1NURSING Type 2 diabetes (T2D) is a chronic health condition, whose prevalence is increasing globally. According to the data by Australian Bureau of Health Statistics (2018), one in twenty Australians had diabetes in 2017-2018. With the increase in risk of diabetes, the rate of other chronic health issue such as hypertension and heart disease has increased too. Research literature has established correlation between diabetes and hypertension as both the condition exists together and worsens clinical outcomes in patients. Hypertension in diabetes patient can further increase the risk of cardiovascular disease and nephropathy (Khangura et al., 2018). Thus, payingattentiontohypertensivediabeticpatientisimportanttoreducetheburdenof cardiovascular disease. This essay will look into the case scenario of a patient who has similar issue of hypertension and diabetes. The case study is about Bill McDonald, a 75 year old male patient diagnosed with T2D. The essay will examine the symptoms and diagnostic test results of the patient and link it to the pathophysiology of T2D. The essay will also examine the potential management approaches for a hypertensive diabetic patient. Bill McDonald is a patient with diagnosis of diabetes. He has a history of smoking cigarettes for 35 years and a history of alcohol consumption. His blood glucose level had been fluctuating over the past 3 months. His risk of diabetes was linked to family history as his mother had diabetes and diet of heart failure at the age of 65 years. Recently, Mr. Bill was found to have high blood pressure, when he presented for a regular GP visit. His blood pressure was found to be 170/100 mmHg. To understand the events that lead to his diabetes and his current chronic symptoms, looking at the pathophysiology behind the condition is important. The pathophysiology of T2D involves peripheral insulin resistance and declining of beta cell function leading to beta cell failure. The primary event for all patients with diabetes is the initial deficit in insulin secretion and initiation of insulin resistance. Insulin resistance is an
2NURSING important factor for the development of T2D. According toTesauro and Mazzotta (2020), all patients with T2D suffer from varying degree of insulin resistance and insulin deficiency. Insulin resistance is a phenomenon that occurs due to presence of excess glucose in the blood and the reduction in the ability of the blood to use glucose for energy. This is manifested in the form of high blood glucose level in the blood. Similar issue was found for Mr. Bill as his fasting blood glucose level ranged from 4.5 to 7 mmol/L. The blood glucose of 7mmol/L or higher is seen in patient with diabetes and blood glucose between 5.6 to 6.9mmol/L is seen in prediabetes patient. Hence, Mr. Bill’s FPG value shows that he is suffering from moderate blood glucose control issues as his FPG test is fluctuating. There are many driving forces behind insulin resistance in any individual. This is influenced by various factors such as obesity, smoking, genetics and ageing. Obesity can be linked to Mr. Bill’s diagnosis as his weight was 123 kg. Obesity is a condition that is highly associated with developing insulin resistance and T2D. This is because obese individuals have adipose tissues which release large amount of non-esterified fatty acids and pro-inflammatory cytokines. These cytokines can cause insulin resistance in adipose tissue and liver. The initiation of the inflammation occurs in obese individuals, when adipose tissues lead to adipocyte hypertrophy and local oxygen supply is disrupted by the adipocytes leading to activation of cellular stress pathways. This mechanism results in autonomous inflammation and release of cytokines and other pro-inflammatory signals (Kang et al., 2016).Thus, localized insulin resistance takes place leading to abnormal metabolic state. Mr. Bill is an active smoker and his smoking habit can be one of the reasons behind his T2D. In addition to obesity, Mr. Bill’s high blood pressure is because of the effect of diabetes. The main pathophysiology behind hypertension in diabetic patient involves the interaction
3NURSING between the nervous system, rennin-angiotensin-adolesterone system (RAAS) and the influence of individuals and environmental factors (Henson et al., 2018). Mr. Bill had a sedentary lifestyle and the study byKhangura et al. (2018)suggests that sedentary behaviour increases the adiposity level and consequently insulin resistance. This is followed by increase in vascular adhesion, inflammation and decreased nitric oxide levels in the vascular sections. All these changes together promote vascular stiffness and lead to hypertension. RAAS is also an important factor behind the pathogenesis of hypertension in diabetic patients like Mr. Bill. RAAS is a factor that has direct effects on angiotensin II and aldosterone. Obesity and insulin resistance together lead to activation of RAAS and increased adiposity level inhibits insulin metabolic signalling by angiotension II and aldosterone. This induces endothelial-mediated vascular relaxation and developmentofhypertension(Khanguraetal.,2018).Basedonthereviewofthe pathophysiology of T2D and its link with symptoms of Bill, it can be said that he is in need of both pharmacological and life style intervention for the management of his symptoms. Before prioritizing best intervention for the management of Mr. Bill’s condition, finding out his abnormal symptom is important. The first care priority will be to control and reduce blood pressure of Mr. Bill. The target should be to keep blood pressure less than 130/80 mm Hg in Mr. Bill and this will be done by pharmacological intervention. The second priority will be to improve his lifestyle. This is important as currently he leads a sedentary lifestyle and eating bananas, both of which can be detrimental to his diabetic outcomes. During presentation to the GP, he was asymptomatic, however he suffered from symptoms of dizziness or blurred vision and he had pitting oedema in both his lower legs. Lower extremity oedema is a sign of fluid retention issue. This symptom should be taken seriously as such oedema is a sign of poor prognosis in patients (Tesfaye & Wu, 2018).
