Type 2 Diabetes Mellitus (T2DM) Condition Analysis

Condition

Type 2 Diabetes Mellitus (T2DM)

Definition

Type 2 Diabetes Mellitus (T2DM) is a prevalent hyperglycemic condition, constituting for 90% of all diabetes cases. It is characterized by insulin resistance, where insulin-sensitive tissues become unresponsive towards insulin. Initially, the body compensates by increasing insulin production to maintain glucose balance, but overtime, this leads to reduced insulin production, resulting in T2DM. It is largely associated with lifestyle factors and some genetic predispositions. (Goyal R, 2023; Galicia-Garcia U, 2020).

The diagnostic criteria for diabetes include the following:

(1) a fasting plasma glucose ≥126 mg/dL (7.0 mmol/L) on two tests;

(2) classical symptoms of hyperglycemia along with a random glucose level ≥200 mg/dL (11.1 mmol/L);

(3) a plasma glucose of 200 mg/dL after consuming a standard 75g oral glucose load;

(4) a glycated hemoglobin (Hb­_A1C­) higher than 6.5%. (Hammer G.D., 2013)

Pathophysiology

T2DM is associated with insulin resistance and -cell dysfunction. Progression to the disease state is characterized by metabolic changes in the beta cells, whose insulin production cannot regulate body’s glucose levels. (Goyal R, 2023; Galicia-Garcia U, 2020).

The complications associated with T2DM include:

1. Insulin Resistance (IR): IR refers to a reduced metabolic response of insulin responsive cells to insulin or impaired responsiveness to circulating insulin.
2. β-cell dysfunction: It results from inadequate glucose sensing to stimulate insulin secretion therefore there is prolonged elevated glucose concentrations
3. Chronic Hyperglycemia: Persistently elevated glucose concentrations above the physiological range result in the manifestation of hyperglycemia.
4. Incretin Effect: Reduced incretin effect contributes to inadequate insulin secretion and hyperglycemia.
5. Central Obesity: Central adiposity is closely linked to insulin resistance.

Causes

Many studies have pointed out the following factors that predispose a healthy individual to T2DM (Ismail L, 2021; Galicia-Garcia U, 2020):

1. Hereditary and Genetics
2. Age: Individuals aged above 35.
3. Poor Sleep quality/quantity
4. Medical conditions: Persons with conditions like cardiovascular disease, dyslipidemia, Hypertension, polycystic ovarian disease and pancreatic diseases (such as cystic fibrosis, Pancreatitis and pheochromocytoma) are more prone to get T2DM.
5. High level serum uric acid
6. Smoking: The risk of developing the disease is 30 – 40% greater in smokers.
7. Depression
8. Physical Inactivity
9. Obesity
10. Ethnicity: Indians, Melanesians, Bangladeshis, non-Hispanic Whites, Americans are at higher risk.

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Symptoms

Physical, psychosocial & cognitive (Hammer GD, 2013; Lippincott, 2019; Damanik, 2021):

Physical Symptoms:

• Excessive thirst (Polydipsia)
• Frequent urination (Polyuria), including nocturia (Nephropathy)
• Weight Reduction
• Blurred/unclear vision (Retinopathy)
• Fatigue
• Delayed/impaired wound healing
• Decreased light touch, vibratory, temperature sensations (Peripheral Neuropathy)
• Nausea/vomiting, early satiety, diarrhea (Autonomic Neuropathy)
• Changes in skin health (integrity) due to diminished peripheral circulation (Peripheral Vascular Disease)
• High BP, Aphasia (Cerebrovascular Disease)
• ECG changes (coronary artery disease)

Psychological Symptoms:

• Excessive eating (Polyphagia)
• Sorrow/depression
• Anxiety
• Diabetes distress

Cognitive Symptoms:

• Changes in mental flexibility
• Decrements in information processing speed
• Decrements in executive functioning

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Treatment (Lippincott, 2019)

Diet:

1. Making a meal plan to achieve/maintain healthy weight.
2. Implementing a balanced, low-carbohydrate diet with emphasis on whole grains, vegetables, lean proteins and healthy fats.

