Assignment Task

Case Study for Part A

Luigi is a 77 year old Italian man who has lived in Australia for 40 years. He lives with his wife and son, who was born in Australia and attends university. Luigi speaks English well as he worked as an accountant for many years before his retirement. His wife who is also Italian has limited English as she has stayed at home caring for her husband and her son for most of her married life, thus Luigi does most of the shopping, pays bills etc.

Luigi’s health has declined over the last 15 years with a history of poorly controlled  type 2 diabetes for which he takes metformin 500mg BD. He is overweight, does not pay much attention to his blood sugar levels or his diet and leads a relatively sedentary lifestyle.

Lately Luigi notices his ankles are swelling and his vision is blurring. After a visit to the GP it is noticed his blood pressure is elevated and he has protein and glucose in his urine. This leads to further investigations where Luigi is diagnosed with chronic renal failure.

Rationale

Chang, 2014). Nurses need to be able to provide care to all health consumers, with a significant role in assessing a person, planning care, communicating with colleagues and ensuring that the holistic needs are met and evaluated. The ongoing nature of the conditions can result in longer term debilitating outcomes if not addressed appropriately. Children, young people, adults and older adults all experience the full range of health issues yet manage them differently.

This assessment task addresses the following subject learning outcomes:

• Plan nursing care for patients with complex co-morbidities demonstrating rationale for how one affects the other.
• It is known that chronic disease is the leading cause of death across the world (Johnson & Plan nursing care of a patient with a co-morbidity in consultation with individuals/groups significant others and the interdisciplinary health care team in the clinical setting
• Collaborate with the interdisciplinary health care team to provide comprehensive nursing care in the clinical setting
• Evaluate and reflect on their own ability to implement strategies to lead teams and care coordination

  Answer

Complex Nursing

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Table of Contents

Introduction. 2

Over View of the Case Study. 2

The pathophysiology of chronic and complex conditions and their related clinical manifestations  3

A discussion of the complexity and chronicity of the patient’s condition. 6

The patient’s comorbidities. 7

Impact of these conditions on the health of the patient and his family. 7

Clinical manifestations and medications of the patients. 8

Conclusion. 9

Recommendations. 9

Reference. 10

Introduction

In medical science, the comorbidity refers to one or more than one additional disorders or diseases co-occurring with a “primary disorder or disease.” According to ACCORD Study Group (2010), it is found that the comorbidity may include behavioural as well as mental disorders along with several related issues. Although the concept of comorbidity initially indicates an association of other diseases or conditions independently along with another medical condition or disorder, it is found that sometimes the sense of this terminology is overlapped with the concept of “complications.” In the case of prolonged diabetes mellitus, Group (2010) opined that it is very complicated to measure whether the occurrence of coronary artery disease is independent of the primary disease (diabetes mellitus) or it is the comorbidity of the primary disease.

In medical science, the comorbidity can be synonymised as polymorbidity, multimorbidity, polypathy, multifactorial diseases, dual diagnosis and pluralpathology (Scirica et al., 2013). In this article, the researcher aims to identify the comorbidities of type 2 diabetes based on a case study.

Over View of the Case Study

Luigi (77), a retired old man is living in Australia for 40 years with his wife and a son. His health condition is declining from past 15 years as he is suffering from type 2 diabetes. Although he was consuming metformin 500mg BD, it is found that he is careless about his declining health condition. Luigi never pays attention to his overweight or increasing blood sugar level. It is found that he is also very reluctant about his diet chart. Recently, Luigi noticed that his vision is blurring and ankles are swelling. It is also recognized that his blood pressure has increased, and protein, as well as glucose, is present in his urine sample. Later he is diagnosed with “chronic renal failure.”

The pathophysiology of chronic and complex conditions and their related clinical manifestations

According to Malik et al. (2010), the diabetes mellitus type 2 can be characterized as insulin resistance, high blood sugar as well as the relative lack of insulin. The common symptoms of this disease may include frequent urination, increased thirst, as well as unexplained weight loss. On the other hand, Nouwen et al. (2010) opined in their study that diabetes mellitus type 2 is a “heterogeneous syndrome,” which can be characterized by abnormalities in fat and carbohydrate metabolism. It is also found from the research study that the causes of type 2 diabetes are “multifactorial,” which may include both environmental as well as genetic elements, which can affect tissues (muscle, adipose tissue, liver, and pancreas) as these are insulin sensitive. The environmental and genetic factors can also have an impact on the beta-cell function. All though both reduced insulin sensitivity and beta-cell dysfunction play an important role in the development of type 2 diabetes, it is found that the researchers debated about the relative contributions of these two factors to the pathogenesis of type 2 diabetes.

