Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance or deficiency - Type 1 Diabetes is characterized by the inability of the pancreas to produce insulin due to autoimmune destruction of beta cells. Type 2 Diabetes is due to the body's inability to use insulin effectively, known as insulin resistance, often paired with a relative insulin deficiency.

• Secondary mechanism: Glucose regulation disruption - Without adequate insulin, glucose cannot enter cells for energy. Instead, it builds up in the bloodstream, leading to high blood sugar (hyperglycemia). This constant hyperglycemia damages various body systems over time.

• Key complication: Micro and macrovascular complications - Persistently high blood sugar levels can damage both small (microvascular: kidneys, eyes, and nerves) and large (macrovascular: heart and blood vessels) blood vessels, leading to complications such as nephropathy, retinopathy, neuropathy, cardiovascular disease, and stroke.

Patient Profile

Demographics:

56-year-old male, office-based job

History:

• Diagnosed with Type 2 Diabetes 8 years ago

• Current medications: Metformin, Lisinopril for high blood pressure, Atorvastatin for cholesterol

• Allergies: None

Current Presentation:

• Chief complaint: Persistent high blood sugar levels despite medication, frequent urination, increasing fatigue, and recent unexplained weight loss

• Key symptoms: Blurred vision, signs of poor wound healing, frequent urination, constant thirst, fatigue, unexplained weight loss

• Vital signs: Blood pressure 140/90 mmHg, pulse 80 bpm, respiratory rate 18 breaths per minute, temperature 98.6 degrees Fahrenheit, blood glucose 200 mg/dL.

Section 1

New Diagnostic Results:

Following an initial assessment, laboratory tests were ordered to further investigate the patient's symptoms and poor glycemic control. The results revealed persistent hyperglycemia with a Hemoglobin A1C (HbA1C) of 9.0%, indicating poor diabetes control over the past three months. The patient’s fasting blood glucose levels were 220 mg/dL, well above the desired range of 70-130 mg/dL. Additionally, the patient’s urine test showed the presence of microalbuminuria – an early sign of diabetic kidney disease (nephropathy). The estimated glomerular filtration rate (eGFR) was 55 mL/min/1.73 m², indicating a moderate decrease in kidney function.

Initial Assessment Findings:

During a comprehensive foot examination, the patient mentioned he had been experiencing tingling sensations and numbness in his feet, suggesting possible diabetic peripheral neuropathy. A small, unhealed wound was also found on the patient's left foot, which he reported he had not noticed due to lack of sensation. His BMI was calculated to be 29, which is in the overweight range and could contribute to his insulin resistance. The patient's lipid profile showed increased low-density lipoprotein (LDL) levels at 160 mg/dL and decreased high-density lipoprotein (HDL) levels at 35 mg/dL, heightening his risk for cardiovascular disease.

These findings provide valuable insight into the patient's condition and require immediate attention to prevent further deterioration. The patient's diabetes management plan needs to be reevaluated and intensive lifestyle modifications should be strongly considered.

Section 2

Change in Patient Status:

Over the following week, the patient's condition showed signs of deterioration. His fasting blood glucose levels remained elevated, averaging around 230 mg/dL, despite adjustments to his insulin regimen. Furthermore, the patient began to experience visual disturbances and complained of blurriness, suggesting the onset of diabetic retinopathy. His blood pressure readings were consistently high, with readings often measuring around 155/90 mmHg, further increasing his risk of cardiovascular complications.

Additionally, the wound on his left foot had not shown significant signs of healing, and the patient reported increased numbness in both feet. The patient also mentioned feeling more fatigued than usual, which could be linked to his elevated blood glucose levels and decreasing kidney function. These worsening symptoms coupled with the patient's poor diabetes control necessitate a critical reassessment of his current management plan and potential incorporation of new interventions. The team needs to intensify efforts to reduce his blood glucose, blood pressure, and LDL levels, while closely monitoring his renal function and foot wound.

Section 3

New Diagnostic Results:

To further evaluate the patient's condition, a series of diagnostic tests were ordered. A retinal examination was performed, which confirmed early signs of diabetic retinopathy with microaneurysms noted in the retinal blood vessels. An HbA1c test showed a value of 9.2%, indicating poor glycemic control over the past few months. The patient's lipid profile was also concerning, with LDL cholesterol level at 160 mg/dL, total cholesterol at 240 mg/dL, and HDL at 35 mg/dL.

A 24-hour urine collection for microalbuminuria revealed 45 mg of albumin, suggesting early nephropathy. The patient's serum creatinine level was 1.8 mg/dL, further supporting the suspicion of deteriorating renal function. In addition, a foot examination revealed decreased sensation to monofilament testing, indicative of peripheral neuropathy. The findings from these diagnostic tests suggest that the patient's diabetes is not well-controlled and that he is developing complications in multiple organ systems. This necessitates a rigorous therapeutic intervention and potentially a multidisciplinary approach to manage his condition.

Section 4

New Complications:

Just a week later, the patient presented with new complaints of persistent nausea, vomiting, and abdominal pain. He also reported that his vision has been increasingly blurry over the past few days. On examination, the patient appeared dehydrated, with dry mucous membranes and poor skin turgor. His blood pressure was 90/60 mmHg, pulse 110 beats per minute, respiratory rate 22 breaths per minute, and temperature 36.6°C. Blood glucose levels were elevated at 350 mg/dL.

Urine ketones were found to be positive, raising concerns for diabetic ketoacidosis (DKA). Blood gas analysis revealed a metabolic acidosis with a pH of 7.25 and bicarbonate level of 18 mEq/L. A repeat HbA1c was performed, which remained high at 9.4%. These findings suggest that despite previous interventions, the patient's diabetes control has further deteriorated, precipitating a potentially life-threatening complication of DKA. This situation warrants immediate medical intervention and critical care monitoring, along with a reassessment of the patient's diabetes management plan. The persistent blurry vision also indicates that the retinopathy may be progressing faster than anticipated, which will require further ophthalmologic evaluation.

Section 5

Change in Patient Status:

Over the next 48 hours, the patient’s condition seemed to worsen. He developed Kussmaul breathing, a deep and labored breathing pattern often associated with severe metabolic acidosis and DKA, and his level of consciousness began to fluctuate. The patient’s blood pressure dropped further to 80/50 mmHg, pulse increased to 120 beats per minute, and respiratory rate rose to 28 breaths per minute. His blood glucose levels remained persistently high at 360 mg/dL, despite aggressive insulin therapy, and his serum bicarbonate levels dropped to 15 mEq/L, indicating worsening acidosis.

This change in patient status may suggest a severe form of DKA known as hyperglycemic hyperosmolar state (HHS), which is characterized by extremely high blood glucose levels and severe dehydration. This condition can lead to coma or even death if not treated promptly and aggressively. The patient’s fluctuating level of consciousness, worsening metabolic acidosis, and unresponsive hyperglycemia provide strong evidence for this diagnosis. The healthcare team needs to reassess the patient's management plan and consider the possibility of HHS. The team also needs to be on high alert for other potential complications such as electrolyte imbalances, renal failure, and infection, as these can significantly worsen prognosis.