Diabetes Mellitus Management: Case Study and Treatment Plan for a 66-Year-Old Male Patient, Exams of Nursing

Download Diabetes Mellitus Management: Case Study and Treatment Plan for a 66-Year-Old Male Patient and more Exams Nursing in PDF only on Docsity! NURSING.DIABETES WELL EXPLAINED . Download to score Diabetes Mellitus Management Objective: History of Present Illness: Patient is a 66-year-old Caucasian male here today for his 3-month follow up for his diabetes mellitus management. He was diagnosed back in 2008 and has had issues in maintaining his blood sugars and changing his lifestyle habits (diet and exercise). He checks his blood sugars on a consistent basis and logs them appropriately. His A1C in May of this year was 7.9. He currently is taking Metformin, Byetta, Lantus, and Novolog for his DM II management. Patient is frustrated at this time because he has to face the physician and go over his gain in weight and the need to change medication management. He states that he has been trying to watch his diet but has not been getting exercise in his daily life. Patients log of recent blood sugars (10 days) Blood Sugar Log Averages Morning: 232 190 201 145 133 186 199 155 175 166 Noon: 175 169 210 132 178 240 112 90 142 178 Bedtime: 110 131 180 210 160 224 155 121 190 285 Past Medical & Surgical History: Diabetes Mellitus – 2008 Hyperlipidemia – 1998 Hypertension – 1993 Left Knee Arthroplasty – 2010 Endo: obese, no temperature intolerance, has noticed increase polyphagia and polydipsia. No increase in nervousness. Psych: no report of feeling depressed or anxious but is worried about diabetes management. Objective: Physical Examination: General: Patient is overweight, dressed appropriately for weather conditions, nervous about meeting with physician because of his weight gain; skin color consistent with ethnicity. VS: BP 136/81, HR 59, RR 18, Sp02 97% on RA, Temp 36.6 BMI 27.2 Skin: No lesions noted. Skin intact, dry and warm, nails well trimmed and no clubbing present. Bottom feet inspected with no evidence of skin breakdown. HEENT: lymph nodes nonpalpable; head atraumatic and normocephalic, some balding, PERRLA, conjunctiva white in color, EOMI, red reflex present, discs flat with sharp margins, no retinal hemorrhages present, receding gums with tooth decay present. CV: s1/s2 audible with no pathological auscultation; PMI with landmarks Lungs: CTA, equal chest expansion, no evidence of cough; no adventitious breath sounds. Abd: Bowel sounds present in all 4 quadrants, no pain upon palpation (both deep and soft) in all 4 quadrants, and no masses palpated (*Didn’t check hepatosplenomegaly – will check next time*) GU: not assessed Rectal: not assessed PV: +2 pulses in upper and lower extremities; extremities normal temperature with equal hair distribution; no edema present MSK: full ROM in all extremities with some 2/10 pain upon extension of the left knee Neuro: steady gait, no neuropathy present in lower extremities, monofilament and two-point discrimination negative for pathological concerns from diabetes. Alert and oriented Diagnostic Tests: CBC/Hematology Hemoglobin: 12.7 Hematocrit: 46.8 WBC (w/o diff): 9.1 HgA1c: 8.2 (5/13 7.9) Lipid Profile: Cholesterol: 236 Triglycerides: 212 HDL/LDL: 49/110 CMP: Na: 138 K: 4.3 Cl: 98 BUN: 20 Cr: 1.1 Glucose (fasting): 168 GFR: 92 Assessment & Plan Diabetes: Patient has ongoing diabetes that needs treatment plan modifications. Patient has been adhering to medication dosing but has not been following dietary and lifestyle changes. 1. Patient will continue to monitor his blood sugars in the home setting. 2. A refill will be made for the patient’s glucose strips. Diabetes Mellitus is such disorder that is complex in nature as well as complex in the effects it has on other organ systems. From a pathological standpoint, the main issue with diabetes in general is that it results from a deficiency in insulin in the bloodstream. “Type 2 diabetes presents on a background genetic predisposition and is characterized by insulin resistance and relative insulin deficiency. Insulin resistance is aggravated by physical inactivity and by overweight or being obese (O’Connor, 2013).” Because our cells need insulin to carry in glucose from the blood stream, our bloodstream accumulates with glucose. But when it comes to diabetes mellitus, it can be caused by a decrease in the production of insulin in the beta cells of the pancreas or our cells in our body build a resistance to the insulin. This is what defines diabetes mellitus from Type-1 Diabetes, which is due to the fact that our beta cells no longer make insulin and rely on insulin through injection. With diabetes mellitus characterized by decreased insulin production and/or cellular insulin resistance, this causes a pathway of problems for our body. It leads to vascular destruction due to the high osmolality gradient caused by the high serum blood glucose. This vascular destruction tends to work initially on the microvascular tissue including the eyes, peripheral nerve tissue, kidneys, and coronary tissue. Diabetes and hyperglycemia create a proinflammatory microenvironment that progress to microvascular complications such as nephropathy, retinopathy, and neuropathy (Nguyen, Grant, Shaw, 2012). Therefore, the microvascular tissue destruction then will cause a further decline and cause ischemia and organ death over a period of time. Leadership/Professional Role: The leadership in this visit was initially me, but when it came to treatment changes and treatment plan modifications, my preceptor took over. I was able to get a good history on the patient and identify issues in the follow up. I was able to lead the education for the patient and provide