Melanie is distressed that her blood glucose level is elevated and asks you for help in understanding her diabetes. She tells you that she has a friend who is very overweight, eats lots of cake and hardly ever exercises, and he does not have diabetes.
1. Type 2 diabetes is a condition in which the body is resistant to insulin which is produced by the B cells in the pancreas. The pathophysiology of T2DM is quite complex and it involves the red blood cells ,muscle cells, fat and liver cells that take glucose from blood and convert it to energy (Areosa Sastre, Vernooij, González-Colaço Harmand, & Martínez, 2017). For them to achieve their functions, they need insulin which is attached to the insulin receptors and the GLUT4 transporters. Type 2 diabetes occur when the cells lose their sensitivity to insulin and therefore fail to bind glucose leading to accumulation of glucose in blood. Different risk factors are responsible in making the cells insensitive to the insulin .One of the risk factor is genetics(Besseling, Kastelein, Defesche, Hutten, & Hovingh, 2015) .If at any point one of the family members had this condition, it is likely to affect another family member. This is the case for Melanie in the case study since she said that she was aware of the risk due to family history. She said that her mother and sister were diagnosed with type 2 diabetes in the 50s. Another risk factor for type 2 diabetes is overweight. This is in fact the primary risk factor in the case study since Melanie weighs 105 kg (Christine et al., 2015). Studies have established that the more the fatty tissue an individual has, the higher the risk of resistance to insulin. Another important risk factor for type 2 diabetes is inactivity. According to Melanie, she has pain in her knee and it is therefore difficult for her to exercise. This is because scientists have established that exercise consumes the excess glucose and also assists an individual to control his or her weight. Age is another risk factor (Chrvala, Sherr, & Lipman, 2016). Studies have revealed that individuals who are above 45 years old are likely to suffer from type 2 diabetes. In the case study, Melanie was 63 years old. This is because old people are more likely to exercise less. They also have the tendency of losing muscle mass than gain weight. This places them at the risk of type 2 diabetes. Polycystic ovarian syndrome is another risk factor for diabetes (DeFronzo, Ferranninin, Groop, Henry, Herman, Holst and Weiss, 2015) .This is however experienced in women alone. This condition is characterized by excess growth of hair as well as obesity .In the case study, Melanie once had a cyst and therefore places her at risk of type 2 diabetes.
Diabetes affects different organs of the body if left untreated. The complications usually develop with time and eventually become disabling or life threatening. Some of the notable complications of type 2 diabetes include the heart and blood vessel disease. Studies have linked type 2 diabetes to different cardiovascular diseases such as stroke and angina. Another complication is nerve damage which is also called neuropathy since excess glucose harm capillaries that supply blood to nerves. This therefore leads to lose of sense (“Diagnosis and Classification of Diabetes Mellitus,” 2013).Type diabetes also leads to damage of the kidney by the excess glucose destroying the small filtering systems. Eye damage is also a complication of T2DM where the glucose destroy blood vessels in the retina and this leads to blindness. Other complications include foot damage by destroying nerves that supply the foot, hearing impairments, skin conditions and finally the Alzheimer’s disease.
The three treatment options for type 2 diabetes include eating well as this will assist in managing of the body glucose as well as the weight of the body .Another option is regular exercise so as to reduce the fatty tissue from the body (Inzucchi et al., 2014). Finally, monitoring the blood glucose level assists in management of blood glucose.
2. Causes: Type 1 diabetes is an autoimmune system where the immune system attack and destroy cells that produce insulin in the pancreas. Type 2 diabetes is a metabolic disorder where the body either does not produce insulin or it is resistant to it.
Insulin production: In type 1 diabetes, the body does not produce insulin hormone while in type 2 diabetes, insulin is produced.
Prevention: There is no means for preventing type 1 diabetes while in type 2 diabetes, staying active and healthy diet reduce the risk of type 2 diabetes.
Treatment: In type 2 diabetes, insulin injections and monitoring glucose is a treatment option while in type 2 diabetes, the treatment options include changes in lifestyle.
The risk factors: The risk factors for type 1 diabetes include family history, genetics and environmental factors while for type 2diabetes, the risk factors are genetics, lifestyle choices and overweight.
Common physical attributes: In type 1 diabetes, the BMI is usually within the normal range or lower while in type 2 diabetes, the BMI is either overweight or the obese range.
3. In the case study, the BGL for Melanie was at 22 mmol/L even after fasting from midnight. There are two reasons however as to why the blood glucose was still high. The two factors include the secretion of growth hormone and then the secretion of stress hormones (Macaluso et al., 2002). According to the case study, Melanie was very stressed about the surgery. Studies have established that emotional stress as well as physiological stress stimulate the body to release stress hormones into the blood stream. The common stress hormones include adrenaline and cortisol. The liver is the organ that stores glucose in the form of glycogen (Portillo Sanchez et al., 2014) .The liver only breaks little amount of glycogen to form glucose which is then released into the blood stream so as to provide nourishment to the brain, the nerves, the heart and other important organs. According to studies however, it is only possible for the liver to release the glucose into blood under the influence of certain hormones. Out of all the hormones in the body, it is only insulin that stimulates the liver to take glucose from the blood stream and then store it in form of glycogen. On the contrary, all the remaining hormones stimulate the liver to release glucose into the blood stream (Reynolds, Mann, Williams, & Venn, 2016) .The reason why Melanin experienced high glucose level on admission was therefore due to stress that stimulated the release of adrenaline which in return stimulated the liver to release glucose into the bloodstream.
Another reason for the elevated blood glucose on admission was growth hormones. Scientists established that growth hormones are produced after a cycle of every 24 hours (Scheen, 2014). Scientists’ link an increase in blood glucose to this growth hormones and the elevated blood glucose is usually experienced either during the night or early in the morning .In this case study, it was early morning.
The surgery is successful and Melanie comes to see you in the outpatient clinic for cortisone injections (Kenacort-A 40). She has been commenced on metformin (APO-Metformin Tablets) and glipizide (Minidiab Tablets) to help control her diabetes. Her blood test on this visit were BGL 8.8 mmol/L; HbA1c: 8%.
1. Metformin is a prescription drug that comes either in oral tablet or the oral solution. This drug has been prescribed to Melanie in the form of APO-Metformin Tablets and it is used to treat type 2 diabetes. This drugs belong to the class of biguanides and all the drugs in this class have a similar mechanism of actions. The metformin usually work by reducing the quantity of glucose made by the liver .It also reduce the amount of glucose that the body absorbs (Semenkovich, Brown, Svrakic, & Lustman, 2015) .Finally, the drug work by increasing the activity of insulin in the body. There are different side effects that are associated with metformin and they include diarrhoea, nausea, stomach pain, heartburns. These are mild side effects. Serious side effects include lactic acidosis that is shown by fatigue, unusual muscle pains, slow and irregular heart rate and then dizziness or light-headedness. The drug is also associated with low blood sugar and this can be seen by headaches, confusion, and irritability and sweating. The nursing interventions in this case involves the nurse educating the patient to avoid vitamins or herbs since they interact with metformin.
Another drug that has been prescribed for Melanie is cortisone which has been prescribed in the form of Kenacort A40.This drug is only available in the generic form. This drug is used to treat different conditions in the body but basically it is used as a replacement therapy for certain hormones like adrenaline and prevents inflammation in the body. It is also used to treat arthritis, asthma, ulcerative colitis, lupus and anaemia .For the case of this case study however, and it is used as a replacement therapy for hormones(Zaccardi, Webb, Yates, & Davies, 2015). Since this drug belong to steroids, they work by releasing certain molecules in the body which prevent inflammation. They also prevent the body experiencing immune responses. The most common side effects of cortisone include confusion, excitement, restlessness, headache, nausea, vomiting as skin problems. The drug is also associated with insomnia and weight gain. Serious side effects include allergic reactions, fluid and electrolyte problems and muscle problems. The nursing interventions in this case involves the nurse teaching the patient not to introduce vitamins and herbs since they interact affecting its efficacy in return.
Glipizide is another drug that has been prescribed for Melanie. This drug is used to reduce blood glucose in people with type 2 diabetes. This drug belongs to the sulfonylureas class and they work in a similar manner. This drug works by stimulating the release of insulin from the pancreas .Insulin the assists in removing the glucose from the blood stream to the cells where they belong. This generally reduces the level of glucose in the blood. The common side effects for glipizide include headache as well as irritability .It also causes seating, faster heart rate, dizziness, nausea ,hunger ,anxiousness, diarrhoea, constipation, skin rash, redness or itching. Just like the other drugs, the nursing intervention is similar since they also react with vitamins and herbs .However, they further react with antifungals and the non-steroidal anti-inflammatory drugs and therefore it is important for the nurse to provide such education to the patient.
2. There were two blood tests conducted on Melanie, one was done prior to surgery and the results were 22.9 mmol/L. The HbA1c values in this case was 11%.After the surgery, the same blood glucose level test was done and the results were 8.8 mmol/L and HbA1c was 8%.The first test is used to measure the level of glucose in the blood and the second test is used to measure the HbA1c in blood.HbA1c is a component that carries oxygen within the haemoglobin and the test is therefore used to estimate the quantity of the HbA1c that is in blood (Zaccardi et al., 2016).
