diabetes

| August 24, 2015

diabetes

825 words (please wrthout In text references)
12 references
Structure and presentation:
Your response should include a brief (one sentence) introduction, followed by the case
analysis (one paragraph for each of your chosen topics) and a brief (one/two sentence/s)
conclusion. Do not use dot points, headings or tables.
Questions:
This question is based on the case studies(Nick and Marty). Nick has Type 1 Diabetes
Mellitus and Marty has Type 2 Diabetes Mellitus. They are both managed by the same
General Practitioner and see the Community Diabetes Nurse. You notice that their
diagnosis is different in that Nick has Type 1 Diabetes Mellitus and Marty has Type 2
Diabetes Mellitus and that their management plans including their medications are also
very different.
1. Discuss the potential causes for the loss of the pancreatic beta cells function in the
DM1 and the DMZ.
2. Describe two types of diabetes medications including one oral and one
subcutaneous and their effects on blood glucose in relation to Diabetes Mellitus
(pharm kinetics and pharmacodynamics).
Evaluation of Thinking
-_
Clear, detailed description of pathophysiology identifying the
Science alterations from the normal anatomy and physiology, thoroughly
5?
5 PathophySIology revnews and Integrates current and relevant literature.

E Succinct description of the drug including mechanism of action.
8 Pharmacology Detailed description of the pharmacodynamics.
3 Logic and flow Development is logical and clear to reader; points are addressed
2 individually and linked appropriately
The paper presented will address 2 questions.

Marty Jones visits the Indigenous health clinic
Marty Jones seeks help

Marty visits the clinic
You are on clinical placement at an Indigenous primary health clinic. Marty Jones, a 67
year old local man, presents to the clinic asking to see a health care worker. You and
Stacey, an experienced Indigenous Registered Nurse, are assigned to assess Mr Jones.
He reports that he has been in good health until about two months ago when he started
to feel weak and tired more rapidly than usual. On questioning, he admitted to getting up
two or three times a night to urinate. He also is often thirsty at those times and drinks a
glass of water each time.
His weight was average through high school, when he was on the rugby league team.
After leaving school, he has gradually gained weight over the years. His appetite remains
good, but he is now losing weight and describes feeling weak.
He reports that he gets pain in his feet, but the pain is worse at night and sometimes
keeps him awake. It is burning in character and sometimes his toes feel numb. The
tingling and numbness in his fingers is causing him problems at his work as an auto
mechanic because he frequently drops small parts or has difficulty making fine manual
adjustments to engines.
His vision is blurry at times, especially in the afternoon.
Apart from an appendectomy in 1976, he reports no surgeries or chronic illnesses. His
last dental visit was 6 years ago.

Marty’s family history
Both Marty’s parents are deceased. His father died at age 69 from a massive stroke. His
mother died at age 62 from end-stage kidney disease. She was found to have type 2
diabetes mellitus at age 48, which was marked by major complications including partial
amputation of her right foot. She was on dialysis for three years before her death. Marty
was primarily responsible for his mother’s care during her later years. He administered
her insulin twice a day and transported her to and from the dialysis centre.

Marty is the youngest of four children and weighed 4.6 kg (10 lb 3 oz) at birth. Both
parents were overweight, as are his siblings, two of whom have diabetes.

Social history and habits
He is married and lives at home with his wife. He has three adult children. He works as
an auto mechanic. He does not smoke. He drinks an occasional beer. He takes no
medications, nutritional supplements or herbal remedies.

Physical examination








Weight: 98 kg
Height: 180cm
Pulse: 76, regular
BP: 142/78
Mild bleeding of gums reported with tooth brushing. Halitosis present.
Chest and abdomen examination normal.
Feet – skin dry with calluses on the medial side of the big toes. Nails normal. Pulses
strong and equal. Sensation normal.
Urinalysis – 4+ glucose, negative for ketones and protein
Random blood glucose – 13.5mmol/L ?

Medical diagnosis and treatment
Dr Smith, the centre’s doctor, diagnoses Marty as having type 2 diabetes mellitus and
starts him on Metformin 500mg tds. He refers him to the centre’s diabetes nurse for
education.

