Diabetes, BMI And Mental Health Of Michael: Clinical Reasoning Cycle

What type of diabetes do you think that Michael has?

Michael’s holistic assessment by the General Practitioner (GP) today indicates:

Physical:

• Weight 140kg (up from 135kg six months ago)
• Height 176 cm
• BP 160/70; HR 88
• Temp 37.7
• BGL: 9.0mmol
• Pain in his knees and ankles (rated as 4/10 on pain scale) – patient states this makes it difficult to do any exercise
• Laboratory testing indicated that chemistries, Blood Urea Nitrogen, creatinine, liver function tests, thyroid function tests and urine microalbumin are all normal
• Glycated Haemoglobin (HBA1c) was 7% for one year but is now 9%
• LDL: 2.2 mmol/L
• HDL: 1.6mmol/L

• 9 year history of diabetes
• Obesity
• Depression
• Hypertension
• Arthritis

Surgical history:

• Trans-urethral resection prostrate
• Cholecystectomy  

Nurofen, Metformin, Coversyl, Atorvastatin, Lexapro

Michael lives on his own after losing his wife five years ago.  He has learned some cooking skills and prepares most of his meals although takeaways are an easy option for him during his work day as a taxi driver.  He has good family support from one daughter, one son and two grandchildren who live close.   Michael has little social engagement other than his children and often chooses not to leave the house.

The National Health Priority Areas of Diabetes Mellitus, Obesity and Mental Health were established with the aim of improving health outcomes in these areas.  Review your modules, references and extended reading in regard to these National Priority areas.

Diabetes is a chronic condition marked by high levels of glucose in the blood caused by either the inability to produce insulin or by the body not being able to use insulin effectively.  The main types of diabetes are Type 1, Type 2 or Gestational.  In 2014-2015 approximately 1.2 million people (6% of Australian adults) had diabetes, based on self-reported data.  This is a growing issue with increasing hospitalisations due to diabetes and one in ten Australian deaths having diabetes as an underlying and/or associated death.

In 2011-2012, almost 2 in 3 (63%) of Australian adults are overweight or obese.  Obesity is a major risk factor for cardiovascular disease, Type 2 diabetes, some musculoskeletal conditions and some cancers, while making the management of and controlling of chronic disorders difficult.

Mental health and behavioural disorders describe a wide spectrum of disorders which can vary in both severity and duration.  The most common disorders are depression, anxiety and substance use disorders and are important drivers of disability and morbidity.  There is also an association between diagnosis of mental health disorders and a physical disorder with 1 in 8 (12%) of people with a 12-month mental disorder also reporting a physical condition and 1 in 20 (5%) reporting two or more physical conditions.

There is a clear bidirectional association between diabetes and mental illness.  Statistics show that Australians with diabetes have a higher prevalence of poor mental health than those without diabetes.  People with diabetes are more than twice as likely to have mental or behavioural problems as those without diabetes.

Use the Clinical Reasoning Cycle on the following pages to review the nursing priorities in relation to the care of Michael.

What is Michael’s BMI and how is this calculated?

Gain an initial impression of your patient Question 1:

Review the anatomy and physiology of the three types of diabetes (Type 1, Type 2 and Gestational). 

The patient had been suffering from diabetes for the past nine years and his signs all indicate at the possibility of the patient having diabetes type two, which is the most common type of diabetes seen in adults.

It has to be mentioned in the justification of this diagnosis is the fact that high blood glucose levels are characteristic feature of this type of diabetes which is high in case of the patient as well. Moreover, The type 1 diabetes in mainly juvenile diabetes which is hereditary and is manifested in the early childhood years, which is not the case of the patient, as he had been suffering from diabetes only for 9 years.

For gestational diabetes as well, this condition occurs to pregnant women, which is not the case fir the patient under consideration. Hence the patient has been suffering from type 2 diabetes, a chronic lifestyle based condition for the adult to middle aged patients (American Diabetes Association, 2010).

Gain an initial impression of your patient. Question 2:

The BMI is generally calculated by a complex ratio involving the height and weight of the particular individual involved.

According to the most common statistical metrics, the BMI of 30 or higher relates to the fact that the person is obese and needs immediate attention to their excessive body weight. It has to be mentioned in this context that the patent under consideration for this assignment had a BMI of 45.2, which is far higher than the normal range. Hence it can be stated that with the extremely high BMIU that the patient has, the chances of the patient being severely overweight is extremely high and the subsequently the health risks of the patient is also going to be extremely high like hypertension, anxiety and several other health complications (Feng et al., 2012)

Gain an initial impression of your patient. Question 3:

Review and recall your knowledge of diabetes and the possible adverse complications that may occur.

a.List four signs and symptoms of hypoglycaemia that Michael might experience

b.Using your knowledge of anatomy and pathophysiology, explain in detail why one of these signs and symptoms could occur.

a.As the patent high blood glucose levels and extremely obesity situation, the patient will have increasingly high risk of having hyperglycemic attacks that the patients will have to be very careful to detect early and take adequate actions. The four signs and symptoms of the possible hyperglycemia attacks tat the patient will need to be very careful about include: suddenly higher than normal heart rate, paleness, sudden bouts of fatigue, and blurred vision (Inzucchi et al., 2012).

Discuss what this BMI means for Michael?

b.Hyperglycaemia can be considered a situation where the patients with high diabetes or high blood glucose levels encounter the effect of a sudden change in the plasma glucose levels and the concentration of free immmunoreactive insulin and C-peptide immunoreactivity. Emphasizing on the manifestation of one of the symptoms, the increased feeling of hunger and fatigue is directly reacted to the sudden reduction in the plasma glucose levels of the patient below the normal threshold. This reduction acts on the cellular and metabolic activity of the body and the feeling of fatigue and hunger in the patient (Luitse et al., 2012).

(a)Review current information

(b)Gather new information

(c)Recall knowledge (A&P, ethics, law, cultural safety) Question 4:

Review current information: review and think about Michael’s presentation, the observations that have been carried out and what further assessment you would want to carry out now.

a.Lexapro is a commonly used medication to treat anxiety and depression in adults.  Describe the mode of action of this medication for Michael.

b.How should this medication be taken?

c.List two side effects of the medication.

a.Lexapro oral is the trade name for the medication Escitalopram which is a very common medication given to the patients to treat depression and anxiety. It has to be mentioned in this context, that this a key medication that helps in reducing and maintaining the level of anxiety and depression in the patients by regulating and maintaining the level of a key signaling factor, serotonin. Serotonin belongs to the class of selective serotonin reuptake inhibitors (SSRI), and is a neuromoderating factor that helps to maintain the levels of serotonin in the brain relaxing the patient and relieving the patient of the feeling of tension or stress. Along with that this medication can also help in improving the energy levels of the patient and can help the patient feel good (Uher et al., 2011).

b.The administration of this medication should be based on the discretion of a registered health practitioner, however the most frequently observed mode of administration for this medication is orally. This medication is to be consumer once everyday wither in the morning or in the evening.

Two side effects of this medication are: nausea and constipation.

(a)Review current information

(b)Gather new information

(c)Recall knowledge (A&P, ethics, law, cultural safety) Question 5:

A normal BGL is:

a)2.5-3.5mmol

b)4.0-8.0mmol

c)5.0-10.0mmol

A normal BGL or blood glucose levels for the adults has to be option b) 4.0 to 8.0 mmol

What allied health professional would you consider referring Michael to?

(a)Review current information

(b)Gather new information

(c)Recall knowledge (A&P, ethics, law, cultural safety) Question 6:

Obesity can be considered as one of key health adversities and extreme obesity puts the patients at extremely high risk of many health conditions. For instance, it has to be mentioned that obesity is a health condition where the victim carries at least more than 20 % more body weight than what is required based on the height, age and body structure.

Excessive body weight puts the patient under the risk of coronary heart diseases and cardio- vascular complications which is by far one of the most harmful and deadliest of health adversities (Dixon, 2010).

