Diabetes Mellitus Case Study
Diabetes mellitus is a group of metabolic diseases in which the individual has high blood glucose levels as a result of the inability of the pancreas to produce insulin, or as a result of the cells in the body not responding to the insulin produced. The aim of this documentation is to outline the normal regulation of blood glucose levels in the body which includes the role of the hormone producing alpha cells and beta cells in regulating these levels, and the effect that the pathophysiology of diabetes mellitus type one has on this regulation.
This documentation further outlines the three main presenting symptoms of diabetes mellitus type one, polyuria, which is characterised by excess urination, polydipsia, which is characterised by extreme thirst, and polyphagia, which is associated with extreme hunger. A further insight is given relating to these symptoms, explaining the metabolic processes behind them. Associated symptoms relating to diabetes mellitus type one are also covered, these include feelings of weakness or fatigue, numbness and tingling of the extremities and a compromised immune system which results in slow healing wounds and injuries.
The management of diabetes can often be quite complex, particularly in Anna’s case where she has been been newly diagnosed with diabetes mellitus type one and is a young fourteen year old girl. The five components of diabetes management need to be looked at when developing a care plan for Anna which includes, nutritional management, exercise, monitoring and pharmacologic therapy and education. The pancreas is a mixed gland composed of both endocrine and exocrine gland cells, which plays a major role in controlling blood glucose levels in the body.
Distributed throughout the acinar cells are pancreatic islets, which are small cell clusters that produce pancreatic hormones. The islets contain two hormone-producing cells, the glucagon-synthesising alpha cells, and the insulin-producing beta cells. These cells act as fuel sensors, secreting glucagon and insulin when needed during the fasting and fed stages. Stimulis such as increased blood glucose levels prompts the pancreas to release insulin from the beta cells to lower blood glucose levels.
Circulating insulin lowers blood glucose levels in three main ways, by increasing membrane transport of glucose into body cells, particularly muscle and fat cells, by inhibiting the breakdown of glycogen to glucose and by inhibiting the conversion of amino acids or fats to glucose.
Consequently, this counters any metabolic activity that would increase plasma levels of glucose. On a cellular level, insulin activates a receptor which phosphorylates specific proteins, beginning the process that leads to increased glucose uptake and insulin’s other effects.
On the contrary, stimulis such as decreased blood glucose levels prompt the pancreas to release glucogen from the alpha cells to raise blood glucose levels. The major target for glucogen is the liver, where several activities are prompted including the breakdown of glycogen to glucose, also known as glycogenolysis, the synthesis of glucose from lactic acid and from non carbohydrate modules, also known as gluconeogenesis, and the release of glucose to the blood via the liver cells, causing blood glucose levels to rise.
Furthermore, a fall in the amino acid concentration in the blood occurs as the liver cells segregate these molecules to make new glucose molecules (Marieb & Hoehn 2010). Type one diabetes mellitus is a genetic disease of the immune system, characterised by pancreatic beta cell destruction which usually leads to absolute insulin deficiency, resulting in the failure of anabolic processes.
(Meece 2003, pg. 17). When insulin is either absent or deficient in the body, blood glucose levels remain high after a meal because glucose is incapable of entering majority of the tissues cells.
Generally, when blood glucose levels rise, hyperglycemic hormones are not released, but when hyperglycemia becomes disproportionate, the individual begins to feel nauseated which precipitates the fight or flight response . This response results in all the reactions that occur in the hypoglycemic state to make glucose available, which includes; glycogenolysis, lipolysis and glucogenolysis. As a repercussion of this, the already elevated blood glucose levels rise even further, and excesses of glucose begin to be lost from the body in the urine, in a process called glycosuria (Marieb & Hoehn 2010).
As Glucose cannot enter the cells, it instead accumulates in the blood. Consequently, this results in hyperglycemia, causing excess urination, also known as polyuria, then excess thirst, also known as polydipsia, to compensate for the loss of water, and then is followed by excess hunger, also known as polyphagia, because the cells are deficient in fuel (Guthrie & Guthrie 2004, pg. 115) Symptoms associated with diabetes mellitus type one, particularly in newly diagnosed patients include the aforementioned polyuria, polydipsia and polyphagia.
