Question

I have a case study that I need to make a concept map of and write interventions, patients response and evaluation. I'm having difficulty with doing it.

Below is the case study Scenaria:

Case Study 1 Diabetes Mellitus Type 2

? Scenario

Y.L., a 34-year-old Asian woman, comes to the clinic with complaints of chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination.

She tells you she has a vaginal yeast infection that she has treated numerous times with over-the-counter medication. She works full time as a clerk in a loan company and states she has difficulty reading numbers and reports, resulting in her making frequent mistakes. She says, “By the time I get home and make supper for my family, then put my child to bed, I am too tired to exercise.” She reports her feet hurt; they often “burn or feel like there are pins in them.” She has a history of gestational diabetes and reports that, after her delivery, she went back to her traditional eating pattern, which is high in carbohydrates.

In reviewing Y.L.'s chart, you notice she has not been seen since the delivery of her child 6 years ago. She has gained considerable weight; her current weight is 173 pounds. Today, her BP is 152/97 mm Hg, and a random plasma glucose is 291 mg/dL. The primary care provider suspects that Y.L. has developed type 2 diabetes mellitus (DM) and orders the following laboratory studies:

Chart View

Laboratory Test Results

Fasting glucose 184 mg/dL

HbA1C 8.8%

Total cholesterol 256 mg/dL

Triglycerides 346 mg/dL

LDL 155 mg/dL

HDL 32 mg/dL

UA +glucose, − ketones

1.     Interpret Y.L.'s laboratory results.
Fasting glucose 184 mg/dL = Tested after 8 hrs of fasting before breakfast.
Normal (below 100 mg/dL), Prediabetes (100-125 mg/dL) and Diabetes (over 126 mg/dL)
HbA1C 8.8% = When glucose binds to blood (hemoglobin), becoming ‘glycated’.
Normal (below 42 mmol/mol), Prediabetes (42-47 mmol/mol) and Diabetes (over 48 mmol)
Total cholesterol 256 mg/dL = Measures of the total amount of cholesterol in your blood, which is also measured based on age and gender: Healthy Women 20+ (125-200 mg/dL)
Triglycerides 346 mg/dL = type of fat in blood. Normal Triglyceride (below 150 mg/dL)
LDL 155 mg/dL = Known as bad cholesterol and known for buildup and blockage in arteries. Healthy Women 20+ (Less than 100mg/dL)
HDL 32 mg/dL = Known as good cholesterol for removal of buildup and blockage in arteries. Healthy Women 20 (+50mg/dL or higher)
Urinalysis (UA) = Glucose and Ketones are not normally found in the urine. Glucose found in the urine (glucosuria) is indication of high blood glucose. Ketone is part of the metabolism of fat (fasting) and can be found in urine (ketonuria) when fasting for long periods of time
2.     Identify the three methods used to diagnose DM.
1.     HbA1C
2.     Fasting glucose 184 mg/dL
3.     Oral glucose tolerance test = measures your body's response to sugar (glucose). Normal glucose (below 140 mg/dL), Prediabetes (140 and 199 mg/dL) and Diabetes (above 200 mg/dL)
3.     Identify three functions of insulin.
1.     Stimulates the uptake of glucose from the blood into cells
2.     Provides anabolic properties of glucose
3.     Usage of glucose by cells to produce energy
4.     Describe the major pathophysiologic difference between type 1 and type 2 DM.
1.     Type 1: The body is unable to produce insulin because the beta cell of the pancreas are destroyed by auto-immune cell, usually affect those of a younger age, obesity and family history is usually ruled out as cause, insulin is required
2.     Type 2: The body is unable to respond to insulin, usually affect those of older age, obesity and family history is usually considered as cause
5.     What are the risk factors for type 2 DM? Place a star or asterisk next to those that Y.L. exhibits.
Risk factors associated with Type 2 Diabetes M:
1.     Lack of exercise*                        4. Family History                              7. Ethnicity
2.     Overweight*                    5. Age (over 40 years old)               8. Lifestyle*
3.     Unhealthy eating*                     6. High Blood Pressure*     9. Gestational Diabetes*

Y.L. is diagnosed with type 2 DM. The PCP starts her on metformin (Glucophage) 500 mg and glipizide (Glucotrol) 5 mg orally each day at breakfast and atorvastatin (Lipitor) 20 mg orally at bedtime. She is referred to the dietitian for instructions on starting a 1200-calorie diet using an exchange system to facilitate weight loss and lower blood glucose, cholesterol, and triglyceride levels. You are to provide education regarding pharmacotherapy and exercise

