NURS2100 Assignment: Pathophysiology and Management of T2DM Case

This assignment presents a detailed case study analysis of Mr. McDonald, a 75-year-old male with Type 2 Diabetes Mellitus (T2DM) and cardiovascular complications. The report begins by connecting Mr. McDonald's symptoms, including high HbA1c levels, pitting edema, proteinuria, and hypertension, to the pathophysiology of T2DM and related complications. It explores the impact of elevated blood glucose, renal disease, and the use of Metformin. The second part of the assignment outlines both pharmacological and non-pharmacological interventions for managing Mr. McDonald's condition, including weight management strategies, edema control, and interventions for tired eyes. Medical interventions discussed include diuretics, ACE inhibitors and ARBs. The report concludes with an overview of the discussed nursing and medical interventions that can be used to manage T2DM and its complications.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
The following assignment is based on the case study of Mr. McDonald who is
suffering from Type 2 diabetes mellitus (T2DM) and cardio-vascular complications. He is
also having high levels of HbA1c. The first part of the assignment will attempt to relate the
symptoms exhibited by McDonald with T2DM. The second part of the assignment will draft
pharmacological and non-pharmacological interventions that will be helpful for management
of T2DM symptoms.
Question set A
Pathophysiology of Diabetes
People who are suffering from diabetes have risk of developing high level of HbA1c
and higher risk of developing other diabetes related complications. HbA1c is also referred as
haemoglobin A1c and glycated haemoglobin. The presence of higher level of sugar in the
blood increase the concentration of glycated haemoglobin as more glucose molecule
(monosaccharide) is linked with sugar and thus increasing the concentration of HbA1c. In
reference to the case study, it can be stated that McDonald has diabetes and thus having
higher level of HbA1c (7.2% while the normal level is 4% and 5.6%) (Eyth & Naik, 2019).
Eyth and Naik (2019) have further highlighted that HbA1c serves as an indicator towards
several glycemic control and serves as a reflection of the average blood sugar during the past
three months. HBA1c reflects average plasma glucose during the past 12 months and the test
can be performed at any time in the day with no strict requirement of fasting. Thus, it is
regarded as one of the most preferred test for assessing the glycaemic control in people
suffering from diabetes.

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The case study highlights that McDonald has developed pitting oedema in both the
lower legs. Oedema is defined as fluid build-up in the body or water retention that leads to
swelling. It mainly affects the lower extremity of the body and thus also known as peripheral
oedema. The pathophysiology underlying the fluid retention is difficult to isolate and might
be an indicator to secondary to multiple etiologies. Diabetes is a string yet independent risk
factor of oedema and use of antihyperglycemic drug, in this case Metformin (500 mg oral
twice daily later 1000 mg) (Wu et al., 2017). McDonald was diagnosed with diabetes 1 year
ago with HbA1c level is 7.2% and fasting glucose is 4.5 to 7 mmol/L. This high level of
glucose in the blood increase the risk of developing micro and macrovascular complications
of diabetes. Under macor-vascular complications of diabetes, there occurs deposition of
cholesterol over the peripheral capillaries (arthrosclerosis). This leads to reduction in the
overall diameter of the capillaries causing restriction in the flow of blood. The restriction in
the flow of the blood towards the peripheral regions of the legs creates pressure over the total
surface areas of the capillaries. As a result of this pressure, the capillary walls leak resulting
in the inflow of the extracellular fluid inside the capillary cells causing swelling or oedema.
McDonald used to consume heavy alcohol and this further aggravated the chance of
developing arthrosclerosis (Wu et al., 2017).
The urine analysis of McDonald indicated high level of protein (4+). Blood serum test
of McDonald indicated the presence of urea (25 mg/dl) along with the serum albumin (6.1
mg/dl). Decreased Estimated Glomerular Filtration Rate (EGFR) was observed and 24 hours
urine test highlighted higher urine albumin excretion in comparison to the normal rate. All
these condition indicated the presence of proteinuria. The detection of protein in the urine is
an indicator of renal disease. McDonald was also suffering from renal disease and this is
evident from the decreased EGFR. Decreased EGFR is attributable to the formation of
glomerulonephritis. The glomerulonephritis is defined as inflammation n the kidneys