Other symptoms experienced include fatigue and weakness, vision changes, tingling or numbness in the hands or feet, dry skin, skin lesions or wounds that are slow to heal and recurrent infections. The onset of diabetes type one may also be associated with unexplained weight loss, nausea, vomiting or abdominal pain (Farrell & Dempsey 2011). Polyuria is defined as the excretion of abnormally high volumes of urine, caused by conditions such as diabetes insipidus, diabetes mellitus, use of diuretics and hypercalcaemia (Harris, Nagy, Vardaxis 2010).
Under normal conditions, the kidneys retrieve as much glucose as possible, essentially rendering the urine glucose free. The glomeruli filter from plasma approximately 180 grams of glucose per day, which is then reabsorbed through glucose transport proteins that are present in cell membranes within the proximal tubes. If the capacity of these transporters is exceeded, glucose then materialises in urine, producing high volumes of glucose-containing urine (Triplitt 2012, pp. 12-13). Polydipsia is defined as excessive thirst.
It is a characteristic of several different conditions, including diabetes mellitus.
This thirst is caused by the excessive concentration of glucose in the urine that increases urine formation and excretion. The symptoms of polydipsia include having persistent, unexplained thirst, regardless of the amount of fluid intake, and passing more than five litres of urine a day. (Harris, Nagy, Vardaxis 2010). Polyphagia is defined as excessive, uncontrolled eating (Harris, Nagy, Vardaxis 2010).
Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats.
In uncontrolled diabetes where blood glucose levels are abnormally high, glucose from the blood cannot enter the cells due to a lack of insulin or insulin resistance so the body cannot convert food eaten into energy, resulting in excessive hunger (Farrell & Dempsey 2011). The onset of diabetes results in the disintegration of stored muscle protein to nourish starved cells, resulting in unexplained fatigue and weakness.
Furthermore, cells in the brains have to rely primarily on glucose for nourishment, however they cannot properly utilise the available glucose, consequently resulting in mental fatigue, with associated forgetfulness, vision changes and loss of concentration (D’Arrigo 2007, pg. 52). Nerve damage caused by diabetic neuropathies can make an individual extremely sensitive to touch, with associated symptoms of numbness and tingling.
This condition often interferes with daily acitivites of living such as walking, working and socialising, and often manifests as a symptom of diabetes type one.
However, only a small proportion of those diagnosed with diabetes suffer from diabetic neuropathy (Johnson 2010, pg. 17). People with diabetes are at increased risk for complications from wound healing for several reasons. An elevated blood sugar level stiffens the arteries and causes narrowing of the blood vessels resulting in decreased blood flow to a wound site. Diabetic neuropathy can contribute to slow wound healing as a diabetic patient may not being able to feel a change in the status of a wound or the actual wound, meaning the severity can progress and there may be complications with healing.
Diabetes causes changes in the immune system at a cellular level as a consequence of high glucose levels in the body, causing immune cells to function ineffectively, increasing the changes of reoccurring infection (Collins 2003, pg. 292). The main objective of nutritional management includes achieving and maintaining blood glucose and blood pressure levels in the normal range, or as close to the normal range as possible. The nutritional management of individuals with diabetes type one focuses on providing adequate energy for growth and development.
The recommended meal plan should take into account the individual’s usual appetite, food intake patterns, level of exercise and insulin regime. Recommendations should be based on three balanced meals per day, healthy snacks, and regular physical activity (Barclay et al.
2010, pg. 580). In the case of Anna, the registered nurse can assist with nutritional management by referring Anna to a dietician, who can develop an eating plan for Anna ensuring her nutritional needs are met.
The registered nurse can further assist Anna by educating both her and her parents on the importance of eating the correct amount of food in order to help maintain her blood glucose levels. Exercise or physical activity is a necessity in management of diabetes because of its effects on lowering blood glucose and reducing cardiovascular risk factors.
Exercise lowers blood glucose levels in the body by increasing the uptake of glucose by body muscles and improving insulin utilisation.
People with diabetes should exercise at the same time each day each day preferably when blood glucose levels are at their peak, and for the same amount each day, undertaking at least 30 minutes of exercise on at least five days a week, accounting to a total of 150 minutes of exercise each week (Farrell & Dempsey 2011). Blood glucose levels can significantly drop during and after physical activities, due to the increased utilisation of glucose as a fuel during exercise and the up regulation of glucose transport into working muscles.
Therefore patients must account for the effects of exercise and adjust their medication and nutrients accordingly (Zisser et al. 2011, pg. 71).
