NURS8730 Diabetes Management Case Study: Patient Assessment & Care

This case study presents a comprehensive analysis of diabetes management, focusing on a 76-year-old male patient, Mr. J, with a history of hypertension, thyroid nodules, and a family history of diabetes and kidney failure. The case details Mr. J's patient history, assessment upon admission for giddiness and shortness of breath, and laboratory findings indicating hyperglycemia and other metabolic imbalances. It delves into the pathophysiology of Type 2 Diabetes Mellitus, explaining insulin resistance, hyperinsulinemia, and the impact of obesity. Diagnostic methods, including Glycated Hemoglobin Test and Fasting Blood Sugar tests, are discussed, followed by a detailed overview of the pharmacological management, including insulin, aspirin, metformin, amlodipine, perindopril and glyceryl trinitrate and lifestyle modifications employed to manage Mr. J's condition. The case study highlights the importance of a holistic approach to diabetes management, integrating medication with lifestyle changes for optimal patient care. Desklib offers a wealth of similar case studies and solved assignments for students.

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CASE STUDY ON DIABETES MANAGEMENT
Student’s Name
University Affiliation
Course
Date

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Patient History
Mr J is a 76 year-old male patient. He has a height of 1.73m and weight of 85kg leading
to a BMI of 28.0kg/m2 (overweight). He is a retired school teacher currently he stays in a nearby
town with his wife and his 4 children. He visits the clinic after every 3 months for general
checkup and to obtain his insulin medications since he has been on course of insulin pills. His
family is faring fairly well and no issues of financial constraints. He prefers to go to this
particular clinic because he is not charge since he is an ex-government employee.
On addition to this, Mr.J suffered from hypertension, mainly because of stress from his
previous work as a teacher. In the past, Mr.J had been diagnosed with a thyroid nodule in the
throat which was benign and it was removed 5 years ago and hypertension. When he was a baby,
he had asthma, but it became less apparent with time. He claimed that he neither smokes nor
drinks. His two sisters and father had diabetes making it a hereditary condition. He also has a
positive history of kidney failure and hypertension. On addition to insulin Course in pill form,
Mr.J also uses alternative medications such as Barley Green Herb and supplements. He has
rashes which is are an insect bite allergy which is possibly has a relationship with diabetes
(Tricco et al., 2012, pp 2252-2261).
Patient Assessment
Mr J was admitted to the hospital with complains of mild giddiness and shortness of
breath (SOB). Mr.J also had complains of painful chest. On examining him, he was conscious
and alert and well-oriented to person, place and time. Venous Blood Gas sampling was carried
out and the pH was discovered to be 7.31 which was low, pO2 was 45.7mmHg, pCO2 was

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44.3mmHg and HCO3 of 24.6mmol/L. His blood pressure was 159/97mmHg, pulse rate was
74beats/minute, body temperature was 35.60C, SPO2 was 98% and the rate of respiration was 21
breaths/ minute. Reflo value was 17.2mmol/L and the value of ketones was 1.0. The lungs were
found to be and symmetrical clear while the abdomen was non-tender and soft. Cardiovascular
testing indicated dual rhythm with no murmur.
Patient's laboratory investigations and findings
Sodium was 130 mmol/L (Reference range 135-145 mmol/L), Creatinine was 84 μmol/L
(Reference range 60- 110 umol/L) , Potassium was 3.2 mmol/L(Reference Range 3.5-5mmol/L),
Fasting Glucose was high at 14.1 mmol/L(Reference range 70-100mg/dl) , Total Body
Cholesterol was 5.9 (Reference range 3-5.5mmol/L), High Density Lipoproteins were at 0.83
(Reference range 40-80 mg/dl), AST was normal at 24 IU/I (Reference range 10-40IU/I),
Triglycerides were at 6.9mg/dL (Reference range 50-150 mg/dL) , ALT-45 IU/I (10-65IU/I),INR
was at 1.05 (Reference range 2.0-3.0), Bilirubin was normal at 14 μmol/L(Reference range 2-
20umol/L) , the Trop I was at -0.05 (Normal less than 15ng/L) while the CKMB was 0.5 against
a reference range of 0-0.4ng/mL.
Disease Background and pathophysiology
The prevalence of diabetes mellitus (DM) changes largely across populations globally. In
United Kingdom (UK), prevalence of diabetes is ever- raising. The incidence of type 2 DM
indicates a rise every year. As long as the DM incidence is ever- increasing, it is very clear that
many people have not yet been diagnosed and treated for diabetes (Bos and Agyemang, 2013).

