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NURBN2016 Pathophysiology And Pharmacology

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Course Code: NURBN2016
University: Federation University

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Question:

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.

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.
Differentiate between T2DM and T1DM (at least 6 differences).
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%.

Discuss the three medications Melanie is on. Include in your answer the action, complications/side effects and nursing considerations linked to Melanie’s situation. (500)
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 Discuss why the terms insulin dependent diabetes mellitus/ non insulin dependent diabetes mellitus and early onset/mature onset are misleading.
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:

Part 1: 
Pathophysiology, risk factors, pathogenesis, possible complications and treatment options for type 2 diabetes mellitus  
Type 2 diabetes mellitus is a more common form of diabetes which is contacted on a wider rate by people all over the world.  The plausible factors for the development of type 2 diabetes are insulin resistance or impaired insulin secretion. The impaired insulin secretion could be referred to as a decrease in glucose responsiveness. The decrease in adequate amount of insulin secretion after the meals results in the development of postprandial hyperglycaemia. As reported by Kohei (2010), the impaired insulin secretion is generally progressive in nature. These could be correlated with the dysfunction of pancreatic β cells in the long run which is responsible for the synthesis of sufficient amount of insulin. In the lack of insulin, the blood glucose level highly increases resulting in a condition known as hyperglycaemia.
Another condition which is responsible for the development of type 2 diabetes within an individual is development of insulin resistance. As reported by Kahn, Cooper and Del Prato (2014), the insulin resistance could be referred to a condition where the insulin present in the blood does not equate to action equivalent to its concentration.  The causative factor for insulin resistance could be related to polymorphisms at the genetic level.  As reported by Antonioli  et al. (2015), polymorphisms at the β3 adrenergic receptor gene and uncoupling protein gene are seen to promote insulin resistance.
In this respect, the patient Melanie was a 63 year old woman who had been recently diagnosed with type 2 diabetes mellitus and had a strong family history. The patient here had also been seen to develop complications such as Baker’s cyst which restricted her movements and could be attributed to elevate blood glucose levels. The lack of effective medication and high cost of insulin injection for Type 2 diabetes have been seen to enhance the grievances within the patient due to the lack of cure.
Some of the risk factors of type 2 diabetes are family history, race /ethnicity of a patient, gestational diabetes and polycystic ovarian syndrome.  Family history has been seen to possess a strong correlation in the development of type 2 diabetes. Additionally, some ethnic groups are more at danger of developing type 2 diabetes such as African Americans, native and Asian American, as it could be linked to certain specific genes which have been passed onto generations.  The high is the percentage of penetrance or expressivity; the higher are the chances of a defective gene being passed from a generation to the next. Some of the other risk factors are low level of HDL, obesity, high blood pressure and high level of triglycerides. The development of diabetes in the gestation or pregnancy period increases the chances of development of type 2 diabetes later.
A number of complications could arise in type 2 diabetes management, a few of which has been discussed over here. As suggested by Zinman (2015), hectic lifestyle and ill management of medications could result in the blood glucose level to drop sharply resulting in hypoglycaemia.  It is very important to manage the diet effectively as a measure of type 2 diabetes controls.  
Some of the diagnosis and treatment methods which could be mostly commonly used for the patient over here is fasting blood sugar test, glycated haemoglobin test (A1C test) and random blood sugar test. The AIC test gives an indication regrading the average blood sugar level within the past two to three months. The fasting blood glucose level is monitored after an overnight test. In this respect, a blood sugar level of 100-125 mg/dL is considered as pre-diabetes, whereas blood sugar level of 126 mg/dL or higher is considered as diabetes. Lifestyle intervention is one of the most important interventions that nursing professionals should suggest to the patient. One of the most important interventions is healthy eating where the patient should be focused on intake of more fruits, begetables and whole grains with lowering of the intake of fewer animal products, less carbohydrates and sweets. A dietician can be referred to the patient who would help her to understand the importance of low glycemic index foods and make a list for het to take. High glycemic index foods cause quick increase of blood glucose level affecting the health of the patient. The patient should also undertake physical activities including daily aerobc exercises like walking, swimming and others. 30 minutes of aerobic exercises along with walking five days a week and yoga two days a week are essential for controlling type 2 diabetes (Hausenblas, , Schoulda & Smoliga, 2015). Third, the patient needs to monitor her blood sugar level by checking and recording blood sugar level more than once a day. This would help the patient to be sure that the level of blood glucose is within the target range. Medication therapy with metmorfin, sulfonylureas and others can be advised depending upon the diagnosis of the patient. Insulin therapy can be also initiated. In the earlier days, it was advsed as last resort but nowadays, researchers are of the opinion that it should be prescribed sooner for more benefits and healthy outcomes.
