Assignment 3: Case study
Assignment 3: Case study
You are required to read the following case study and assessment data and then answer all the questions. All questions must be answered to a satisfactory level for you to pass this assessment.
Case study
Mary Baker is 54-year-old woman of Aboriginal and Torres strait Islander background. She has presented to hospital with fatigue and an ulcer that wont heal for investigation. She lives with her husband and spends most of her day watching TV.
On admission, the following information was obtained from Mary:
Measurements
Height: 162 cm
Weight: 90 kg.
Waist Circumference: 100 cm.
Past Hx
Hypertension 165/95
Hypercholesterolaemia
Current smoker: 15 cigarettes / day
3-4 alcoholic drinks per day
Family history
Father deceased aged 68 MIMother deceased aged 62, type 2 DM and strokeAssessment data
fatigue
polyuria
polydipsia
tingling and numbness in both feet
blurry vision
nocturia
BGL - 15.2mmol/L
left foot is dusky and cool to touch, with sluggish capillary refill3cm x 2.5 cm ulcer on her left heel, which has been there for at least 18 months, and will not healdevelops pain in her left calf when walking around housereports chest pain and feels sweaty and anxious when ambulating for longer periods, i.e. walking around shops.
urinalysis showed positive for protein
Questions
Mary has now been diagnosed with type 2 diabetes. What risk factors did Mary present with that would have contributed to the development of this disease?
Age (>45) 54 years old, therefore represents a higher riskHypertension- Having high blood pressure makes diabetes more likely to develop.
Family history- (genetically) father deceased aged 68 MI mother deceased aged 62, type 2 DM and stroke
Aboriginal and Torres strait Islander background most risky group
Inactive lifestyle- spents most of her day watching lifestyle.
Obesity BMI 34.3 (Female, Height 162cm, Weight 90kg) higher risk category
Passive smoking - Current smoker: 15 cigarettes / day, contributes to higher chances
Alcohol consumption- 3-4 alcoholic drinks per day, excessive intske can increase the risk
How does her pancreas and her body cells function differently to someone who has Type 1 diabetes?
In type 1 diabetes, the pancreas stops producing insulin because the body's own immune system has destroyed its beta cells, but in type 2 diabetes, the pancreas either does not produce enough insulin or it is insufficiently effective to have the desired effect of allowing blood glucose to enter cells.
Explain the pathophysiology of ALL the assessment data reported:
fatigue
polyuria/polydipsia/nocturia
tingling and numbness in both feet
blurry vision
BGL - 15.2mmol/L
left foot is dusky and cool to touch, with sluggish capillary refill3cm x 2.5 cm ulcer on her left heel, which has been there for at least 18 months, and will not healdevelops pain in her left calf when walking around housereports chest pain and feels sweaty and anxious when ambulating for longer periods, i.e. walking around shops
urinalysis showed positive for protein
FATIQUE
or exhaustion, happens when the body cells do not receive enough glucose to produce ATP, despite the fact that it is present in the blood. Insulin makes it easier for glucose (sugar) to pass from the blood into the body's cells. Her disease is the result of either a lack of insulin or its ineffectiveness.
POLYURIA
Because of the high blood sugar levels, the kidney is working harder to filter out the extra sugar in the blood, which causes more frequent urine.
POLYDIPSIA
As the body produces more urine in an effort to eliminate sugar from the blood, they get extremely thirsty as a result of the fluid movement. This causes the body to lose water, which causes dehydration and severe thirst.
NOCTURIA
A normal person's kidneys should produce less urine and urine that is more concentrated at night. However, in diabetes patients, the kidneys are actively trying to filter out too much sugar in the blood, which results in increasing urine outputs even at night.
TINGLING AND
NUMBNESS
Long-term high blood sugar levels can induce diabetic neuropathy, which damages the peripheral nerve system severely and frequently results in numbness, discomfort, pain, and sensations like needles and pins. Microvascular injury can result in reduced tissue perfusion, which in turn might also cause oedema in her extremities.
BLURRY VISION
Blood that contains too much sugar destroys the retinal blood vessels in the eye, causing them to leak and cause diabetic retinopathy, which impairs vision.
