QUESTION 1:
THE PATHOPHYSIOLOGY OF TYPE 2 DIABETES AS IT RELATES TO THE CHRONIC SYMPTOMS:
Diabetes has been found to be the prevalent cause of death in the world (Werfalli ET AL., 2014). The inability of the islet beta cells to function properly or to become insulin resistant has resulted in patient to become hyperglycemic. Hyperglycemia has caused a list of severe diseases that if left untreated may further increase the chronic conditions of patient. A number of reasons increase the occurrence of diabetes such as obesity, sedentary lifestyle; hereditary, bad diet intake etc. This problem is the most occurring issue in the developing world and is usually the main cause of other chronic conditions (Ginter and Simko, 2013).
Our patient has been diagnosed with type 2 diabetes past a year and has been suffering from a number of chronic conditions:
- High blood pressure of 170/100mmHg
- Tiredness in eyes
- Pitting edema in lower extremities
- Kidney disease: Decrease glomerular filtration rate and High albumin in urine are major signs of kidney disease.
HIGH BLOOD PRESSURE/HYPERTENSION:
Patient has a blood pressure of 170/100mmHg which falls under the category of stage 2 hypertension. Although he faced no related symptoms but his age, weight and genetic history requires immediate treatment before it causes a stroke. As the patient was not taking hypertensive medicines, his blood pressure is newly diagnosed. One of the most important causes of hypertension is type 2 diabetes. They share a common metabolic pathway and causes increase in bodily dysfunction (Li et al., 2012).
Diabetes induced hypertension is caused in people that have either acquired it hereditary or through lifestyle such as overweight, loss of exercise, being alcoholic etc.
Diabetes can cause high blood pressure through 3 different pathological pathways (Lastra et al., 2014):
- Insulin resistance – Dyslipidemia-- narrowing of arteries--hypertension
- Increase oxidative stress-- Renin angiotensin aldosterone system imbalance—hypertension
- Hyperinsulinemia—causing sodium retention—causing hypertension
Insulin resistance –Dyslipidemia--narrowing of arteries—hypertension:
Type 2 diabetes is usually partnered with obesity. Obesity is accumulation of fat in the body. Over weight has its disadvantages but in diabetic patients it is the precursor of blood pressure. It causes accumulation of fats and lipids in the arteries which forces them to narrow down and become hard resulting in atherosclerosis. There is a great increase in the pressure against the walls of the arteries and thus a sudden increase in blood pressure. Treating dyslipidemia can aid in controlling hypertension (Jani et al., 2014).
Increase oxidative stress-- Renin angiotensin aldosterone system activation——hypertension:
Increase in oxidative stress and chronic inflammation leads to increase production of angiotensin 1 and angiotensin 2 which further leads to RAAS activation. Overproduction of angiotensin 1 and 2 has a local as well systemic effect on BP regulation. It increases BP and may cause related adverse effects
- Hyperinsulinemia—causing sodium retention—causing hypertension
Hyperinsulinemia insulin resistance leads to abnormalities in vascular form resulting in malformation in structure, function, stiffness etc. In addition, insulin increases reabsorption of sodium and decreases its excretion causing increase sodium in blood. Hyperinsulinemia produced sodium retention could directly lead to hypertension and cardiac myopathy (Jia et al., 2017).
TIREDNESS IN EYES/ DIABETES FATIGUE SYNDROME:
Fatigue is a strong sign of diabetes and high blood pressure. Diabetes has been observed to cause ‘diabetes fatigue syndrome’ that affects people who are overweight, less active and have high blood pressure (Sahay, 2018). Human requires sugar to produce energy. In type 2 diabetes, insulin is not effective or body becomes insulin resistance, as a result high blood sugar cannot be controlled and absorbed by the cells. This leads to inability to produce energy for the body and thus high blood pressure and fatigue.
PITTING EDEMA IN LOWER LEGS:
Pitting edema is the accumulation of fluid that causes swelling. The patient was observed to have pitting edema in his lower limbs, which is one of the possible pathophysiological signs of diabetes.
Type 2 diabetes causes accumulation of glucose in the blood as a result of insufficient insulin. Hyperglycemia damages the blood vessels and results in poor blood circulation. Due to improper circulation, fluid gets trapped in specific areas such as ankles, legs and foot and causes swelling (Mandal, 2014). Overtime, hyperglycemic conditions leads to damage to the nerves present there. It causes numbness and inability to feel pain. Edema may also be caused due to decrease kidney function in diabetic patients.
