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NURBN2016 Advanced Pathophysiology And Pharmacology

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Course Code: NURBN2016
University: Federation University

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Country: Australia

Question:

Part 1 Questions
Melanie is distressed that her blood glucose level is elevated and asks you for help in understanding her diabetes. She tells you that she has a friend who is very overweight, eats lots of cake and hardly ever exercises, and he does not have diabetes.
1.Describe the pathophysiology of T2DM with links to Melanie’s case. Include in your answer risk factors for T2DM, the pathogenesis of T2DM, possible complications of T2DM and outline the 3 levels of treatment options for T2DM.
2.Differentiate between T2DM and T1DM (at least 6 differences).
3.Identify at least 2 reasons Melanie’s BGL is high on admission. Discuss how each reason you identify effects
BGLs.
Part 2 Questions
The surgery is successful and Melanie comes to see you in the outpatient clinic for cortisone injections (Kenacort-A 40). She has been commenced on metformin (APO-Metformin Tablets) and glipizide (Minidiab Tablets) to help control her diabetes. Her blood test on this visit were BGL 8.8 mmol/L; HbA1c: 8%.
1.Discuss the three medications Melanie is on. Include in your answer the action, complications/side effects and nursing considerations linked to Melanie’s situation.
2.Discuss the two blood results, one from prior to surgery and one from the clinic visit of Melanie’s BGL and HbA1c. What are they? What do they measure and why have they changed?
Part 3 Questions
While Melanie is waiting to see the doctor, she starts talking to you about her condition. She asks if she has insulin dependent diabetes or early onset diabetes. She is also unsure of how to use her BGL machine and BGL strips.
1.1  Discuss why the terms insulin dependent diabetes mellitus/ non insulin dependent diabetes mellitus and early onset/mature onset are misleading.
2.2  You need to teach Melanie how to use her BGL machine. Discuss the “teach back” method for patient education (include evidence from peer reviewed sources). Discuss how you would use this method to teach Melanie how to use her BGL machine.

Answer:

In relation to Melanie’s case it is identified that the pathophysiology of type 2 diabetes mellitus is mainly caused due to genetic reasons in relation to the environment that determine the resistance of insulin along with beta cell dysfunction. The changes in the gene pool often lead to the rapid increase of the type 2 diabetes prevalence. The genes that are linked to the type 2 diabetes mellitus where with the use of candidate gene approach, where the PPARG gene was identified initially. Thereafter using the genome-wide association studies, there was identification of the 50 gene loci that was seen to be linked with type 2 diabetes (Gregory et al., 2013). Some of these loci are related to insulin resistance and obesity along with the links to the function of the beta cell. Additionally the increase in the caloric uptake along with the reduced expenditure of energy contributes to the pathophysiology of diabetes mellitus. Composition of nutrition in addition increased amount of dietary fat lead to obesity and insulin resistance along with glucose intolerance and beta cell dysfunction (American Diabetes Association, 2014).
The risk factors that contribute to type 2 diabetes mellitus includes obesity, old age above 45, presence of family history of diabetes, presence of high blood presence, presence of low level of HDL cholesterol or the high level of triglycerides, presence of the history of heart disease, presence of depression, presence of  polycystic ovary syndrome.
The pathogenesis of type 2 diabetes mellitus involves insulin resistance which is often responsible for the metabolic abnormality that leads to the development of type 2 diabetes.  Insulin resistance is generally compensated by increase of insulin secretion (hyperinsulinemia) (Cherney et al., 2014). This allows glucose metabolism to remain normal. It is the beta cells that are genetically susceptible and the individuals become impaired, which leads to delayed along with insufficient insulin secretion. The decrease in beta-cell function results in the individual with insulin resistance to first develops postprandial hyperglycemia thus developing fasting hyperglycemia. Chronic hyperglycemia is responsible a further suppression of pancreatic beta-cell insulin secretion which causes the worsening of insulin resistance (Atkinson et al., 2014). 
The complications of type 2 diabetes might be short term or long term. The short term diabetes involves hypoglycaemia which is often caused due to the low blood glucose. Another short term complication is hyperosmolar hyperglycemic nonketotic syndrome. However this is quite rare in occurrence. The long term complications include the microvascular complications that involve the eye, kidney, and nerve diseases. There are also the macrovascular complications including the heart, brain, and blood vessels (Purnell, Zinman & Brunzell, 2013). The three levels of treatment of type 2 diabetes mellitus involve healthy eating habits, followed by regular exercise and the possible diabetes medications and the insulin therapy. In case of healthy eating, the diet should focus on the low fat foods including fruits, vegetables and whole grains. Animal products should be in taken in low amounts, along with refined carbohydrates and sweets (Hu et al., 2013). Physical exercise should involve regular aerobic exercise along with walking, swimming and biking. The diabetes medications include metformin, sulfonylureas, meglitinides, thiazolidinediones, sglt2 inhibitors and glp-1 receptor agonists. The insulin therapy involves Insulin glulisine (Apidra), Insulin lispro (Humalog), Insulin aspart (Novolog), Insulin glargine (Lantus), Insulin detemir (Levemir) and Insulin isophane (Humulin N, Novolin N) (Fullerton et al., 2014).
Type 1 diabetes can take place at any age, however most commonly it is diagnosed from infancy to the late 30s. In this type of diabetes, the pancreas does not produce any insulin. It occurs when the immune system of the body attacks and destroys the insulin-producing cells in the pancreas. Use of insulin is the only treatment for type 1 diabetes, which is generally injected or infused through a pump (American Diabetes Association, 2015).
Type 2 diabetes is one of the most common types of diabetes. This type of diabetes usually affects those over 40. However, in the recent times this is becoming a common problem among young adults due to lifestyle problems. The symptoms of type 2 diabetes are most of the time not certain and, unlike with type 1, this disorder takes a longer time to develop. Type 2 diabetes generally can be manged through proper diet along with exercise glucose monitoring by self. A progressive condition can be seen to occur in type 2 diabetes, where most of the people will be  eeded to take medications as well as inject insulin even after living with it for five to ten years (Zoungas et al., 2014).On admission to the hospital it was observed that the blood glucose level was quite high for Melanie. This was mainly because her lack of exercise and secondly because of her diet effects. The first reason is lack of exercise or the inability of the patient to be physically active due to the presence of the baker’s cyst. Presence of this behind the knee makes it difficult for the patient to exercise or to even walk. Physical activity is responsible for lowing of the blood pressure (Haidar et al., 2015). Therefore absence of physical exercise makes difficult for blood glucose level to reduce in the patient. Diet also has an effect on the level of blood glucose. Here the patient Melanie seems to be eating food products which are high in fat therefore this has an effect on the blood glucose level. Eating ice-cream also increases her BGL.  
