Exam (elaborations) NR 601 Week 5 Case Study Diabetes Care (NR601)
Mrs. G Case Study
The purpose of this case study is to interpret subjective and
... [Show More] objective
information in order to diagnose disease processes and develop a plan of
care for the patient based on national, evidence-based clinical guidelines.
Assessment
After reviewing Mrs. G’s symptoms and evaluating her blood work, a
few issues have been identified. Some of these issues need to be addressed
right away, such as an elevated hemoglobin A1c (HgbA1c), obesity, and the
abnormal lipid panel. Some of the identified issues are either a cause of or a
result of the elevated HgbA1c and lipids, such as her being obese, her
borderline hypertension, and her decreased GFR. There are other possible
disease processes at play here based on her lab work, such as possible
metabolic syndrome, pre-hypertension versus stage 1 hypertension, and her
decreased free T4. These issues will be used as differential diagnoses;
however, further lab work will be needed to be certain.
Primary Diagnosis
Mrs. G’s primary diagnosis is type 2 diabetes mellitus (T2D) (E11).
T2D is a metabolic disease that is caused by deficiencies in the action of
insulin, the secretion of insulin or from both; specifically, T2D is directly
related to insulin resistance (Pippitt & Li, 2016). The signs and symptoms
NR 601 Week 5 Case Study Diabetes
Care
one may see that are associated with diabetes mellitus, type 1 and 2, include
fatigue, polyphagia, polydipsia, polyuria, wounds that do not heal,
fluctuation in weight, blurry vision, proteinuria, a pins and needles sensation
in the lower extremities, poor wound healing, nausea, delayed gastric
emptying, impotence, and frequent yeast infections in women. (Kennedy-
Malone, Fletcher, & Plank, 2014; Pippitt & Li, 2016)
Mrs. G’s pertinent positive physical findings include fatigue, obesity
based on a BMI of 35.7, excessive hunger and thirst, and polyuria. Mrs. G’s
pertinent negative physical findings include no complaints of poorly healing
wounds, blurry vision, pins and needles sensation, nausea, frequent yeast
infections, or delayed gastric emptying. Mrs. G’s pertinent lab value findings
include a hemoglobin A1c (HgbA1c) of 7.6%, a GFR of 88 mL/min/1.73L,
and a urinalysis that is positive for glucose and protein. The HgbA1c
expresses the percent of hemoglobin that is bound to glucose in the body
over a 60 to 90 day period; it is part of the criteria needed for the diagnosis
of diabetes (Cornelius, 2016). The provider wants their patient’s HgbA1c to
be less than or equal to 6.5% and can base treatment plans on this result as
long there is no debate of accuracy between levels of HgbA1c and serum
blood glucose (ADA, 2017; Garber et al., 2017). The provider would notice
Mrs. G’s GFR is decreased and would monitor this closely because diabetes
is a common cause of renal disease (Garber et al., 2017). A urine
microalbumin can be used to indicate the beginning of renal disease and
therefore can be a good tool for providers.
Mrs. G has many pertinent positive physical findings such as her
obesity, fatigue, excessive hunger, excessive thirst, and polyuria. She also
has pertinent abnormal lab values such as the HgbA1c, a decreased GFR,
and a urinalysis that is positive for protein and glucose. Mrs. G has some
pertinent negative physical findings as well, they include poorly healing
wounds, blurry vision, and a pins and needles sensation. Even with these
pertinent negative findings, Mrs. G can be confidently diagnosed with T2D
based on her physical symptoms and HbA1c results.
Secondary Diagnosis
The first secondary diagnosis is obesity (E66.9) because obesity
increases the risk factors for multiple disease processes. Based on Mrs. G’s
height and weight, her BMI is 35.7. A BMI of 25 to 29 kg/m2 is considered
overweight while anything over 30 is considered obese (Skolnik and
Chrusch, 2014). Obesity is a direct result of consuming more energy than
one can expend, this extra energy stays in the body and is stored as fat
(Skolnik and Chrusch, 2014). Obesity is associated with many serious health
problems, including type 2 diabetes, cardiovascular disease, myocardial
infarction, stroke, respiratory disease processes, and even cancer (Skolnik
and Chrusch, 2014). It is thought that obesity is the likely causative factors
for many of these problems just listed (Skolnik and Chrusch, 2014). Based
on Mrs. G’s BMI and weight of almost 200 pounds, the provider can
confidently diagnose her as obese.
