Discussion

Lorraine

NUR 502

Case Studies

Case Study 1

Constipation is a clinical symptom that manifests itself as too little frequency of bowel movements (≤2 times per week) or hard, hard stool, which can result from both mechanical and functional reasons. The first group includes obturation of the colon lumen with any organic substrate (often tumor tissue), which was excluded using colonoscopy in the presented clinical situation. Among the functional reasons, it is possible, on the one hand, to include a decrease in the activity of peristaltic movements (a contraction of smooth muscle cells in the intestinal wall) or a change in the consistency of feces towards an increase in density, which often occurs due to the low fiber content in food consumed by a person and dehydration. