diabet - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance or deficiency causes diabetes. Type 1 is due to autoimmune destruction of beta cells in the pancreas, leading to insulin deficiency. Type 2 is generally due to increased resistance to insulin's effects, often associated with obesity, causing beta cells to overwork and eventually fail.

• Secondary mechanism: Hyperglycemia occurs when glucose cannot enter cells for energy due to lack of insulin or resistance. The liver compensates by making more glucose, worsening hyperglycemia.

• Key complication: Chronic hyperglycemia damages blood vessels, leading to microvascular (retinopathy, nephropathy, neuropathy) and macrovascular complications (stroke, heart disease). This is often exacerbated by concurrent hypertension and dyslipidemia.

Patient Profile

Demographics:

55-year-old male, works as a truck driver.

History:

• Diagnosed with Type 2 Diabetes five years ago

• Currently on Metformin and Glipizide for diabetes, Lisinopril for hypertension

• Allergic to Penicillin

Current Presentation:

• Chief complaint of increased fatigue, frequent urination, and blurred vision

• Other symptoms include numbness in hands and feet, slow-healing sores, and unexplained weight loss

• Vital signs: Blood pressure 145/90, Pulse 88, Blood glucose levels consistently above 200 mg/dL, BMI 30, Cholesterol 220 mg/dL.

Section 1

Change in Patient Status:

The patient's condition has begun to deteriorate. He has been complaining of increased thirst and hunger, even after eating. His fatigue has worsened, and he now experiences dizziness upon standing. He also reports persistent tingling and numbness in his hands and feet, indicating possible diabetic neuropathy. His blood glucose levels have been consistently in the range of 250-300 mg/dL despite medication, and his blood pressure has risen to 155/95. His latest cholesterol reading was 240 mg/dL, indicating dyslipidemia.

The patient also reported experiencing episodes of chest discomfort which he described as a 'heavy' feeling, especially after meals or physical exertion. He also noticed swelling in his feet and ankles. These symptoms may indicate the development of macrovascular complications such as ischemic heart disease. His BMI has dropped to 28, suggesting continued unexplained weight loss. Despite his worrying symptoms, the patient admits to a poor diet rich in saturated fats and simple sugars, combined with a sedentary lifestyle due to his job as a truck driver.

These new developments require immediate medical attention and possibly a revision of his treatment plan. It is crucial to manage his persistently high blood sugar levels and hypertension, as well as addressing his potential heart disease. This includes an urgent need for lifestyle modifications, potential changes in medication, and regular monitoring. His neuropathy and potential heart disease also need further diagnostic evaluation. These changes in his status present opportunities for clinical reasoning to prevent further complications and improve the quality of his life.

Section 2

New Diagnostic Results:

After an extensive evaluation, the patient's laboratory results came back with alarming findings. His HbA1c level was 9.2%, significantly above the target level of less than 7%, indicating poor glycemic control over the past 2-3 months. His proteinuria test showed 500mg/24h, suggestive of early stage diabetic nephropathy. An electrocardiogram (EKG) revealed ST-segment depression and T-wave inversion, indicating myocardial ischemia. A stress test was then ordered, which the patient was unable to complete due to shortness of breath and chest discomfort indicative of angina pectoris. This confirms the suspicion of underlying ischemic heart disease.

These results indicate that the patient's diabetes is not well-controlled and is leading to multiple complications, including diabetic neuropathy, nephropathy, and ischemic heart disease. The nephropathy, in particular, could be contributing to his hypertension. The new findings necessitate an immediate reassessment of his treatment plan. The challenge for the healthcare team is to manage not just his diabetes but also his comorbid conditions. The team needs to address his poor glycemic control, dyslipidemia, and hypertension, while also managing his heart disease and preventing progression of his kidney disease. This will require a coordinated effort involving dietary and lifestyle changes, medication adjustments, and possibly the involvement of specialists.