BGL
When we take carbs, they are digested and transformed into glucose, which is taken into the bloodstream. Insulin is required to transport blood glucose into cells from the bloodstream; otherwise, blood glucose levels would continue to rise, resulting to Hyperglycemia, as in her situation.
LEFT FOOT DUSKY AND
COOL TO TOUCH
They may display the symptoms mentioned above due to impaired blood circulation induced by high sugar levels causing damage to blood vessels such as constriction of blood vessels due to atherosclerosis resulting in Peripheral Vascular Disease (PVD).
3CM X2.5CM ULCER
Decreased blood circulation (Peripheral Vascular Disease) to the site to aid healing, as well as elevated blood sugar levels, increase bacterial development and infection, further complicating the recovery and healingprocess.
DEVELOP PAIN IN
Left calfDecreased blood circulation and nerve damage caused by high blood sugar levels, resulting in muscular soreness during activity and walking related to decreased blood flow, depriving cells of much needed nutrients and oxygen.
REPORT CHEST PAIN AND
FELLS SWEATY
May be triggered by a number of causes such as exhaustion due to a lack of energy produced by insulin insufficiency, impaired blood vessels due to blood vessel constriction caused by atherosclerosis, which leads to cardio vascular disease and its related symptoms.
URINALYSIS SHOWED
POSITIVE FOR PROTEIN
The pancreas produces enough insulin in a person with type 2 diabetes, but the body cannot utilise it properly. High blood sugar levels may strain the kidneys as they filter the blood, causing kidney injury. Protein (albumin) can leak into the urine as a result of this injury.
Mary will require care from a multi-disciplinary care team. List seven health care professionals that could aid Mary and detail the care that they would provide. Make sure it is relevant to Mary.
General practitioner (GP) - plays a key role in monitoring and management of diabetes including general health. They can help set blood glucose targets and review on a regular basis formulating care plans for patient. Also provides referrals to specialists such as podiatrist, dietician, physiotherapist as and when required
Diabetes educator -. assists patients in understanding and managing their diabetesAccredited practicing dietitian - They can collaborate with the patient to encourage and discuss a healthy diet.
Ophthalmologist or optometrist - People with diabetes are at a higher risk, so they are able to maintain an eye on patients' eye health and manage any necessary treatment.
Podiatrist - A specialist that can examine, observe, and treat any difficulties that patients may have with their feet in order to keep them healthy.
Pharmacist - A a specialist who may advise patients on how and when to take their medications, how they function, and any possible adverse effects.
Endocrinologist - A medical professional who specialises in glands and hormones. They can provide expert advise to individuals on how to control their diabetes. If necessary, GPs will send their patients to an endocrinologist.
Identify three nursing diagnoses related to Mary. These could be something that she is at risk of or something she already has. Remember a nursing diagnosis is not a medical diagnosis. Think of it terms of the problems she is experiencing or may experience related to her medical problems. For each diagnosis, list three nursing interventions, each with a rationale (reason why the intervention will work), you would implement to help this client. Use three separate plans one for each nursing diagnosis.
Nursing diagnosis 1 Interventions Rationale
State relevant issue What is to be done What are the reasons this is relevant/necessary/will work
Impaired wound healing related to peripheral vasucular diseseFollowing and maintaining stict wound care regime or as per doctors order
To make sure optimum healing and infection prevention
Ensure aseptic technique is maintained while attending to wound care
To prevent the spread of infectious pathogens through the wound.
Refer to dieticianTo plan and discuss most effective nutritional consumption.
Nursing diagnosis 2 Interventions Rationale
State relevant issue What is to be done What are the reasons this is relevant/necessary/will work
Risk for unstable blood glucose related to lack of adherence to diabetes management
BGLs should be checked and monitored before meals and before going to bed. Tomakeensure blood glucose levels are within the therapeutic range of 4-8 mmol/L. If not, take precautions to avoid hypoglycemia or hyperglycemia.
Encourage patients to exercise for 30-60 minutes at least 3-4 times per week.
