Metabolism is an essential process of chemical reactions, needed for energy, that occurs inside the cells that function throughout the body. One of the most widespread metabolic diseases is diabetes. Diabetes is considered a chronic disease with several pathogenic processes that, range from autoimmune destruction of the -cells of the pancreas with consequent insulin deficiency to abnormalities that result in resistance to insulin action (American Diabetes Association 2010, p. S62). My six-foot, 210 pounds, 77-year-old male client suffered major consequences from the deadly, chronic disease of diabetes.
The cause of type one diabetes is an autoimmune disorder where there is an absolute deficiency in insulin ( -cells) secretion from the pancreas endocrine cells, also known as, the islets of Langerhans. Markers of the immune destruction of the -cell include islet cell autoantibodies, autoantibodies to insulin, autoantibodies to [the enzyme] GAD (GAD65), and autoantibodies to the tyrosine phosphatases IA-2 and IA-2 (American Diabetes Association 2010, p. S63). GAD65 and tyrosine phosphatases IA-2 and IA-2 are both antibodies that are used to diagnose type one diabetes. Type two diabetes is the most common type of diabetes and is referred to as, insulin resistant or non-insulin dependent.
Glucose is abundant throughout the blood and isnt taken up into the cells due to inability to use the insulin properly; yet, -cells are not destroyed in type two. Majority of people diagnosed with type two diabetes are obese. Gestational diabetes is defined as, any degree of glucose intolerance with onset or first recognition during pregnancy (American Diabetes Association 2010, p. S65). This type of diabetes is similar to type two; yet, when birth of the child occurs, the gestational diabetes usually disappears.
Diabetes impacts many different processes that occur inside the body as well as outside. The things most impacted by diabetes, that have also caused a major toll on my clients body, are; nutrition, fluid and electrolyte balance, tissue-integrity, mobility, wound-healing, and perfusion. The biggest problems faced by upcoming diabetics today, according to Waqas Samis review article, Effects of diet on type 2 diabetes mellitus: A review, food choices, size of portions and sedentary lifestyle have increased dramatically that resulted in high risk of obesity (Sami 2017, p. 67). With diabetes, a bad nutritious pattern can lead to major complications.
The most basic diet for diabetics is the consistent carb diet. This diet includes eating the same amount of carbohydrates at each meal. Usually, a dietitian will help pick out an amount right for the individual based on their blood sugar, weight, and activity levels. Many people fear that they will have to completely stop eating foods they love, when in reality, they just need to eat smaller portions or eat them less often.
Fluid and electrolyte imbalances are another major concern for diabetic patients. An increase in blood glucose levels (hyperglycemia) causes the kidneys to work overtime to try and excrete the excess glucose. This excretion happens through urine, producing polyuria. When there is an increase in urinary output, there is also an increase in the amount of water and electrolytes lost, causing fluid and electrolyte imbalances. This is a major concern for my client who has chronic kidney disease (CKD) because, his kidneys do not filter as proper as a healthy individuals.
Perfusion is, essential for the integrity of tissue and organ function (Levy et al. 2018, p.968). Chronic hyperglycemia can lead to vessel walls (and cell walls) stiffening and becoming rigid. Narrowing of the vessel walls lead to little or no perfusion of blood to the tissues. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation (Okonkwo & DiPietro 2017, p.1). My clients history of coronary artery disease (CAD) and peripheral artery disease (PAD) were the effects of blood vessel damage from chronic hyperglycemia and being a long-term smoker. This led to low perfusion to his tissues and organs, which caused them to start failing. Due to low oxygenation getting sent to the peripheral tissues, he started experiencing peripheral neuropathy.
Peripheral neuropathy is nerve damage, usually to the hands and feet. This led to tissue integrity problems, such as diabetic pressure ulcers on his heels. Minor wounds often lead to chronic, nonhealing ulcers that are predisposed to infection (Greenhalgh 2003, p.37). With these ulcers forming, it created a higher need for those tissues to get oxygen; his vessels were too damaged to perfuse this oxygen needed to those affected tissues. Without any oxygen or blood circulating to those tissues, the ulcers couldnt heal fast enough causing progression of the infection, which led to hospitalization. When he was hospitalized, the ulcers on his heels had already become necrotic. This tissue death caused him a lot of pain which left him bedridden. Being bedridden leads to; no mobility, slower perfusion, slower wound healing, increased risk for more pressure injuries, and much more possibilities that cause this cycle to keep going.
Diagnosis of type two diabetes, can be made with an A1C level of 6.5% or greater, a fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or greater, or a two-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test with 75-g glucose load; however, testing should be repeated on a subsequent day to confirm the diagnosis (Pippitt & Gurgle 2016, p. 106). As stated in the quote, these glucose readings should be abnormal on two different visits to ensure there was no error. These abnormal readings will usually be accompanied by symptoms of hyperglycemia such as; polydipsia, polyuria, and unexplained weight loss. When my client first was first admitted to the hospital his A1C was 8.0%, which means his average plasma glucose level was 183 mg/dL (10.2 mmol/L).
With blood glucose levels this high, many complications can arise (like experienced with my client). Medications and lifestyle changes are the best way to avoid these issues.