After the diagnosis
On the way out from the doctor’s visit, Mr Jones admits to you that he’s scared now. He
had hoped it wasn’t diabetes like his mother and siblings, and is frightened that he’ll have
to lose his legs.

Marty seeks further help

Marty revisits the clinic
2 weeks has passed and you are now in the final week of your cinical placement when
Marty returns to the clinic concerned about his foot. On a previous review at the clinic
Mary mentioned that he was having some burning pain and numbness in his feet, but
now Martyl has noticed that one of his socks is sometimes blood stained and damp,
stating that sometimes this “smells funny”. He asks you to take a look at his feet.
On review you can identify a diabetic ulcer under Marty’s big toe on his right foot. Marty
thinks this was caused by a stone in his shoe. Before you dress the wound, the doctor
reviews his wound orders a wound swab and commences Marty on empiric oral
antibiotics (Amoxycillin-Clavulanate 500mgs QID). You clean and dress Marty’s wound
as instructed by your clinical facilitator, meanwhile, she contacts the community nurse to
arrange a referral for daily dressings. The RN also contacts the community diabetic nurse
educator who already knows Marty from his diagnosis a few weeks ago, to inform her of
Marty’s current health issue.

Marty worries about loosing his legs

Psychological concerns regarding complications
Marty once again mentions that he is worried about loosing his legs. Marty has a friend
who has had a below knee amputation and has seen how devastating this complication
of diabetes can be.
The RN discusses Marty’s medication regime, his diet, blood glucose monitoring and foot
care, reassuring Marty that if he remains vigilant with his diabetes management that
there is minimal risk of this. The RN also relays these concerns of Marty’s to the diabetic
educator for her to followup with Marty on her next visit.

Nick’s health is suffering as he starts to live life in
the ‘fast lane’
Nick begins university

Nick at uni
Nick, 18, has just begun his first semester in his first year of an engineering degree at
University of Sydney. He was diagnosed with type 1 diabetes mellitus at age six and prior
to his first semester at uni, Nick’s parents had helped Nick maintain strict control over his
blood glucose levels, insulin administration, diet, exercise and overall health. He is
currently prescribed Humulin R Twice a day. When Nick was in high school, several
teachers on staff were very supportive of his condition and encouraged Nick to maintain
regular eating schedules and inject insulin at regular intervals. For years, his diabetes
was managed well.
He is living away from his parents and siblings for the first time and lives in on-campus
dormitory university accommodation. Over the past several months, Nick has been
introduced to many stressors that he is challenged by. He is away from the support of his
family, he is responsible for his own meals and insulin management, he is involved in a
whole new social group, and he is struggling to keep up with the workload of his course.
In addition, Nick is on the university’s rugby team and feels peer pressure from his
teammates to engage in activities such as chasing girls, binge-drinking, late night fastfood runs, skipping class, pulling all-nighters before exams and extreme training
schedules.

Presentation to Emergency
After a night of hard-core partying, friends found Nick looking unwell in the dorm’s
common room and brought him to the hospital’s Emergency Department. Nick’s friends
reported that they found him shaking and sweating uncontrollably, and floating between
being unconscious and irritable and uncooperative. They put him in their car and brought
him straight to the Emergency Department.

Observations on arrival
Upon arrival, Nick’s observations were:




Blood pressure – 140/94
Pulse rate – 116bpm
Respiratory rate – 26 breaths/min, shallow
Temperature – 37.5oC
O2 Sat – 93%.



Skin – diaphoretic, warm and pale
Trembling
Blood glucose level – 2.5mmol/L

Medical diagnosis and treatment plan
The doctor diagnoses Nick as having a hypoglycaemic episode. Nick’s immediate
treatment includes the administration of SC 1mg glucagon and 50mL of 50% Glucose, IV
over 2 hours.