The pathophysiology is considered as a “junction” of physiology with pathology. Pathology is defined by Chen et al. (2012) as the medical discipline, which elaborates conditions typically notices in the period of a disease state. On the other hand, physiology can be best described as the biological discipline, which elaborates mechanisms or process operating within an “organism.” While discussing the pathophysiology of the type 2 diabetes, it is found that both environmental and genetic factors play an equal role in the occurrence and severity of the disease. However, the mechanisms to control the interplay of environmental factors and the genetic factors are not very clear. Carter et al. (2010) suggested in their research study that there may be some factors that can be possibly linked with beta-cell dysfunction and insulin resistances in the context of the pathogenesis of type 2 diabetes. From the study of Ismail-Beigi et al. (2011), it is found that a majority of patients who are suffering from type 2 diabetes are diagnosed as obese with central visceral adiposity. Therefore, it can be said that the adipose tissue should play an important role in the pathogenesis of diabetes mellitus type 2. One of the most important paradigms used to explain this link is “the visceral / portal hypothesis, which plays a key role in the elevation of the concentration of non-esterified fatty acid. Apart from this paradigm, two new paradigms are also discussed among the researchers, such as “ectopic fat storage syndrome” as well as “the adipose tissue as endocrine organ hypothesis.” The hypothesis of ectopic fat storage syndrome is focused on the deposition of triglycerides in pancreatic cells, liver, and muscle. On the other hand, the adipose tissue as endocrine organ hypothesis includes the secretion of different adipocytokinase such as leptin, resistin, TNF – alpha, which take part in beta- cell dysfunction and insulin resistance.

The comorbidity, which is related to this chronic disease are obesity, glaucoma, chronic kidney failure and high blood pressure. According to Inzucchi et al. (2012), due to type 2 diabetes mellitus the adipose tissues get harmed and lead towards the increase of weight. On the other hand, the study showed that the patients with type 2 diabetes mellitus also have uncontrolled hypertension as the blood pressure continuously get elevated. According to Qaseem et al. (2012), the kidneys cells are also affected due to type 2 diabetes mellitus and leads to the acute kidney failure. Increasing level of glucose can also affect the retina and cause blurred vision. And last but not the least occurrence of this chronic disease can lead toward the cardiovascular disease (CVD) and cause heart failure.

A discussion of the complexity and chronicity of the patient’s condition

Based on the case study it is found that Luigi is suffering from longstanding type 2 diabetes mellitus (from last 15 years). The health condition of Luigi is continuously declining due to the suffering of type 2 diabetes which is recognised to be a chronic disease. According to Singh et al. (2013), chronicity is considered as a term, which denotes continuance and consistency, in the onset of an illness. It is also found that the chronicity of an illness indicates to the disease, which goes upon for a prolonged treatment.

It is found from the research study of Rubino et al. (2010), that diabetes can be considered as a chronic illness, which anchors other illnesses and increases morbidity. Luigi is suffering from this disease for a long time, which has a deep impact on his health. Due to the presence of type 2 diabetes and his negligence he developed other diseases such as chronic kidney failure, glaucoma, high blood pressure as well as overweight. The increasing number of anchored diseases in his body also increased the complexity of his treatment and in his lifestyle.

According to Bangalore et al. (2011), it is found that the management of the complex chronic diseases is always difficult as well as critical for the older people. Patient like Luigi, who is suffering from several comorbidities, needs to have special care as well as specific medical attentions.

The patient’s comorbidities

According to the case study, Luigi is suffering from a chronic disease (type 2 diabetes mellitus) from past 15 years. As a trained professional nurse, after reviewing his present condition, it can be said that the reason behind the continuous declining of the health of the patient is not only the occurrence of type 2 diabetes mellitus but also the comorbidity-related with this chronic diseases.

It is found that Luigi is already suffering from several comorbidities such as glaucoma, dyslipidemia, high blood sugar (hypertension), glucosuria, obesity, cardiovascular disease and acute kidney failure. According to Lee et al. (2011), it is recognized that these comorbidities are the medical conditions that occur and are facilitated by the primary diseases; however, they can also exist as own specific disease. On the other hand, it is also found that it is not necessary that all of the comorbidities should occur in every person who are suffering from the same chronic disease. In this case study it is found that Luigi is suffering from most of the comorbidities of type 2 diabetes but not necessarily all of them. According to the study of Singh et al. (2013), NAFLD (Nonalcoholic fatty liver disease) is one of the most frequently occurring comorbidity of type 2 diabetes; however, after studying the case study, it is found that Luigi was not suffering from NAFLD.

Impact of these conditions on the health of the patient and his family

According to Qaseem et al. (2012), the occurrence of type 2 diabetes mellitus not only has an impact on the health of a patient but also has an impact on the social life as it interferes with day to day work of the patient. Luigi is unable to perform the outdoor work, which is evidently not supporting the sustainability of the family.

Uncontrolled diabetes leads to elevated blood sugar and eventually welcomes the risk of heart failure, damage of blood vessels, nerves and eyes. According to () fifty per cent of the patients with type 2 diabetes undergo heart stroke. Damage of nerves or neuropathy causes numbness of feets, hands and limbs including pain (Chen et al. 2012). Neuropathy accompanied with reduced blood flow in the feet enhances the possibility of foot ulcers and further limb amputation. Retinopathy was found to be the contributing factor of blindness resulting from damage of retinal blood vessels (Lee et al. 2011). According to (Rubino et al. 2010) about 10 % of patients develop visual impairment after being diagnosed with diabetes for fifteen years.

