Diabetes Knowledge Of Nurses In Different Countries
Questions:
- The correct term for “borderline diabetes” is impaired glucose tolerance (IGT). How would you have explained this term to Sue?
- What are the criteria for the diagnosis of IGT?
- What laboratory value indicated that Sue had impaired glucose tolerance?
- Provide a list of major signs and symptoms of Diabetes Mellitus.
- What recommendations would you have made to Sue to minimize her risk of developing diabetes mellitus? Identify two factors?
- What laboratory values would be part of the diagnostic work up for type 2 diabetes?
- What is a C-Peptide lab test?
- According to the Canadian Diabetes Association’s 2008 Clinical Best Practice Guidelines, what is the recommended AbA1c level?
- Your educational approach with Cindy is divided into three basic components: Medical Nutrition Therapy, Exercise, and Pharmacotherapy. Using the 2008 Canadian Best Practice Guidelines in Diabetes, answer the following: A – Identify important content to be included under medical nutrition therapy. B – Identify important content to be included under exercise (focus on the potential benefits, precautions and best treatment recommendations). C – Identify important content to be included under pharmacologic therapy.
- What information would you give Sue to educate her about Neuropathy?
- Identify seven areas of focus to include when teaching Sue about diabetic foot care.
- Sue states that her friend is on insulin and has Type 1 Diabetes. Sue wonders why she isn’t on insulin, too and states she is confused as to why she has been diagnosed with having Type 2 Diabetes. She asks you to explain the difference between Type 1 and Type 2 diabetes. How would you answer this question so that Sue can understand?
- Sue brings up questions regarding her experience with blurred vision and eyesight. She states that she has heard people with diabetes go blind. How would you approach this question? What would you tell her in addressing her question?
- In reviewing all of the case study information related to Sue Wong, what diabetes-related complication do you believe that Sue is most at risk for? Provide substantiated rationale for your response.
- Provide three nursing interventions to help Sue decrease her risk of developing Macrovascular Disease.
- What special considerations do health professionals need to be aware of and practice when caring for an elderly client with Diabetes?
Answers:
Answer 1
Apart from past medical history, it is important to know about Jodi’s lifestyle and other medical information as these factors that potentially increase the CVA risk. The patient need to be asked about her lifestyle like dietary pattern, body weight (overweight or obese), physical activity level, any kind of addictions like smoking, binge or heavy drinking and substance abuse. These are modifiable risk factors associated with CVD and can be altered that reduces this condition (O’Donnell et al. 2016). The toxins in tobacco can cause vasculature damage supplying the brain, alcohol raises blood pressure and cholesterol and poor diet like high salt and saturated fat can increase risk for CVD. Cholesterol level also need to be considered as raised levels can significantly narrow down the arteries and increase chances of blood clot. The nurse should ask whether the patient has a family history of diabetes as raised blood glucose levels can cause vascular damage and increase the risk for CVD and CVA.
Answer 2
CVA recovery occurs when the disease stabilizes and the brain slowly starts responding to the damage and change or alters the way of functioning for accommodating loss or damaged parts. The CVA recovery process need to be understood as it is unpredictable and slow. As evident from the case study, the initial recovery process starts during the first visit at the hospital increasing the likelihood of recovery of brain functioning and damaged parts. Range of motion, walking or standing movements is encouraged in recovery process. In CVA recovery, during the first five to six weeks, inpatient or outpatient therapy is given followed by intense occupational and physical therapy in five days per week. In first three months, Jodi will experience improvement with significant gains in range of motion. Therefore, depending on the patient’s effort and support, improvements happen within six months of initial CVD episode up to two years with 10% complete recovery (Winstein et al. 2016).
Answer 3
Clopidogrel or Plavix is recommended post CVA as it provides greater protection against another attack or recurrent ischemic stroke than aspirin. It is advised for preventing recurrent vascular events like vascular death or MI providing anti-thrombic therapy. This drug has emerged as an alternate anti-platelet therapy for CVD prevention along with aspirin as dual therapy in reducing the chances of further chances of stroke. It is a blood-thinning medication that prevents blood clots formation (Wang et al. 2013). It is generally prescribed after a CVD or transient ischaemic attack (TIA) as evident in the case study as blood clots are linked to stroke event and prescribing blood thinning medication, often prescribed to reduce the risk of stroke or TIA.
