Diabetes is one of the key chronic diseases that seriously affect the health of populations, along with obesity and cardiovascular dysfunctions. In Australia, the rates of people diagnosed with diabetes mellitus increase, which creates the need to properly understand its pathophysiology and potential steps to assist patients. This paper focuses on examining the case of a 58-year-old male patient, who has diabetes, hypertension, and obesity. This patient’s conditions will be assessed in terms of his chronic symptoms and pathophysiology of type 2 diabetes. Based on the findings, management approaches and the education plan will be developed in view of support resources available in Australia.
Pathophysiology of Type 2 Diabetes as it Relates to a Patient’s to Chronic Symptoms
Type 2 diabetes is marked by insulin deficiency in patients. It means that there is a lack of insulin effects at normal or elevated levels of the hormone in the blood. The relative insulin insufficiency can be based on three types of disorders, including secretory β-cell insufficiency, the phenomenon of insulin resistance, and the action of contra-insular factors (Scott, de Courten, & Ebeling, 2016). The patient’s family history and current symptoms are representative of the identified dysfunctions. The secretory deficiency of β-cells is a genetic defect in which they are preserved, but insulin secretion is reduced, which is manifested in conditions of an increased need for insulin (Craft, Gordon, Huether, McCance, & Brashers, 2015). At the same time, polyphagia, the increased appetite and hunger, and obesity may also have a genetic nature. Since the given patient’s mother had diabetes, the genetic predisposition may be noted among other disorders.
The phenomenon of insulin resistance is a violation of the realization of the effects of insulin. In this case, β-cells produce and secrete a sufficient amount of insulin, yet the tissues are resistant to insulin. The phenomenon of insulin resistance can occur at the insulin receptor level and the post-receptor level. The patient’s HbA1c level is 7.2 percent, which shows how the so-called old red blood cells (RBCs) and new ones appear with non-glycated hemoglobin. The patient’s test results indicate that his glucose level management is not appropriate since HbA1c less than seven percentage points to normal control. In addition, glucose fluctuates within the last three months. The unstable glucose level is another sign of insulin resistance.
The damage to the early stage of insulin secretion leads to excessive production of the hormone at a later time, which is clinically manifested by a boost in body weight as in the case of the given patient. The patient’s serum albumin (6.1 mg/dl) proves his diagnosis of diabetes and may be a sign of dehydration of the body. This is accompanied by the rise of insulin resistance, an increase in gluconeogenesis, a decrease in glucose utilization by the tissues, which together lead to glycemia (Craft et al., 2015). There is a decrease in insulin secretion induced by glucose and the conversion of proinsulin to insulin.
The peak of insulin secretion causes an immediate suppression of the production of glucose by the liver that controls the level of glycemia and inhibits lipolysis and glucagon secretion. As a result, one may observe the increases in insulin sensitivity of tissues, facilitating their utilization of glucose (Craft et al., 2015). Since the main place of the synthesis and accumulation of glycogen in the liver, its severe lesions that are accompanied by inhibition of glycogen-forming functions lead to a pronounced decrease in total glycogen stores. The level of protein (4+) that is above normal, as well as excessive urea level (25 mg/dl), show that the patient’s liver functioning is impeded and violated to some extent. In other words, the patient has a risk of the increased use of insulin in the future.
To diagnose diabetic nephropathy, it is significant to evaluate the presence of albumin secretion in urine analysis. The patient’s test presents albumin in his urine, which is characteristic of albuminuria. It is also important to pay attention to the complications of diabetes mellitus, such as damage to the eyes, nerves, and other symptoms that may indirectly indicate the presence of diabetic nephropathy. Babaliche, Nadpara, and Maldar (2019) state that the decreased Estimated Glomerular Filtration Rate is a sign of renal impairment, while it also may point to diabetic retinopathy. To correctly diagnose n nephropathy and retinopathy, other tests are needed. In addition, high blood pressure (HBP) faced by the patient may have the link with diabetes that damages arteries and leads to atherosclerosis, when arteries tend to narrow and block the blood flow. Currently, the patient’s HBP is asymptomatic except for tiredness of the eyes, yet medication should be prescribed to avoid further complications.
Potential Management Approaches
The management of patients with diabetes mellitus and hypertension should be focused on a complex of dietary and physical measures, drug therapy, and nursing interventions. According to the recommendations of the Australian Diabetes Society (ADS), a patient-centered approach should be applied to ensure that every patient’s individual health status is taken into account (Gunton, Cheung, Davis, Zoungas, & Colagiuri, 2014). One of the medical approaches is to start with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers, to which highly selective b-blockers should be added (de Boer et al., 2017). If required by the condition of the patient, both calcium channel blockers and diuretics can be included in the same combination. Diuretics are also useful for managing the patient’s pitting edema.
The second approach is to apply Sulfonylureas that significantly reduce insulin resistance, thereby negating the risk of cardiovascular complications. According to Gunton et al. (2014), lipid metabolism normalizes the level of triglycerides, and low-density lipoproteins decrease, while the level of free fatty acids and high-density lipoproteins increases. Since the patient’s glucose control is not stable, his Metformin intake should be supplemented by Sulfonylureas as the second-line dual oral therapy, as recommended by the ADS (Gunton et al., 2014). It is critical to take the patient’s obesity into account. There is a tendency to its reduction (123 kg compared to the previous 156 kg). However, in case of weight gain, the mentioned medication should be canceled, and the preference is to be given to a dipeptidyl peptidase (DPP)-4 inhibitor option in combination with metformin (Colagiuri, 2014). Considering that the patient has pitting edema in both legs, thiazolidinediones may be introduced to address fluid retention.