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Diabetes mellitus (DM) refers to a physiological disorder associated with elevated blood
glucose which is persistently more than the normal range. In other words, it is called
hyperglycemia which is thought to be associated with either insulin deficiency, insulin
resistance. Some of the signs and symptoms of Diabetes Mellitus include weight loss, fatigue,
blurred vision, increased hunger and thirst, frequent and sores which heal slowly (Siddiqui,
2013).
Diabetes Mellitus is categorized into 4 major types. They include Type 1 DM, Type 2
DM, DM due to particular diseases and gestational DM. This essay will only discuss Type 2 DM
which normally results from both insulin resistance and decreased secretion of insulin which is
used in overcoming the resistance. Type 2 diabetes is a very common type of DM and it accounts
for approximately 89-95 percent of the total cases of DM. Some of the commonest risk factors of
type 2 DM are increased age, overweight, high intake of calories, sedentary lifestyle, central
adiposity (Pellico and Bautista, 2012).
The pathophysiology of Type 2 DM is associated with physiological mechanisms such as
cell damage, excess toxicity, excess oxidation, glucose transport (GLUT4) dysfunction, insulin
insensitivity and impaired regulation of production of hepatic insulin. Some of the cells that are
initially affected due to hyperinsulinemia and hyperglycemia are the Glycated Red Blood Cells,
liver, fat and muscle cells. The cells are particularly meant to take glucose/sugar out of the blood
system, pull it into the cells and convert it to energy. These cells often require insulin in order to
absorb glucose into cells through GLUT4 transporters and insulin receptors. At the cellular level,
insulin secreted by the pancreas binds to insulin receptor’s on the external edges of the cells
(Haas, 2012, pp 619-629).

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The binding of insulin on its receptors triggers the GLUT4 glucose Transporters within
the cells to shift to the outer edge hence pulling the glucose into the cell. Once the glucose is
inside the cell, it is then transported to the mitochondria (energy factories) whereby it is changed
to energy which is always in form of Adenosine Triphosphates (ATP). Consequently, the cells
makes use of this energy to carry out its primary functioning (Kuehl and Stevens, 2012, p 405).
Now in the case of diabetes, these cells fail to adequately respond to the level of
circulating insulin hence losing the sensitivity towards insulin, usually known as insulin
resistance. This leads to a rise in levels of blood glucose. In this case, the insulin secreted by the
pancreas does not bind to the receptors hence no signal is send to GLUT4 glucose Transporters
which then fails to move to the outer side of the cell hence no glucose is pulled into the cell (Bos
and Agyemang, 2013, pp 387).
Based on this, no glucose is transported to the mitochondria leading to production of no
energy by the cells hence causing ineffective primary functioning of the cell. The blood glucose
begins to increase when insulin is binding to the receptors. The body then reacts to this by
physiologically triggering the pancreas to secrete insulin leading to elevated levels of insulin in
blood. This condition is often called hyperinsulinemia (Yau et al., 2012). Based on this, liver
cells become more resistant to insulin and they respond by producing excess sugar. Since the
sugar in blood is not absorbed by cells, it accumulates in blood leading to hyperglycemia.
Hyperglycemia leads damage of the Red Blood Cells leading to damage in the circulatory system
which extends to the capillaries and arteries (Bos and Agyemang, 2013, pp-387).
Obesity is among the major causes of type 2 diabetes. Abdominal fat triggers fat cells to
produce pro-inflammatory substances which consequently reduces the sensitivity of the body