Section 3

Change in Patient Status:

Over the next few days, the patient's condition continued to deteriorate. His blood pressure readings consistently remained at 160/90 mmHg despite the administration of antihypertensive medications, indicating uncontrolled hypertension. His blood glucose levels also continued to fluctuate, with fasting readings ranging from 200-250 mg/dL and postprandial readings above 300 mg/dL, reflecting inadequate glycemic control. Additionally, the patient complained of persistent chest discomfort and shortness of breath, even with minimal exertion. He also reported a decrease in urine output and swelling in his lower extremities, suggestive of worsening kidney function.

Furthermore, a follow-up lab test showed an increase in his serum creatinine level from 1.5 mg/dL to 2.8 mg/dL, indicating a significant decline in his kidney function. His HbA1c level remained at 9.2%, suggesting that his diabetes is still not well-managed. These new developments imply that his diabetic nephropathy is progressing and his ischemic heart disease symptoms are becoming more severe. His healthcare team needs to reassess his current treatment regimen and consider more aggressive therapeutic interventions. This may include a consultation with a nephrologist and a cardiologist, in addition to more stringent glycemic control and blood pressure management strategies.

Section 4

Change in Patient Status:

Despite the administration of insulin and other hypoglycemic agents, the patient's blood glucose levels remained persistently high. In the subsequent days, he began to show signs of confusion and lethargy, suggesting the development of hyperosmolar hyperglycemic state (HHS), a serious diabetes complication. His vital signs revealed a heart rate of 120 bpm, respiratory rate of 22 breaths per minute, and a slightly elevated temperature at 100.4°F, indicating potential systemic inflammation or infection.

New Diagnostic Results:

An arterial blood gas (ABG) test was performed, revealing a pH of 7.3, PaCO2 of 35 mmHg, and HCO3 of 18 mEq/L, suggestive of metabolic acidosis possibly secondary to renal insufficiency or uncontrolled diabetes. His blood glucose level spiked to 600 mg/dL. The urinalysis showed high levels of glucose and ketones, which aligns with the diagnosis of HHS. Moreover, a repeat serum creatinine level showed a further increase to 3.5 mg/dL, highlighting the worsening kidney function. His B-type natriuretic peptide (BNP) level was also elevated at 900 pg/mL (normal range is less than 100 pg/mL), suggesting possible worsening of his heart failure.

These new findings necessitate a thorough reevaluation of the patient's management plan. His healthcare team must now consider the initiation of intravenous insulin therapy and aggressive fluid resuscitation to address his HHS. The consultation with the nephrologist and cardiologist becomes more urgent to manage his deteriorating kidney function and congestive heart failure, respectively. The patient's condition demonstrates the complex interplay of diabetes, heart disease, and kidney disease, requiring a comprehensive, multi-disciplinary approach.

Section 5

Response to Interventions:

Despite the initiation of intravenous insulin therapy and aggressive fluid resuscitation, the patient's blood glucose level remained above 500 mg/dL. The patient's confusion continued, and lethargy deepened. His heart rate had increased to 130 bpm, respiratory rate to 26 breaths per minute, and temperature rose to 101.2°F, suggesting a persistent systemic inflammation or infection. The healthcare team initiated a broad-spectrum antibiotic coverage, suspecting a possible septicemia.

New Complications:

The patient's worsening condition was further complicated when he suddenly became short of breath. His oxygen saturation dropped to 88%, and a chest X-ray revealed new infiltrates in the left lower lobe suggestive of pneumonia. A sputum culture was ordered to identify the causative pathogen. The worsening kidney function, indicated by a further increase in serum creatinine to 4.0 mg/dL, necessitated the initiation of renal replacement therapy. The patient's case is further complicated by the development of pneumonia, which is likely secondary to aspiration due to his altered level of consciousness. His increasing BNP level, now at 1100 pg/mL, suggests the progression of heart failure, requiring an urgent cardiology consult and adjustment in heart failure medications.

These new complications illustrate the intricate relationship between diabetes, heart disease, and kidney disease, and the potential for rapid deterioration in a patient with these co-morbidities. The healthcare team needs to address these issues promptly and efficiently while continuously monitoring the patient's response to the interventions.