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resulting in decreased filtration rate of kidneys. The inflammation in the kidney results from
high level of blood glucose (diabetes). Diabetes mellitus is associated with hemodynamic and
metabolic alterations that lead to the activation of diverse pathways of transduction in
nephrons (García-García et al., 2014). This leads to the development of systemic renal
inflammation. This local inflammation in the renal cells activates the hypersensitivity
pathways l(JAK/STAT pathway and nuclear transcription factor-kappa B pathway [NF-kB])
leading to the activation of the inflammatory factors and cytokines (interleukin (IL)-1, IL-6,
IL-18). As a result the mononuclear phagocyte, mast cells and neutrophils infiltrate the
glomeruli leading to the development of inflammation. Inflammated glomeruli decrease its
filtration rate leading to decrease in the filtration rate. Decrease in the filtration rate decreases
the filtration of water along with decrease in the re-uptake of protein from the glomeruli and
thereby increasing the protein concentration in the urine (García-García et al., 2014). The
higher level of urea in the blood is excreted through urine. Marginally high level of urea in
blood resists the beta cells of Islet of Langerhans to secrete adequate level of insulin for the
re-uptake of glucose from the blood to the hepatic cells. The higher blood glucose of
McDonald indicates higher level of urea in blood. This high level of urea is excreted through
urine. Higher level of urea in the blood is diabetic neuropathy. It is one of the chronic causes
of renal failure (Xie et al., 2018). Alternative pathophysiology states that higher level of urea
in blood increase the concentration of reactive oxygen species (ROS) and thus reducing the
level of insulin secreting resulting out of the celluar toxicity (Schrauben et al., 2019). Another
cause behind marginally high level of urea is long-term and higher dosage intake metformin.
Inzucchi et al. (2014) stated that use of higher dosage of metformin for a prolong period of
time leads to the development of mild to moderate chronic kidney disease and is mainly
defined by the EGFR. The kidney disease is mild to moderate as indicated by the marginal
level of urea (25mg/dl).

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Potential Management Approach (Nursing and Medical)
Nursing Intervention
Weight management
McDonald is 175 cm tall with height of 123 kilograms. Initially he was 156 kilograms
(2 years ago). Thus the potential nursing approach will include effective management of
weight of McDonald. Munshi et al. (2016) stated that high BMI (basal metabolic index)
increase the level of fat deposition in the adipose tissue. The increase in the level of the fat
content of the body hampers the progress of the type 2 diabetes mellitus and also increases
the tendency of developing arthrosclerosis. Thus the nursing intervention will cover effective
management of weight. Since McDonald is suffering from lower feet oedema, conduction of
mild to moderate physical exercise might not be feasible. In such cases, the main intervention
for effective weight management will include restricted dietary intake. Restricted dietary
intake will include decreased or minimal consumption of carbohydrate and sweetened
products. Decrease in the level of carbohydrate and sugar helps to reduce the level of glucose
in the blood and thereby decreasing the HbA1c level and at the same time reducing the
calorie intake of the body. Calorie deficiency will help in reduction in the body weight. A
nursing professional must take help from the trained dietician in order to frame the diet plan
for McDonald based on his weight, height, age, gender and BMI. The reduction in the body
weight will further help to reduce the severity of lower feet oedema (Fruh, 2017).
Management of Oedema
One of the effective nursing strategy for the effective management of Oedema include
restricted intake of electrolyte. Carson and Clare (2019) stated that sodium is the major factor
behind the proper development of oedema and thus the main nursing intervention for the
effective management of oedema will include reducing the in-take of sodium from the diet.

