diabet - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin dysfunction - In Type 1 diabetes, the immune system destroys the beta cells in the pancreas that produce insulin. In Type 2 diabetes, the body either resists the effects of insulin or doesn't produce enough insulin to maintain a normal glucose level. Both scenarios lead to high blood glucose levels.

• Secondary mechanism: Glucose utilization - Without sufficient insulin, the body cannot effectively move glucose from the blood into cells, where it's needed for energy. The result is a buildup of glucose in the blood (hyperglycemia), which can cause a variety of health problems if not managed properly.

• Key complication: Long-term damage - High blood glucose over time can cause damage to various organs, particularly the eyes, kidneys, nerves, heart, and blood vessels. This can lead to complications like retinopathy, nephropathy, neuropathy, and cardiovascular disease.

Patient Profile

Demographics:

55-year-old male, office worker

History:

• Diagnosed with type 2 diabetes 10 years ago

• Currently on Metformin and Glipizide

• No known drug allergies

Current Presentation:

• Chief complaint of increased frequency of urination and unquenchable thirst

• Also experiencing blurred vision, persistent fatigue, and unexplained weight loss

• Vital signs: Blood pressure 150/95 mmHg, pulse 90 bpm, respiration rate 20 breaths per minute, body temperature 98.6 degrees Fahrenheit, blood glucose levels 200 mg/dL

Section 1

New Diagnostic Results:

During the patient's next visit, he complained of tingling sensations in his feet and difficulty in maintaining balance, suggesting a possible development of diabetic neuropathy. The physician ordered a complete blood count, urinalysis, and an HbA1C test. The blood count and urinalysis results were within normal parameters; however, the HbA1C results showed a level of 9.0%, indicating poor blood glucose control over the past three months.

Furthermore, a comprehensive foot examination was conducted, revealing decreased sensation to monofilament testing and diminished ankle reflexes. The physician also ordered a renal function test due to the patient's longstanding diabetes and the potential risk of nephropathy. The results showed a slightly elevated serum creatinine level of 1.3 mg/dL and a microalbuminuria of 45 mg/day, suggesting early stages of diabetic kidney disease.

These findings have significant implications for the patient's management, requiring a revision of his current treatment regimen to prevent further progression of diabetic complications. The patient's failure to achieve glycemic control with the current medication regime suggests a possible need for insulin therapy. The development of neuropathy and early signs of nephropathy highlight the importance of regular follow-up and monitoring of his condition.

Section 2

Change in Patient Status:

Over the next few weeks, the patient's condition continued to deteriorate. He reported increased numbness and tingling in his feet, which was now extending up into his calves. The patient also described a sensation of "walking on cotton," and there were several instances of him tripping over his own feet. His gait was noticeably unsteady, and he had to use a cane for support. These symptoms reflect a worsening of his diabetic neuropathy, with possible development of sensory ataxia due to loss of proprioception.

In addition, the patient's latest laboratory results showed further deterioration in renal function, with a serum creatinine level rising to 1.6 mg/dL and his microalbuminuria increasing to 80 mg/day. Meanwhile, his HbA1C level remained elevated at 9.2%, indicating continued poor glucose control despite adjustments to his medication regimen. Blood pressure was consistently high, averaging 150/90 mmHg, further exacerbating the risk of nephropathy progression. Despite the patient's adherence to the prescribed treatment, these findings suggest that his diabetes is becoming increasingly difficult to manage, warranting a more aggressive therapeutic approach.

Section 3

New Complications:

During a routine follow-up, the patient reported experiencing episodes of dizziness, particularly when he stood up from a sitting or lying position. He also mentioned a few instances when he nearly fainted. A physical examination revealed postural hypotension, with blood pressure readings of 110/70 mmHg when lying down and 90/60 mmHg after standing. These symptoms, along with his previous unsteady gait, suggest the occurrence of autonomic neuropathy, another complication of his progressing diabetes.

Further, the patient also complained of occasional heartburn and feelings of fullness after eating a small amount of food. He admitted to episodes of nausea and vomiting, which have led to a decreased appetite and unintentional weight loss. These symptoms indicate possible gastroparesis, a condition associated with autonomic neuropathy in which the stomach takes too long to empty its contents. The presence of these new complications indicates that the patient's diabetes is advancing and affecting his autonomic nervous system, further complicating his clinical picture and treatment plan.

Section 4

New Diagnostic Results:

To further evaluate the patient's condition, a series of diagnostic tests were ordered. A gastric emptying study confirmed the suspicion of gastroparesis, revealing delayed gastric emptying with 70% of the meal remaining in the stomach 4 hours after ingestion. Laboratory tests also showed an elevated HbA1c level at 8.5%, reflecting poor glycemic control over the past three months.

Moreover, an electrocardiogram was performed, revealing a resting heart rate of 50 beats per minute, suggestive of possible cardiac autonomic neuropathy. A tilt table test further confirmed the presence of autonomic neuropathy as the patient's heart rate did not increase appropriately upon standing, and his blood pressure dropped significantly, leading to a near syncopal episode.

These results provide a clearer picture of the patient's current state and the progression of his diabetes. The gastroparesis and cardiac autonomic neuropathy will require further management and adjustments in the patient's treatment plan. The elevated HbA1c also indicates a need for improved glycemic control, which will be crucial in preventing further diabetic complications. These findings create the opportunity for further clinical reasoning and careful planning of the next steps in the patient's care.

Section 5

Change in Patient Status:

In the days following the diagnostic tests, the patient's condition began to deteriorate. His food intake decreased significantly due to nausea and early satiety, symptoms of worsening gastroparesis. Despite his reduced food intake, his blood glucose levels remained erratically high, with readings ranging between 200 and 300 mg/dL. Additionally, he began to experience episodes of dizziness and lightheadedness, particularly upon standing, suggestive of orthostatic hypotension due to the cardiac autonomic neuropathy.

The patient's resting heart rate also dropped further to 45 beats per minute, causing him to feel fatigued and weak. His blood pressure readings showed significant variability, with systolic readings ranging from 100 to 130 mmHg and diastolic readings from 60 to 80 mmHg. These fluctuating vital signs, coupled with his worsening gastroparesis and high blood glucose levels, indicate a complicated and deteriorating state that necessitates a swift and comprehensive reassessment of the patient's management plan. These changes in the patient's status demand critical clinical reasoning to manage and improve the patient's overall condition and quality of life.