NR 508 Week 5 Case Study Discussion
NR 508 Week 5
NR 508
NR 508 Week 5 Case Study Discussion.
Maria is a 46-year-old woman who presents for her
... [Show More] yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Six months ago, her fasting lipid profile was normal. Maria report that her mother and brother have diabetes and hypertension. She reports that she knows she should be on a low calorie, low fat diet and exercising but with her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. …. is 66″ tall and weighs 219lbs today, no current medication….. does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only drinks sweet tea with each meal, 3-4 cups of coffee per day.
Today: BP 155/95mm Hg, TC 234 mg/dL, LDL 137 mg/dL, HDL 35 mg/dL, triglycerides 241mg/dL, fasting plasma glucose is 179 mg/dL; HgbA1C is 7.4mg/dL. Physical Exam reveals notable for acanthosis nigricans at the neck but otherwise is normal.
What are your treatment goals for Maria?
What…is your plan for drug therapy? What is the mechanism of action for each drug?
Please give five teaching points for each drug prescribed.
How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.
Variant 2: Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for mild depression and moderate obesity. Six months ago her fasting lipid profile was normal. Maria report that her mother and brother have diabetes and hypertension. She reports that she knows she should be on a low calorie, low fat diet and exercising but with her full-time job and four children, she finds it difficult to exercise, and she eats out most of the time…. 67″ tall and weighs 225lbs today, no current medication. … does report taking a multivitamin daily but still feels tired, biotin Vit-C when she remembers. She is a nonsmoker, only drinks sweet tea with each meal, 3-4 cups of coffee per day.
Today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, weight 225 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%, TSH 5.6. The physical exam is notable for acanthosis nigricans at the neck but otherwise is normal.
What are your treatment goals for Maria?
What is your plan for drug therapy? … the mechanism of action for each drug?
Please give five teaching points for each drug prescribed.
How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.
What are your treatment goals for Maria?
Maria had cholesterol screening six months prior to this appointment so as a base line we can say that she does have some issues with those numbers. Her total cholesterol was 234. Ideal total cholesterol would be <200. Her triglycerides were 241 most likely because her total cholesterol is high, her LDL is high and her HLD is low. The possibility of pre-diabetes can play a role in these numbers also. The good cholesterol HDL is 35; ideally a healthy number would be greater than 50, (American Heart Association, 2018). She is also slightly hypertensive. All of these negative factors may improve with a diet change and exercise regimen. As a primary care provider I would consider my first line a treatment for Maria and recheck all her levels in six months. The elevated HbA1C needs to be greater than 5.7 on two blood tests consecutively in order for it to be considered diabetes of any type, (NIDDK).
What is your plan for drug therapy? What is the mechanism of action for each drug?
At this initial office visit, I would not start her on any medications with the hope that he can lose some weight and make healthy food choices over the next six months. Losing weight will not only help her cholesterol but it will decrease her blood pressure and continue to delay the possibility of type 2 diabetes. It is not to say that she is predisposed to HTN and type 2 diabetes. Due to her family history but she can try to do things now to prevent these things from happening in the near future.
Please give five teaching points for each drug prescribed.
Since I am not going to prescribe medications this time I will tell you what I do recommend. She is a busy mom with four kids and works full time. No one can understand that more than I. My suggestion to her would be to start off slow and just walk every day. Each day walk a little longer and a little faster. Try to get the kids to walk with you or follow them on their bike. The next thing I recommend is to stop the eating out every night. I know that it is much easier to have someone else cook dinner and not have to clean up the mess but it is very unhealthy and a ton of calories eating out every night. Next, give up the sweet tea and replace it with water. The added sugar in sweet tea is contributing to her high blood sugars and elevated HbA1C. She also states she drinks 3-4 cups of coffee a day. That is a lot of coffee to drink regardless if she uses cream/sugar or drinks it black. She should cut back to 1-2 cups and if she uses creams and sugar she should start cutting back on the amounts of both.