In addition to diabetes medication, regular exercise can help control diabetesblood sugar control.
Educate the patient on the importance of following the prescribed dietary planfrom dietician Prescribing a nutrition plan would help her maintain stable blood sugar levels.
Nursing diagnosis 3 Interventions Rationale
State relevant issue What is to be done What are the reasons this is relevant/necessary/will work
Fatigue related to decreased metabolic energy production
By assisting patient in prioritising her role responsibilities and preferred activities.
To let the patient to utilize available energy to accomplish most important tasks therefore reaching her intended goals which might enhance the mood and sense of emotional wellness.
Encourage the patient to participate in an exercise conditioning programme to improve muscular strength and tone. Fatigue that results from deconditioned weak muscles can be treated with muscle strengthening activities that enhance functional ability.
She can learn ways to conserve energy with the help of an occupational therapist. Organisation and time management can assist patients in conserving energy and decreasing exhaustion. The occupational therapist can supply assistive equipment and educate the patient on ways to conserve energy.
Mary is commenced on oral hypoglycaemic therapy. Describe in simple terms the different ways these drugs work. You do not have to list their different names but you must explain how they help maintain stable BGLs.
Biguanides- Lowers BGLs through decreasing glucagon release, increases insulin sensitivity and muscle uptake, and lowers intestine absorption.
Sulphonylureas- Increase insulin production by stimulating beta cells.
Alpha-glucosidase Inhibitors- aid in the slow digestion and absorption of specific dietary carbohydrates in the stomach (intestine)
Dipeptidyl peptidase 4 (DPP4) inhibitors- decrease blood glucose levels by improving insulin secretion while lowering glucagon secretionSodium-glucose transporter (SGLT2) inhibitors - kidney glucose reabsorption inhibition
Incretin mimetics - Increases pancreatic insulin production and secretion, decreases glucagon secretion, and delays stomach emptying.
This morning, before breakfast, you go to assess Mary and find that she is pale and sweaty, irritable and restless. You take her BGL and the reading is 3.5mml/l. What nursing interventions will you provide immediately? What follow up interventions will you implement depending on how she responds?
We would treat her for hypoglycemia given her BGL is less than 4 mmol/L; she is conscious, we could give her 6-7 jellybeans OR 1/2 can of ordinary soft drink OR 1/2 glass of fruit juice OR 3 tablespoons of sugar or honey OR Glucose tablets equivalent to 15 grams carbohydrate. Checkherblood sugar again after 15 minutes to see if blood sugar is above 4 mmol/L. If not, you can repeat the above process up to the equivalent of 15 grams of carbohydrates. Snacks containing long-acting carbohydrates such as 1 slice of bread, 1 glass of milk, 1 piece of fruit, or 2-3 dried apricots, figs, or other dried fruits if your blood sugar is above 4 mmol/L or feed. or 1 cup low-fat natural yogurt or pasta or rice.
Mary confides in you that she is having difficulty coping with her diagnosis. List three factors that may impact on her self-esteem.
She has chronic illnesses such as diabetes that require her to take medication andmonitorher diet for the rest of her life.
The condition has developed physical limitations that limit her capacity to complete everyday tasks and meet her job responsibilities, causing pain and tiredness.
Recognising the vulnerability she would be to complications such as a foot ulcer that may not heal easily and problems with her eyes.
In the RACGP hand book for general practice Management of type 2 diabetes it is recommended that patients should be advised to eat according to the Australian dietary guidelines (Eatforhealth, n.d.). Using these guidelines develop a detailed meal plan for one day that you could give to Mary as a dietary guide to use upon discharge.
