Comprehensive Case Study: Diabetes Management and Patient Outcomes

This case study focuses on the comprehensive management of a patient with type 2 diabetes, detailing the patient's symptoms, including obesity, respiratory issues, polyuria, and a diabetic foot ulcer. The pathophysiology of the disease is explored, linking obesity and metabolic changes to i...Read More

Running head: DIABETES MANAGEMENT
DIABETES MANAGEMENT
Name of the student:
Name of the university:
Author note:

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Introduction:
Diabetes is a chronic disorder where the glucose level builds up in the blood. It is seen
that in patients who have type 2 diabetes, the pancreas successfully produces insulin but the cells
of the body become resistant to it. The cells of the body could no longer use the insulin produced
by the islets of Langerhans of the pancreas to convert the glucose into energy that affects the
physiological systems of the body (Inzucchi et al., 2015). Moreover, it is seen that blood glucose
level starts to increase in the blood. All these lead to a situation, which results in development of
the disorder called the type 2 diabetes. The assignment will show a similar case study where the
patient is suffering from type 2 diabetes (Mingrone et al., 2015). Proper management of the
symptoms would be explained along with the pathophysiology of the disorder and how the
disorder is affecting the patient in different ways. Moreover, it will also show how proper health
literacy would help in development of quality life of the patient.
Pathophysiology and symptoms faced by the patient:
Obesity and diabetes:
The body mass index also called BMI is one of the indicators of obesity in patients. The
weight of the patient is 120 kg and his height is 175 cm. After calculation, it is found that his
BMI is 39.2 that come into the status of being obese. Therefore, his obese health status is one of
the reasons that might have contributed to the development of type 2 diabetes. Researchers had
conducted extensive studies to find out the associations between obesity and development of
type 2 diabetes (Forslund et al., 2015). Extensive researches have shown that when individuals
become overweight, inside of the cells become stressed out. Overeating habit by the individuals
mainly develops stress on the membranous network that exists on the inside of the cells that are

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called endoplasmic reticulum. They have found that when endoplasmic reticulum has more
nutrients for processing than it can accumulate and handle successfully; it results in sending of
signals to the cells. These signals are actually alarming signals which convey the cells to dampen
down the receptors of the insulin present of the surface of the cells. This results in translating to a
situation where the cells become resistant to insulin as well as to high level of concentrations of
the sugar in the blood. Many of the other researchers have given other factors, which causes
obesity to create symptoms of diabetes type 2 (Kahn et al., 2014). They are of the opinion that
abdominal fat causes the different fat cells to release a specific type of pro-inflammatory
chemicals. They have stated that these chemicals are mainly responsible for making the body
less sensitive to the hormone insulin present in the blood. The function of the insulin responsive
cells thereby is disrupted and therefore their ability to respond to the insulin in blood is affected.
Another important issue faced by obese people is that obesity triggers changes in the metabolism
system of the body. Such modifications result in forcing the fact tissue to release huge number of
molecules in the blood that affect insulin responsive cells that lead to reduced insulin sensitivity.
As the patient is obese, therefore, these pathologies had resulted in development of the disorder
(Rubino et al., 2016).
Respiratory issue and diabetes:
Another symptom which was noticed in the patient was his irregular breathing of 40
breathes per minute when the normal is 20 breathes per minute. This may be due to the
occurrence of obesity hyperventilation syndrome also called the Pickwickian syndrome. In such
cases, obese people are seen to fail miserably to breathe rapidly or deeply. This results in low
amount of oxygen levels as well as high blood carbon dioxide levels. Excessive belly fat is
responsible for pushing the diaphragm as well as the wall of the chest. This makes it harder for

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the lungs to be filled with air (Courcoulas et al., 2015). Moreover, the weight of the fat on the
chest wall results in decreasing the amount of space for air in the lungs. The diaphragm therefore
gets pushed up and its movement is restricted. This is felt more when the individuals try to bend
or lie down. A huge burden is put on the entire body where more oxygen is moved around for the
excess tissues. This forces the heart to work harder which thereby places greater burden on the
cardiopulmonary system for which the pulse rate may get affected as that happened in case of the
patient.
Polyuria in diabetes:
Moreover, the analysis of the urine also showed that high amount of glucose and ketones
are also present. This is said so because amount of ketones found in urine is 3+ and that of
glucose is + when the presence of such compounds should be negative in the urine. This shows
that his diabetes is poorly managed as the presence of glucose and ketones in urine is the
symptom of the disorder. Uncontrolled diabetes mellitus causes osmotic dieresis where the
glucose levels in the blood are found to be so high that glucose is excreted from the urine and the
presence of high glucose in his urine is therefore a symptom of uncontrolled diabetes (Donath,
2014).
Foot ulcer and diabetes:
Another huge suffering of the patient was the diabetic foot ulcer that had not only caused
him pain for a long number of days but had also affected poor quality lives. Foot ulcers mainly
take place due to the result of breaking of the skin tissue thereby exposing the layers that remain
underneath the tissue. Most of the people with diabetes develop foot ulcers and the patient has
not been an exception, as he had not taken proper care for his feet that could have prevented the

