Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insufficient insulin production or resistance to insulin's effects. In type 1 diabetes, the immune system destroys insulin-producing beta cells in the pancreas, leading to insulin deficiency. In type 2 diabetes, body tissues become resistant to insulin, and pancreatic beta cells can't keep up with the increased demand.

• Secondary mechanism: High blood glucose levels. Lack of insulin or insulin resistance prevents glucose from entering cells for energy, causing it to accumulate in the blood. This hyperglycemia can damage blood vessels and organs over time.

• Key complication: Diabetic ketoacidosis (DKA). In the absence of adequate insulin, the body breaks down fat as an alternative energy source, producing ketones. High levels of ketones can lead to DKA, a serious condition characterized by hyperglycemia, metabolic acidosis, and dehydration.

Patient Profile

Demographics:

62-year-old male, retired school teacher

History:

• Key past medical history: Diagnosed with Type 2 Diabetes 10 years ago, Hypertension for the past 7 years

• Current medications: Metformin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Excessive thirst and urination, unexplained weight loss

• Key symptoms: Blurred vision, frequent urination, tingling in hands and feet, slow healing of wounds

• Vital signs: Blood pressure 140/90 mmHg, Pulse 80 bpm, Temperature 98.6°F, Respiration 18 breaths/minute, Blood sugar level 200 mg/dl

Section 1

New Diagnostic Results:

Further lab results reveal that the patient's hemoglobin A1c (HbA1c) is 9.0%, significantly above the recommended target of below 7.0% for individuals with diabetes. His fasting lipid profile is also abnormal with total cholesterol at 220 mg/dl, LDL cholesterol 130 mg/dl, HDL cholesterol 35 mg/dl and triglycerides 250 mg/dl, indicating dyslipidemia. Urine microalbumin-to-creatinine ratio is also elevated at 350 mg/g, indicating potential early kidney damage.

The patient's elevated HbA1c suggests that his blood glucose levels have been poorly controlled over the past 2-3 months. The abnormal lipid profile is a common complication in uncontrolled diabetes, increasing the risk for atherosclerosis and cardiovascular disease. The elevated urine microalbumin-to-creatinine ratio could be a sign of diabetic nephropathy, a condition that may eventually lead to kidney failure if not managed. These diagnostic results raise immediate concerns about the patient's current diabetes management and the need for more aggressive treatment and lifestyle modifications to prevent further complications.

Section 2

Change in Patient Status:

Over the next several days, the patient begins to exhibit signs of worsening condition. He complains of persistent fatigue, increased thirst, and frequent urination. His blood pressure readings have been consistently high, with an average systolic pressure of 150 mmHg and diastolic pressure of 90 mmHg. His blood glucose levels remain elevated despite adherence to his current insulin regimen, with fasting glucose levels consistently between 150-180 mg/dl.

These symptoms and clinical data suggest worsening hyperglycemia, which is causing polyuria, polydipsia, and fatigue. The consistently high blood pressure readings indicate uncontrolled hypertension, a common co-morbidity in diabetic patients and a major risk factor for both cardiovascular disease and kidney damage. Given the patient's elevated HbA1c, abnormal lipid profile, and increased urine microalbumin to creatinine ratio, these changes in status suggest that his diabetes and associated conditions are not well managed, raising concerns about the potential for escalating complications. The healthcare team needs to reassess the efficacy of his current treatment plan and consider more aggressive interventions.

Section 3

Upon reassessment, the healthcare team noted a significant decrease in the patient's weight, a loss of 8 pounds in a week. He also reported an increased frequency of nocturia, and his fatigue persisted despite adequate rest periods. His blood glucose levels continue to rise, with a most recent reading of 210 mg/dl. Furthermore, his blood pressure remained elevated with a reading of 155/95 mmHg. His peripheral pulses were palpable but weak, and his feet appeared pale with delayed capillary refill.

Following these findings, the healthcare team ordered a new set of diagnostic tests. The results revealed a further increase in his HbA1c level of 9.0%, and his lipid profile was abnormal with elevated LDL cholesterol of 160 mg/dl and reduced HDL cholesterol of 35 mg/dl. His urine protein-to-creatinine ratio was also elevated at 0.3, suggesting early nephropathy. His eGFR was lower than expected at 45 ml/min/1.73 m², which is indicative of moderate kidney damage.

These new findings and diagnostic results indicate a worsening of the patient's diabetes and the emergence of diabetic nephropathy. The healthcare team must reassess and modify his current treatment plan to manage the hyperglycemia, hypertension, and early signs of kidney damage. It is crucial to address not only the diabetes but also the associated co-morbidities to prevent further deterioration of the patient's health status.

Section 4

In response to the worsening condition, the healthcare team initiated a comprehensive intervention plan. This included an adjustment to his medication regimen, the introduction of a renal-protective angiotensin-converting enzyme (ACE) inhibitor for his hypertension, and a diuretic to help manage his fluid balance. The patient was also placed on a strict dietary plan to aid in the control of his blood sugar levels and cholesterol. Furthermore, a referral was made to a diabetic educator and a nutritionist for further counseling and management.

Although the patient responded positively to the interventions initially, his condition started to decline two weeks later. Despite adherence to his new medication regimen and dietary plan, his blood glucose levels remained high, with a persistent reading above 200 mg/dl. His blood pressure also remained elevated at 150/92 mmHg. The patient reported a persistent feeling of fatigue and increased episodes of nocturia. His weight continued to drop with an additional loss of 4 pounds within two weeks. Moreover, a follow-up urine protein-to-creatinine ratio further increased to 0.5, indicating progressive kidney damage.

This change in patient status indicates an uncontrolled diabetes and hypertension despite the interventions. The healthcare team must consider other potential factors contributing to this lack of response, such as medication resistance, the possibility of other underlying conditions, or non-adherence to dietary restrictions. This warrants a further comprehensive patient assessment, including a review of his medication regimen, dietary habits, and lifestyle. Further diagnostic tests may also be required to rule out the presence of any other complications.

Section 5

Upon further assessment, the healthcare team discovered that the patient had developed peripheral neuropathy, a common complication in people with prolonged diabetes. The patient reported a persistent numbness and tingling sensation in his feet, and a loss of sensation to touch and temperature. Upon examination, he also exhibited reduced ankle reflexes and decreased vibration sensation. Physical examination also revealed dry, cracked skin and a non-healing ulcer on his right foot. This indicated the development of diabetic foot, a common complication of peripheral neuropathy in diabetics.

In response to these findings, the healthcare team decided to conduct further diagnostic tests. The patient's HbA1c was significantly elevated at 9.6%, indicating poor blood glucose control over the past 2-3 months. His serum creatinine increased to 2.5 mg/dL from 1.5 mg/dL, and his estimated glomerular filtration rate (eGFR) dropped to 30 mL/min/1.73 m^2, further suggesting the progression of diabetic nephropathy. A duplex ultrasound showed significantly reduced blood flow in the lower extremities, suggesting peripheral arterial disease (PAD), a common complication in diabetics and hypertensive patients.

These findings call for an immediate revision of the patient's management plan. The healthcare team must now incorporate strategies to manage peripheral neuropathy and PAD, prevent the progression of the foot ulcer, and adjust the treatment plan to better control his diabetes and hypertension. Further consultations with a podiatrist and vascular specialist may also be necessary. These new complications underline the importance of comprehensive patient assessment and the need for ongoing monitoring and adjustment of care plans in managing complex chronic conditions like diabetes.