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towards insulin leading to disruption of primary functioning of body cells. Changes in body
metabolism due to obesity causes release of fat molecules by adipose tissue into the blood which
impacts on the insulin responsive cells leading to reduction in insulin sensitivity (Evert et al.,
2014, pp 120-143).
If diabetes mellitus goes untreated, it can lead to very severe complications which are
fatal in nature. Some of the possible complications include cardiovascular disorders, neuropathy,
retinopathy, nephropathy, skin disorders, kidney failure, impairment of hearing and Alzheimer’s
disease. Heart diseases lead to an increased risk of cerebrovascular accident. Other additional
complications may be feet amputations because of infections and dental problems (Diabetes,
2012).
Diagnosis of Type 2 Diabetes Mellitus
To diagnose DM, hyperglycemia must be ruled out before the confirmation that the
patient has DM. There are three major tests of plasma glucose test applied in diagnosis of DM.
They include Fasting Plasma Glucose, Casual Plasma glucose and Oral Glucose Tolerance Test
(OGTT) used in Fasting Glucose. To diagnose diabetes, the criteria applied include symptoms of
diabetes such as polyuria, thirst, polydipsia, weight loss and a Casual Plasma Glucose of
11mmol/L (Diabetes, 2012).
Some of the tests that were used in diagnosis of type 2 DM include: Glycated
Hemoglobin Test (AIC) which was used to indicate the patient’s average levels of blood sugar
for the past 2 months. It was used to measure the sugar percentage attached to the hemoglobin
and the values were 6.9 %. Random Blood Sugar was also done and it showed 28.3mg/dl.

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Fasting Blood Sugar test was done for an overnight fast and it showed 9mmol/L (Ding et al.,
2015, pp 306-315). Additionally, Oral Glucose Tolerance Test was carried whereby the patient
was given a sugary drink and the levels of blood sugar were measured periodically every two
hours. Based on this test, the result was 13.2mmol/L (Diabetes, 2012
Pharmacological Management
The patient was put on course of insulin pills 0.4units/kg/day (Inzucchi et al., 2015, pp
140-149) was prescribed. Insulin is a peptide hormone that is produced by Beta Cells of the
pancreas. Insulin binds to a glycoprotein receptor on cell surface. This receptor has alpha sub-
unit and beta-sub-unit, which is an insulin-stimulated tyrosine-specific protein kinase. Kinase
activation generates a signal which eventually initiates action of insulin on lipid, protein and
glucose metabolism. It causes the liver, muscles and fat tissue to absorb glucose from the blood
system. This medication was meant to reduce the level of glucose from the blood. Insulin
regulates metabolism of proteins, carbohydrate and fats in order to increase the utilization of
glucose in the body. Hypoglycemia is one of the potential problems associated with insulin
(Brown et al., 2017).
Aspirin, 250mg 3 times a day dose was used as a prophylaxis or anti-platelet agent to
cardiovascular problems. Aspirin acts by inactivating cyclo-oxygenase and prostaglandin
synthase and inhibiting thromboxane formation in the platelets. This was used to prevent any
cardiac events associated with type 2 diabetes (Hawwa et al., 2013, pp 54-62). Metformin, oral
500mg twice in a day, a biguanide was prescribed for Mr.J. Metformin is an antihyperglycemic
agent that is meant to improve the level of glucose tolerance in the patients by reducing intestinal
glucose absorption and the hepatic production of glucose and hence improving sensitivity of