BREAKFAST All bran, cereal, oats, porridge and milk
Whole meal toasted with margarine
Apple or pear
Tea or coffee with sweetner if needed
Drink plenty of water if appropriate (unless on fluid restriction)
LUNCH Rice ( low GI), pasta (wholemeal or grain)
Lean meat, chicken, fish or eggs
Least starch vegetable (mushrooms, cabbage, beans, broccoli, spinach, cauliflower)
Fresh fruits, sugar free jelly, no added sugar tinned fruit
Drink plenty of water if appropriate (unless on fluid restriction)
DINNER Vegetable soup, lentil soup, pea and ham soup
Wholemeal bread with margarine
Low carb salad plate
Sugar free jelly or low fat un sweetened yoghurt
Tea or coffee
Drink plenty of water if appropriate (unless on fluid restriction)
MID MEAL/ SUPPER Wholemeal sandwiches
Sugar free cakes and biscuits
Tea or coffee
Drink plenty of water if appropriate (unless on fluid restriction)
AVOID OR LIMIT FOOD THAT CONTAINS SATURATED FATS, ADDED SALT, ADDED SUGAR , TOO MUCH PRESERVATIVES AND CONSUMPTION OF ALCOHOL
List two organisations that could provide support to Mary and detail the support that they provide. Ideally should be an Australian organisation that Mary could contact directly.
Diabetes Australia
It may assist Mary with information on her disease, how to control it, what to eat, how to handle medication, and an extensive range of other diabetes-related topics.
Diabetes Australia is dedicated to decreasing diabetes's consequence. To reduce the burden of diabetes on the Australian population, they collaborate with diabetic health professionals and educators, researchers, and healthcare providers. Individuals suffering with diabetes can use it as a resource for information and guidance in obtaining care.
National Diabetes Services Scheme (NDSS)
Mary can get help from NDSS to get access to support services, subsidised equipment, and supplies. They can also teach her about the illness process and how to deal with its effects. NDSS improves persons with diabetes' ability to comprehend and self-manage their diabetes, as well as access services, support, and subsidised diabetic products.
What education will you proved to Mary to ensure that her diabetes is well managed and to reduce her risk of her complications worsening. List all the information that she would need to know to manage her condition well, e.g. diet, medications, lifestyle changes, sick days, complications, monitoring etc. Use 300-500 words for this section.
Heart Disease- Educate her about the dangers that diabetes individuals face in terms of heart disease caused by blood glucose blocking the blood arteries (atherosclerosis) and so increasing blood pressure.Educate her the relationship between activity, food consumption, and blood glucose levels.
Slow healing and recovery- Discuss with her that she should not ignore any cuts or blisters and that they should be treated right away or they can become major infections, resulting in amputations. Educate her how to monitor her blood sugar levels and when it is appropriate to do so.
Eye impairement or vision issues- Let her aware that she is at risk for serious eye illnesses that include cataracts, glaucoma, and harm to the blood vessels of the retina, which may result in blindness.
Kidney damage or impairment- Discuss how repeatedly increased blood sugar levels may strain the kidneys, resulting in permanent kidney disease that requires dialysis or a kidney transplant. Explain her the significance of adhering to approved meal plans in order to reduce the risks that are associated.
Nerve damage- Discuss how elevated sugar levels may cause issues including neuropathy, which causes tingling, numbness, discomfort, and burning sensations. It might start at the extremities and progress upwards. Numbness may cause her to be ignorant of injury to her body. To avoid harm, she should be encouraged to use protective aids such as shoes.
Skin issues or conditions- Advise her that her high blood sugar levels will make her more susceptible to skin disorders such as bacterial and fungal infections, since her body's capacity to fight them will be limited.
Providing Information on the necessity of having a healthy lifestyle, such as eating good foods, becoming active, decreasing weight, quitting smoking, reducing alcohol use, and avoiding lengthy periods of sitting down.
Other potential issues include an increased chance of developing hearing impairment, sleep apnea, and Alzheimer's disease, which cannot be directly connected to the condition but can be linked to a combination of effects from Peripheral Vascular Disease and diabetic neuropathy.
Explain the medications that she was prescribed and how they function to reduce her blood glucose.
Educate herthe signs and symptoms of hypoglycemia, as well as the measures she may take to improve her blood glucose levels if required. This includes managing'sick days' where blood glucose control differs from regular days.
Educate her regarding the health carespecialists and the multi- disciplinary teamthat are involved andthe ways she may benefit from them, and the ways she can seek referrals to access their services.
How will you immediately evaluate her understanding after you have provided this education?
