NR 601: Week 5 Case Study Assignment 2023 | Primary Care of the Maturing and Aged Family

NR 601: Week 5 Case Study Assignment 2023 | Primary Care of the Maturing and Aged Family. Primary Diagnosis Diabetes Mellitus Type 2 (DM2) (E11.9). Pathophysiology: The primary diagnostic for Mrs. Wong is diabetes mellitus type two. Diabetes Mellitus is a chronic disease, which is due to a decrease or lack of insulin secretion, or/and inability of cells to utilize insulin (Ramachandran, 2014). According to Goroll (2014), diabetes type two occurs when pancreas is unable to produce enough insulin to meet the metabolic needs CASE STUDY ASSIGNMENT of the body. Common signs and symptoms include polydipsia, polyuria, polyphagia and extreme fatigue (Dunphy, 2015). Pertinent Positive findings: Weight gain, polyuria, polydipsia, fatigue, fasting blood glucose of 127, HbA1c of 6.6, positive glucose in urine, and elevated CO2 of 29. According to the ADA, 2019 guidelines, Asian American population age of 45 or greater with a BMI more than 23 kg/m2, and HbA1c equal or greater to 6.5% on initial testing is considered diabetes (ADA, 2018.p 29). Pertinent Negative Findings: Patient exercise regularly, former smoker, normal BUN, creatinine and GFR, skin dry and intact, negative ketones in urine analysis, (ADA, 2018). Rationale for the diagnosis: Diabetes mellitus type two is the chosen primary diagnosis for Mrs. Wong is based on her laboratory results of fasting plasma glucose of 127, and hemoglobin A1C level above 6.5 percent, and clinical presentation of fatigue, hunger and thirst. Also Mrs. Wong’s BMI put her at greater risk to develop diabetes because data has shown that in Asian Americans a BMI greater than 23 kg/m2 puts an individual at increased risk of diabetes mellitus (ADA, 2019). Secondary Diagnosis: Hyperlipidemia, unspecified (E78.5) Pathophysiology: Hyperlipidemia is a major cardiovascular risk factor that increases the rate of atherosclerosis disease in the general population (Kennedy- Malone, Plank & Duffy, 2019). The primary cause of hyperlipidemia is genetic mutations that result in the overproduction or defective elimination of triglycerides and LDL or the underproduction of excessive elimination of HDL (Dunphy, 2015). The secondary cause of hyperlipidemia is a sedentary lifestyle with dietary choices that consist of saturated and trans fats and CASE STUDY ASSIGNMENT cholesterol. There are no signs and symptoms associated with the disease however the risk of developing symptomatic vascular disease increases (Dunphy, 2015). Pertinent positive findings: Objective findings that are pertinent to the diagnosis of hyperlipidemia in Mrs. Wong include a cholesterol of 215 mg/dl, LDL 144 mg/dl, VLDL 36 mg/dl, HDL 32 and Triglycerides 229 (Grundy, Stone, Bailey, Beam, Birtcher, Blumenthal & Yeboah, 2018). Pertinent negative findings: Subjective negative findings for Mrs. Wong’s diagnosis of hyperlipidemia include regular physical activity and being a former smoker (Grundy et al., 2018) Rationale for the diagnosis: Mrs. Wong’s lipid panel result indicated elevated cholesterol. According to Kennedy- Malone, Plank and Duffy (2019), Mrs. Wong is at a higher risk of coronary artery disease due to ethnicity because failure to identify at risk females and the discrepancy is higher among minority females. Differential Diagnosis: Obesity (E66) Pathophysiology: McCance and Huether (2015) explained that obesity is an increase in adipose tissue causes a dysfunction of the body adipokines (cell-signaling proteins). Adipokines are involved with the regulation of food and fat storage as well as the body’s metabolism and tissue sensitivity causing an increase in adipose tissue. Pertinent positive Findings: Weight 165, height 5’ 1.5”, fatigue, decreased energy and weakness, gained four pounds over three months, and hunger. Pertinent Negative Findings: Patient walking on the treadmill and going to the gym. CASE STUDY ASSIGNMENT Rationale for the Diagnosis- Mrs. Wong’s BMI is 30.7 which identifies her as obese for her given height. The most common symptoms of obesity are elevated BMI, central obesity and generalized obesity (Kennedy-Malone, Plank & Duffy, 2019, p.392). Plan Diagnostics Lab test: Repeat hemoglobin A1c (Hb A1c), / Fasting plasma glucose (FPG) Rationale: Since Mrs. Wong’s hemoglobin A1c are elevated to 6.6% and fasting plasma glucose was 127. American Diabetes Association (2018), explained that a repeat test of FPG result can be more than or equal to 126 mg/dL (7.0 mmol/L), and hemoglobin A1C measurement greater than or equal to 6.5 is a revealing of type 2 diabetes. After the initiation of diabetic medication, the Hb A1C should be repeat in three months. Lab test: Vitamin D level Rationale: Patient will need Vitamin D level to check for deficiencies, which could also be contributing to her fatigue (Hollier, 2016). The vitamin D level varies from person to person. The total serum 25 hydroxy vitamin D level helps the providers to find the deficiency or insufficiency with the patient. The correct level of vitamin D varies from person to person (Lefebvre, 2015). Serum Vitamin B12: Rationale: Vitamin B 12 deficiency is very widespread among patient with type 2 diabetes mellitus. Initiation of metformin therapy with type 2 diabetes patients should screen for vitamin B12 deficiency due