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insulin in the body tissues. Gastrointestinal effects of metformin include abdominal pain, nausea
and diarrhea (Brown et al., 2017).
The patient was also on amlodipine 5mg orally once in a day for one week, a calcium
channel blocker which interferes with the passage of calcium ions through the cell membrane
channels. It mainly acts mainly on the vascular smooth muscle and myocardial cells to reduce
myocardial contractility. Perindopril, an Angiotensin Converting Enzyme (ACE) inhibitor was
used for the hypertension to reduce blood pressure to normal. It inhibits conversion of
angiotensin I to angiotensin II, a potent vasoconstrictor which is associated with high blood
pressure, sodium and fluid retention systemic vasoconstriction (American Diabetes Association,
2014, pp 14-80).
For the chest pain, the patient was given Glyceryl Trinitrate (GTN) 5mcg/min
intravenous via non-absorptive tubing as a prophylaxis in angina. It directly causes vascular
smooth muscle relaxation and dilation of the coronary vessels hence improving supply of oxygen
to the heart. Dilation of the blood vessels leads to reduced preload and afterload hence reducing
myocardial consumption of oxygen. Sublingual GTN was used since it is more effective in
providing immediate symptomatic relief of chest pain. It possible side effects tachycardia,
include postural hypotension, dizziness, nausea, throbbing headache, flushing, vomiting and
heartburn (American Diabetes Association, 2015, p-97).
Life style modification techniques were also used in management of the diabetic
condition of Mr.J. This modification included health eating such as avoiding sugary foods and
high sodium intake in order to regulate his body weight and manage the blood glucose levels
(Garber et al., 2013, pp327-336). Physical exercise was encouraged to promote effective

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functioning of insulin, reduce blood pressure and lower the risks of cardiovascular diseases.
Blood glucose was monitored regularly by performing tests to check the prescribed medications
were managing the blood glucose levels or any adjustment was required (Dunning, 2013).
The nursing interventions for Mr.J were educating him about glucose monitoring while at
home in order to prevent deterioration and promote healing. Educating the client on the
mechanisms of action of the prescribed medications was done to promote patient adherence to
medications which is useful in promotion of patient recovery. The nurses also emphasized on
checking the viability of insulin for expirations and proper storage to enhance its efficiency and
effectiveness in management of diabetes mellitus (Al-Khawaldeh et al., 2012, pp 10-16).
Conclusion
Mr.J was diagnosed with type 2 DM and he was put on both pharmacological and non-
pharmacological management techniques. Diabetes mellitus is classified into type 1, type 2 and
gestational diabetes. Type 2 diabetes mellitus involves insulin resistance and regulation of
insulin production. Hyperglycemia and hyperinsulinemia are the two major symptoms of type 2
diabetes. Some of the risk factors of type 2 DM are ageing, obesity or overweight, physical
inactivity, sedentary life style and family history. Diagnosis of type 2 DM involves fasting
glucose test, OGTT, oral glucose test and casual plasma test. If the blood glucose remain
uncontrolled after medications, change of medications is required for the patient. Compliance to
prescribed medications and life style modifications are they key strategies of managing type 2
DM.

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References
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management, and glycemic control in adults with type 2 diabetes mellitus. Journal of
Diabetes and its Complications, 26(1), pp.10-16.
American Diabetes Association, 2014. Standards of medical care in diabetes—2014. Diabetes
care, 37(Supplement 1), pp.S14-S80.
American Diabetes Association, 2015. Standards of medical care in diabetes—2015 abridged for
primary care providers. Clinical diabetes: a publication of the American Diabetes
Association, 33(2), p.97.
Bos, M. and Agyemang, C., 2013. Prevalence and complications of diabetes mellitus in Northern
Africa, a systematic review. BMC public health, 13(1), p.387.
Brown, D., Edwards, H., Seaton, L. and Buckley, T., 2017. Lewis's Medical-Surgical Nursing:
Assessment and Management of Clinical Problems. Elsevier Health Sciences.
Diabetes, U.K., 2012. Diabetes in the UK. London: Diabetes UK.
Dunning, T., 2013. Care of people with diabetes: a manual of nursing practice. John Wiley &
Sons.

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Evert, A.B., Boucher, J.L., Cypress, M., Dunbar, S.A., Franz, M.J., Mayer-Davis, E.J.,
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