Exercise: Doing a regularly scheduled and moderate exercise for 30 to 60 minutes every other day helps the utilization of carbohydrates, improves insulin action and boosts cardiovascular fitness.

Medication:

1. Administer the use of injectable/oral antidiabetic agents if glucose control cannot be achieved through diet and exercise.
2. Insulin therapy is essential when unresponsive to diet, exercise or oral antidiabetic agents.
3. Metformin as the first-line medication improved insulin sensitivity and lowers hepatic glucose production.
4. If the glucose levels of Seema still fail to come under control, then other medications may be prescribed.

General Health (Lippincott, 2019): There should be a regular follow up of Blood Pressure (BP), creatinine levels, and lipid control to prevent further complications.

Nursing Interventions

Nursing interventions can improve the health of individuals with type 2 diabetes (T2DM) greatly through several key actions (Lippincott, 2019; Mouri MI, 2023):

1. Education and Counseling: Nurses can teach patients how to manage their diabetes, which would include blood sugar monitoring, insulin administration, diet, and exercise.

This empowers patients to take control of their condition.

• Medication Management: Nurses can make sure patients understand their medications and help them adhere to their doses.
• Regular Monitoring: Nurses can conduct routine check-ups to monitor vital signs and prevent complications, such as diabetic foot ulcers.
• Psychosocial Support: Nurses can provide emotional support and stress management techniques, which is important for overall well-being.
• Coordinating Care: Nurses can coordinate with other healthcare providers to ensure comprehensive, multidisciplinary care.

These interventions can be effective because they offer personalized, holistic care that addresses all aspects of diabetes management, from education to emotional support. Therefore, improving adherence, preventing complications, and enhancing the overall quality of life.

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Nursing Interventions that can be used for Seema Sharma (Lippincott, 2019; Mouri MI, 2023)

Refining Nutritional status of the patient:

1. Evaluate Seema’s content and timing of meals.
2. Counsel Seema on the significance of timely meals and encourage her to reduce the intake of carbohydrates.
3. Assist her to identify problems with her dietary adherence and suggest possible solutions.
4. Explain the role of physical activity in weight management.
5. Assist her to establish weekly weight loss goals.
6. Identify financial barriers to accessing medications.

Teaching about Insulin Administration:

1. Help Seema overcome the fear of injection by conveying a sense of empathy.
2. Show and explain the procedure for insulin self-injection. Assist her to master the technique.
3. Discuss insulin dosage and injection timings in relation to meals and activity.

Preventing Hypoglycemia related injuries:

1. Monitoring blood glucose levels regularly, especially after exercise to detect hypoglycemia.
2. Instruct Seema about the importance of accurate insulin preparation and meal timing.
3. Recognize hypoglycemia symptoms:
4. Early symptoms (Adrenergic) – Sweating, tremor, pallor, fast heartbeat, palpitations and nervousness.
5. Late symptoms (Neurologic) – Dizziness, headache, confusion, irritability, slurred speech, lack of co-ordination, staggering gait.
6. Encourage Seema to take glucose sources orally in hypoglycemic cases.

Enhancing activity tolerance:

1. Advise Seema to check her blood glucose levels before and after exercise.
2. Instruct her to schedule regular daily exercise.
3. Counsel Seems to inject insulin into her abdominal site on the days when she exercises her arms or legs.

Educating on oral antidiabetic drugs:

1. Explain the action, uses, and side effects of oral antidiabetic drugs.

Ensuring patient’s Skin Integrity:

1. Check feet and legs for skin temperature, sensation, injuries, corns, calluses, dryness, hair growth, distribution and deep tendon reflexes.