Along with that, high body weight also increases the chances of the patient developing chronic high blood pressure which in turn paves way for many health adversities.

The next health risk that the patient is under due to obesity and high body weight is High blood cholesterol and triglycerides.

And lastly, the possibility of bone and joint problems like osteoarthritis can be the outcome of excessive body weight (Zalesin, 2011).

• Interpret data – what does it all mean?
• It is important to consider the potential inter-relationships between diabetes, obesity and mental health issues

It has to be understood that obesity is a health condition that paves way for many health risks and equal amount of health complexities. that is the reason why the patients suffering with health conditions like obesity must take acute care to maintain a healthy and fulfilling diet that will help them regain control of their body weight without compromising on the daily nutritional requirements. In this case, that patient under consideration is highly obese and has been already dealing with type two diabetes which can be considered as one of the most crucial health adversities affecting the living condition and lifestyle of the patient effectively. In this context, not having a controlled and efficient diet plan can be extremely harmful for the patent and can increase the risk of the patient developing cardiovascular conditions (Psaltopoulou, Ilias & Alevizaki, 2010). Hence, I would recommend the patient to consult a registered nutritionist or a registered dietician and follow a planned diet.

According to the authors, it has to be mentioned that the concept of nutritional counseling is considered to be a very important element of the overall care planning that the patients undergo in an attempt to maintain the health statistics after diabetes type two. Consuming uncontrolled amount of fatty food can be extremely harmful for the patient and can lead to many health related concerns for the patient and can worsen the obesity due to unwarranted consumption of triglycerides. Keeping aside the threat of obesity for a diabetic maintaining a BGL balance is extremely crucial and hence following a professionally designed patient centered diet developed by the registered dietician or nutritionist will be significantly beneficial (Azadbakht et al., 2011).

• Interpret data – what does it all mean?

What have you learned from this experience?

Of the physical assessment on Michael – what finding is of most concern?

a.BGL

b.BP

c.Temperature

d.Pain

Discuss why this is of most concern.

As per the objective data gathered of the patient the two most concerning health statistics that the patient is showing can be the fact that the patient has extremely high blood pressure at 160/80 and the blood glucose level at 9mmol. However, it has to be mentioned that the normal blood glucose levels of a patient with diabetes is close to 7.0 mmol, and concerning that fact that the patient has been suffering from diabetes for nine long years a slight fluctuation to 9.0 an not be on the most important priority list.

On the other hand, in this case the patient had high blood pressure in the patient which is 160/80. Now it has to be mentioned that as per the vita; signs of the patient, the SBL and DBL figures shown by the patient indicates that the patient is in hypertension stage II (Kotsis et al., 2010).

There are various risk factors are associated with the various health risk factors which can be potentially fatal for the patient. The very first risk factor is the coronary arterial blockages and resultant heart attacks. It has to be mentioned in this context that the patient can be at life risk for the cardio- vascular complications he can develop due to stage II hypertension. Along with that patient had also been suffering through conditions like renal and peripheral arterial diseases. Hence, it can be stated that the patient under consideration in this case study assignment is at high risk of lower life expectancy due to the extremely high blood pressure. Hence, this is the most important health concern for the patient (Hall et al., 2014).

Synthesise all information that has been collected and processed. Question 9:

Select from the list below the three highest priority relevant nursing diagnoses for Michael.  Justify your answers.

a.Activity intolerance

b.Impaired social interaction

c.Cognitive impairment

d.Insomnia

e.Impaired nutrition

f.Antisocial personality disorder

Among the different answers given below, the first highest priority while car planning for the patient under consideration is the impaired nutrition that the patient is having, it has to be mentioned in this context that the patient has had a long term type two diabetes that the patient has been struggling with for 9 years. Despite that the patient has been dealing with high obesity and extremely high blood pressure which further increases the health risks that the patient in under. In such a condition, despite having 45.2 BMI and 9.00 mmol BGL, the patient carries on a more or less sedentary life style and has no planned diet or dietary restriction. The patient has also shared that he even indulges in frequent snacking and has no BMO diet plans in the nine years that he has been suffering with the diabetes. In this case, the nutritional impairment is very clear, where the fat and carbohydrate rich diet is contributing to the weight increase and uncontrolled blood glucose level hike (American Diabetes Association., 2015).

