Mrs. X.
Relationship of high cholesterol levels to the development of cardiovascular disease
Diabetes, heart disease, and high cholesterol are all strongly correlated. Even when diabetes is being well-managed, the patient’s risks factors increase for comorbidity with these disorders. “High blood pressure has long been recognized as a major risk factor for cardiovascular disease. Studies report a positive association between hypertension and insulin resistance. When patients have both hypertension and diabetes, which is a common combination, their risk for cardiovascular disease doubles” (Cardiovascular disease and diabetes, 2014, AHA). Also, in the case of Ms. X, because of her uncontrolled diabetes, her risk for high cholesterol is higher than average even in the absence of obesity and inactivity. “This triad of poor lipid counts often occurs in patients with premature coronary heart disease. It is also characteristic of a lipid disorder associated with insulin resistance called atherogenic dyslipidemia, or diabetic dyslipidemia in those patients with diabetes” (Cardiovascular disease and diabetes, 2012, AHA). Because of the nature of diabetes, patients tend to have lower ‘good’ cholesterol and higher ‘bad’ cholesterol and the imbalance grows over the duration of the patient’s illness.
Thus as an older woman suffering from poorly-managed diabetes, diabetic dyslipidemia should be one of the major high-risk conditions monitored for by a nurse attending to Ms. X. Corresponding with this risk, high blood pressure and stroke (particularly given the family history) is also of concern since high blood pressure is the number one risk factor for stroke. Once again, even for diabetic patients without other risk factors, the dangers of stroke are much greater. “Overall, the health risk of cardiovascular disease (including stroke) is two-and-a-half times higher in men and women with diabetes compared to people without diabetes” (Stroke and diabetes, 2013, WebMD). And Ms. X already has a number of additional risk factors, including obesity and inactivity, as well as her age for stroke. “High blood pressure is the number one risk factor for stroke. Other risks include smoking cigarettes and high levels of LDL (‘bad’) cholesterol” (Stroke and diabetes, 2013, WebMD). Furthermore, while stroke is potentially deadly in all patients, it is even more so in patients with diabetes. “When the oxygen supply is cut off, other arteries can usually deliver oxygen by bypassing the blockage. In people with diabetes, however, many of the bypass arteries are also affected by atherosclerosis, impairing blood flow to the brain” (Stroke and diabetes, 2013, WebMD).
Since Ms. X is a smoker (with emphysema), lung cancer is a distinct possibility even though she is asymptomatic, given the notably higher risk of smokers for contracting this type of cancer. “People who smoke are 15 to 30 times more likely to get lung cancer or die from lung cancer than people who do not smoke” (What are the risk factors, 2013, CDC). There is a history of bowel cancer in the family and smoking is associated with not only lung cancer but also a variety of other types of cancers. Smoking raises the risk of heart disease, high blood pressure, and smoke even independent of diabetes. Often, the symptoms of lung cancer do not manifest themselves immediately but only after the cancer becomes advanced.
The problems Ms. X is experiencing with her feet are not unusual for a patient with diabetes. “Uncontrolled diabetes can damage your nerves. If you have damaged nerves in your legs and feet, you might not feel heat, cold or pain. This lack of feeling is called diabetic neuropathy. If you do not feel a cut or sore on your foot because of neuropathy, the cut could get worse and become infected” (Foot and skin conditions, 2010, Cleveland Clinic). Additionally, the risk for peripheral vascular disease is also increased with diabetes: “Diabetes also affects the flow of blood. Without good blood flow, it takes longer for a sore or cut to heal” (Foot and skin conditions, 2010, Cleveland Clinic). Although the conditions of most immediate concern to her healthcare providers seems to be related to cholesterol and heart disease, it is imperative that foot-related problems are also addressed given the statistical likelihood that problems may arise later and result in the need for future hospitalization. “People with diabetes spend more time in the hospital for treatment of foot problems related to diabetes than for any other reason. Approximately 15% of individuals with diabetes have had an ulcer on the foot or ankle. Diabetes is estimated to be the primary causative factor in 45% of all lower extremity amputations, with 60% of nontraumatic amputations being the result of long-term complications of diabetes” (Heitzman 2013)
Although Ms. X is experiencing a number of serious health-related complaints, most of her symptoms and risks are due to lifestyle-related issues, specifically obesity and smoking. Obesity and a poor diet can cause or exacerbate diabetes along with a failure to exercise. Thus, appropriate changes to diet and exercise are essential for long-term management of her condition. “Self-efficacy refers to the extent of an individual’s belief in his or her abilities. Because self-efficacy is based on feelings of self-confidence and control, it is a good predictor of motivation and behavior” (Provide patient education and support, 2014, NDEP). A healthcare educator can reinforce this by enhancing skills mastery; modeling; and using social persuasion. Ms. X must believe that change is possible and worthwhile. Presenting a feasible meal plan and exercise plan that she can conceivably perform despite her limitations is essential so changes do not seem overwhelming. Changing habits is always challenging, but particularly at Ms. X’s age. A support network can be helpful, either of family members, friends, a formal one through another institution, or even online.