health promotion from a nursing perspective. When it came to the treatment plan, my preceptor took over and helped the patient and I understand what was going to change and why. Barriers to Care: There was one perceived barrier in this visit and it was dietary intake associated with finances. He will be going to go see a nutritionist to talk about modifying his meal plans. Patient has had a hard time trying to eat better and it is due to “everything good for you costs too much.” Explaining to him that, even though the costs of the food are higher than junk food, the costs of increasing the medications and the increase in the progression of his illnesses cost more in the long run. I also advised him to locate Aldi’s grocery stores. He could be saving a lot of money on groceries and he would be able to buy groceries that were good and nutritious for him. He liked the idea and I helped him locate a couple stores in his residential area. Hopefully this education will help alleviate barriers in the future. Pharmacology Information: Incretin is a hormone, which is produced in the gastrointestinal tract and responds to food when it enters. This hormone causes the pancreas to quickly release insulin to help initiate the push of glucose into the cells because more glucose will be entering the bloodstream. GLP-1, also known as glucagon like peptide-1, is derived from incretin and plays a crucial role in helping people with Diabetes Mellitus because of its role in slowing down gastric contents, increasing insulin secretion, and by increasing satiety in the brain (Cooppan, n.d.). A medication, known as Byetta (exenatide), helps diabetic patients by mimicking GLP-1. “Exenatide mimics incretin and promotes insulin secretion, suppresses glucagon, and slows gastric emptying (Exenatide Injectable Solution (Rx) - Byetta).” Since it was FDA approved in 2005, it has made a positive impact on helping diabetic patients and their weight. Unlike some of the other diabetic medications such as Metformin, it has been shown to help decrease weight in patients who have Diabetes Mellitus. “A weight loss of 1–4 kg is generally observed in patients treated with a GLP-1 receptor agonist, whereas DPP-4 inhibitors are weight neutral (Reid, 2012).” Byetta is not for everyone. It shouldn’t be used in pediatric patients and should not be solely used as monotherapy in diabetic patients. Like any other medications, Byetta does have serious and common reactions. Nausea, vomiting, diarrhea, hypoglycemia, and constipation are a few of the common reactions with this medication. One of the serious reactions with this medication is pancreatitis. It is important to educate the patient to stop taking the medication if they experience signs of pancreatitis such as severe abdominal pain, especially in the upper stomach. Other education should include what signs and symptoms to watch of hypoglycemia to watch for. From a financial point of view, Byetta is a very expensive drug if the patient does not have health insurance or a drug plan. After reviewing goodrx.com, which my preceptor linked me to, it shows that the cost of the medication ranges $370-$400 per month. Insurance plans typically will cover the medication with a co-pay. After looking into medications similar to Byetta, it appears that Byetta is cheaper among the GLP-1 agonists such as Bydureon (exenatide) and Victoza (liraglutide). Critical Thinking/Critical Decision Making: After reading about this sliding scale regimen and how it really isn’t supported in the family practice setting, I want to discuss this with my preceptor. I work full time in the hospital and I see the sliding scale insulin regimen on a daily basis. When I saw my preceptor go through with initiating this for the patient, I thought it was fine and evidenced based. But after reading into it, it seems it is not well supported. It seems to be more work for the patient and not as effective as we may think. Critique: This was a very busy day for me in the clinic and I learned an immense amount of information, especially about diabetes management and regimen changes. This was my first experience when working with a patient on diabetes management. There was one case last semester that we put a patient on Lantus and initiated Metformin but this was a completely different case. This gentleman was on several different medications for his diabetes and it was a little overwhelming at first. I am looking forward to working with patients with diabetes. It has spread like wildfire among our country and it is something that needs to be extinguished or at least controlled. I feel as a nurse, I have very strong educational skills and I think that’s why nurse practitioners can make a difference in primary care. We focus a lot of our attention on health promotion and educating on lifestyle modifications. My preceptor, whom is an MD, seems to focus a lot of attention on medications and testing, which is great! That is why the nurse practitioner in the clinical setting can offer more of the education because it is part of our nursing care model. Overall I think this visit went well. I was able to incorporate some of the diabetic education information that I’ve learned in the program. I was able to learn how to increase insulin dosages and what to watch for in blood glucose patient logs. I have a lot to learn but that is why I am here! References Byetta - Patient Education. (2012, March 8). Epocrates Online. Retrieved September 10, 2013, from https://online.epocrates.com/noFrame/showPage.do?method=drugs Cooppan, R. (n.d.). Type 2 Diabetes: The Pathophysiologic Basis of Treatment Design. Medscape. Retrieved September 16, 2013, from http://www.medscape.org/viewarticle/580684