Question

Mrs. Mendoza was diagnoses with type 2 diabetes 17 years ago. She had a below-the-knee amputation of her gangrenous left foot yesterday. Her electronic medical record indicates that she has peripheral neuropathy, diabetic retinopathy with loss of vision acuity, and two previous hospitalizations for hyperosmolar hyperglycemic nonketotic syndrome. Her physician has met with Mrs. Mendoza and her husband to discuss her high risk for experiencing an MI. Mr. Mendoza is now completely overwhelmed and a little weepy. He does not understand how diabetes could affect so many body systems. All he knows is that he is "loosing his wife a little at a time."

Discuss clinical assessments, decisions, and interventions for the situation presented

Answer 1

Following is the detailed Information on Diabetes Mellitus. If you find the answer useful please give a feedback. Thank you & All the Best.

Description of Diabetes Mellitus: Diabetes mellitus is a group of metabolic diseases that occurs with increased levels of glucose in the blood. Diabetes most often results in defects in insulin secretion, insulin action, or even both.

Classification of Diabetes: Diabetes has major classifications that include

Type 1 diabetes

Type 2 diabetes

Gestational diabetes and

Diabetes mellitus associated with other conditions.

The two types of diabetes mellitus are differentiated based on their causative factors, clinical course, and management.

Pathophysiology of Type 2 Diabetes

Type 2 diabetes mellitus has major problems of insulin resistance and impaired insulin secretion.

Insulin could not bind with the special receptors so insulin becomes less effective at stimulating glucose uptake and at regulating the glucose release.

There must be increased amounts of insulin to maintain glucose level at a normal or slightly elevated level.

However, there is enough insulin to prevent the breakdown of fats and production of ketones.

Uncontrolled type 2 diabetes could lead to hyperglycemic, hyperosmolar nonketotic syndrome.

The usual symptoms that the patient may feel are polyuria, polydipsia, polyphagia, fatigue, irritability, poorly healing skin wounds, vaginal infections, or blurred vision.

Clinical Assessment:

Hypoglycemia may occur suddenly in a patient considered hyperglycemic because their blood glucose levels may fall rapidly to 120 mg/dL or even less.

Serum glucose: Increased 200–1000 mg/dL or more.

Serum acetone (ketones): Strongly positive.

Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

Serum osmolality: Elevated but usually less than 330 mOsm/L.

Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.

Glycosylated hemoglobin (HbA_1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.

Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.

Electrolytes:

Sodium: May be normal, elevated, or decreased.

Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.

Phosphorus: Frequently decreased.

Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO₃ (metabolic acidosis) with compensatory respiratory alkalosis.

CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal perfusion).

Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.

Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.                                                                                                                               Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.   Cultures and sensitivities: Possible UTI, respiratory or wound infections

Medical Management

• Normalize insulin activity. This is the main goal of diabetes treatment — normalization of blood glucose levels to reduce the development of vascular and neuropathic complications.
• Intensive treatment. Intensive treatment is three to four insulin injections per day or continuous subcutaneous insulin infusion, insulin pump therapy plus frequent blood glucose monitoring and weekly contacts with diabetes educators.
• Exercise caution with intensive treatment. Intensive therapy must be done with caution and must be accompanied by thorough education of the patient and family and by responsible behavior of patient.
• Diabetes management has five components and involves constant assessment and modification of the treatment plan by healthcare professionals and daily adjustments in therapy by the patient.

Nutritional Management

• The foundations. Nutrition, meal planning, and weight control are the foundations of diabetes management.
• Consult a professional. A registered dietitian who understands diabetes management has the major responsibility for designing and teaching this aspect of the therapeutic plan.
• Healthcare team should have the knowledge. Nurses and other health care members of the team must be knowledgeable about nutritional therapy and supportive of patients who need to implement nutritional and lifestyle changes.
• Weight loss. This is the key treatment for obese patients with type 2 diabetes.

Meal Planning

• Criteria in meal planning. The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background.
• Managing hypoglycemia through meals. To help prevent hypoglycemic reactions and maintain overall blood glucose control, there should be consistency in the approximate time intervals between meals with the addition of snacks as needed.
• Assessment is still necessary. The patient’s diet history should be thoroughly reviewed to identify his or her eating habits and lifestyle.
• Educate the patient. Health education should include the importance of consistent eating habits, the relationship of food and insulin, and the provision of an individualized meal plan.
• The nurse’s role. The nurse plays an important role in communicating pertinent information to the dietitian and reinforcing the patients for better understanding.