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symptoms. Such diabetic foot ulcers mainly take place due to vascular (blood vessel) as well as
neuropathic (nerve) complications of the diabetes. Vascular diseases are found to be the major
problem in diabetes that are seen to affect very small blood vessels that feed the skin (Hausenbas
et al., 2015). This is called microangiopathy. Here doctors may face two issues. In one situation,
doctors may be able to find normal pulses in the feet as the arteries remain unaffected. In other
situations, patients may have narrowed arteries that results the doctors to find no pulses in the
feet, which is called ischemia. This lack of healthy blood floe result in ulceration and this gets
affected as wound healing is also affected due to high amount of sugar in blood. On the other
hand, nerve damage results from diabetes. It causes altered as well as complete loss of feeling of
the individuals in foot as well as leg. This leads to peripheral neuropathy (Mokhlesi et al., 2016).
Pressure from shoes, wounds, and bruises as well as any injury of the foot are often seen to get
unnoticed due to this reason. As the patients lose their protective sensation, they cannot come to
know that their skin is injured and cause skin loss, blisters as well as ulcers. High glucose levels
results in slowing down the healing process of the infected foot ulcer and such patients face huge
issues while fighting off infections from ulcers. Similar had been the case with the patient. As his
ulcer was painful, therefore chance of him developing ulcer from nerve damage is less but from
vascular impairment is high.
Proper management of the symptoms:
One of the most import symptoms that need to be managed is the foot ulcer that is
affecting the quality of his life. It has become very painful for him and therefore one of the
nursing priorities would be proper caring of the wound by the nurse. The nurse should first
assess the vascular status of the patient’s foot with the ankle brachial index called the ABI as
well as with toe pressure. She can also use pedography system as well as the thermometer to

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assess foot pressure and thereby foot temperature. This would help the nurses to understand the
severity of the problems of the foot and the risks associated with the foot ulcer can be identified.
This should be followed by the nurse’s duties of providing proper intervention so that the patient
may get relieved from the pain he is going through (Inzuchi et al, 2015). One of the most
important aspect of nursing intervention would be to select an appropriate dressing according to
the type of the ulcer that the students have developed. Selection dressing is one of the most
important attribute, as the nurses have to first identify whether the wounds are wet or dry and
according to this, they need to apply the dressing at the same time of keeping the wound clean
and thereby maintain proper wound moisture. The nurse should also take initiatives to conduct
properly the debridement and thereby reduce the number of bacteria. The nurses need to have
proper knowledge about the dressing that should be applied depending upon the condition of
wound of the patient. In case of this patient, the nurse should initiate by identifying the wound
type properly and then debride the dead tissue of the surface. She should then clean the wound
with antiseptic as well as superoxide solution. She can then apply the synthetic wound dressings
so that a moist environment can be assured. Many researchers suggest that honey dressings are
also helpful in these situations. She should put her focus on the type of ulcer and the stage of
healing and thereby should apply her knowledge and skills accordingly to help the patient to
develop better quality lives (Rios et al., 2015).
Management of blood sugar level:
Normally, the blood sugar level of human beings should be maintained at 5.5 mmol/L.
the level can fluctuate throughout the day but by very little values. This causes no abnormal
physiological effects. However, in case of the patient, it was found that his blood glucose level is
about 25 mmol/L that is indeed very high and is a life-threatening situation for the patient. The

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patient is admitted to the hospital emergency ward in serious situations and he need emergency
treatment for controlling his hyperglycemic situation and diabetic ketoacidosis (Muller et al,
2015). Nursing professionals may need to provide three important interventions. The first one is
the fluid replacement therapy. Here the nurses will provide fluids to the patient either orally or
may be through veins like intravenously until the patient is rehydrate. This fluid helps in
sufficing two important functional requirements. One of them is that the fluids replace those
fluids that the patient loses through urination. The other function is that this fluid helps in
diluting the excess sugar that is present in the blood which helps in reducing and controlling the
blood sugar level. The second intervention is proper electrolyte management of the patient.
Electrolytes are mainly minerals in the blood that are necessary for the tissues so that tissues can
function successfully (Shaw et al., 2016). When the insulin is not present, it can result in the
lowering of the level of electrolytes in blood. The patients should receive electrolytes through the
veins so that the heart, muscles as well as the nerve cells function properly. The third
intervention is called the insulin therapy. Insulin mainly helps in reversing the procedures by
which ketones are prepared in the body when energy cannot be formed by the cells. Therefore,
insulin therapy is also provided through the vein besides electrolytes and veins.
Health education plan for the patient:
The patient should have a thorough knowledge about how to take care of his feet so that
he can maintain them and do not have to suffer from severe pain. The patients should be first
taught that how diabetes may lead to situations like nerve damage, problems with circulation and
infections that enhance issues with foot problems. Therefore, four important aspects should be
taught to the patients that will protect him from further emergencies regarding his foot conditions
(Miller et al., 2015). He should be taught how to manage his diabetes successfully and maintain a