KIDNEY DISEASE/ DIABETES NEPHROPATHY:
The patient’s urine test confirms albuminuria which is a late sign of kidney disease (Gundpatil et al., 2014)
Diabetes causes high blood sugar level in blood. This hyperglycemic state causes damage to the blood vessels in the kidney (U.S. Department of Health and Human Services, n.d. ). Kidneys have filters in them to separate nutrients and excrete toxic substance out. When blood vessels get damaged, these filters also start losing their function. Glomerular filtration rate is a test that explains how much blood is passing through these filters. With a decrease GFR, the filters will not work properly and as a result will start excreting useful substance such a protein. This may further advance to glomerular sclerosis and fibrosis, if left untreated.
Patient has a decrease glomerular filtration rate and high concentration of urea in blood. He also was found to have high albumin in urine which confirms defect in the kidney function. These chronic symptoms are the signs of kidney disease due to diabetes.
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QUESTION 2:
POTENTIAL MANAGEMENT OF HYPERTENSIVE DIABETIC PATIENT
An obese patient, with diabetes and sedentary lifestyle is a dangerous combination. There is a huge risk of hypertension and other chronic occurrences. A holistic approach is needed for a hypertensive diabetic patient (Dunning, 2013).
Management of hypertension and diabetes in a patient requires both pharmacological and non-pharmacological approach (Viswanathan et al., 2011). Pharmacological usually involves medication, tests, and therapies whereas; non pharmacological usually involves diet, physical therapy, emotional support etc.
MEDICAL AND NURSING APPROACH:
Some medical interventions are done to control diabetes such as normalizing insulin activity, intensive treatments if required, prescribing certain foods, restricting certain intakes etc. Nursing interventions require the role of nurses in assessing symptoms and needs of the patient, diagnosing patients fear and queries, monitoring drug dosage, blood glucose level and blood pressure and evaluating patient’s awareness.
The management approaches include medication approach, nutritional approach, weight management approach, observation and monitoring approach, emotional support and educating the patient. Every need is discussed from a medical as well as nursing perspective.
MEDICATION APPROACH:
- Physicians based on the test reports will prescribe the desired medication and dosage.
- Diabetes: First and foremost the medication of diabetes should be decided. The first line of therapy considered is Metformin 500mg (Aroda et al., 2017). Later according to the need and severity of the condition, drugs and their doses can be adjusted.
- Hypertension: For diabetic patients that are also hypertensive, specific kinds of drugs are used such as ACE inhibitors, Angiotensin receptor blockers, diuretics and Beta blockers. These drugs have been found to have an effect on diabetes as well and therefore are effective in management therapy (Elisaf et al., 2014). Physician will prescribe proper dosage that can be given in combination with diabetes drug.
- Nurses will assess medication, allergy symptoms, diagnose, manage and evaluate the patient based on the readings and will aid in on time medication.
- Nurses will educate the patient on the medication therapy and stress its importance.
NUTRITIONAL MANAGEMENT:
- Nutritional decisions and meal planning should be done based on patient’s fitness, likes and dislikes, cultural preferences and keeping hypertension and diabetes in mind.
- Dietitian will plan a detail meal plan after consulting with the physician. The plan will cater to the condition of the patient as well as his food preferences. Certain lifestyle changes are imperative to bring about the change (Unger, 2013).
- Diabetes: patients with diabetes are required to maintain a low calorie diet and encouraged healthier eating such as fruits and vegetables.
- Hypertension needs to be controlled through lowering the salt intake and decreasing the desire for processed foods. Green vegetables are encouraged for such condition.
- Nursing staff will aid in understanding and ensuring the meal plan is being followed.
WEIGHT MANAGEMENT:
- Long-term management of illness requires weight balance. Physical activity is essential for the progress (Bird and Hawley, 2012).
- Physical therapist provides a detailed plan for the patient after discussing with the physician and nurse.
- Diabetes: losing weight has been proved to decrease blood sugar level. Such patients that are diabetic require proper weight management. Overweight or obesity will further deteriorate their condition. A proper BMI is significant in combating diabetes. Physical activity has been observed to decrease insulin resistance (Goldstein and Mueller-Wieland, 2016)
- Hypertension: it has been noted that loss of 1 kg in weight has been seen to decrease arterial blood pressure by 1mmHg. Light exercise can provide the desired result.
- Walking, swimming, light exercise, yoga etc are some forms of exercises that are effective.
MANAGEMENT THROUGH OBSERVATION AND MONITORING:
- Hypertensive diabetic patients require time to time checkup in order to diagnose any further complications, wounds, malfunctioning etc.
- The first step in management is observing and monitoring the readings. Blood sugar level and blood pressure should be checked and monitored. They should be within prescribed range.