Answer 4
Jodi was not placed on HRT post CVA as it slightly increases the risk of stroke as it increases the risk of blood clot formation and also increases blood pressure. HRT is given to control symptoms of menopause; however it carries many health risks. Jodi is 68 years old; the risk of stroke is high if HRT is continued as this is a small risk factor specific to women. Estrogen is considered a protective factor against stroke as it affects cholesterol; however, it increases the likelihood of blood clot and in turn increases risk of stroke (Panay et al. 2013). Therefore, HRT is discontinued for Jodi post CVA event. Research showed that HRT was strongly associated with increase in stroke risk caused by blockage and should be discontinued after short-term use.
Answer 5
The symptoms of CVD vary depending upon the affected area of brain and lack of oxygen. There is impairment in nerve functioning that arises suddenly and occur at one side of the body. Weakness, numbness, trouble speaking and in understanding speech is CVD symptoms that were observed in Jodi. F (Face). A (Arm. S (Speech). T (Time) acting is also used for providing immediate treatment after CVD attack (Lever et al. 2013). Jodi also had a slight-left sided facial droop, experienced difficulty in saying words, weakness in left hand, fatigue and mild headache over right temple.
Answer 6
For an emergency CVD treatment, it is important to quickly restore the flow of blood to the brain with medications as emergency treatment. Clot-busting medications like thrombolytic therapy or tPA should be given to Jodi within 4.5 hours of CVD symptom onset as it is time critical and earlier the treatment, it would give better outcomes. To stop CVD progression, acute anti-platelet therapy stops CVA progression along with core interdisciplinary team that comprises of nursing, medical, physiotherapy, and occupational therapy and speech-language staff. This can be helpful in the assessment of patient within 48 hours of hospital admission that would in turn improve the quality of life and prevent CVD related medical complications (Ciccone et al. 2013). In addition, vital signs like temperature, oxygen saturation levels, blood sugar, and blood pressure and heart rhythm are also monitored in a neurological unit.
Answer 7
CVA can result in difficulty in swallowing called dysphagia that can cause severe complications like aspiration pneumonia and choking. Therefore, before any dietary changes is recommended to Jodi, it is important to evaluate the swallow functioning via modified barium swallow study or videofluoroscopy (VFS) where the x-ray image of upper oesophagus and throat is taken for evaluating swallowing movements. Speech language pathologist (SLP) is required for Jodi as she experienced difficulty in speaking words being a serious CVD complication. SLP would help Jodi in attaining the highest level of communication and language functioning. Occupational therapist (OT) is also essential for her as to assist her in Activities of Daily Living (ADL) like bathing, dressing, eating and cooking, benefit in regaining functioning in daily lives and equip better for independent living (Jauch et al. 2013). CVA would also devastate Jodi’s nutritional health limiting her ability to perform daily tasks and therefore, it is important that her daily nutritional and calorie needs should be met. For this, Registered Dietician (RD) would develop a plan of care that provides nutritionally adequate and satisfying diet for her to prevent malnutrition.
Answer 8
Community Stroke Rehabilitation Model in Ontario, a project is developed to provide a range of home-based and community rehabilitation program that can be given to Jodi aiming to provide best practice recommendations post CVA event. Outpatient and Community-Based Stroke Rehabilitation (Including ESD) is a free online access for CVA outpatients in supporting information like updated practice recommendations, evidences and references that can also be accessed by Jodi. Cardiac Health Foundation of Canada, Canadian Association of Cardiovascular Prevention and Rehabilitation, Bridge point Active Healthcare, Stroke Recovery Exercise Workshop and Regional Stroke Network are some of the community services that can be used by Jodi for CVA rehabilitation in Canada.