Mrs. G’s other secondary diagnosis is hyperlipidemia (E78.5). Lipid
disorders are caused by alterations in the metabolism of lipoproteins and
these alterations include an increase in the total cholesterol, an increase in
LDL, an increase in triglycerides, and/or an inadequate amount of HDL
(Stone et al., 2014). Hyperlipidemia can be something one acquires related
to unhealthy lifestyle choices but for some people it is hereditary, which
requires medical management regardless of their lifestyle choices (Stone et
al., 2014). The risk of atherosclerotic cardiovascular disease (ASCVD) is
significantly increased in patients with T2D (Garber et al., 2017).
In most people, hyperlipidemia does not present with common signs
and symptoms, although HTN or chest pain is usually a good indication ones
cholesterol is high. For Mrs. G, she does not have any outward signs and
symptoms; however, her lab work shows another story. All of Mrs. G’s lipid
levels are off, her cholesterol is high, her LDL is high, her VLDL is high, her
HDL is low, and her triglycerides are very high. Her elevated lipid panel is
the most important pertinent positive finding for hyperlipidemia. The
pertinent negative findings include no chest pain or HTN. However, Mrs.
G’s blood pressure is creeping close to the recommended blood pressure of
140/90 for someone her age with diabetes; her provider would want to keep
a close eye on this (ADA, 2017; Armstrong, 2014).
Most patients with T2D have abnormal lipid panel results, specifically
low HDL levels and high triglyceride levels (Stone et al., 2014). Mrs. G’s
pertinent negative physical findings include no chest pain and no HTN,
albeit this number is borderline on being hypertensive. Even with her
negative physical findings, Mrs. G’s pertinent positive lab values are clearly
indicative of hyperlipidemia. Hyperlipidemia in general increases the
patient’s risk for ASCVD; having diabetes increases this risk significantly
(Garber et al., 2017). With Mrs. G’s lab results, the provider can confidently
diagnose her with hyperlipidemia.
Differential diagnoses
Metabolic syndrome (E88.81), which is associated with insulin
resistance and obesity, is one possible differential diagnosis for Mrs. G. To
diagnose a patient with metabolic syndrome, one must meet 3 out of 5 of the
following criteria; triglyceride levels over 150 mg/dL, abdominal obesity (35
inches or greater for females), a fasting glucose level more than 110, a blood
pressure higher than 135/85 mmHg, and low HDL levels (Goroll & Mulley,
2014). The pertinent positive physical findings for Mrs. G include a
triglyceride level of 232 and an HDL level of 37. The negative pertinent
physical findings include a blood pressure of 130/82, a presumed fasting
blood glucose level of 97, and unknown abdominal obesity. Mrs. G’s blood
pressure is borderline for meeting the criteria and should continue to be
monitored. Mrs. G is obese based on her BMI, however, while one could
assume her abdomen is 35 inches or greater, it is not specified and therefore
cannot be used. Based on the positive and negative pertinent information,
one would have to conclude that Mrs. G is at a high risk of developing
metabolic syndrome, if she does not already have it. The provider would
want to correct her lipids and decrease her BMI via medications and lifestyle
changes.
Another differential to be considered is HTN. Mrs. G is considered
stage 1 hypertension (I15.9) per AHA/ACC guidelines (Yancey et al., 2017)
and pre-hypertensive (R03.0) according to JNC 8 guidelines (Armstrong,
2014). The American Association of Clinical Endocrinologists and the
American College of Endocrinology have determined that a blood pressure
of 130/80 should be acceptable for most patients (Garber et al., 2017).
Providers must take into account the white coat syndrome, which is very
real. Given Mrs. G’s blood pressure reading and based on clinical guidelines,
Mrs. G could be pre-hypertensive or have stage 1 HTN. Mrs. G does not
have any pertinent negative physical findings, however, per the guidelines
she is at least pre-hypertensive, if not stage one. Given the pertinent positive
findings, the provider could diagnose her either way but would have to keep
a close eye on it.
Lastly, Mrs. G’s free T4 level is slightly low, but her TSH is
normal. This is most likely secondary hypothyroidism caused by failure of
the hypothalamus or the pituitary to properly stimulate the thyroid gland
(Gaitonde, Rowley, & Sweeney, 2012). The symptoms associated with
secondary hypothyroidism are typically vague and may include fatigue,
weight gain, depression, decreased ability to concentrate, and muscle pain
(Gaitonde, Rowley, & Sweeney, 2012).
Mrs. G’s pertinent positive physical findings include weight gain
and fatigue. Her pertinent negative physical findings include no depression,
muscle pain, or decreased ability to concentrate. Her pertinent positive lab
value findings include a normal TSH and a decreased free T4. Based on this
information, secondary hypothyroidism is a plausible differential for Mrs. G;
however, this differential requires more information before a diagnosis can
be concluded.
Plan
The plan of care developed for Mrs. G will include primary,
secondary, and tertiary prevention. The appropriate plan will be formulated
using evidenced based resources to provide safe and effective care while
considering the patient’s wants and values.