- For diabetic patients, blood pressure should be below 140/90mmHg.
- Nursing staff will scan and communicate the result to the physician and physician will decide further steps
MANAGEMENT THROUGH EDUCATING PATIENT AND CAREGIVER:
- Patient’s acceptance and determination is the key role in bringing about a positive change. For this purpose, knowledge is power. Educating the patient and enlightening him on different topics, discussing the consequences and repercussions, adverse events of the disease proved positive in management (Graffigna et al., 2014).
- Nurses, social workers and caregivers, are the backbone of support program
- For better management, nurses will aid in teaching the patients how to use home glucose testing kit, encouraging them to read the labels on food, discussing the pros and cons of anti-diabetic and antihypertensive drugs etc.
MANAGEMENT THROUGH EMOTIONAL SUPPORT:
- Another significant step in management therapy is providing emotional and psychological support to the patient and caregivers.
- Nursing care requires nurses, psychologists and others to direct compassion and understanding to the patient. It has been observed that significantly improved outcome was noted in patients that were subjected to support and understanding (Matteo et al, 2013).
- Various programs that connect diabetics with each other and aid in their treatment and management can be arranged. This will assist in their fear and anxiety.
REFERENCES:
Barry J. Goldstein, D. M.-W. (2016). Type 2 Diabetes: Principles and Practice, Second Edition. CRC Press.
- B. Gundpatil, B. L. (2014). Serum Urea:Albumin Ratio as a Prognostic Marker in Critical Patients With Non-Chronic Kidney Disease. Indian Journal of Clinical Biochemistry , 97-100.
DiMatteo, T. A. (2013). Importance of family/social support and impact on adherence to diabetic therapy. Diabetes Metab Syndr Obes , 421-426.
Dunning, T. (2013). Holistic Assessment, Nursing Diagnosis, and Documentation. In T. Dunning, Care of People with Diabetes: A Manual of Nursing Practice (pp. 44-59). John Wiley & Sons.
Elisaf, C. V. (2014). Antihypertensive drugs and glucose metabolism. World Journal of Cardiology , 517-530.
Emil Ginter, V. S. (2013). Type 2 Diabetes Mellitus, Pandemic in 21st Century. In A. S.I., Diabetes. Advances in Experimental Medicine and Biology (pp. 42-50). New York: Springer NY .
Guanghong Jia, A. W.-C. (2017). Diabetic cardiomyopathy: a hyperglycaemia- and insulin-resistance-induced heart disease. Diabetologia , 21-28.
Guendalina Graffigna, S. B. (2014). How to engage type-2 diabetic patients in their own health management: implications for clinical practice. BMC Public Health .
Guido Lastra, S. S. (2014). Type 2 diabetes mellitus and hypertension: An update. Endocrinol Metab Clin North Am. , 103-122.
Li, B. M. (2012). Diabetes and Hypertension: Is There a Common Metabolic Pathway? Current Atherosclerosis Reports , 160-166.
Mahmoud Werfalli, A. M. (2014). The prevalence of type 2 diabetes mellitus among older people in Africa: a systematic review study protocol . BMJ .
Mandal, A. K. (2014). Generalized Edema: a systemic approach to diagnosis and management. In A. K. Mandal, Textbook of Nephrology (pp. 112-124). JP Medical Ltd.
Sahay, S. K. (2018). Diabetes Fatigue Syndrome. Diabetes Therapy: research, treatment and education of diabetes and related disorders , 1421-1429.
Services, U. D. (Nil). Diabetic Kidney Disease. Retrieved April 11, 2020, from National Institute of Diabetes and Digestive and Kidney Diseases: https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-kidney-disease
Stephen R.Bird, J. A. (2012). Exercise and type 2 diabetes: New prescription for an old problem. Maturitas , 311-316.
Unger, J. (2013). Lifestyle Interventions for Patients with Diabetes. In J. Unger, Diabetes Management in Primary Care (pp. 62-112). Lippincott Williams & Wilkins.
Vanita R. Aroda, W. C.-S.-S. (2017). Metformin for diabetes prevention: insights gained from the Diabetes Prevention Program/Diabetes Prevention Program Outcomes Study. Diabetologia , 1601-1611.
Viswanathan, J. G. (2011). Management of diabetic hypertensives. Indian J Endocrinol Metab , 374-379.
Ylber Jani, A. K. (2014). Influence of dyslipidemia in control of arterial hypertension among type-2 diabetics in the western region of the Republic of Macedonia. American Journal of Cardiovascular Disease , 58-69.
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