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4NURSING To control hypertension, it will be necessary to implement pharmacological interventions for Mr. Bill. ACE inhibitors and angiotensin receptor blockers (ARBs) are the preferred drugs for management of hypertension and diabetes. ACE inhibitors exerts it action by inhibiting the action of the ACE enzyme and preventing conversion of angiotensin 1 to angiotensin II. This mechanism of action of the drug leads to decrease in peripheral resistance and antihypertensive effect. This can further prevent the likelihood of kidney disease and early nephropathy for hypertensive patient with dibetes. ARBs also have similar effect like that of ACE inhibitor. However, evidence points out to the side effect of hyperkalemia due to the use of ACE inhibitors and ARBs (Khangura et al., 2018). This risk can be minimized by if it is combined with other medications like diuretics. According toHorr and Nissen (2016), thiazide diuretics can be used as monotherapy or combination therapy in the treatment of hypertension in diabetes patient. However, this drug is less effective in patients with diminished renal function. One of the marker of decreased renal function is decrease in glomerular filtrate rate (GFR) values to less than 50 mL per min per 1.73 m2.As Mr. Bill’s blood test revealed decreased GFR rates, he needs to be provided loop diuretic to control his hypertension. The above pharmacological intervention can be followed up with regular blood pressure measurement. This will help to track changes in blood pressure and detect the therapeutic effect of the drugs too. In addition, his renal function should be regularly assessed by detecting urea and serum creatinine level to prevent the progression of risk to end stage renal disease (Fukuda et al., 2018). Lifestyle intervention is most crucial for recovery of Mr. Bill because lifestyle is the major cause behind his fluctuations in blood glucose level and presence of other complications in patient. As the pathophysiological discussion identified sedentary behaviour as a major cause behind insulin resistance and increase in blood glucose level, it is planned to increase Mr. Bill’s
5NURSING activity level first. This can be started by encouraging Bill to engage in regular aerobic physical activity like brisk walking for 30 minutes every day. The benefit of aerobic exercise is that it can increase cardiorespiratory fitness of patient, reduce insulin resistance and reduce blood pressure and HbA1c level (Horr & Nissen, 2016). Aerobic exercise can have a positive effect on improving peripheral nerve functions too (Mirtha & Permatahati, 2018).As part of lifestyle modification, diet modifications, smoking cessation and reduction in alcohol consumption will be crucial for recovery of Mr. Bill. Currently, Mr. Bill is heavily consuming alcohol and there is need to limit his alcohol consumption to two drinks per day. He needs to quit smoking to protect his overall cardiovascular health too (Horr & Nissen, 2016).Beer or any form of alcohol contains carbohydrate which can further increase blood glucose level of Mr. Bill. Hence, reducing alcohol intake is necessary to clinically manage diabetes. In addition, the positive benefit of smoking cessation is that it can alter fat distribution and improve lipid profile of patient too. In addition, insulin sensitive of Mr. Bill will increase with smoking cessation intervention too (Hu et al., 2018). In terms of diet modification, a diet chart should be planned for Mr Bill so that he east four to five servings of fruits per day and takes adequate vegetables and whole grains too (Gray & Threlkeld, 2019).The above intervention can help in the management of hypertension too. For the management of the sign of pitting oedema for Mr. Bill, it will be necessary to conduct appropriate history checking and physical health assessment of patient. This form of assessment can help to rule out systematic pathology. After this nursing interventions like elevation of the foot of Mr. Bill can be considered as it can reduce lower extremity edema. Another advantage of foot elevation is that it can decrease pedal tissue oxygenation as this position can increase blood flow within the arterial system. The nurse can consider using mild
6NURSING compression stockings too as it can reduce lower leg edema without compromising vascular flow (Wu et al., 2017). Peripheral edema is common symptom in diabetes patient because of damage to the capillaries and the leakage of fluid into the surrounding tissues. Any sign of edema should be taken seriously because it is a sign of peripheral complications and risk of diabetic foot ulcer. Compression therapy is helpful for patients who suffer from diabetic foot ulcer as it promotes healing of the ulcer (Tesfaye & Wu, 2018). From the analysis of the case study of Mr. Bill, it can be concluded that presence of hypertension is an additional issues for diabetic patient and this should be prioritized as it can disrupt both blood glucose control and affect renal functions too. Three intervention that was identified for the management of Mr. Bill included use of pharmacological therapy followed with bloodpressuremonitoring,lifestyleintervention,useofcompressionstockingsanddiet modifications. It is critical that while administering drugs to hypertensive patient with diabetes, the side-effect of drugs and its impact on current health state of patient is monitored. This may help to identify alternatives drugs just like it was done in the case of Mr. Bill.
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