Hello Chrystn,
I enjoyed reading your post and can respect your views on the modest treatment, or lack thereof, for Maria on this first visit to the office. However, I just wanted to throw out some ideas and see what you thought about them. I myself took a somewhat modest approach, where I thought the patient could benefit from not being overloaded with medication on this first visit, as I did not prescribe anything for her high cholesterol levels. I chose to wait and see if she was going to be compliant with the lifestyle modifications recommended in an effort to decrease her cholesterol levels and to see if the other medications that were prescribed would assist in this area as well. But, with the statistics that we are presented with in the case scenario, (patient current BP, cholesterol, and diabetes status) do you feel, as a nurse practitioner, you would have an obligation to prescribe medication, to Maria, for the things that need immediate attention, such as her hypertension and diabetes to prevent further complications such as MI, CVA, or possibly even stroke? Knowing that she has a family history of hypertension and diabetes in her immediate family, do you think that diet and exercise will be effective in decreasing her immediate change for these complications? What are the risks that Maria will have diabetes and HTN due to hereditary genetics? According to American Diabetes Association (2018), new recommendations for hyperglycemic therapy for adults with type 2 DM should begin with lifestyle modifications and metformin and to successively combine therapy to reduce major cardiovascular complications and/or mortality. It is also recommended that patients that have blood pressures 140/90 have prompt treatment to reduce blood pressures to prevent cardiovascular complications (American Diabetes Association, 2018).
After doing more research on Maria’s situation on more in-depth reading about higher HgbA1c levels, I wanted change my thought in what I would do if Maria’s HgbA1c was 10.2% mg/dL and her fasting blood glucose was 305 mg/dL. In my original post I indicated that I indicated that I wouldn’t change anything from the original treatment, however according to the American Diabetes Association (2018), if a patient has a HbgA1c >10% they should be started on a basal insulin in conjunction with metformin. So in addition to Maria’s metformin 500 mg BID that was prescribed, I would add a basal insulin at 10 units per day.
In summary, patients who are often diagnosed with diabetes type 2 have co-morbidities that must be considered in their treatment plan and sometimes limits the range of medication available depending on the co-morbidity (i.e. renal disease) (Lipska, 2017). A lot of the diabetic drugs must be monitored for renal function, contraindicated in, and/or require a dose titration for those patient that have renal insufficiencies. Metformin is the recommended first line treatment in type 2 DM for a patient without renal disease, and a second-generation sulfonylurea may be used in those patients who have renal disease (Avogaro & Schernthaner, 2013). Patients on metformin must be monitored and educated about the potential side effect of lactic acidosis due to the buildup of lactate in the system of those patient on metformin therapy. Other signs and symptoms must be monitored for vitamin B12 deficiency, as over an extended period of time, metformin can lead to these deficiencies (Blough, Moreland, & Mora, 2015). Care must be taken when prescribing medication and caring for patients at this level to ensure that safety is maintained and a holistic approach is taken.
Marlene Ermis
Reference
American Diabetes Association. (2018). Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes 2018. Diabetes Care 2018, 41(1). S28–S37. Retrieved from http://care.diabetesjournals.org/content/diacare/suppl/2017/12/08/41.Supplement_1.DC1/DC_41_S1_Combined.pdf
Avogaro, A., & Schernthaner, G. (2013). Achieving glycemic control in patients with type 2 diabetes and renal impairment. Acta Diabetologica, 50(3), 283. doi:10.1007/s00592-012-0442-x
Blough, B., Moreland, A., & Mora, A. (2015). Metformin-induced lactic acidosis with emphasis on the anion gap. Baylor University Medical Center Proceedings, 28(1), 31-33
Lipska, K. J. (2017). Metformin use in patients with historical contraindications. Annals of Internal Medicine. 225-226. doi:10.7326/M16-2712. [Show Less]