NR 601 Week 5 Case Study Diabetes Care (NR601)

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 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