Diagnostics
According to the diabetes clinical practice guidelines, Mrs. G has a
resulted HbA1c, which is what is needed to diagnose a patient with diabetes
(ADA, 2017). Providers want their patient’s HbA1c to be less than 6.5%,
Mrs. G is at 7.6% (Pippitt & Li, 2016). The HbA1c is also used to monitor
how treatment plans are working; typically monitoring HbA1c results every
three months (Hollier, 2016). The only downside to HbA1c tests, and what
providers need to be aware of, is that blood loss and hemolytic anemias can
cause a false low result while aplastic anemias and spleen injuries can cause
false high results (Pippitt & Li, 2016).
The diagnostics for obesity include uncovering the reason for obesity,
whether it is psychological or an underlying medical reason (Hollier, 2016).
The underlying problems that can cause obesity can be evaluated with blood
work; these tests include a CBC, CMP, thyroid functions, amylase, lipase,
lipid panel, and a HgbA1C (AACE & ACE, 2018). An electrocardiogram
can also be ordered to rule out heart failure as a cause for her fatigue and
exercise intolerance (AACE & ACE, 2018).
The diagnostics used to monitor Mrs. G’s hyperlipidemia is a lipid
panel, which will be ordered every 3 months to evaluate the effectiveness of
his treatment plan (Stone et al., 2013).
The diagnostics used to evaluate Mrs. G for secondary
hypothyroidism include a repeat free thyroxine (T4), a TRH, a free T3, a
reverse T3, thyroid peroxidase antibody (TPO), thyroglobulin antibody, and
a procalcitonin level. The TRH level is the most important lab value for this
differential because it helps differentiate if her problem lies within the
thyroid or the pituitary gland (AACE & ACE, 2012; Uphold & Graham,
2013).
Medication
For her diagnosis of T2D, Mrs. G will be started on Metformin 500
mg twice a day with meals (ADA, 2017; Epocrates, 2018). Mrs. G will be
instructed to check her blood glucose levels three times a day, before meals,
and to keep track of the results in a journal (ADA, 2017).
Mrs. G’s BMI is 35.7, which is considered obese. Besides lifestyle
changes that include diet and exercise, a medication to help control her
appetite and cravings would help her significantly. Contrave, which is a
combination of naltrexone and bupropion, is indicated for use in
combination with diet and exercise for patients with a BMI greater than 30
kg/m2 or a patient with a BMI greater than 27 but also has another
comorbidity such as T2D or hyperlipidemia (Early & Whitten, 2015;
Epocrates, 2018).
For Mrs. G’s hyperlipidemia, the ACC/AHA guidelines will be used to
calculate Mrs. G’s 10-year risk score of developing Atherosclerotic
Cardiovascular Disease (ASCVD)(Stone et al., 2013). Mrs. G has a 5.4
percent risk of developing ASCVD without any other kinds of medical
treatment. In order to keep her risk low, a moderate intensity statin is
indicated (ACC, 2018). Based on Mrs. G’s lipid panel and the information
above, Mrs. G will be started on atorvastatin 20 mg, take one tablet at
bedtime. Atorvastatin will help to increase her HDL and lower her
triglycerides and LDL (ACC/AHA, 2013; Epocrates, 2018)
According to AHA/ACC (2013), Mrs. G has stage 1 HTN; however,
according to JNC 8 and Armstrong (2014), Mrs. G is pre-hypertensive.
Based on the ACC/AHA guidelines, stage 1 HTN only requires medication if
the patients risk of developing ASCVD within 10 years is more than 10
percent (ACC/AHA, 2013; Whelton et al., 2017). Since Mrs. G’s risk is
5.4%, she does not need to start a blood pressure medication at this time.
However, the patient will be instructed to monitor her blood pressure 3 times
a day and record the results in a journal. She will bring this journal with her
to her next follow up visit for further evaluation.
In regards to Mrs. G’s possible secondary hypothyroidism, additional
diagnostic studies will be done to either exclude or confirm the diagnosis of
secondary hypothyroidism. Therefore, medications will not be initiated until
a diagnosis can be confirmed.
The last differential diagnosis is metabolic syndrome, which is being
addressed by treating the hyperlipidemia, the T2D, and her obesity. If the
provider is able to manage these disease processes, they can help to reduce
the long-term impact on Mrs. G (AACE/ACE, 2018).
It is okay for Mrs. G to continue taking her multivitamin and Tylenol as
needed for her osteoarthritis pain. Using Lexicomp, there are no major
interactions between her OTC medications and the 3 medications being
prescribed.