Nick in the medical ward

On the ward
It is now three days later and Nick’s condition is stable. You are the nurse assigned to
Nick for the duration of your shift on the medical ward. Nick’s current vital signs are as
follows:
BP
Pulse
RR
Temp O2 sats
128/78 60 beats/min 16 breaths/min 37.5oC 97%

He is alert and oriented to person, place, and time with no subjective complaints of pain.
He is neurologically intact. His blood glucose level has stabilized to his pre-university
state of 7.8 mmol/L (non-fasting state). He is eating regularly and his fluid intake is equal
to his fluid output.

Where to from here?
Nick does not want his parents to discover that he is in the hospital for the second time in
seven months and has asked the team not to inform his parents. After his last admission
in his first semester, his parents were threatening to pull him out of university and have
him attend a local university so that he can return home.

Nick is readmitted to hospital and transferred to the
medical ward
Nick becomes unwell again
It is now at the end of the university year and Nick has represented to the local hospital.
He presented to the Emergency Department late the previous evening very unwell,
complaining of vomiting for the past two days and admitted to skipping several doses of
insulin recently. He mentioned that he was feeling feverish at home and reported an
occasional cough. He was transferred to the medical ward this evening from the
Emergency Department and is assigned to your care.
Whilst reading through Nick’s notes from his assessment in the Emergency Department,
you find the following: pain throughout all abdominal quadrants with “cramping” reported
in all four abdominal quadrants. He was extremely lethargic and difficult to rouse at times.
He complained of severe thirst. His skin was extremely dry. Electrocardiogram (ECG)
showed a sinus tachycardia at 120 bpm. Lungs were clear bilaterally, but respirations
were deep and rapid. There was an acetone smell to Nick’s breath. He denied alcohol
and illicit drug use and could recall no drug or food allergies. He did report that one of his
aunts has type 1 diabetes mellitus.
You are aware of Nick’s social history as a university student. You notice Nick’s last
hospital admission was for hypoglycaemia resulting from his university life style.
However, since Nick has presented with a different health issue related to his Type 1
Diabetes, you ask him about his current situation. Nick states, “I often struggle with the
costs of university and rugby and sometimes my medication runs out or I forget to get my
scripts filled”.
During the past year, Nick has been admitted to the hospital with the diagnosis of
hypoglycaemia once and diabetic ketoacidosis (DKA) once. In addition, he had failed to
attend two of his follow up appointments, because he couldn’t take time off university to
attend appointments.

On arrival at the ED

Observations
On arrival at emergency, Nick’s observations were:



BP 124/80
HR 122 bpm
Respirations 32/min
Temperature 35.8o C

Urinalysis
His initial urinalysis revealed:





Specific gravity: 1.015
Ketones: 4+
Leukocytes: few
Glucose: 4+
Nitrates: 0
RBCs: many

Bloods
His initial blood studies revealed:










Hgb: 14.5 g/dl
Hct: 58%
Ca+: 8.8 mmol/L
Phosphate: 6.8 mg/dl
Na+: 126 mmol/L
K+: 5.3 mmol/L
Cl-: 95 mmol/L
Creatinine: 0.9 mg/dl
BUN: 52 mg/dl
Glucose: 254 mg/dl
Ketones positive

Arterial blood gases




pH: 7.19
PO2: 100 mm Hg
HCO3: 10 mEq/l
PCO2: 20 mm Hg
SAO2: 98% (room air)

Medications
Nick’s daily insulin doses are as follows:

mane 16U 30/70 Humulin
nocte 12U 30/70 Humulin

Whilst in Emergency, the priority of care for Nick was the correction of the following: fluid
loss with intravenous fluids, hyperglycaemia with insulin, electrolyte disturbance,
particularly potassium loss, and his acid-base balance. Fortunately, he responded well to

his treatment, and once his blood studies began to improve and he was able to tolerate
oral fluids and food, he was transferred to the medical ward for ongoing assessment over
the next three to five days.

Treatment on the ward
Nick arrives on the ward with the following orders:






IV 0/9% normal saline q6h
Strict fluid balance chart
Diabetic diet, as tolerated
Hourly blood glucose test
q6h blood tests (including full blood count, serum electrolytes and chemistry, venous
blood gas, glucose, urea)
Test all urine
Continue with his insulin regime

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