Answer 9:
Sue might not have enough knowledge about scientific terms and technical jargons and therefore the healthcare professionals need to describe to her in language that is easily understandable by her. It should be stated to her that borderline diabetes means that the blood glucose level of the patient is beyond the normal levels but not high enough to warrant a diabetes diagnosis (Ismail et al. 2018). The blood glucose level of 7.8 mmol/L or more but it should be less than 11.1 mmol/L after a two-hour oral glucose tolerance test suggest that the patient has borderline diabetes. Sue should be stated that with impaired glucose tolerance, there remains a greater risk for developing diabetes and cardiovascular disorder and hence she should be advised to be careful about her health.
Answer 10:
The normal glucose tolerance in normal healthy human should not rise higher than 140 mg/dl two hours after the drink. In cases of impaired glucose tolerance cases, the two-hour blood glucose level is found to be within the 140 to 199 mg/dl. When the level of their glucose rises above 200 mg/dl, then the person is said to be having diabetes (Williams and Hopper 2015). This criterion can be followed for finding out whether the person is suffering from borderline diabetes or diabetes.
Answer 11:
The patient named Sue has a blood glucose level of 140/90 which is just the on the lower level of the value range of the borderline diabetes and therefore she can be seen to be suffering from the clinical condition of borderline diabetes.
Answer 12:
Some of the major symptoms of diabetes mellitus mainly involve frequent urination, excessive thirst, intense hunger, unusual weight loss, weight gain, irritability, increased fatigue, blurred vision and itchy skin. The cuts and wounds also do not heal properly and gun infection takes place. Numbness or tingling especially occurs in the feet and hands (Kuiper et al. 2016).
Answer 13:
The patient is suffering from borderline diabetes and immediate steps need to be taken by the patient for reducing the risk for occurrence of the diabetes mellitus. Researchers are of the opinion that losing weight and keeping it maintained prevent or delay the occurrences of diabetes. They suggest that losing 5 to 7 percent of the starting weight can be planned. The patient is obese, as her BMI has been calculated to 32.6. Therefore, she needs to reduce her weight. Physical activity should be ensured where the patient should carry about 30 minutes of physical activity for 5 days a week as it leads to prevention of diabetes (Canadian Diabetes Association 2008 Clinical Practice Guidelines 2008). The patient mainly leads a sedentary lifestyle and her comment of sitting for hours in front of the computer justifies it. The patient should be also suggested to select healthy foods all the time as choosing foods wisely will help in reducing the weight.
Answer 14:
Four important laboratory tests help to diagnose the patients to be suffering from diabetes. The first one is the HbA1c level that is 6.5% or higher but in case of the patient it was found to be 9.5%. Another important laboratory test is the fasting plasma glucose or the FPG whose level should be 126 mg/dL or 7.0 mmol/L or higher but in case of the patient, it was found to be 7.7mmol/L. Another important laboratory test is the 2-hour plasma glucose level of 200 mg/Dl or that of 11.1 mmol/L or higher but in case of the patient, it was found to be quite higher like that of. Another is the random plasma glucose of 200 mg/dL or higher in patients. Therefore as all the levels of the laboratory diagnostics tests are seen to be higher, so that patient can be said to be having the clinical condition of diabetes.
Answer 15:
C-peptide can be defined as the substance that is a short chain of amino acids and is released into the blood as the byproduct of the formation of the hormone called insulin by the pancreas. This test is mainly helpful in calculating the total amount of C-peptide in the blood or the urine sample. C-peptide is produced at the same rate as that of the insulin and hence it is often used as the marker of insulin production. In particular, the C-peptide testing can be used for evaluation of the production of the insulin made by the body (endogenous) and participates in differentiating it from the exogenous insulin that is the insulin that is not produced by the body of the individuals like in case of diabetic medication. Healthcare professionals can be also done in conjunction with the insulin test (Martínez-González et al. 2015).