to metformin causing a decrease in serum B12 concentration (Kibirige & Mwebaze, 2013). Vitamin B12 affect brain functions and causes depression (Gorrol & Mulley, 2014). Vitamin B12 management in CASE STUDY ASSIGNMENT type 2 diabetes-mellitus begin with 1000 μg daily intramuscular or orally for a week and then once every week for 4 weeks which are sufficient to treat vitamin B12 deficiency (Kibirige & Mwebaze, 2013). Lab Test: Repeat UA Rationale: Mrs. Wong’s UA result was positive for glucose. Glycosuria is an indication for hyperglycemia and it means her kidneys are not reabsorbing all the glucose and is being passed out into the urine and repeat UA in 4-6 weeks (Cash &Glass, 2017). Medications Rx: Metformin 500mg tablets Sig: take 1 (one) tablet by mouth twice daily for diabetes mellitus Dis: # 60 (sixty) Refill: 2 (Hollier, 2018, p. 218) Rationale: Metformin is the first line drug therapy in type 2 diabetes mellitus and may be initiated with lifestyle changes with each individual. Metformin decreases insulin resistance and glucose production (Goroll & Mulley, 2014, p.783). Glomerular filtration rate (GFR) less than 30 and HbA1c less than 9% it is safe to prescribe metformin drug therapy. Metformin is effects on Hb A1C levels, weight reduction, and reduces the risk of cardiovascular event and death. Mrs. Wong HbA1c is 6.6% and GFR rate is 99. Per these values it is safe to prescribe metformin. (ADA, 2018). Rx: Atorvastatin 20mg tablets Sig: take one (1) tablet by mouth at bedtime for hyperlipdemia Disp: #30 (thirty), CASE STUDY ASSIGNMENT Refill: 2 (two) (Hollier, 2018 p.59) Rational: Rationale: Health care providers focus on the use of cost-effective pharmacotherapy agents that should be initiated in case where lifestyle changes fail to achieve the desired LDL-C level. Statins can reduce LDL by 21 to 55% and it is recommended by clinical practice guidelines. Atorvastatin is a medication can be titrated as needed for both moderate to high intensity therapy (Jellinger et al., 2018). Guidelines from the American College of Cardiology and American heart Association (ACC/AHA, 2018) statin is considered first line drug therapy lowering LDL cholesterol. Patient age greater than 40 with diabetes mellitus can benefit from high-intensity daily dose of statin that can reduce the LDL by greater than 50 percent (Hollier, 2018). Rx: Aspirin EC, 81mg tablets Sig: take one (1) tablet by mouth daily Disp: #30 (thirty) Refill: 2 (ADA, 2018) Rationale: The American Diabetic Association (2018) recommended that low-dose aspirin therapy is a secondary prevention with diabetic patient and a history of atherosclerotic cardiovascular disease (ASCVD). However, aspirin is a primary prevention is with diabetes and no previous history of vascular disease but increased risk of ASCVD (ADA, 2018). According to Bullock- Palmer (2015), patients should take enteric-coated aspirin 81 mg daily who is type 2 diabetes- mellitus and hyperlipdemia are at risk for coronary artery disease. Patients can start aspirin therapy unless they have no contraindication and serious adverse effects. CASE STUDY ASSIGNMENT Non pharmacological treatment Rx: Glucometer x1 Lancets- Disp #100 (1 box) Test Strips- Disp #100 (2 boxes) Alcohol pads- Disp # 1 box Sig- Test blood sugar two times daily before breakfast and dinner Disp # as indicated Refill: 0 Rationale: When providing patient with appropriate tools to monitor their health, it creates independency and better health outcomes. Monitoring blood glucose twice daily is very important and is helpful for the provider to manage the medications correctly. The best diabetes management is to keep blood sugar less than 180 mg/dl. In order to keep blood glucose level between 70-130 mg/dl daily blood glucose monitoring is highly recommended (ADA, 2018). Education Diagnosis: The key aspects to managing Type 2 Diabetes Mellitus are education, lifestyle modifications, self-management and support. The goal of diabetic interventions is for one to have glycemic control. Easy ways to assess glycemic control consist of daily monitoring of glucose, and a Hemoglobin A1C laboratory draw every 3 months (ADA, 2019). The optimal goal is to have the HgbA1c of 7% or less. When managing hyperlipidemia, the goal is to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) (ADA, 2019). Reducing some of these risk factors can be done with a heart healthy lifestyle and statin therapy (Grundy et al., 2018). Ppatients with BMI score of 30.7 is a clear indication of obesity. Obesity is characteristic by CASE STUDY ASSIGNMENT having an excessive body fat and is determined by a BMI higher than or equal to 30 kg/m2 (Dunphy et al., 2015). Obesity is caused by when one is consuming more calories than burning and is converted into body fat. It is the major cause of CVA, T2DM, CAD and hyperlipidemia (Dunphy et al., 2015). Medications: Metformin should be taken with a meal and at the same time everyday swallowed whole. The major side effect of the medication includes gastrointestinal upset. Side effects can include, diarrhea, bloating or abdominal discomfort (Woo & Robinson, 2016).The medication itself does not cause weight gain. When metformin is used for an extended period of time a deficiency in vitamin b12 may be the result (ADA, 2019). Atorvastatin is generally well tolerated and safe to use.