Why are patients with mental illness at particular risk of patient safety?

The next highest priority for the patient is the activity intolerance that the patient has due to his arthritis and joint pain. The patient has shared the fact that he is unable to maintain a regular exercise regimen for the acute knee pain that he suffers from. Hence, providing short term meditational and long term non-pharmacological interventions for the knee pain can be necessary care goals for the patient (Handelsman et al., 2011).

The third and final priority from the list can be the possible insomnia that the patient might suffer from due to

the anxiety, depression and pain that the patient suffers from. The patient has also shared that he had long stopped taking the antidepressants and has been feeling increasingly helpless. Hence, insomnia medication prescribed to the patient along with antidepressants can be beneficial.

From the list below choose the three most important short-term goals and justify the importance for Michael’s management at this time:

a.For Michael to lose weight

b.For Michael to sleep for eight hours/night

c.For Michael’s BGL to stablise

d.For Michael to be more social

e.To improve Michael’s mood

f.For Michael to take time off work.

Among the given set of optiobs the three most important short term, goals for the patient are:

For Michael to lose weight: the BMI for the patient is 45.2, which is excessively higher than the normally permissible limit, indicating that the patient is obese. It has to be mentioned in this context that the patient has been suffering from three adverse health consequences of obesity like diabetes, high blood pressure and joint pain. Hence, losing weight is extremely important for the patient to avoid further health complications like coronary heart diseases and renal diseases.

For Michael’s BGL to be more stabilized: regardless of the fact that the patient has been suffering from a long term diabetes type two, the permissible blood glues levels of a diabetic adult is still upto 7.0 mmol. Whereas the blood glucose levels of the patient is at 9.0 mmol which is far higher than the desired level and can cause acute complications for the patient (Kirkman, 2012).

To improve Michael’s mood: the patient has shared that fact that he had been dealing with anxiety and depression for a considerable among of time and along with that the patient has stopped taking antidepressants prescribed to him. his present health restrictions and his worsening condition has also worried and depressed him further to a point where the patient feels helpless. Hence relaxing the patent is one of the most important short term care goals for the patient.

Waist circumference can also be used to determine obesity.

What action/interventions will you do?

The GP suggests to Michael that he might need to commence insulin.  List two strategies that you would suggest and educate Michael on to avoid this.

Justify these strategies.

Insulin injection can be a very fearful and dangerous administrative task and hence the patient needs o be educated on how to correctly and successfully administer the insulin.

One of the greatest strategies to administer insulin to the new patents is injecting in the abdomen. It has to be mentioned that the absorption in the abdomen issues are much higher than in the arms, upper thighs and buttocks. Hence the patient should be educated on the most effective injection site of the body (Peyrot et al., 2012).

The second strategy to administer insulin is to regularly rotate the site of injection so that any clotting or acute pain by injecting at the same site (Mader et al., 2013).

What action/interventions will you do?

• Question 12:

If Michael develops a wound, being diabetic puts him at higher risk of healthcare associated infections.  Explain why this is the case?

It has to be mentioned that diabetes is a medical complication that comes with many a complications and among all the possible restrictions impaired wound healing can be considered as a very complicating one. It has to be mentioned that wound healing is a very slow and meticulous process for diabetics and there are many contributing factors to this phenomenon (Kolluru, Bir & Kevil, 2012). First and foremost, it has to be mentioned that the possibility of uncontrolled and excessively high blood glucose levels can damage the peripheral arterial diseases and peripheral neuropathy. These two factors contribute to reduced blood flow in the body and reduced supply of oxygen and nutrients, which are absolutely necessary for healing. Hence for diabetic patients with uncontrollably rising diabetes can be facilitator of delayed wound healing and eventual infections (Amos et al., 2010).