Enhancing Coping Strategies:

1. Talk with Seema about how she feels diabetes affects her lifestyle, finances, family life and profession.
2. Help her family in providing the emotional support.

Legal & Ethical considerations (Lippincott, 2019)

Legal Issues in Nursing

1. Licensing: Nurses must maintain a valid license and adhere to regulations.
2. Scope of Practice: Work within the defined scope to avoid legal issues.
3. Documentation: Accurate records are essential for legal protection.
4. Patient Consent: Ensure informed consent before procedures.
5. Confidentiality: Protect patient privacy to comply with laws like HIPAA.
6. Negligence and Malpractice: Avoid actions that fall below the standard of care.

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Ethical Issues in Nursing

1. Patient Autonomy: Respect patients’ healthcare decisions.
2. Beneficence and Non-maleficence: Act in the patient’s best interest and avoid harm.
3. Justice: Provide fair and equitable care.
4. Confidentiality and Privacy: Maintain patient confidentiality.
5. End-of-Life Care: Handle decisions about life-sustaining treatments ethically.
6. Professional Boundaries: Maintain appropriate boundaries with patients.

Professional Issues in Nursing

1. Competence: Stay current through ongoing education.
2. Professionalism: Exhibit professionalism in all aspects of work.
3. Collaboration: Work effectively with other healthcare professionals.
4. Advocacy: Advocate for patients’ needs and wishes.
5. Workplace Safety: Follow safety protocols to protect everyone.
6. Workplace Ethics: Address unethical practices and maintain a positive workplace culture.

Ethical Aspects:

1. Upholding Respect and Autonomy: The Nurse’s duty involves maintaining Seema’s autonomy and preserving her privacy.
2. Beneficence: Aim to support Seema in achieving a better life by improving her help.
3. Nonmaleficence: Professional nurses must avoid harming the patient, whether directly or intentionally.
4. Justice: Thisrelates to the fair and equal distribution of services and resources to the patients.

Legal Aspects:

1. Accountability: Professional nurses should proactively ensure that their practices are efficient and not deficient in any way.
2. Advocacy: Advocate what is best for the patient, ensuring that their needs are met, and rights are upheld.
3. Confidentiality: Maintain confidentiality of patient’s (Seema’s) health info in accordance with HIPAA.
4. Informed consent: Ensure Seema is fully informed about her treatment, diagnosis, and treatment related risks and benefits.

Relevant Literatures

Curriculum Development: Develop and update curricula for training future health care professionals in managing T2DM.

Recent Studies: Research articles that help the health professionals understand the disease in a better manner to come up with treatment, diagnosis and prognosis of T2DM.

Books and References

1. Nettina, S. M. Lippincott Manual of Nursing Practice. Philadelphia: Lippincott, Williams & Wilkins; 2019.
2. Goyal R, Singhal M, Jialal I. Type 2 Diabetes. [Updated 2023 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513253/
3. Galicia-Garcia U, Benito-Vicente A, Jebari S, et al. Pathophysiology of Type 2 Diabetes Mellitus. Int J Mol Sci. 2020;21(17):6275. Published 2020 Aug 30. doi:10.3390/ijms21176275
4. Mouri MI, Badireddy M. Hyperglycemia. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430900/
5. Ismail L, Materwala H, Al Kaabi J. Association of risk factors with type 2 diabetes: A systematic review. Comput Struct Biotechnol J. 2021;19:1759-1785. Published 2021 Mar 10. doi:10.1016/j.csbj.2021.03.003
6. Damanik, J., & Yunir, E. (2021). Type 2 Diabetes Mellitus and Cognitive Impairment. Acta medica Indonesiana, 53(2), 213–220.
7. In: Hammer GD, McPhee SJ. eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, Seventh Edition. McGraw-Hill Education; 2013. Accessed June 07, 2024. https://accessmedicine.mhmedical.com/content.aspx?bookid=961&sectionid=53555360