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healthy lifestyle. The first one is the regular medical examination that would include foot checks
on every visit to the doctor and check three important components called ABC. These are
hemoglobin A1c levels, blood pressure as well as cholesterol. He should monitor his blood sugar
level daily so that the blood glucose level is kept in check. Eating a balanced diet that is rich in
fruits and vegetables is also important. Regular exercises should also be done. Some of the
proper foot care habits that he should also maintain are proper inspection of the foot. The patient
should check his toes and feet by properly inspecting the sides, heels, soles, tops and the other
areas in between the toes (Davies et al., 2015). He can also use a mirror or ask someone for help
if he is unable to check the feet properly. The doctor should immediately summon if he notices
any kind of sores, redness, blisters, bruises and even cuts. The second habit would be to wash his
foot everyday with warm water and mild soap. The patient should first check the water
temperature with fingers or elbow washing feet as too hot water may damage the skin. Then the
feet should be dried well as infections may develop in moist areas (Li et al., 2015). Then the skin
should be moisturized so that it does not get dry. Moreover, antiseptic lotions can burn the skin.
Therefore, it should be avoided. Heating pad, hot water bottle as well as electric blanket should
be avoided. Walking barefoot should be avoided and the feet should be protected from heat and
cold. Removers, razor blades, liquid corn as well as callus removers should never be used to
remove corns, warts and other foot lesions. Proper shoes and socks should be worn according to
the advice of the patients (Hayward et al., 2015). The patients should know some of the
symptoms so that they can be warned earlier before the intensification of the heart conditions.
These are burning, tingling as well as painful feet, loss of sensation, changes of color or shape of
feet, losing of hair on toes and feet, thickening, yellow toenails, and many others.

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Obesity is considered to be one of the most important factor for which the patient has
become highly vulnerable to the effect of diabetes. Therefore, management of weight of the
patient is very important. The patient should take right diet and nutrients to ensure proper weight
management. The patient should take well-balanced meal that should have proper amount of
green leafy vegetables, correct amount of meat and protein and also whole grains, legumes and
starchy vegetables. Fast food should be avoided as they are high in calories. The patient should
be also active and undertake exercises at a regular level. Walking, jogging and physical exercises
may help individuals to keep their calories in check (Gonzalez et al., 2016). He can also do yoga,
use stretch bands and conduct heavy gardening to keep him fit. Keeping track of the blood sugar
level, taking correct doses of medicines at the right time, checking the foot for ulcers, brushing
teeth properly, quitting smoking and others are the initiatives that he should take. Proper
resources he can seek for is the community support centers through which he can book
appointments with experts according to his needs. Dentists, diabetes educator, diabetes
specialists, dieticians, podologists or foot doctor, eye doctor, mental health counselor, nursing
professionals, social workers and pharmacists (Alattore et al., 2017).
Conclusion:
From the entire discussion, it is seen that obesity is one of the most important risk factor
for diabetes. The patient has a very high BMI that states that he is obese. Obesity results in
increasing the risk for diabetes. The patient has poorly controlled diabetes and his obese
condition can be stated as some of the reason that has contributed to the occurrence of diabetes
symptoms by many folds. Therefore, care should be taken that he initiates activities that help him
to keep his calorie intake in check. Moreover, his foot condition is also very poorly maintained
which also requires care and assistance. Therefore, with the support of community care centers,

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he can develop proper quality life. With proper health education, he can develop habits that
would help him to maintain proper lifestyles and his symptoms of diabetes will be in check.