What action/interventions will you do?

• Who should be notified? Question 13:

For Michael’s ankle and knee pain from osteoarthritis, in addition to taking the prescribed Non-Steroidal Anti-Inflammatory Drug, as a nurse you should also instruct him to:

a.Start a regular exercise program

b.Avoid all fatty foods

c.Ensure eight hours sleep each night

d.Rest the ankles and knees as much as possible to decrease inflammation.

The patient while taking NSAID drugs must start a regular exercise program.

What action/interventions will you do?

Give a rationale for your answer to Q13?

Why might this be a better measurement of obesity than BMI?

The NSAID drugs are known to effect the muscular growth and tenacity when consumed on a long trem basis or in older age. A mild yet affective exercise program can be very effective in bossting the muscle activity and growth counteracting the negative effect of the NSAID drugs (De Weck et al., 2010).

Assess the effectiveness of actions

List two signs and symptoms that would indicate that Michael’s goals are being achieved.

Two signs or symptoms that will indicate that the basic care goals are being met are:

a.The BMI of the patient is decreasing which will indicate that the weight of the patient is decreasing and the obesity situation that the patient had been under is improving rapidly. Along with that a lower BMI will also indicate that the blood glucose levels of the patients is decreasing.

b.The blood pressure of the patient will decrease to normal levels, and he will eventually be more active and energetic.

It is important for Michael to ensure that his feet are examined regularly.  Why is this?

Diabetic foot ulcer is very common phenomenon in type two diabetes and is considered to be one of the most significant risks of the patients. It has to be mentioned in this context that for the diabetics the increased blood glucose levels and the nerve and peripheral arterial damage leads to impaired or reduced blood circulation throughout the body. The lack of proper circulation leads to impaired oxygen flow to the peripheral parts of the body; hence, the regular pressure put on the foot leads to blood clotting and develops infectious ulcers. Along with that fact, it has to be mentioned that the body weight of the patient in this case is excessive as well, with acutely high blood sugar level, which increases the chances of him developing diabetic foot ulcers. Hence, he must examine his foot on a regular basis to avoid any risks (Dorresteijn & Valk, 2010).

What have you learned from this experience?

a)Increased risk for high blood pressure and atherosclerosis

b)Impaired sensation in the hands and feet

c)Increased risk for heart failure

d)All the complications listed above.

1. d) All the complications listed above

Among all the health risks and problems, it has to be mentioned that mental illnesses are the most threatening and complicated of all the different health adversities. It has to be mentioned in this cont4ext that mentally unstable patients are completely dependable on their family members and the mental health care providers. The mentally ill individuals are increasingly at risk for many hazards due to the fact that they lack any reasonable thinking and better judgment. Along with that it has to be mentioned that the patents dealing with mental illness are often living in a fabricated reality than the rest of the individuals and hence these patients often are at more risk of patient safety than the normal patients. It has to be mentioned in this context that the mental patients often remain irritated, agitated and vulnerable due to the societal stigmatization, lack of sense of safety and security and ill treatment. This also increases their violent tendencies that can be significant risks to their own safety (Sammer et al., 2010).  

What should happen to improve problems/issues and by when?

Measurement of waist circumference is significantly more effective way to determine obesity when compared to BMI. First and foremost, BMI is calculated taking into consideration the height and weight of the patients, which in most cases are self reported. The chance of bias is significantly high in the measurement of obesity with BMI for this particular reason (Camhi et al., 2011). Waist circumference on the other hand is devoid of any possibility of bias and is a authentic measurement parameter for measuring obesity as there are no chances of this being self reported. Along with that, it also needs to be mentioned that the BMI is often more indicative of adiposity than accurate obesity which is not the case for waist circumference. Hence, waist circumference measurement is a much more authentic parameter for measuring when compared to BMI (Bener et al., 2013).

Reference:

American Diabetes Association. (2010). Diagnosis and classification of diabetes mellitus. Diabetes care, 33(Suppl 1), S62.

American Diabetes Association. (2015). Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 33(2), 97.

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