Diabetes type 1 - Nursing Case Study

Pathophysiology

• Primary mechanism: Autoimmune destruction - The body's immune system mistakenly attacks and destroys insulin-producing beta cells in the islets of Langerhans in the pancreas. This leaves the body with little to no insulin, a hormone crucial for converting glucose into energy.

• Secondary mechanism: Insulin deficiency - Without sufficient insulin, glucose cannot enter cells effectively, leading to high blood sugar levels (hyperglycemia). The glucose instead builds up in the bloodstream, causing various symptoms and complications.

• Key complication: Ketoacidosis - Prolonged hyperglycemia can lead to diabetic ketoacidosis (DKA), a serious metabolic disorder where the body starts to break down fat for energy, leading to a build-up of ketones in the bloodstream, causing symptoms like nausea, vomiting, and abdominal pain.

Patient Profile

Demographics:

45-year-old male, office worker

History:

• Diagnosed with Type 1 Diabetes at age 15

• Currently on insulin therapy, Metformin, and Lisinopril

• Allergic to Penicillin

Current Presentation:

• Chief complaint: Increased frequency of urination, unexplained weight loss, and constant fatigue

• Key symptoms: Blurred vision, tingling in hands and feet, slow-healing sores, and recurring gum infections

• Vital signs: Blood pressure 140/90 mm Hg, heart rate 90 bpm, respiratory rate 18 breaths per minute, body temperature 98.4°F, blood sugar 250 mg/dL

Section 1

Change in Patient Status:

A few weeks later, the patient returned to the clinic with complaints of increasing fatigue, shortness of breath, and swelling in his legs. He also mentioned that he has been feeling dizzy and occasionally experiencing palpitations. On examination, his blood pressure was 150/95 mm Hg, heart rate was 102 bpm, and blood sugar was 280 mg/dL. He also had pitting edema in both lower extremities. His breath sounds were slightly diminished at the lung bases, and his heart sounds were distant with an added third heart sound (S3 gallop).

These new symptoms coupled with the physical examination findings are suggestive of heart failure, a common complication in long-standing diabetes. The patient's prolonged hyperglycemia likely has resulted in damage to the heart muscle, reducing its ability to pump blood efficiently. The S3 gallop is often an early sign of heart failure, and the edema suggests fluid overload. This shift in his health status indicates the need for further diagnostic testing, including a complete blood count, renal function tests, and an echocardiogram to evaluate his cardiac function. Prompt intervention is necessary to manage his heart failure and to optimize his blood sugar levels, which will involve adjusting his medications and possibly introducing new ones.

Section 2

New Diagnostic Results:

The patient underwent the recommended diagnostic tests. His complete blood count (CBC) results showed hemoglobin of 10.2 g/dL (normal range: 13.5-17.5 g/dL) and hematocrit of 31.8% (normal range: 38.3-48.6%), suggesting anemia, which could be contributing to his fatigue and shortness of breath. The renal function tests revealed elevated creatinine levels at 1.8 mg/dL (normal range: 0.84-1.21 mg/dL) and a decreased glomerular filtration rate (GFR) of 45 mL/min (normal range: >60 mL/min), suggesting impaired kidney function. This may be due to diabetic nephropathy, another common complication in long-standing diabetes. The echocardiogram showed an ejection fraction of 45% (normal range: 55-70%), confirming the suspicion of heart failure.

These new findings are indicative of multiple system complications likely due to uncontrolled diabetes. The presence of anemia, renal impairment, and heart failure present a complex clinical picture that requires careful management. The patient's treatment plan will need to be adjusted to address these issues while still managing his diabetes. The care team will need to consider the interplay between these conditions and the potential impact of treatment decisions on each of these areas. This may involve the introduction of new medications, such as diuretics for fluid overload, angiotensin-converting enzyme (ACE) inhibitors for both heart failure and diabetic nephropathy, and erythropoiesis-stimulating agents for anemia.

Section 3

Change in Patient Status:

Over the next several days, the patient's status began to change. His fatigue and shortness of breath worsened, signaling a possible exacerbation of his heart failure. His blood pressure readings fluctuated, ranging from 140/90 mmHg to 160/100 mmHg, despite the addition of ACE inhibitors to his treatment regimen. His blood glucose levels also remained inconsistent, with fasting readings varying between 180 mg/dL and 220 mg/dL. His urine output declined, averaging around 500 mL/day, which is a significant decrease from the normal range of 800-2000 mL/day. This could be a result of the diminished kidney function indicated by his elevated creatinine levels and decreased GFR.

Simultaneously, the patient's hemoglobin levels fell further to 9.8 g/dL, exacerbating his anemia. This may be contributing to his worsening fatigue and could signal a lack of response to the erythropoiesis-stimulating agents. The healthcare team must now reevaluate the treatment approach, considering the possibility of more aggressive interventions or the addition of new medications to better manage these interconnected complications. The team must also keep in mind the potential for further complications, such as hyperkalemia, which can result from both diabetes and the use of ACE inhibitors, especially in the setting of declining renal function.

Section 4

New Diagnostic Results:

The healthcare team decided to perform further diagnostic tests to better understand the patient's deteriorating condition and tailor a more effective treatment plan. The results indicated a rise in his potassium levels to 5.8 mmol/L, confirming the suspicion of hyperkalemia. This new complication could be a result of the worsening kidney function, the use of ACE inhibitors, or the uncontrolled diabetes. Additionally, arterial blood gas (ABG) analysis revealed a pH of 7.32, PaCO2 of 45 mmHg, and bicarbonate levels of 22 mEq/L, suggesting a metabolic acidosis, possibly a complication of diabetic ketoacidosis (DKA).

Moreover, the patient's HbA1c level was found to be 9.2%, which is higher than the desired target of less than 7% for people with diabetes. This further confirmed that the patient's blood glucose levels were not well-controlled, warranting a reevaluation of his current insulin regimen. The healthcare team also noted a reduced ejection fraction of 40%, indicating a worsening of the patient's heart failure. With these new diagnostic results, the healthcare team must now determine how best to manage these overlapping complications while also considering the patient's overall health status and potential risks. This will require a careful balance of medication adjustments, potential introduction of new therapies, and close monitoring of the patient's response to these interventions.

Section 5

New Complications:

After several days of treatment adjustments and close monitoring, the patient's condition started to show further complications. He began experiencing extreme fatigue, excessive thirst, and frequent urination, classic symptoms of worsening diabetes, despite the adjustment in his insulin regimen. His blood glucose levels remained consistently high, averaging around 280 mg/dL. The healthcare team also noted a significant increase in his creatinine levels to 3.6 mg/dL, from a previous value of 1.5 mg/dL, and a decrease in his glomerular filtration rate to 30 mL/min/1.73m2, which indicated a rapid decline in his renal function.

The patient also began to show signs of peripheral neuropathy. He reported tingling and numbness in his lower extremities. On examination, the patient had diminished sensation to light touch and temperature in a stocking-glove distribution, further confirming the diagnosis. His ankle reflexes were absent bilaterally, and he had a positive monofilament test. The new findings indicated that the patient's uncontrolled diabetes was causing nerve damage, adding to the complexity of his case. These new complications will necessitate further changes in his treatment plan and monitoring, with a focus on preventing further deterioration and managing symptoms. The healthcare team must also consider the psychological impact of these developments on the patient, requiring a holistic approach to care.