KENACORT-A 40 is utilized to treat hypersensitive illnesses, bad skin issues or joint pain. To treat these issues it is infused profoundly into a muscle. From the muscle it is gradually ingested into the blood and conveyed by the blood to all parts of the body. KENACORT-A 40 can likewise be utilized to treat difficult muscles, joints or ligaments by infusing straightforwardly into the excruciating site. It ios necessary to inquire as to whether the person has any inquiries regarding why KENACORT-A 40 has been recommended. The way that KENACORT-A 40 works is entangled. It is seen that KENACORT-A 40 stifles aggravation and swelling and eases torment. However it is also perceived that it doesn’t fix the fundamental issue. KENACORT-A 40 is accessible just with a specialist’s remedy. KENACORT-A 40 is not reasonable for intravenous, intradermal or intraocular utilize. KENACORT-A 40 is not reasonable for infusion into the nasal turbinates or intralesional infusion about the head. KENACORT-A 40 isn’t prescribed for use in kids younger than six. KENACORT-A 40 isn’t for use in infant or untimely newborn children (Kennedy et al., 2013).
APO-Metformin is utilized to treat compose 2 diabetes (additionally called non-insulin subordinate diabetes mellitus or development beginning diabetes) in grown-ups and children more than 10 years old. It is particularly valuable in the individuals who are overweight, when eating regimen and exercise are insufficient to bring down high blood glucose levels (hyperglycaemia). For grown-up patients, metformin can be utilized alone, or in blend with other oral diabetic medications or in mix with insulin in insulin requiring type 2 diabetes mellitus (McKnight et al., 2015).
Minidiab is utilized notwithstanding eating routine and exercise to control glucose in patients with Type II diabetes mellitus. This sort of diabetes is otherwise called non-insulin-subordinate diabetes mellitus (NIDDM) or development beginning diabetes.  Minidiab is utilized when eating regimen and exercise are insufficient to control (glucose). Minidiab can be utilized alone, or together with insulin or different drugs for treating diabetes.
The side effects of kenacort includes skin changes acne, along with dryness, redness, bruising of the skin accompanied by  discoloration, there is increased hair growth, or thinning hair in addition to nausea, bloating, appetite changes. There are also problems like stomach or side pain, cough, runny or stuffy nose; headache, sleep problems (insomnia) in addition to slow healing of wounds; sweating more than usual. The side effects of metformin includes heartburn, stomach pain, nausea or vomiting, bloating, gas, diarrhea, constipation and weight loss. The side effects of minidab involve mild nausea; diarrhea, constipation, dizziness, drowsiness; or skin rash, redness, or itching (Atkinson, Eisenbarth & Michels, 2014).
Prior to the surgery, the blood test results of Melanie showed that the BGL levels were 22.9 mmol/L and HbA1c was 11%. After the surgery it was seen that the BGL was 8.8 mmol/L and HbA1c was 8%. This difference was due to the fact that before the surgery Melanie was quite stressed about it. This lead to the increase of the level of blood sugar. However after the surgery this reduced as the surgery was successfully over. BGL measures the level of the glucose that is present in the blood of the individual on the other hand HbA1c measures the glycoheamogloboin in the blood. This test helps to determine the amount of average level of glucose that is bound with the haemoglobin. Another reason for the BGL and HbA1c to be higher in the blood reports prior to the surgery is the starvation because of the surgery. Skipping of meals or starvation is quite dangerous in people suffering from type 1 diabetes mellitus. This increases the risk of diabetes in people. In addition to this because of the stress of her surgery, Melanie has been eating very less during the last week. This has also effected in a major way. Eating less also increases the risk of rise in the sugar level of the blood. This is turn increases the HbA1c as it measures the glycated haemoglobin that has increased over the last one week or so (Lind et al., 2017).
The terms insulin dependent diabetes mellitus/ non insulin dependent diabetes mellitus are misleading because it fail to describe the actual condition that has happened. Generally the term insulin dependent diabetes mellitus refers to the occurrence of type 1 diabetes and non insulin dependent refers to type 2 diabetes mellitus. However the latter type also requires insulin therapy along with diet, exercise, medication or any other form of treatment. Hence the term is quite misleading. Similarly for type 1 diabetes it cannot be always insulin dependent only. In case of the terms early onset and mature onset, the terms can be misleading since the term early onset often refers to the visibility of diabetes in the younger adults similarly with mature onset it is understood the same. However practically it is not the same. Mature onset often refers to the onset of the diabetes in the younger adults due to a genetic mutation (Steineck et al., 2015). Therefore the terms are quite misleading.