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The decrease in the intake of sodium in the diet can be done by reducing the salt in-take.
Decrease in the salt intake will reduce the concentration of sodium (Na) in the blood and
thereby helping to eliminate sodium from the body and helping to reduce peripheral oedema.
Karafa, Karafová and Szuba (2020), management of oedema in the lower extremity of
legs under non-pharmacological interventions can be done by use of the compression
stocking. The compression stockings increase the targeted pressure over the affected area and
thereby helping to reduce swelling through equal distribution of the accumulated water
throughput the body. However, a nursing professional must keep in mind that the prolong use
of the compression stockings are not permissible and the implementation of the therapy must
be done under the presence of the trained occupational therapists and healthcare physicians.
Intervention for tired eyes
McDonald is suffering from tired eyes. This might be regarded as the initial stage of
diabetic retinopathy that eventually leads to dual vision. Thus nursing intervention apart from
reduction of the blood glucose level will include resting of eyes after frequent interval and
reduction in the use of the mobile phones and watching television. In order to reduce the level
of fatigue, deep breathing can be practice. This must be done in empty stomach under the
presence of trained nurse and physical exercise trained. Now if McDonald has pulmonary
embolism then deep breathing must be refrained (Lelliott, Basu & Besser, 2019)
Medical intervention
Pharmacological management of oedema
The medical intervention for the effective management of oedema can be done with
the use of the diuretics. Diuretics mainly act over the pair of kidneys help to reduce the re-
absorption of sodium from the glomerular filtrate and in response to the secondary effect,
there occurs increase in the water loss from the body and reduction in oedema. One of the

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commonly used diuretics includes Lasix (Furosemide) or water pill or loop (Henle’s loop)
diuretic. The medication prevents the body from absorption of unwanted salt and thus helping
loss of electrolyte from the body through urine. Since McDonald is suffering from estimated
RGFR, the dosage of Lasix must be regulated strictly (Abass, 2016).
Management of proteinuria and blood pressure
McDonald is hypertensive and at the same time is suffering from diabetes. Thus, for
the treatment of the excess excretion of protein through the urine (proteinuria), the medical
intervention will be, administration of angiotensin-converting enzyme (ACE) inhibitor. The
ACE inhibitors are commonly prescribed for the treatment of high blood pressure and other
heart problems . It also helps in the reduction of excess excretion of protein through the urine.
ACE inhibitors mainly reduce the blood pressure by exerting vaso-constriction of the artieres
and veins carrying blood and thus helping to reduce the overall cardiac output and thereby
reducing the level of blood pressure (Coleman et al., 2020). ACE inhibitors prevent the ACE
from secreting angiotensin II in the body. Angiotensin II mainly acts by narrowing the blood
vessels and thus increasing the blood pressure and thereby increasing the cardiac output. ACE
inhibitors and angiotensin receptor blockers (ARBs) reduce the intraglomerular pressure by
inhibiting angiotensin II -mediated vaso-constriction of the efferent arteriol and thus reducing
high blood pressure. In case of McDonald, the administration of ACE inhibitors might be
helpful in reducing alarming high blood pressure 170/100 mmHg. This anti-vaso-constriction
mechanism of ACE inhibitor is independent of its proteinuria reducing effect. Reduction in
the proteinuria is attributable to decrease in the intraglomerular capillary pressure (Coleman
et al., 2020). ACE inhibitors (Lisinopril) are best suited in this case because it regarded more
potent in comparison to other anti-hypertensive drug for the reduction of proteinuria. ACE
inhibitors also help in reducing the over-expression of albumin in blood (Perico, Ruggenenti
& Remuzzi, 2017).

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Conclusion
Thus from the above discussion it can be concluded that health-related condition of
Mc. Donald indicate that he is suffering from macro and micro-vascular complications of
T2DM. Application of nursing interventions like diet management will be helpful for
reducing the body weight and use of compression stockings will help to reduce the chances of
pressure ulcers. The pharmacological interventions include medication for managing renal
complications and hypertension.

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References
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