Answer 16:
Canadian Diabetes Association’s 2008 Clinical Best Practice Guidelines are of the opinion that the recommended target haemoglobin A1c would be of the level of ≤ 7% for all the patients who are suffering from diabetes. The association is of the opinion that less than the target of ≤ 6.5% need to be considered for some of the patients so that all complications of micro-vascular disorders can be stated.
Important content to be included in the medical nutrition therapy
Adoption of the diabetes friendly eating habits is one of the best ways for managing the blood glucose levels and help in reduction of the risk of development of blood vessel and heart disorder. The patient named Sue should be instructed to select whole as well as less refined foods in place of unhealthy foods like fast foods, refined grain food as well as processed foods. The patient should give proper attention regarding the quantity as well as the quality of carbohydrates. The diet of the patient should also involve low-glycemic index foods that would include legumes, fruits, vegetables, whole grains and many others. This would help in controlling the cholesterol levels and the blood glucose levels (Canadian Diabetes Association 2008 Clinical Practice Guidelines 2008). Quantity of the carbohydrate eaten at one particular time is important and therefore it is important for the patient to be taught how to count carbohydrate in diet. More vegetable protein as well as lean animal proteins needs to be chosen. The diet style that should be chosen is the Nordic style diet, Mediterranean style diet as well as DASH diet or vegetarian style diet. This is because it has the evidence of such diet styles to help in maintaining blood glucose level.
Important content to be included under exercise
Physical activity helps in improvement of the glucose control and results in facilitation of the weight loss. It should be advised to the patients to avoid any form of prolonged sitting. The patient should be instructed to interrupt any form of seating by getting up briefly for every of the 20 to 30 minutes. The patient should be also instructed to take aerobic exercises of at least 150 minutes per week and this could be in the form of walking, cycling as well as joggling. The patient can also use the step monitor just like that of the pedometer as well as accelerometer which is helpful in tracking the activity (Canadian Diabetes Association 2008 Clinical Practice Guidelines 2008). It is also advisable for the professionals to try out strength training twice per week in addition to that of the aerobic exercises. Getting instruction from trainer or qualified gym specialist is important for strength training. If it is not becoming possible for the maintenance of the recommended levels, small amounts of activities can also be done as also they have health benefits.
Identification of the important content under the pharmacologic therapy
Metformin is mainly the first choice of the people with type two diabetes as they are safe, low in cost and has possible heart benefits. Second line glucose lowering medication includes the DPP-4 inhibitors that help in lowering the blood glucose levels by increasing the insulin levels after meals and even lowering down the glucagon levels (Blair 2016). GLP-1 receptor agonists are the injectable medications when the blood glucose level is seen to increase in blood after taking meals. Different types of side effects remain associated which include nausea but it also goes away with time, unlike the previous medication, this medication cause weight loss and results in the lowering of the risk of hypoglycemia. SGLT2 inhibitors are the medications that mainly work by eliminating all the glucose in the urine. Different side effects include urinary tract infections, genital yeast infections low blood pressure and even increased urination. Insulin secretagogues (meglitinides, sulfonylureas) mainly help the pancreas to release more insulin. Different types of side effects are seen to include fractures, increased chances of heart attack, weight gain and others. Many patients also receive insulin therapy and they are mainly prescribed with mixtures of different insulin types for being used day and night (Canadian Diabetes Association 2008 Clinical Practice Guidelines 2008)
It should be stated to sue that diabetes could result in harming the nerves of the patients and this is called neuropathy. This mainly occurs when the blood glucose level remains too high in the patient for too long. They are seen to damage mostly the nerves in the legs and feet and might result in pain and numbness depending upon the affected nerves (Kim et al. 2015). It can result in different symptoms of digestive system, blood vessels, heart as well as urinary tract and the heart. Some people might have mild symptoms but in case of others, it might be painful and disabling.