In the case of Anna, the registered nurse can assist by educating Anna and her family about the benefits and limits of exercise in relation to diabetes. The registered nurse can also provide further information on when to exercise and how long to exercise for. Blood glucose monitoring is the cornerstone of diabetes management and self monitoring of blood glucose levels by patients has significantly altered diabetes care.
Frequent self monitoring of blood glucose by individuals with diabetes has been linked to obtaining optimal blood glucose control as it enables the individual to adjust treatment regimes. Consequently, this allows for both detection and prevention of hypoglycemia and hyperglycemia.
A variety of self monitoring of blood glucose methods are available, most commonly involving obtaining a drop of blood from the fingertip, applying the blood to a particular regent strip, which is then tested for the blood glucose value after approximately 5-30 seconds.
The nurse plays an important role in educating the patient about self monitoring of blood glucose techniques. For most patients who require insulin, self monitoring is recommended two to four times a day, usually before meals and at bedtime (Farrell & Dempsey 2011). In the case of Anna, the registered nurse plays a vital role in educating Anna and her family about the correct way to obtain blood for the blood glucose testing . Furthermore the registered nurse should educate both Anna and her parents about the importance of accurate testing, and what is the normal range of blood glucose levels for Anna.
As Anna is quite young, her parents may be able to assist her with this self monitoring. In the absence of adequate insulin formation, pharmacologic therapy is a necessity. As the insulin dose required by the individual is determined by the amount of glucose in the blood, accurate monitoring of blood glucose levels is essential. (Farrell & Dempsey 2011). Insulin can be delivered via a number of different methods including insulin pens, jet injectors and insulin pumps. It is critical to consider that a patient with diabetes may equire more than one type of insulin.
For example, a patient receiving rapid acting insulin and intermediate acting insulin receives more sustained control of blood glucose over 24 hours (Crisp & Taylor 2009). Insulin regimes vary between one and four injections per day, the goal of these daily injection insulin regimes is to mimic the normal pattern of insulin secretion . The patient should be very involved in the decision regarding to which insulin regime to use, and should consider the potential benefits of different regimes, as the associated costs. Farrell & Dempsey 2011). In Anna’s case, the registered nurse can assist with pharmacologic therapy by injecting the insulin Anna needs while in hospital.
Furthermore, the registered nurse can educate both Anna and her parents by showing them the correct way to inject insulin while at home, explaining to them when insulin needs to be injected and explaining to them why insulin needs to be injected. Diabetes mellitus is a chronic illness that requires a multitude of self-management behaviors.
Because diet, physical activity and physical and emotional stress affect diabetic control, patients must learn how to balance these factors. Patient education is a significant task undertaken by the nurse who plays a vital role in providing basic education, reinforcing the teaching provided by the specialist, and referring patient’s for follow up care after discharge. Teaching survival skills in relation to avoiding severe hypoglycaemic or acute hyperglycaemic must be taught to newly diagnosed patients.
An outline of survival information includes simple pathophysiology of diabetes, treatment modalities, recognition, treatment and prevention of acute complications and pragmatic information.
Another component of patient education is teaching the patient to self-administer insulin, which involves explanations of the equipment used, the insulins used, the syringes used and how to mix insulin. In conclusion, the regulation of blood glucose levels in the body has been discussed, including the role that the insulin secreting beta cells and the glucagon synthesising alpha cells play in the regulation of the body’s blood glucose levels.
Furthermore, the effect of the pathophysiology of diabetes mellitus type one on normal blood glucose regulation is discussed, with the inability of the pancreas to secrete insulin and the resulting increase of blood glucose levels being explained. Symptoms associated with newly diagnosed diabetes are primarily polyuria, which is associated with excessive amounts of urine, polydypsia, which is associated with extreme thirst and polyphagia, which is associated with extreme hunger. The metabolic processes behind these symptoms have been discussed.
In summary, the excess amounts of glucose in the body render in the urine, which causes greater urine output.
Excess amounts of glucose formation and secretion in the urine increases thirst levels in the individual, the catabolic state induced by insulin deficiency and the breakdown of proteins and fats increases hunger levels in the individual. Associated symptoms of diabetes such as increased weakness and fatigue, numbness and tingling in the extremities and the compromised immune system resulting in slow healing wounds and injuries has also been discussed in this documentation.
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