On the other hand, the occurrence of type 2 diabetes mellitus and comorbidities of this disease can also have an impact on the family economy. According to Ismail-Beigi et al. (2011), the increasing rate of fees and cost of medicines in Australia for the treatment of diabetes is considered as a burden on the family who has members suffering from type 2 diabetes mellitus.

Clinical manifestations and medications of the patients

The clinical manifestation of type 2 diabetes may firstly, include diagnosis which can be started with blood testing for sugar levels. Secondly, high blood pressure, obesity, decrease sensation in legs, weak pulse rate, ulcers, infections of the feet are the common symptoms that are helpful for diagnosing diabetes.

The laboratory tests may include: FPG (fasting plasma glucose), OGTT (oral glucose tolerance test), random blood glucose test, blood creatinine test, and clinical examination for kidney disease and lipid profile of the patient.

To control the type 2 diabetes, it is important to follow a proper diet chart and exercise routines. According to Chen et al. (2012), it is found that those patients with type 2 diabetes who are maintaining a good diet chart have improved from their present condition. A healthy diet chart of a person with type two diabetes mellitus should include low cholesterol, less amount of Trans fat, fewer calories and nutritionally balanced food.  Apart from these, it is also found that injection of insulin and other medicines such as metformin are essential.

Conclusion

After analysing the present condition of the patient as described in the case study, it can be said that Luigi is suffering from chronic type 2 diabetes mellitus, which not only has an impact on his health but also in his social life. He is a 77 years old person and therefore he is less potential to fight against this chronic disease. On the other hand, it is also found the comorbidities of this disease has affected his life style. The reason behind of his health decline is not only the type 2 diabetes mellitus but also the comorbidities such as glaucoma, hypertension, chronic kidney failure and obesity. However, his negligence of diet chart and medicines has lead to the deterioration of his health. Therefore, it can be said that with a better diet chart, medicines and involvement in proper exercise procedure, he will be able to recover himself from the current state.

Recommendations

After reviewing the current state of Luigi, he is recommended to follow a proper diet chart along with a proper exercise routine. He is recommended to adhere to his medication strictly and also intake medicines for the chronic disease as well as comorbidities. He must control his blood sugar level strictly and avoid using NSAIDS.

Reference

ACCORD Study Group. (2010). Effects of intensive blood-pressure control in type 2 diabetes mellitus. The New England journal of medicine, 362(17), 1575.

Bangalore, S., Kumar, S., Lobach, I., & Messerli, F. H. (2011). Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation, 123(24), 2799-2810.

Carter, P., Gray, L. J., Troughton, J., Khunti, K., & Davies, M. J. (2010). Fruit and vegetable intake and incidence of type 2 diabetes mellitus: systematic review and meta-analysis. Bmj, 341, c4229.

Chen, L., Magliano, D. J., & Zimmet, P. Z. (2012). The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives.Nature Reviews Endocrinology, 8(4), 228-236.

DeFronzo, R. A., Cersosimo, E., & Mandarino, L. J. (2011). Pathogenesis of Type 2 Diabetes Mellitus 6.

Group, T. A. S. (2010). Effects of combination lipid therapy in type 2 diabetes mellitus. The New England journal of medicine, 362(17), 1563.

Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., … & Matthews, D. R. (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55(6), 1577-1596.

Ismail-Beigi, F., Moghissi, E., Tiktin, M., Hirsch, I. B., Inzucchi, S. E., & Genuth, S. (2011). Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Annals of internal medicine,154(8), 554-559.

Kohei, K. A. K. U. (2010). Pathophysiology of type 2 diabetes and its treatment policy. JMAJ, 53(1), 41-46.

Lee, W. J., Chong, K., Ser, K. H., Lee, Y. C., Chen, S. C., Chen, J. C., … & Chuang, L. M. (2011). Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Archives of surgery, 146(2), 143-148.

Malik, V. S., Popkin, B. M., Bray, G. A., Després, J. P., & Hu, F. B. (2010). Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation, 121(11), 1356-1364.

Nouwen, A., Winkley, K., Twisk, J., Lloyd, C. E., Peyrot, M., Ismail, K., … & European Depression in Diabetes (EDID) Research Consortium. (2010). Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis. Diabetologia, 53(12), 2480-2486.

Qaseem, A., Humphrey, L. L., Sweet, D. E., Starkey, M., & Shekelle, P. (2012). Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 156(3), 218-231.

Rubino, F., Kaplan, L. M., Schauer, P. R., & Cummings, D. E. (2010). The Diabetes Surgery Summit consensus conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus. Annals of surgery, 251(3), 399-405.

Scirica, B. M., Bhatt, D. L., Braunwald, E., Steg, P. G., Davidson, J., Hirshberg, B., … & Cavender, M. A. (2013). Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. New England Journal of Medicine, 369(14), 1317-1326.

Singh, S., Chang, H. Y., Richards, T. M., Weiner, J. P., Clark, J. M., & Segal, J. B. (2013). Glucagonlike peptide 1–based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA internal medicine,173(7), 534-539.