To assess how well she understands, we may ask her to describe her knowledge of this illness and how it relates to the symptoms she is experiencing.
Afterwards we might offer her open-ended questions to assess her knowledge of what she had learned and the relevant supportingwritten resources.
It is essential to determine if she is aware of risks associated with her condition, how much prioritise she gives on them, and how she aims to manage them.
We need to look at how she reads prescription medicine labels in accordance with what she has been educated.
Encouraging her to ask questions and clear up her issues should be a part of the process.
If there happen to be any issues understanding as a result of communication skills or cultural differences, we must address them to allow for learning to be helpful.
Marys sister is living in outback Australia. Explain the environmental and social factors contributing to diabetes in Aboriginal and Torres Strait Islander populations.
Walkability- People who live in safe neighbourhoods that are walkable that have fewer crime, traffic, and pollution and ample sidewalks were shown to be more physically active and at a lower risk of acquiring diabetes than those who live in less secure areas.
Air pollution- According to research, air pollution raises the likelihood of developing type 2 diabetes. It has been suggested that air pollutants lead towards dysfunction of endothelial cells, adipose inflammation and insulin resistance all which contribute towards the disease condition.
Elderly population with a reduced level of activity because of illnesses- With individuals living longer as a result to improved diagnostic capabilities and medical treatment choices, the majority of the older population falls into the high diabetes risk group of being elderly, having hypertension, beingoverweight, and being not physically active.
Fast food comfort, which may be harmful in many ways. People are busiest than ever before, with less time to prepare healthy meals for their own health, thus eating fast food is an easy way out with a higher diabetes risk.
Social media, streaming applications, and video games have a priority over outdoor recreational sports, encouraging insufficient physical exercise and the intake of high sugar beverages and unhealthy andpoor junk food, both of which increase the risk of becoming overweight and contribute to diabetes.
In terms of diabetes being increasingly common in Aboriginal and Torres Strait Islander populations, some claim that changing from a 'hunter-gatherer lifestyle' to a 'westernised lifestyle' contributed to metabolic abnormalities of diabetes in them; however, the following factors can be considered in the current context. When compared to non-indigenous persons, Aboriginal and Torres Strait Islander people were more likely to be overweight, hve high blood pressure, more likely to intake alcohol and smoke, less likely to meet the vegetable and fruit consumption recommendation.
REFERENCES
RACGP - Applying the 5As to each risk factor. (2018). Racgp.org.au. https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/snap/applying-the-5as-to-each-risk-factorSane Australia. (n.d.).StackPath. Www.diabetesaustralia.com.au. https://www.diabetesaustralia.com.au/wp-content/uploads/The-SANE-Guide-to-Good-Mental-Health.pdfPrevention of Type 2 Diabetes, Gestational Diabetes & Cardiovascular Disease. (n.d.). The Life! Program. https://lifeprogram.org.au/prevention/Glycemic index NDSS. (n.d.). Www.ndss.com.au. https://www.ndss.com.au/living-with-diabetes/health-management/nutrition/glycemic-index/Dendup, T., Feng, X., Clingan, S., & Astell-Burt, T. (2018). Environmental Risk Factors for Developing Type 2 Diabetes Mellitus: A Systematic Review.International Journal of Environmental Research and Public Health,15(1), 78. https://doi.org/10.3390/ijerph15010078Australian Indigenous HealthBulletin : Review of nutrition among Aboriginal and Torres Strait Islander people. (n.d.). Healthbulletin.org.au. https://healthbulletin.org.au/articles/review-of-nutrition-among-aboriginal-and-torres-strait-islander-people/#australian-dietary-guidelinesmyDr. (2018, June 28).Diabetes and Indigenous Australians. MyDr.com.au. https://mydr.com.au/aboriginal-health/diabetes-in-indigenous-australians/#:~:text=Why%20are%20Indigenous%20Australians%20atDiabetes Australia. (2022).Diabetes resources for Aboriginal and Torres Strait Islander people. Www.diabetesaustralia.com.au. https://www.diabetesaustralia.com.au/atsi/resources/