The “teach back” method refers to the tools that can be used in order to teach the patient and other clinical staff about something. It helps to improve patient understanding and adherence in addition to improving patient satisfaction and outcomes. It is a test of how well one can explain the concept. The method should involve planning of the approach followed by checking of the chunk. There is also a need of clarification and using it consistently and starting out slowly. Practise is requite for teach back method. There can also be a use of the show-method in this process. Handouts can be used along with the teach back method. In order to teach the patient about using the BGL machine, the teach back method van be implemented. In order to explain the use of the BGL machine, there can be interactive sessions held with the patient, where through communication and standard approach, things can be demonstrated to the patients. It is required to reintroduce the concepts that were presented previously. The following should be considered: Using simpler language while discussing timing or other details related to using the machine. It is required to allow extra time for patients to ask questions. The information needs to be broken up into smaller segments. This allows the patient to focus on less information at one time (American Diabetes Association, 2014).
References 
American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes care, 37(Supplement 1), S81-S90.
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), 97.
Atkinson, M. A., Eisenbarth, G. S., & Michels, A. W. (2014). Type 1 diabetes. The Lancet, 383(9911), 69-82.
Cherney, D. Z., Perkins, B. A., Soleymanlou, N., Har, R., Fagan, N., Johansen, O. E., … & Broedl, U. C. (2014). The effect of empagliflozin on arterial stiffness and heart rate variability in subjects with uncomplicated type 1 diabetes mellitus. Cardiovascular diabetology, 13(1), 28.
Cherney, D. Z., Perkins, B. A., Soleymanlou, N., Har, R., Fagan, N., Johansen, O. E., … & Broedl, U. C. (2014). The effect of empagliflozin on arterial stiffness and heart rate variability in subjects with uncomplicated type 1 diabetes mellitus. Cardiovascular diabetology, 13(1), 28.
Fullerton, B., Jeitler, K., Seitz, M., Horvath, K., Berghold, A., & Siebenhofer, A. (2014). Intensive glucose control versus conventional glucose control for type 1 diabetes mellitus. Cochrane Database Syst Rev, 2(2).
Gregory, J. M., Moore, D. J., & Simmons, J. H. (2013). Type 1 diabetes mellitus. Pediatrics in review, 34(5), 203-15.
Haidar, A., Legault, L., Messier, V., Mitre, T. M., Leroux, C., & Rabasa-Lhoret, R. (2015). Comparison of dual-hormone artificial pancreas, single-hormone artificial pancreas, and conventional insulin pump therapy for glycaemic control in patients with type 1 diabetes: an open-label randomised controlled crossover trial. The lancet Diabetes & endocrinology, 3(1), 17-26.
Hu, J., Yu, X., Wang, Z., Wang, F., Wang, L., Gao, H., … & Wang, Y. (2013). Long term effects of the implantation of Wharton’s jelly-derived mesenchymal stem cells from the umbilical cord for newly-onset type 1 diabetes mellitus. Endocrine journal, 60(3), 347-357.
Karlsson, F. H., Tremaroli, V., Nookaew, I., Bergström, G., Behre, C. J., Fagerberg, B., … & Bäckhed, F. (2013). Gut metagenome in European women with normal, impaired and diabetic glucose control. Nature, 498(7452), 99.
Kennedy, A., Nirantharakumar, K., Chimen, M., Pang, T. T., Hemming, K., Andrews, R. C., & Narendran, P. (2013). Does exercise improve glycaemic control in type 1 diabetes? A systematic review and meta-analysis. PloS one, 8(3), e58861.
McKnight, J. A., Wild, S. H., Lamb, M. J. E., Cooper, M. N., Jones, T. W., Davis, E. A., … & Almdal, T. (2015). Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison. Diabetic Medicine, 32(8), 1036-1050.
Purnell, J. Q., Zinman, B., & Brunzell, J. D. (2013). The effect of excess weight gain with intensive diabetes mellitus treatment on cardiovascular disease risk factors and atherosclerosis in type 1 diabetes mellitus: results from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC) study. Circulation, 127(2), 180-187.
Purnell, J. Q., Zinman, B., & Brunzell, J. D. (2013). The effect of excess weight gain with intensive diabetes mellitus treatment on cardiovascular disease risk factors and atherosclerosis in type 1 diabetes mellitus: results from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC) study. Circulation, 127(2), 180-187.
Zoungas, S., Chalmers, J., Neal, B., Billot, L., Li, Q., Hirakawa, Y., … & Cooper, M. E. (2014). Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. New England Journal of Medicine, 371(15), 1392-1406.

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