Difference between type 1 and type 2 diabetes 
There are a number of differences between type 1 and type 2 diabetes a few of which have been discussed over here. As mentioned by Santi et al. (2015), there lies a very thin line of difference between type 1 and type 2 diabetes. For instance, people with type 1 diabetes don’t produce insulin whereas people with type 2 diabetes have poor or no response to insulin. In type 1 diabetes, the immune system mistakes body’s own cells as foreign pathogens and produces antibodies against it, as a result of which the insulin producing beta cells are destroyed and the body fails to produce sufficient insulin. On the other hand, people with type 2 diabetes have insulin resistance where the insulin present in the blood is not used effectively (Patel et al., 2016). This causes the blood glucose level to rise resulting in a condition known as hyperglycaemia. The third difference is that type 1 diabetes cannot be prevented whereas proper diet and lifestyle intervention can result in prevention of type2 diabetes and safe and healthy life. The fourth difference is that the risk factors for type 1 diabetes are age, genetic and geography whereas the risk factor for type 2 diabetes are having pre-diabetes, being overweight or obese, immediate family member with type 2 diabetes, physically inactive, polycystic ovarian syndrome and many others. The fifth difference is that the type1 diabetes has no treatment options other than insulin injection given in soft tissues. On the other hand, type 2-diabetes can b even reversed with proper diet and exercise and other lifestyle management. When lifestyle management is not sufficient, doctors prescribe medications that work well beside insulin therapy to cure the patient (Chaudhury et al., 2017). The sixth difference is that type 1 diabetes can be diagnosed in childhood but type 2 diabetes is usually diagnosed over 30 years.
Possible diagnosis of high blood glucose level 
Type 2 diabetes happens due to a progressive chain of physiological events. Insulin resistance is the first step in the development of type 2 diabetes. In case of insulin resistance, the insulin produced becomes insensitive to the elevated amount of blood glucose level (Hausenblas, , Schoulda & Smoliga, 2015). It results in condition known as hyperinsulimenia , which results in the blood glucose level to remain normal. An individual with insulin resistance first develops postprandial glycaemia later resulting in fasting glycaemia.
In this respect, the patient Melanie had high blood glucose level on admission. Some of the reasons which had been identified over here were that the patient had not been receiving any proper treatment for the management and control of her diabetic condition. She was only suggested by her doctor to take proper care of her diet. However, the patient had been increasingly concerned about her weight and had been dieting and eating the wrong things such as ice-cream. This could have resulted in a misbalance of her blood glucose level within the patient.
In this respect, the patient had not been taking any medication leading to development of more complications.As mentioned by Scheen and Van Gaal (2014), suggesting the patient population with insulin therapy could help in the conditions management of type 2 diabetes. Here, the patient Melanie had a family history of type 2 diabetes making her vulnerable to the development of insulin resistance. Additionally, fasting for a prolonged period can cause the body to stop produce insulin in order to compensate for the reduced blood glucose level (Van Gaal & Scheen, 2015).  Hence, providing the patient appropriate education on eating right along with putting the patient on effective treatment intervention could possible control the high blood glucose level.
Part 2: 
Discussion of action and contraindication of suggested medications 
The patient had been suggested a number of medications for the management and control of her type 2 diabetes such as Kenacort A-40, APO Metformin and glipizide tablets. Kenacort A-40 is used for the treatment of allergic disease, skin problems and arthritis. It is injected deep into the muscle of the patient from where it is slowly absorbed into the blood and carried to all parts of the body. As reported by Scheen (2015), there are a number of side effects of Kenacort A-40 such as irregular heartbeat, seizures, nausea, joint pain, mood disorders. In this respect, the patient was already suffering from baker’s cysts restricting the movement in the patient. Therefore, an overdose or prolonged usage of the medication could lead to joint swelling within the patient further making movement difficult. Additionally, unsupervised medication where an individual takes high amount of artificial insulin and give huge time gap in between meals the blood glucose level could fall considerably leading to glycaemic shock. Some of these have been seen to produce rapid heartbeat, confusion, flushed skin, slurred speech and anxiety within the patient. It could also lead to microvascular complications such as retinopathy in the eyes and diabetic neuropathy, where it damages the nerves of the arms and legs in some cases leading to movement restrictions.
The Metformin has been suggested to the patient to control the level of blood glucose level as it slows the release of glucose from the liver. It increases the sensitivity to insulin by enhancing peripheral glucose uptake and utilization and reduces the amount of glucose re-absorption from the food. In this respect, the patient had been fasting resulting in sugar imbalance, which could lead to drowsiness within the patient. As reported by Chaudhury  et al. (2017), unsupervised uptake of metformin have been associated with increased symptoms of drowsiness and fatigue within the patient.