The medical approaches to the given patient should be selected with a focus on his age that 65. Potential life expectancy, cognitive impairment, and a higher risk of cardiovascular dysfunctions should be taken into account. Gunton et al. (2014) claim that “the glycaemic target should be symptom control only, or 64 mmol/mol (8 percent): (p. 653). The multiple drug therapy is to be reviewed periodically to prevent polypharmacy.
The management of hypertension should be carried out simultaneously with glucose-lowering therapy. It is essential to convey to the patient that the control of diabetes and hypertension should be ongoing and comprehensive. The next issue to consider for the patient is weight loss due to his obesity: the patient’s body mass index (BMI) is about 40. In patients with obesity with type 2 diabetes and hypertension, the decrease in body weight of about five percent of the initial weight leads to a decrease in blood pressure by 10 mm Hg. The enhanced lipid profile and relatively low risk of premature death are noted. Losing weight is a difficult task for both the patient and the doctor since the latter requires a lot of patience to explain to the patient the need for these non-drug measures, revising the usual diet, and considering options for regular exercise.
Nutrition is one of the key ways to control both conditions. Since up to 30 percent of hypertension cases are sodium-dependent, salt should be limited or completely excluded from the diet of the patient (Barclay, Gilbertson, Marsh, & Smart, 2010). It is required to clarify that there are a lot of hidden salts, including mayonnaise, dressings for salads, cheeses, and so on. It is also essential to restrict the intake of saturated and trans-fat and focusing on low glycemic index carbohydrates (Barclay et al., 2010). As for exercise as the non-pharmaceutical method to enhance the health status of the patient, it is possible to provide the guidelines developed by Diabetes Australia, the national body for diabetes treatment and prevention. Walking, dancing, gardening, swimming, golfing, cycling, and weight training are noted among the most beneficial sports (“Exercise”, n.d.). At least 30 minutes of exercising per day with low or moderate-intensity should be targeted. Care of feet and monitoring blood glucose level are two essential tips that are to be followed by the patient.
Nursing management approaches may include General Practice Management Plans (PMPs) or Team Care Arrangements (TCAs). Wickramasinghe et al. (2013) report that both of them are beneficial for the team caring about patients with diabetes, while reviews are also required to control the quality of these approaches. The paramount role of nursing care for the given hypertensive diabetic patient is to ensure that he properly follows the prescription of a doctor (Egger, Spark, & Donovan, 2013). In particular, all medications should be taken on time to facilitate current chronic symptoms and prevent their deterioration. For example, the control of the drug therapy may be conducted based on building proper communication with the patient and trust creation (Ginzburg, Hoffman, & Azuri, 2017; Phelps & Hassed, 2011). It is critical to make sure that all the questions, concerns, and expectations of the patient regarding medications would be met by a nurse.
The assistance with maintaining the patient’s lifestyle and nutrition is another approach that is important for the patient to accomplish the goals set. Irmak, Duzoz, and Bozyer (2010) emphasize the significance of educational programs that can be provided as follow-ups for patients once they were prescribed necessary interventions. The study of the identified authors demonstrates that the combination of lifestyle changes and antihypertensive treatment options is a feasible and measurable way nurses may contribute to the successful implementation of the strategies proposed by doctors for hypertensive diabetic patients. In their turn, Handley, Pullon, and Gifford (2010) focus on self-management of such patients and state that personal support systems are needed. Namely, nurses should pay attention to the patient’s specific needs, history, and culture.
The patient education plan should consist of several stages, including general information about target diseases, a focus on specific needs, the provision of support resources available in Australia, and ongoing communication. The Australian Diabetes Educators Association (ADEA) is the main organization that offers training to health care specialists who are expected to care about patients with diabetes and their concomitant diseases. During the two first stages of the education plan, a nurse should clearly structure necessary information and make sure that it is accessible to the patient (“Support services”, n.d.). In case of any questions, he should be encouraged to seek additional explanations from his doctor or nurse. The strategies on how to adjust his lifestyle and nutrition should be developed in cooperation with the nurse. For example, the fact that he has a juice bar is useful to promote more fruit consumption and avoiding a sedentary lifestyle.
A patient with diabetes should assess the level of blood pressure at each visit to the doctor, and people with existing hypertension should be measured at least two times a day. At the same time, it should be explained to the patient that he should measure his blood glucose level daily (Gray, Ferris, White, Duncan, & Baumle, 2018). The patient needs understanding and patience in order to begin to apply all this in life. It is rather important to comprehend that medication for the treatment of hypertension should be continued in a constant mode and at normal values of blood pressure, and not only at high. It is critical for the stable maintenance of blood pressure and the maximum reduction in the risk of acute cardiovascular events in the future.
The third stage of the education plan implies that the patient will be offered a range of support services, such as the helpline, peer support, et cetera. The National Diabetes Service Scheme (NDSS) launched by Diabetes Australia provides a registration card and a book for those who were diagnosed with diabetes as well as the opportunity to participate in group meetings and other related events. At the same time, Diabetes Australia also has information on hypertension management, which can be used by the patients. The patient should be motivated to seek additional information and assistance from his caregivers to timely respond to any changes in his condition and avoid difficulties (Dunning, 2012). Ultimately, the stage of continuous communication refers to contacting the patient to ask about his health and discuss any concerns that may occur.
To conclude, one should stress that the patient has type 2 diabetes and hypertension, which is complicated by obesity, edema, genetic history, and sedentary lifestyles. The patient’s pathophysiology was discussed in relation to his diseases, which allowed their emergence and connection. Both medical and nursing management approaches were examined in detail, considering age, lifestyle, and concomitant issues of the patient. The comprehensive education plan was developed specifically for the patient based on the support resources of Australia, focusing on communication, ongoing support, and increasing awareness of the patient’s diseases.
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