All this tests are carried out differently but they have the same objective. They are used to monitor the blood glucose level of patients with type 2 diabetes. However, the values for both the tests have reduced. The reason why the two values have reduced is because the patient is no longer stressed about the surgery since it has been successful. As a result, the adrenaline hormone that stimulates the liver to breakdown glycogen to glucose is not stimulated and therefore the blood glucose level reduce. Once the blood glucose level reduce, the HbA1c also reduces.
While Melanie is waiting to see the doctor, she starts talking to you about her condition. She asks if she has insulin dependent diabetes or early onset diabetes. She is also unsure of how to use her BGL machine and BGL strips.
1. There are incidences where the terms insulin dependent diabetes mellitus/non-insulin dependent diabetes mellitus and the mature/early onset are used. This terms are always misleading. This is because in all the types of diabetes, there is a defect in insulin. This therefore makes it hard to differentiate between the two. In all the cases, both can begin early or on maturity depending on the exposure to the risk factors .A good example is referring to type 2 diabetes as insulin independent. This could literally mean that the T2DM does not rely on insulin yet in real sense occurs due to the insensitivity of the body to insulin.
2. Teach Back method of patient education can basically be defined as a method whereby a patient is taught a new aspect then the healthcare provider asks the patient to explain or demonstrate what she or he was taught (Callaway et al., 2018). This method ensures that the patient has grasped the concept effectively by demonstrating or teaching back. According to studies, this is the best method of patient education.
Since in this case study Melanie does not know how to use the BGL machine, I will use this method to teach her (Dinh, Bonner, Clark, Ramsbotham, & Hines, 2016). I will ensure that explain things clearly using plain language. I would avoid using medical jargons as well as vague language so that the patient can understand me well. During teaching I would also speak slowly while maintaining eye contact with the patient.
If the patient does not understand, I will have to repeat the procedure frequently. This method needs a good environment and I will provide this by giving the patient time and the opportunity so that she can talk to me. When using this method, it is recommended to use decision aids. In this I will therefore use different decision aids such as videos, written material as well as interactive tools.
References
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Besseling, J., Kastelein, J. J., Defesche, J. C., Hutten, B. A., & Hovingh, G. K. (2015). Association Between Familial Hypercholesterolemia and Prevalence of Type 2 Diabetes Mellitus. JAMA, 313(10), 1029. doi:10.1001/jama.2015.1206
Callaway, C., Cunningham, C., Grover, S., Steele, K., McGlynn, A., & Sribanditmongkol, V. (2018). Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit. Clinical Journal of Oncology Nursing, 22(4), 421-428. doi:10.1188/18.cjon.421-428
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Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Education and Counseling, 99(6), 926-943. doi:10.1016/j.pec.2015.11.003
DeFronzo, R. A., Ferrannini, E., Groop, L., Henry, R. R., Herman, W. H., Holst, J. J., … Weiss, R. (2015). Type 2 diabetes mellitus. Nature Reviews Disease Primers, 15019. doi:10.1038/nrdp.2015.19
Diagnosis and Classification of Diabetes Mellitus. (2013). Diabetes Care, 37(Supplement_1), S81-S90. doi:10.2337/dc14-s081
Dinh, H. T., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. The JBI Database of Systematic Reviews and Implementation Reports, 14(1), 210. doi:10.11124/jbisrir-2016-2296
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., … Matthews, D. R. (2014). Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 38(1), 140-149. doi:10.2337/dc14-2441
Macaluso, C. J., Bauer, U. E., Deeb, L. C., Malone, J. I., Chaudhari, M., Silverstein, J., … Rosenbloom, A. L. (2002). Type 2 diabetes mellitus among Florida children and adolescents, 1994 through 1998. Public Health Reports, 117(4), 373-379. doi:10.1016/s0033-3549(04)50174-7
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Reynolds, A. N., Mann, J. I., Williams, S., & Venn, B. J. (2016). Advice to walk after meals is more effective for lowering postprandial glycaemia in type 2 diabetes mellitus than advice that does not specify timing: a randomised crossover study. Diabetologia, 59(12), 2572-2578. doi:10.1007/s00125-016-4085-2
Scheen, A. J. (2014). Pharmacodynamics, Efficacy and Safety of Sodium–Glucose Co-Transporter Type 2 (SGLT2) Inhibitors for the Treatment of Type 2 Diabetes Mellitus. Drugs, 75(1), 33-59. doi:10.1007/s40265-014-0337-y
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Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2015). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate Medical Journal, 92(1084), 63-69. doi:10.1136/postgradmedj-2015-133281
Zaccardi, F., Webb, D. R., Htike, Z. Z., Youssef, D., Khunti, K., & Davies, M. J. (2016). Efficacy and safety of sodium-glucose co-transporter-2 inhibitors in type 2 diabetes mellitus: systematic review and network meta-analysis. Diabetes, Obesity and Metabolism, 18(8), 783-794. doi:10.1111/dom.12670
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