Losing weight, regardless of the patient’s age, can have a very real, material effect upon diabetes and thus also reduce the risks for high blood pressure, stroke, and foot disorders. “The majority of people (80%) who develop type 2 diabetes are overweight. The basis of initial treatment is to pay attention to dietary intake and to encourage exercise so as to induce weight loss, the rationale being to improve nutrition, maintain normoglycaemia, be aware of cardiovascular risk factors and prevent the complications of diabetes” (Burden 2003). Being overweight can also increase the risk of high blood pressure, stroke, and heart disease for all patients so it is particularly vital that Ms. X engage in weight loss efforts. “As for anybody, the usual advice for healthy eating is to have at least five pieces of fruit and vegetables a day; to restrict alcohol to fewer than three units a day for women or four units a day for men, and to limit salt intake. Calorie restriction is important if the individual is overweight, and advice should be given about having less fat overall, with proportionately more monosaturated and polyunsaturated fat” (Burden 2003). However, rather than stressing what Ms. X cannot have and cannot do, the nurse should present the patient’s ability to engage in positive changes as empowering, stressing that Ms. X can have active control over her fate.
As a diabetic in the hospital, patients like Ms. X must be closely monitored. One of the most frequent complications of insulin-controlled diabetes is severe hypoglycemia or low blood sugar. “Hypoglycaemia is a clinical entity seen in people with diabetes on insulin and some OHAs. Hospital laboratories set a blood sugar level for hypoglycemia, and this is usually below 3.3mmol/L” (Burden 2003). Hypoglycaemia may be “characterized by impairment of cognitive function, irrational or aggressive behaviour – or they can be adrenergic, involving the sympathetic and parasympathetic systems” (Burden 2003). Mental fogginess or even loss of consciousness is possible, which can be very dangerous for obvious reasons if the person is operating a vehicle. Many diabetics do prepare themselves for or anticipate the risks of hypoglycemia (for example, always having a cookie or something to raise the blood sugar) but a nurse cannot assume that Ms. X does so. Even if patients technically know what to do that does not necessarily mean they understand the full seriousness of self-monitoring, particularly since diabetes can be such a burdensome disease.
Ideally, given Ms. X’s challenges and her age, a trusted family member should become part of her overall care plan and help support her in these lifestyle changes. If none is available, the nurse must connect her with resources beyond the purely factual — Ms. X needs either nursing support or other forms of trained support to guide her through the dietary and medical plan of care she will be released with once her condition is stabilized. This highlights the fact that nursing is more than a plan of care — the nurse must ensure that the care is viable and feasible given the patient’s level of education and resources. In the case of Ms. X, her past behaviors and difficulties with adhering to a care plan suggest that a more aggressive level of intervention is demanded.
References
Burden, M. (2003). Diabetes: Treatment and complications. Nursing Times, 99(2) 30/
Retrieved from:
http://www.nursingtimes.net/nursing-practice/clinical-zones/diabetes/diabetes-treatment-and-complications-the-nurses-role/205780.article
Cardiovascular disease and diabetes. (2012). American Heart Association. Retrieved from:
http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp
Foot and skin conditions. (2010). Cleveland Clinic. Retrieved:
http://my.clevelandclinic.org/disorders/diabetes_mellitus/hic_foot_and_skin_related_complications_of_diabetes.aspx
Heitzman, J. (2010). Foot care for patients with diabetes. Nursing Center, 26 (3): 250-263.
Retrieved from: http://www.nursingcenter.com/lnc/journalarticle?Article_ID=1047440
Provide patient education and support. (2014). NDEP. Retrieved from:
http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/patient-centered-interactions/patient-education-support.aspx
Stroke and diabetes. (2013). WebMD. Retrieved from;
http://www.webmd.com/diabetes/guide/diabetes-stroke?page=2
What are the risk factors? (2012). Lung cancer: CDC. Retrieved from:
http://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm
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