NR 508 Week 5: Thyroid Disorders and Diabetes
NR 508 Week 5: Discussion – Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Six months ago her fasting lipid profile was normal. Maria report that her mother and brother have diabetes and hypertension. She reports that she knows she should be on a low calorie, low fat diet and exercising but with her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. She is 66″ tall and weighs 219lbs today, no current medication. She does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only drinks sweet tea with each meal, 3-4 cups of coffee per day.
Today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, weight 219 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%. Physical Exam reveals notable for acanthosis nigricans at the neck but otherwise is normal.
- What are your treatment goals for Maria?
- What is your plan for drug therapy? What is the mechanism of action for each drug?
- Please give five teaching points for each drug prescribed.
- How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.
- What are your treatment goals for Maria?
Treatment goals for Maria include oral medication implementation to treat the new onset diabetes type II and to educate Maria on the lifestyle changes that need to occur to manage this disease. It is essential that she understands the diet parameters as well as the need to incorporate exercise. Many support groups are available for newly diagnosed diabetes patients to help in the transition needed for the lifestyle changes as well as the ability to converse with professionals when questions arise. Maria will need to be educate on the use of operating a blood glucose machine and signs and symptoms to be aware of for both hypoglycemia and hyperglycemia. According to Melmer, Kempf, and Laimer (2018), studies showed that a diet program in combination with resistance training for 6 moths revealed a significant decrease in the HbA1c levels and after just 4 months many of the participants reduced the need for medications to control blood glucose levels. It is important to educate Maria that this disease can be controlled and possibly even eliminated with the proper lifestyle changes. According to the lab results both the fasting blood glucose level as well as the HbA1c were elevated but are manageable if changes and proper medication is applied.
- What is your plan for drug therapy? What is the mechanism of action for each drug?
The drug that I have chosen to start Maria on as treatment for diabetes is metformin. According to Inzucchi, et al., (2015), Metformin is the chosen drug for monotherapy at this time. Metformin works by lowering hepatic glucose production as well as intestinal glucose absorption. When this occurs, it results in increased insulin sensitivity ultimately lowering the blood glucose level. For Maria I would choose to give the extended- release form of metformin and begin with a dose of 500 mg per day for 1 week and increase dose weekly as tolerated by 500mg until with the maximum dose being 2000mg per day (Epocrates). It is essential that Maria is monitoring her blood glucose levels and keeping a log in order to monitor effectiveness. I will follow up weekly until a 3-month scheduled visit when her HbA1c level will be reassessed and the need for further treatment options such as additional medications. I chose a one daily oral medication as the first treatment choice because this will hopefully increase the risk for compliance and management of the disease. In addition to medication treatment Maria will need to incorporate proper diet and exercise to avoid worsening symptoms and progression of diabetes. Metformin has also been shown to cause weight loss which is also beneficial in the management of diabetes.
- Please give five teaching points for each drug prescribed.
- Monitor and document blood glucose levels upon waking and before meals to monitor efficacy of medication. If blood glucose level less than 70 hold dose and contact our provider.
- Take Metformin at the same time each day, preferably in the morning to avoid hypoglycemic episodes throughout the day.
- Do not cut, crush, or chew metformin extended release. Performing these actions will change the efficacy of medication and possibly result in hypoglycemia.
- Common side effects of this medication include: diarrhea, nausea, vomiting, abdominal pain, headache, rash, metallic taste, indigestion, and ovulation induction. Signs of hypoglycemia symptoms include: excessive sweating, light headiness, fainting, blurred vision, fatigue, and confusion.
- If you experience severe fatigue, yellowing of the skin or eyes, persistent muscle cramps, loss of appetite, or altered mental status contact an MD immediately to be assessed for serious conditions.
(Epocrates)
- How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.
If Maria had presented with the above lab results I would change her treatment plan to subcutaneous insulin rather than a oral medication. I would choose to place Maria Humulin N (NPH). This insulin in intermediate- acting insulin and would allow for one once daily administration subcutaneous injection. This particular medication works by “stimulating peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism” (Epocrates). I would begin by prescribing 0.1 units/ kg/ day resulting in a dose of 10 units of NPH subcutaneous injection daily. According to Woo (2016), when a patient presents with blood glucose levels above 300 and a HbA1c over 10 insulin should be started rather than oral medications. According to Inzucchi, et al., (2015), it might also be reasonable to use combination therapy such as insulin and metformin as the beginning treatment for a HbA1c greater than 9. This is another option to discuss with the patient based on lifestyle, weight, and lab results. The patient will need follow up in three months to assess updated lab values and evaluate need for changes in the treatment plan.
NR 508 Week 5: Discussion References
Epocrates an athenahealth service. [Mobile Application Software]. Retrieved from https://services.epocrates.comLinks to an external site.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., … Matthews, D. R. (2015). Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 38(1), 140–149. https://doi-org.chamberlainuniversity.idm.oclc.org/10.2337/dc14-2441Links to an external site.
Melmer, A., Kempf, P., & Laimer, M. (2018). The Role of Physical Exercise in Obesity and Diabetes. Praxis (16618157), 107(17/18), 971. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=131542645&site=eds-live&scope=siteLinks to an external site.
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advance Practice Nurse prescribers (4th ed.). Philadelphia, PA: F. A. Davis Company. Chapter 33.