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References:
Alatorre, C., Fernández Landó, L., Yu, M., Brown, K., Montejano, L., Juneau, P., ... & Swindle,
R. (2017). Treatment patterns in patients with type 2 diabetes mellitus treated with
glucagon‐like peptide‐1 receptor agonists: Higher adherence and persistence with
dulaglutide compared with once‐weekly exenatide and liraglutide. Diabetes, Obesity and
Metabolism, 19(7), 953-961.
Courcoulas, A. P., Belle, S. H., Neiberg, R. H., Pierson, S. K., Eagleton, J. K., Kalarchian, M.
A., ... & Jakicic, J. M. (2015). Three-year outcomes of bariatric surgery vs lifestyle
intervention for type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA
surgery, 150(10), 931-940.
Davies, M. J., Bergenstal, R., Bode, B., Kushner, R. F., Lewin, A., Skjøth, T. V., ... & DeFronzo,
R. A. (2015). Efficacy of liraglutide for weight loss among patients with type 2 diabetes:
the SCALE diabetes randomized clinical trial. Jama, 314(7), 687-699.
Donath, M. Y. (2014). Targeting inflammation in the treatment of type 2 diabetes: time to
start. Nature reviews Drug discovery, 13(6), 465-476.
Forslund, K., Hildebrand, F., Nielsen, T., Falony, G., Le Chatelier, E., Sunagawa, S., ... &
Arumugam, M. (2015). Disentangling type 2 diabetes and metformin treatment signatures
in the human gut microbiota. Nature, 528(7581), 262.
Gonzalez, J. S., Kane, N. S., Binko, D. H., Shapira, A., & Hoogendoorn, C. J. (2016). Tangled
up in blue: unraveling the links between emotional distress and treatment adherence in
type 2 diabetes. Diabetes Care, 39(12), 2182-2189.

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DIABETES MANAGEMENT
Hausenblas, H. A., Schoulda, J. A., & Smoliga, J. M. (2015). Resveratrol treatment as an adjunct
to pharmacological management in type 2 diabetes mellitus—systematic review and
meta‐analysis. Molecular nutrition & food research, 59(1), 147-159.
Hayward, R. A., Reaven, P. D., Wiitala, W. L., Bahn, G. D., Reda, D. J., Ge, L., ... & Emanuele,
N. V. (2015). Follow-up of glycemic control and cardiovascular outcomes in type 2
diabetes. New England Journal of Medicine, 372(23), 2197-2206.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., ... &
Matthews, D. R. (2015). Management of hyperglycemia in type 2 diabetes, 2015: a
patient-centered approach: update to a position statement of the American Diabetes
Association and the European Association for the Study of Diabetes. Diabetes
care, 38(1), 140-149.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., ... &
Matthews, D. R. (2015). Management of hyperglycaemia in type 2 diabetes, 2015: a
patient-centred approach. Update to a position statement of the American Diabetes
Association and the European Association for the Study of Diabetes. Diabetologia, 58(3),
429-442.
Kahn, S. E., Cooper, M. E., & Del Prato, S. (2014). Pathophysiology and treatment of type 2
diabetes: perspectives on the past, present, and future. The Lancet, 383(9922), 1068-
1083.
Li, X., Song, D., & Leng, S. X. (2015). Link between type 2 diabetes and Alzheimer’s disease:
from epidemiology to mechanism and treatment. Clinical interventions in aging, 10, 549.

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DIABETES MANAGEMENT
Miller, K. M., Foster, N. C., Beck, R. W., Bergenstal, R. M., DuBose, S. N., DiMeglio, L. A., ...
& Tamborlane, W. V. (2015). Current state of type 1 diabetes treatment in the US:
updated data from the T1D Exchange clinic registry. Diabetes care, 38(6), 971-978.
Mingrone, G., Panunzi, S., De Gaetano, A., Guidone, C., Iaconelli, A., Nanni, G., ... & Rubino,
F. (2015). Bariatric–metabolic surgery versus conventional medical treatment in obese
patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre,
randomised controlled trial. The Lancet, 386(9997), 964-973.
Mokhlesi, B., Grimaldi, D., Beccuti, G., Abraham, V., Whitmore, H., Delebecque, F., & Van
Cauter, E. (2016). Effect of one week of 8-hour nightly continuous positive airway
pressure treatment of obstructive sleep apnea on glycemic control in type 2 diabetes: a
proof-of-concept study. American journal of respiratory and critical care
medicine, 194(4), 516-519.
Müller-Stich, B. P., Senft, J. D., Warschkow, R., Kenngott, H. G., Billeter, A. T., Vit, G., ... &
Nawroth, P. P. (2015). Surgical versus medical treatment of type 2 diabetes mellitus in
nonseverely obese patients: a systematic review and meta-analysis. Annals of
surgery, 261(3), 421-429.
Ríos, J. L., Francini, F., & Schinella, G. R. (2015). Natural products for the treatment of type 2
diabetes mellitus. Planta medica, 81(12/13), 975-994.
Rubino, F., Nathan, D. M., Eckel, R. H., Schauer, P. R., Alberti, K. G. M., Zimmet, P. Z., ... &
Amiel, S. A. (2016). Metabolic surgery in the treatment algorithm for type 2 diabetes: a
joint statement by international diabetes organizations. Surgery for Obesity and Related
Diseases, 12(6), 1144-1162.

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Shaw, J. E., Punjabi, N. M., Naughton, M. T., Willes, L., Bergenstal, R. M., Cistulli, P. A., ... &
Zimmet, P. Z. (2016). The effect of treatment of obstructive sleep apnea on glycemic
control in type 2 diabetes. American journal of respiratory and critical care
medicine, 194(4), 486-492.