Diabetes - Nursing Case Study
Pathophysiology
• Primary mechanism: Insulin production or usage disruption. In Type 1 diabetes, the immune system mistakenly destroys insulin-producing cells in the pancreas, leading to little/no insulin production. In Type 2 diabetes, cells become resistant to insulin, and the pancreas cannot produce enough insulin to overcome this resistance.
• Secondary mechanism: Hyperglycemia results from disrupted insulin action. Without insulin or with insulin resistance, glucose can't enter cells for energy and builds up in the bloodstream, leading to high blood sugar levels.
• Key complication: Chronic hyperglycemia can lead to macrovascular and microvascular complications. Macrovascular complications include heart disease and stroke. Microvascular complications include kidney disease (nephropathy), eye damage (retinopathy), and nerve damage (neuropathy).
Patient Profile
Demographics:
67-year-old male, retired engineer
History:
• Key past medical history: Diagnosed with type 2 diabetes 10 years ago, hypertension for the past 15 years, and had a mild stroke 3 years ago
• Current medications: Metformin, Lisinopril, Aspirin
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Persistent fatigue, increased thirst and frequent urination
• Key symptoms: Foot pain, unexplained weight loss, blurred vision, and slow-healing sores
• Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, body temperature 98.2°F, blood glucose 200 mg/dL
Section 1
Change in Patient Status:
Three weeks into the patient's management plan, he reported a decrease in his thirst and urination frequency. However, he noted an increase in numbness and tingling sensation in his feet, coupled with a persistent foot pain. Upon evaluation, it was found that his blood pressure remained elevated at 150/95 mmHg and his blood glucose levels had decreased slightly to 180 mg/dl, still higher than the target range. His heart rate was stable at 88 bpm while his respiratory rate increased to 20 breaths per minute.
New Complications:
The patient's numbness and persistent pain in his feet, in conjunction with his elevated blood pressure and blood glucose levels, suggested the potential onset of diabetic peripheral neuropathy. This is a common complication of diabetes where high blood sugar levels damage the nerves, particularly in the legs and feet, leading to pain and numbness. Left untreated, this can lead to serious foot problems like ulcers, infections, and even amputations due to the loss of sensation. The persistence of the patient's hypertension, despite being on Lisinopril, raised concerns over potential renal impairment, a complication of both diabetes and uncontrolled hypertension. Therefore, the need for additional diagnostic tests to ascertain the situation was communicated to the patient.
Section 2
New Diagnostic Results:
The patient underwent an electromyography (EMG) test, which measures the electrical activity of muscles, to assess the severity of the peripheral neuropathy. Results showed that there was indeed nerve damage in the legs and feet, indicating moderate to severe diabetic peripheral neuropathy. The patient was also given a comprehensive metabolic panel (CMP) to evaluate his kidney function. The CMP results showed an elevated creatinine level of 1.5 mg/dL (normal range is 0.8 to 1.2 mg/dL) and a decreased glomerular filtration rate (GFR) of less than 60 mL/min, suggesting renal impairment. Additionally, urine tests revealed the presence of an abnormally high amount of protein (proteinuria), further confirming the suspicion of diabetic nephropathy.
Change in Patient Status:
Despite the patient's initial improvements in thirst and urination frequency, the new diagnostic results revealed that his diabetes was indeed causing significant complications. The patient reported an increase in the severity of foot pain, and also began to experience difficulty in walking due to the numbness. This was consistent with the EMG results that indicated nerve damage in the lower extremities. Additionally, the elevated creatinine levels and decreased GFR suggested that his kidneys were not filtering blood as effectively as they should, potentially leading to build-up of waste in his body. The patient also reported feeling more fatigued than usual, which could be a sign of worsening kidney function. This change in status necessitated a revisit of his management plan, with a need for more aggressive treatment strategies to control his blood sugar levels and blood pressure, and to manage the neuropathy and nephropathy.
Section 3
New Complications:
The patient's condition began to decline further with the development of new complications. He reported experiencing blurred vision and occasional floaters, common symptoms of diabetic retinopathy. An ophthalmologic examination confirmed microaneurysms and hemorrhages in the retina, characteristic signs of non-proliferative diabetic retinopathy.
Moreover, the patient started complaining of persistent nausea and vomiting, along with a decreased appetite. On physical examination, his abdomen was noted to be distended with hypoactive bowel sounds. These signs and symptoms were suggestive of gastroparesis, a complication of diabetes where damage to the vagus nerve slows or stops the movement of food through the digestive tract.
These new complications indicated a further progression of the patient's diabetes and underscored the need for immediate intervention to prevent further deterioration of his health. It was evident that more aggressive strategies were required, not only for the management of his blood sugar levels and blood pressure, but also to address these new complications. The patient's management plan was revised to include a comprehensive eye care regimen and gastric motility agents for the gastroparesis.
Section 4
New Diagnostic Results:
Despite the adjustment in management, the patient's symptoms didn't show significant improvement. Further investigations were carried out to assess the extent of the complications. An electroretinogram (ERG) showed a delayed response, reflecting the severity of the retinopathy. His HbA1c level was 9.5%, indicating poor control over his diabetes and explaining the development of the complications.
Furthermore, a gastric emptying study was done which showed a delayed emptying time of over 4 hours, confirming the diagnosis of gastroparesis. His blood pressure was consistently high, with readings often above 150/90 mmHg, despite antihypertensive treatment. This raised concerns about potential nephropathy, another common complication of diabetes. A urine sample was sent for microalbuminuria which returned positive, confirming the suspicion of nephropathy. These new findings necessitated a reevaluation of the patient's management plan, focusing on a more aggressive approach towards his diabetes and hypertension, along with the management of his complications.
Section 5
Change in Patient Status:
The patient's condition began to deteriorate over the following week. He complained of increasing fatigue and reduced appetite, and his blood glucose levels remained consistently high, often exceeding 200 mg/dL. The patient also reported experiencing episodes of dizziness and was found to have orthostatic hypotension with blood pressure readings dropping to 90/50 mmHg upon standing. His creatinine level also increased, indicating worsening kidney function, while his hemoglobin dropped to 10.5 g/dL, suggesting anemia, possibly due to kidney disease.
The patient also developed diabetic neuropathy, as evidenced by numbness and tingling in his feet. He also reported episodes of hypoglycemia, with glucose levels dropping below 70 mg/dL. This was concerning as it suggested that his body was no longer able to properly regulate his blood glucose levels. A foot examination revealed a non-healing ulcer on his left foot, raising concerns about peripheral arterial disease and increased risk of infection. These changes in the patient's status highlight the need for a comprehensive and multidisciplinary approach to manage his worsening condition.