Glipzide had been suggested to the patient to control blood sugar level by encouraging the production of insulin by the pancreas. The medication is used in combination with diet and exercise to regulate or control the amount of blood glucose level. However, the medication could result in a number of contra-indications within the patient such as consumption of the medicine in hypoglycaemia could result in seizures. In most severe cases it could lead to microvascular complications leading to nerve damage (Heymsfield & Wadden, 2017). Therefore, the medication should only be suggested to the patient under advice and guidance of the physician.
The patient recorded a blood glucose level of 8.8 mmol/L which equals to 178 mg/dl and a HbA1c of 8%. The HbA1c should be less than 6% of total haemoglobin a healthy individual whereas an HbA1c of 6.5 % or greater could signify the development of type 2 diabetes. Therefore, prescription of the drugs such as Metformin, Glipzide could be effective in controlling the high blood glucose level within the patient whereas the administration of Kenacort A-40 has been seen to worsen the problem of arthritis within the patient. Additionally, the patient has been seen to weigh 105 kgs which signifies morbid obesity. As reported by Satin et al.  (2015), Metformin have been seen to increase the complications related to obesity.
Discussion of blood results 
In control of diabetes, lifestyle and medication management has been seen to reduce the health complications, which may otherwise ruin health in the long run. As mentioned by Kohei (2010), the mature onset of diabetes could be referred to as a stage where the condition arises due to mutation in the autosomal dominant gene of the patient. Though in both cases, the disease may not show up till a later stage of time.
 A remarkable difference in the blood glucose level of the patient has been noted before and after admission along with the HbA1c in type 2 diabetes. Initially, the blood glucose level had been recorded at 22.9 mmol/L corresponding to 412.2 mg/dl, whereas the HbA1c corresponded to 11%. Upon admission the patient was put under a number of medications such as Kenacort A-40 injections. This is mainly given to patients for treatment of allergic disorders as well as bad skin problems and even arthritis. They are also used for treatment of painful joints, tendons as well as muscles when the professionals need to inject it directly to the painful site. It was given to the patient for Baker’s cysts. Metformin and Glipizide tablets. The Metformin and Glipizide had been suggested to the patient to reduce the level of blood glucose reabsorption by slowing down the release of glucose from the liver (Chaudhury et al., 2017). As reported by Li  et al. (2015), the HbA1c percentage of around 11% signifies at a critical blood sugar  level and point at the administration of insulin therapy. In this respect, a remarkable change in the blood glucose level had been noted along with reduction in the HbA1c percentage due to the administration of simultaneous doses of Metformin and Glipizide  tablets.
Part 3: 
Discussion of terms 
There are a number of misnomers regarding a number of terms which often creates anxiety and confusion within the patient population. The insulin dependent diabetes or type 1 diabetes is the condition when the body stops producing sufficient insulin which is required to convert the blood glucose into glycogen.  It is often an autoimmune disorder where the body cannot recognise its own tissue or cells and starts producing antibodies to destroy the beta cells which are responsible for production of insulin. On the other hand, in insulin independent diabetes mellitus the tissue sensitivity to insulin is decreased. In both contexts polymorphisms of certain gene segments have been noticed, which affects the insulin secretory capacity. The early onset of diabetes is seen as a condition where the disease has been diagnosed at the pre-diabetic stage and could be simply due to metabolic disorders.
Patient education 
In this respect, to educate the patient regarding blood glucose measurement and monitoring the  teach back method could be used. The patient could be educated upon the use of a blood glucose level monitoring machine which could help her in self managing her condition. The teach back method allows the staff to ensure that patient are able to follow specific instructions (Zaccardi et al., 2015). Thus, as a healthcare professional looking after Melanie need to repeat in her own sentence the steps she needs to follow to use the BGL machine to monitor her blood glucose level.
Researchers are of the opinion that nursing professionals need to use the teach back methods for effective teaching as well as assessment of the comprehension and recalling of the patient. This is one of the best approach for person centred communication and is often called the show me or the closing the loop method. This method confirms that the patient had understood the information that the care provided has provided. It helps in closing the communication gap between the provider and the patient at the same time of enhancing the knowledge of the patient. After completion of imparting the education of the proper procedures to the patient about how to use the blood glucose monitor, maintaining hygiene of the side, keeping records and handling the equipment and others in details, the provider need to confirm certain aspects from patient. She needs to confirm the understanding of the patient by asking her to explain the concept back to her accurately. This would help the professional to understand whether the patient had understood well or there is still gap in understanding. This ensures quality self care by the patient.