6.     What is the rationale for starting Y.L. on metformin (Glucophage) and glipizide (Glucotrol)?
Metformin (Glucophage) taken with a meal to help control the amount of sugar in the blood by decreasing the amount of glucose released by the liver and produced from food
Glucotrol is taken first thing in the morning before breakfast to control blood sugar levels by helping the pancreas to produce insulin.
7.     What teaching do you need to provide to Y.L. regarding oral hypoglycemic therapy?
Teach Y.L.:
1.     To monitor blood glucose and interpret blood glucose readings before each meal
2.     To monitor for sign/ symptoms of hypoglycemia from oral hypoglycemic therapy and how to immediately reverse its effect if needed.
3.     To monitor vital signs: Blood pressure (high), pulse (high) and temperature (sweating)
4.     To monitor physical signs: Pallor, weakness/ fatigue, increased sleeping
5.     Sign of liver damage: Yellow skin, dark urine and pale stool
8.     What potential benefits could Y.L. receive from encouragement to exercise?
Exercise will help catabolize the excess of glucose in the blood into heat and energy for the body to improve glucose control, weight management, lower unhealthy cholesterol level and prevent fatigue. Exercise helps to prompt circulation to extremities to prevent pallor and neuropathy.

Y.L. comments, “I've heard many people with diabetes can lose their toes or even their feet.” You take this opportunity to teach her about neuropathy and foot care.

9. Which of the symptoms that Y.L. reported today led you to believe she has some form of         neuropathy?

Y.L. reported “her feet hurt; they often “burn or feel like there are pins in them.”

10. What findings in Y.L.'s history place her at increased risk for the development of other forms of neuropathy?

Based on the findings frequent urination, difficulty reading numbers and reports and lack of exercise places Y.L. of increased risk of the development of neuropathy. This type of neuropathy cause by diabetes affects the nerves that innervate the autonomic nervous system such as the bladder (urination) and eyes (sight).

      11. How would you educate Y.L. about neuropathy?

Educate the importance on neuropathy’s effect on those with diabetes isn’t immediate and happens only after prolong neglect of high blood sugar levels. Prolonged high blood sugar usually affect nerves fibers innervating the automatic nervous system and extremities. Just like diabetes, there is no cure for neuropathy but the ways treat and manage its progression are similar to diabetes. Also, the signs and symptoms of nerve damage such as pain, burning, tingling and numbness and how it can affect the body especially the feet. Once sensation is lost in the feet special care is then needed to prevent the progression of a serious infection.

12.       Because Y.L. already has symptoms of neuropathy, placing her at risk for foot complications, you realize you need to instruct her on proper foot care. Outline what you will include when teaching her about proper diabetic foot care.

1.     Prevent any or further damage to the foot by wearing shoes at all times in and out doors
2.     Daily foot care routine, which includes: Washing/ drying of feet, having toenails trimmed and taking time to inspect the skin of the foot especially soles of any skin breakdown (blisters, cracks or sores)

     13. What are some changes that Y.L. can make to reduce the risk or slow the progression of both macrovascular and microvascular disease?

1.     Macrovascular disease includes cardiovascular, cerebrovascular and peripheral vascular complications associated with diabetes. Y.L.’s diabetes increases her chances of experiencing a stroke, heart disease and peripheral vascular disease
To slow the progression of macrovascular disease in Y.L. case, she would need a proper diet, regular physical activity and control her LDL levels.
2.     Microvascular disease includes retinopathy, nephropathy and neuropathy complication associated with diabetes. If her diabetes is kept unchecked it can leads to blindness, renal failure and amputation respectively.
To slow the progression of microvascular disease in Y.L. case, she would need to tightly monitor her sugar level, start a low protein diet, monitor kidney and eye function.

     14. Given all of the information in the foregoing scenario, what DM-related complication do you believe Y.L. is most at risk for, and why?

Given all of the information provided, Y.L. is most at risk for neuropathy. In the report she stated “her feet burns or feel like there are pins in them” and that is coupled with lack of exercise. The combination of the two increases her chances the chances of developing diabetes acquired neuropathy if her diabetes is controlled.

     15. What monitoring will be needed for Y.L. in regards to nephropathy and retinopathy?

            1. Nephropathy: In regards to nephropathy, her urine sample will be tested for the proteins albumin and creatinine. If proteins are found in the urine, it may indicate renal damage. Blunt percussion of the kidneys for indication of tenderness, any lower back pain, burning or pain while urinating could indicate kidneys stones, UTI or infections.

            2. Retinopathy: Diabetes complication that affects the individual’s vision by damaging the blood vessels that supplies the retina and causing premature growth of new blood vessels that later leaks fluid increasing fluid pressure in the eye. Any sudden vision changes will need to be monitored.

Answer 1

Process map for Type 2 Diabetes Mellitus