Oral medications, such as Metformin and Glipizide, are used in defense against hyperglycemia. Metformin is considered the agent of first line for treatment of T2DM, in the absence of contraindications (Marn-Pe±alver 2016, p. 359, 360). Metformin works by decreasing hepatic gluconeogenesis, which is the break-down of proteins to glucose. It also aids in the decrease of intestinal glucose absorption. A therapeutic outcome of Metformin is that it, decreases fasting blood glucose by approximately 20% and HbA1c by 1.5% (Marn-Pe±alver 2016, p.360). Glipizide is another anti-hyperglycemic drug that, [stimulates] pancreatic islet beta-cells, which increases insulin secretion (Elseviers Clinical Key, 2018). Injectable agents, such as insulin, are used for treatment of diabetes as well.
There are four main injectable insulin categories; rapid-acting, short-acting, intermediate-acting (NPH), and long-acting. Short-acting and rapid-acting insulins are used for prevention of hyperglycemia following meals. NPH and long-acting insulins are used for basal insulin coverage over a longer period of time. Intermediate- and long-acting insulins can cause low blood glucose if they are absorbed too quickly. Insulin that is kept warm, rather than at room temperature, may also be absorbed too quickly by the body. Massaging the site of injection can also speed the absorption of insulin, as can exercise (John Hopkins University, Basal Insulins (Intermediate and Long-Acting)).
Diet and exercise (weight loss) are the two most modifiable treatments for type two diabetes. With being an overweight diabetic, my clients first focus should be on his nutrition. Even small changes in ones diet can be effective. Diabetic dietary patterns, emphasizes a consumption of fat primarily from foods high in unsaturated fatty acids, and encourages daily consumption of fruits, vegetables, low fat dairy products and whole grains, low consumption of fish, poultry, tree nuts, legumes, very less consumption of red meat (Asif 2014, p.2).
My client and I discussed the importance of maintaining a healthy and balanced diet to decrease the risk for any more diabetic complications. He was surprised to hear that fruits and vegetables had such a good impact on his health. After we finish discussing a good amount of healthy food options, he went on to state that he was going to include more fruits and vegetables in his everyday diet to better his health. He also stated that he was going to eat whole grain bread instead of white bread to ensure he received all the beneficial nutrients that isnt incorporated into white bread.
A safe and effective range for weight loss is one to two pounds per week. Another way to calculate weight loss, other than a scale, is to count cut calories. According to Eve Guths research article, Healthy Weight Loss, A total of 3500 calories equals 1 pound of body weight. This means if you decrease (or increase) your intake by 500 calories daily, you will lose (or gain) 1 pound per week (Nabel 2010 ch.3). Losing weight and eating a healthy diet (cutting down portion sizes) are two modifiable factors discussed with my client about how to effectively improve his diabetes and its complications.
I would like to see my client lose one pound a week until he reaches a healthy weight for his height. After he loses the appropriate amount of weight, I would like him to try and maintain that balanced weight to height ratio. This will allow him to improve his diabetic condition and improve his ability to have proper wound healing.
Smoking cessation was another concern discussed with my client. According to the CDC, smokers are 30“40% more likely to develop type 2 diabetes than nonsmokers (Smoking and Diabetes 2018). Complications from smoking have increased his perfusion issues, oxygenation issues, and slow-wound healing process. Smoking causes, increased blood pressure and altered lipid profiles in smokers with diabetes [and encourages] development of insulin resistance syndrome, setting patients up for further cardiovascular problems (Sherman 2005, p. 202). Insulin resistance is a result from decreased absorption of insulin through subcutaneous tissue (from smoking), therefore, leading to an increase in insulin requirement.
My client and I discussed the effects smoking had on his overall health and how it may worsen the complications he experiences from diabetes; such as, wound healing, perfusion issues, etc. We also went over many different types of smoking cessation techniques (classes, gum, patches, activities). He understood that quitting did not have to happen abruptly although, it had to happen sooner rather than later. My client had listed back to me the effects smoking had on his body and how it complicated his diabetes. After, he agreed to decrease the number of cigarettes he smoked each day, and to attend cycling classes along with indoor water aerobics to keep his mind busy and increase activity.
Aside from smoking and diet, wound-healing was another topic discussed with my client. It was especially important due to the necrotic diabetic ulcers on his heels. If not treated quickly or appropriately, diabetic ulcers can become infected and may lead to amputation. I helped to educate him on the signs and symptoms of infection to decrease the possibility of serious complications, such as amputation. The treatment of diabetic wounds begins with preventative measures that include both controlling hyperglycemia and preventative foot maintenance (Greenhalgh 2003, p. 41).
After a visit from the wound care nurse, we discussed the importance of maintaining a clean wound and eating a balanced diet, high in protein to prevent from further infection. Before I left, my client was able to correctly demonstrate the technique for cleaning his wound (starting from the middle and dabbing around in a circle to the edge) with a normal saline soaked gauze.
Diagnosis of type two diabetes is increasing every day. People are getting diagnosed younger than 20! The health care system is coming up with more and more ways to try and help decrease this sky-rocketing rate. People are getting tricked into thinking some junk food is healthy just because of food marketing labeling it fat-free or sugar-free. What people arent realizing is that when food is rid of fat or sugar, it is replaced with something artificial or worse, just with a different name on the label. Following the safest and most effective practices, I was able to discuss these topics with my client and provide optimal care during my time spent with him. I allowed time for him to express his concerns and provided him with feedback/knowledge to lead him to a fast and healthy recovery.
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