2 diabetes face-to-face interventions improved behavioural, biologic, and diabetes knowledge-related outcomes in adults with T2DM living in rural areas.

Interventions based on behaviour theories uniformly produced significant improvements in metabolic control while interventions that did not mention the use of behaviour theories did not always yield positive results. Incorporating collaborative goal-setting and motivational support were more likely to be associated with positive outcomes than purely educational interventions.

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