Education
For all three of Mrs. G’s primary and secondary diagnoses, lifestyle
modifications, specifically in regards to diet and exercise, are needed in
conjunction with medical management. Considering Mrs. G has been
diagnosed with Obesity, hyperlipidemia, and T2D, the most important
primary prevention is to stop or prevent end organ damage (ADA, 2017).
The only way to avoid end-organ damage is via prevention and the best
preventative measures start with diet and exercise (AACE & ACE, 2018).
In regards to diet modifications, Mrs. G will be referred to a registered
dietician/nutritionist for education on healthy eating, which includes a diet
full of vegetables and fruit with lean proteins, low in in saturated fats, and
little to no simple carbohydrates or refined sugars (ADA, 2017).
The other part associated with lifestyle changes is exercise. Right now
Mrs. G walks for 30 minutes two times a week. Mrs. G will be instructed to
walk for at least 30 minutes 5 to 6 days a week. After about a week, Mrs. G
should begin to acclimate to her new routine and exercises involving weight
training should be incorporated into her routine. Not only will exercising
help with weight loss, it will also help to decrease blood glucose levels in
her body (ADA, 2018). The short-term goal for Mrs. G is to loose 10% of
her current body weight; in doing so can help control HTN, blood glucose
levels, and hyperlipidemia (AACE & ACE, 2018).
Another important aspect of education is to know the signs and
symptoms of hyperglycemia, hypoglycemia, DKA, and HHNK, which
include polyuria, polydipsia, polyphagia, confusion, weakness, lethargy,
shakiness, and flushing. Mrs. G will be taught how to manage symptoms of
low and high blood sugars and to correlate these feelings with glucometer
readings. Wound healing, especially when on the lower extremities, can be
prolonged so checking ones feet before getting in the shower can help
identify any open areas so that treatment an be initiated right away (ADA,
2017). Mrs. G will also be educated on more end-organ damage that can
occur with diabetes mellitus when it is not managed properly; these include
renal failure, peripheral neuropathy, retinopathy, glaucoma, and even
ulcerations in the skin that can lead to limb amputations (ADA, 2017).
Mrs. G was instructed to monitor her blood pressures three times a
day, record the results in a journal, and bring the journal to her next follow
up appointment. It is important to obtain blood pressure readings throughout
the day; sometimes patients experience “white coat syndrome” but their
pressures are normal otherwise. A journal with these results allows the
patient and the provider the opportunity to accurately monitor blood pressure
levels so that they can prescribe medications appropriately (Stone et al.,
2014).
Atorvastatin is a statin medication that works by reducing the total
blood cholesterol and decreasing how much cholesterol that is made by the
liver (Stone et al., 2014). The side effect most often associated with a statin
is muscle pain; if the patient begins having muscle pain they should be
instructed to call the office immediately. It is also important to know a
medications interaction potential with certain foods. For example, grapefruit
juice inhibits enzymes in the small intestine to break down atorvastatin,
leaving higher levels of atorvastatin in the patient’s body (Epocrates, 2018).
Metformin is an antihyperglycemic agent in the Biguanides class of
diabetes medications (Epocrates, 2018). It’s mechanism of action works by
decreasing glucose production in the liver, reducing the amount of glucose
the intestines can absorb, and by increasing insulin sensitivity (Epocrates,
2018). Metformin is a good starting medication for patients newly diagnosed
with T2D because it also helps to decrease post prandial and basal blood
glucose levels, which will eventually cause the HbA1c to decrease (PDR,
2018). It also great for newly diagnosed diabetes patients because it rarely
causes hypoglycemia given it does not change the concentrations of insulin
in the body (PDR, 2018). Metformin may also help some diabetic patient’s
lose weight and it can decrease triglycerides and total cholesterol levels,
both of which would be great for Mrs. G (PDR, 2018).
Contrave, which contains naltrexone and bubropion hydrochloride, is
used for weight loss in combination with diet and exercise. Naltrexone is an
opiod receptor antagonist and bupropion is a dopamine and norepinephrine
reuptake inhibitor (Early & Whitten, 2015). Contrave works on two areas of
the brain that are involved with the regulation of appetite and food intake,
the hypothalamus and the mesolimbic dopamine circuit (PDR, 2018). In
studies, the most common side effects experienced include nausea,
constipation, dizziness, sleep disturbances, and headaches (Early & Whitten,
2015). If the patient has not lost at least 5 percent of their bod weight in
three months, the medication should be discontinued (Early & Whitten,
2015).
Referrals
Mrs. G will require a few referrals in order to properly care for her.
Two of the most important referrals for Mrs. G are a registered
dietician/nutritionist and a diabetic educator. It is important for Mrs. G to
fully understand the disease process of T2D and the dietician to explain how
foods can affect her body and health. The biggest and [Show Less]