When teaching about foot ulcer treatment, the healthcare professionals need to take care for about seven important arenas. The first one would be relieving of the pressure and the protection of the ulcer that might occur due to infection in the foot. The second and third areas are the restoration of the skin perfusion and treatment of the infection respectively. The fourth important arena is the metabolic control as well as treatment of the co-morbidity (Alotaibi et al., 2016). The fifth area is the local wound care and the sixth one is the education for the patient and the relatives. The seventh one is the prevention of the recurrence of the foot ulcers. All these arenas should be taught to sue beforehand so that she can take care of her foot of different issues arise.
People with type I diabetes are the patients where the cells in the pancreas do not produce insulin altogether. As insulin is not produced, the cells fail to accept the glucose and hence glucose levels in the blood rises up. On the other hand, people with type 2 diabetes are seen to suffer from problems where insulin is produced but cells of the body cannot accept insulin. This is known as insulin resistance. As insulin cannot acted upon the body cells, the body cells do not take up glucose and level of glucose increases (Young et al. 2016). Therefore, it is seen that type 1 diabetes patient requires insulin but type 2 diabetes patients do not require insulin therapy. They require medications like metformin that helps in increasing insulin sensitivity of the cells and increases peripheral uptake and utilization of glucose.
Sue should be made to understand that blurring of vision and people becoming blind due to diabetes are totally two different arenas. High level of blood sugar can affect the ability of the eyes to see mainly by causing the lens present inside the eyes to swell. This might result in temporary blurring of the eyesight (Williams and Hopper 2015) . It might also take place during lowering of the blood glucose level as well and this might be reversed when the blood glucose levels come to of normal range. Blindness mainly occurs in cases of diabetic retinopathy. This affects the blood vessels of the light sensitive tissues called retina. Diabetic macular edema is also another consequence of diabetic retinopathy that results in swelling of the arena. Chances of cataract and glaucoma also increase when patients have diabetes. Therefore, by this explanation, anxiety of Sue can be overcome.
The patient might have the risk of cardiovascular disorder that might include risks of coronary artery diseases, stroke, narrowing of arteries and many others. Her father had already suffered from this disorder and presence of the symptoms of diabetes is seen to cause cardiovascular disorder. She also has high blood pressure that is yet another cause of heart disorders. She has abnormal cholesterol and high triglycerides; she is suffering from obesity, lack of physical activity and all these lead to hart complications. Secondly, she might also suffer from nerve damage or neuropathy. Excess sugar can result in the injuring of the walls of the tine blood vessels that are mainly responsible for nourishing the nerves and especially the lungs. This might cause tingling, numbness, burning or pain sensations (Gallagher t al. 2016). The third issue that she might face is the eye damage. She is already suffering from blurring of visions and eyesight issues. Diabetic retinopathy can also affect her. Chances of cataracts and glaucoma can also occur.
In order to reduce the occurrence of the cardiovascular disorders , the LDL cholesterol level should be below 70 mg/dL, the blood pressure should be less than 140/90 mmHg, the BMI should be below 25. The professionals should discuss this to Sue so that she can develop health literacy and understand the different ways for preventing Macrovascular disorders. Aspirin should also be suggested along with clopidogrel for one year to reduce the risk for patients. Asprin mainly helps in the prevention of the blood clots and thereby [prevent the clogging of the blood vessels and hence prevent any cerebrovascular diseases. The third intervention is the maintenance of hypertension in the patient and for this, multidrug therapy can be introduced. ACE inhibitors like ramipril and perindropil are suggested to be used for controlling the blood pressure. Besides, the professionals should also teach the patient about the importance of exercise and healthy diet for preventing any such macrovascular disease.
Elderly diabetic patients have delayed wound healing which might affect their quality of light. The disorder is seen to slow the wound healing procedures. Elevated blood glucose levels in the diabetic patients narrow the blood vessels. These in turn harden the arteries that negatively affect the wound healing. Another important thing that also is quite higher in older patients is that diabetic neuropathy results in loss of sensation (Langford and Thompson 2005). This can also slow down wound healing. Such patients do not feel any more change in the wound and as a result, it can become more severe. Moreover, reduced skin elasticity is another negative factor in older people. As people grow older, the skin loses elasticity and therefore it also prevents the wounds from healing.
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