References
Antonioli, L., Blandizzi, C., Csóka, B., Pacher, P., & Haskó, G. (2015). Adenosine signalling in diabetes mellitus—pathophysiology and therapeutic considerations. Nature Reviews Endocrinology, 11(4), 228.
Chaudhury, A., Duvoor, C., Dendi, R., Sena, V., Kraleti, S., Chada, A., … & Kuriakose, K. (2017). Clinical review of antidiabetic drugs: Implications for type 2 diabetes mellitus management. Frontiers in endocrinology, 8, 6.
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.
Heymsfield, S. B., & Wadden, T. A. (2017). Mechanisms, pathophysiology, and management of obesity. New England Journal of Medicine, 376(3), 254-266.
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.
Kohei, K. A. K. U. (2010). Pathophysiology of type 2 diabetes and its treatment policy. JMAJ, 53(1), 41-46.
Li, L., Cheng, W. Y., Glicksberg, B. S., Gottesman, O., Tamler, R., Chen, R., … & Dudley, J. T. (2015). Identification of type 2 diabetes subgroups through topological analysis of patient similarity. Science translational medicine, 7(311), 311ra174-311ra174.
Patel, T. P., Rawal, K., Bagchi, A. K., Akolkar, G., Bernardes, N., da Silva Dias, D., … & Singal, P. K. (2016). Insulin resistance: an additional risk factor in the pathogenesis of cardiovascular disease in type 2 diabetes. Heart failure reviews, 21(1), 11-23.
Rehman, K., & Akash, M. S. H. (2017). Mechanism of generation of oxidative stress and pathophysiology of type 2 diabetes mellitus: how are they interlinked?. Journal of cellular biochemistry, 118(11), 3577-3585.
Santi, D., Giannetta, E., Isidori, A. M., Vitale, C., Aversa, A., & Simoni, M. (2015). Therapy of endocrine disease: effects of chronic use of phosphodiesterase inhibitors on endothelial markers in type 2 diabetes mellitus: a meta-analysis. European journal of endocrinology, 172(3), R103-R114.
Satin, L. S., Butler, P. C., Ha, J., & Sherman, A. S. (2015). Pulsatile insulin secretion, impaired glucose tolerance and type 2 diabetes. Molecular aspects of medicine, 42, 61-77.
Scheen, A. J. (2015). Pharmacodynamics, efficacy and safety of sodium–glucose co-transporter type 2 (SGLT2) inhibitors for the treatment of type 2 diabetes mellitus. Drugs, 75(1), 33-59.
Scheen, A. J., & Van Gaal, L. F. (2014). Combating the dual burden: therapeutic targeting of common pathways in obesity and type 2 diabetes. The lancet Diabetes & endocrinology, 2(11), 911-922.
Van Gaal, L., & Scheen, A. (2015). Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care, 38(6), 1161-1172.
Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2015). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, postgradmedj-2015.
Zinman, B., Wanner, C., Lachin, J. M., Fitchett, D., Bluhmki, E., Hantel, S., … & Broedl, U. C. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New England Journal of Medicine, 373(22), 2117-2128.

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