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Type 2 Diabetes, Key:, Resources, Group Members: Emily Gonzales, Emily…

- - - - Chronic hyperglycemia and hyperinsulinemia causes damage to the endothelial lining of artery walls. This damage causes an inflammatory response that leads to the accumulation of atherosclerotic plaque within these vessels.
        
        Accumulation of plaque can occur in smaller, microvascular vessels. The initial smaller vessels that are damaged include ...
        
        Plaque buildup can occur in the arterial vessels of the retina. This can cause narrowing of the artery and decreases blood flow to the retina, leading to diabetic retinopathy.
        
        George's Presentation: occasional blurred vision, open-angle glaucoma diagnosis
        
        Interventions: Due to occasional blurred vision, we would educate on fall risk. We would highlight the importance of using well-fitted shoes, having a de-cluttered space, and using proper lighting when moving around a room. We would educate on carrying a Life Alert at all times, in case a fall was to occur without someone there. Additionally, we would educate on not operating any machinery, such as driving, while experiencing blurred vision.
        
        Medications: Latanoprost 1 drop each eye q day
        
        Plaque build up can occur in the nutrient arterial vessels of the neurons that supply the nerves with blood, causing a lack of blood flow. This decrease in perfusion to the nerves causes demyelination and axonal degeneration. It is common for the nerve fibers of the lower extremities to be damaged first, which is how diabetic neuropathy occurs.
        
        George's Presentation: Numbness and tingling on both feet and his toes.
        
        Interventions: Help the patient form a weekly exercise plan that works for them. Educate them on how regular movement can help promote circulation. Educate patient on importance of rolling walker use when ambulating to prevent falls or further injuries. Assist patient in finding non-pharmacological strategies for managing pain, such as warm baths.
        
        Medications: Tramadol HCL 50 mg PO q 8 hours for pain
        
        Plaque build up can occur in the arterial vessels surrounding the nephrons, which leads to the renal vasculature and glomerular basement membrane (GBM) to thicken. This causes glomerular hypertension and the obliteration of the glomerular capillary lumens, leading to renal dysfunction. this is how diabetic nephropathy occurs.
        
        George's Presentation: urinating more often and states "I wake up about 10 times a night to go pee". He is fatigued, confusion, and has a poor appetite.
        
        Interventions: Educate patient on interventions to address urination at night including reducing fluids before bedtime and taking diuretics in the morning. Also educate on fall risk and cleaning up living areas so patient does not fall when getting up to go to the bathroom at night.
        
        Labs: BUN is 29 mg/dL
        
        Albumin is 2.4 g/dL
        
        Serum Potassium is 3.3 mEq/L
        
        George's urinalysis presents with dark yellow and hazy urine.
        
        Labs:
        
        Accumulation of plaque can occur in bigger, macrovascular vessels including ...
        
        Coronary Arteries. Plaque buildup can cause obstruction of blood flow through the coronary arteries to the heart, leading to a lack of blood flow to the heart.
        
        Interventions: This puts George at risk for MI or cardiac arrest. It is important to educate George on reporting any signs of chest pain or difficulty breathing to his provider.
        
        George's Presentation: George is presenting with heartburn and indigestion after meals. Shallow breathing with diminished lung sounds in the BLL.
        
        Medications: Famotidine 20 mg PO q bedtime
        
        Interventions: contact PCP to suggest switching medications due to famotidine being on the BEERS criteria and increasing the risk for delirium.
        
        Labs:
        
        Red Blood Cells 3.9 cells/mcL
        
        Hct 40% (on the lower side for males)
        
        Peripheral Arteries. Plaque buildup can cause obstruction of blood flow through these large peripheral arteries. Lower extremities are the first to get a lack of oxygen and nutrients, leading to poor tissue perfusion.
        
        Can cause necrosis, ischemia, and contribute to poor healing in the lower extremities.
        
        George's Presentation: First visit he presented with a L plantar surface diabetic foot wound measuring 4cm x 4cm x 1cm deep. Wound bed pink with small areas of slough circum around the wound's edges (2mm x 4mm). Toes BLE are pale and cool to touch.
        
        Additional foot wound developed on the outer aspect of his L big toe and is + for MRSA. Wound is 1cm by 2cm with dry eschar to wound bed. Toes on BLE are still pale and cool to touch.
        
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        Medications: Clindamycin 400 mg PO BID
        
        Interventions: Educate patient on medication adherence, daily foot checks, and proper wound cleaning. Educate on the importance of daily physical activity and mobility. Evaluate nutrition and encourage foods that promote wound healing: protein, fruits, vegetables, and foods with
        Vitamin C.
        
        Labs:
        
        Red Blood Cells 3.9 cells/mcL
        
        Hct 40% (on the lower side for males)
        
        This can lead to dyslipidemia, hypertension, and atherosclerosis
        
        George's Presentation: George has been diagnosed with a history of hypertension and dyslipidemia, both of which are caused by the process of atherosclerosis.
        
        Medication: hydrochlorothiazide 12.5mg PO daily for HTN management
        
        Medications: Atorvastatin 40mg PO q day
        
        High insulin in the blood stimulates lipid uptake and synthesis in smooth muscle tissue in arteries, leading to atherosclerosis.
        
        Labs: Hypokalemia: K+ level of 3.3 mEq/L - high levels of insulin in the blood drive potassium into cells, lowering its serum concentration
      - The decreased ability of cells to effectively use glucose within the cells causes them to look for an energy source elsewhere, in fat and muscle tissue.
        
        George's Presentation: reports unintentional weight loss of about 20 pounds in the last couple months. Body has a cachectic presentation.
        
        Labs: Low albumin value of 2.4 g/dL
    - - Beta cells begin to fail in producing enough insulin necessary.
        
        B-cell dysfunction leads to insulin production declining and the cells are unable to utilize and maintain glucose and must breakdown fats/proteins for energy.
        
        Promotes elevated blood glucose levels
        
        Hyperglycemia
        
        High levels of glucose lead to glucose excretion from the kidneys. This creates an osmotic effect within the kidneys that reduces water reabsorption into the renal tubules causes volume less through the kidneys.
        
        High blood glucose causes hyperosmolality in the blood as well. This leads to a shift of fluid from the intracellular space to the vascular space. A decrease in intracellular water can lead to volume loss in the kidney.
        
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        Labs:
        
        Labs: Glucose 148mg/dL, HgA1C 8.0%
        
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        +Ketones in the urinalysis
        
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        Medications: NovoLog Insulin SQ TID per sliding scale
        NPH Insulin 10 units SQ daily at 0900
        Metformin 500 mg PO BID
        
        George's Presentation: unintended weight loss of 45 pounds in 8 months, increase urination, delayed wound healing, fatigue, occasional blurry vision.
        
        Hyperglycemia without enough insulin present in the blood to allow cellular uptake, leads to the process of ketoacidosis.
        
        Cells are not able to uptake glucose for energy and must instead break down fats for fuel.
        
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      - The pancreas attempts to compensate for the body's cellular resistance, leading to high levels of insulin within the body and blood.
        
        Hyperinsulinemia
        
        Produces hyperactivation of the sympathetic system which results in an increased reabsorption of sodium and water by renal tubular cells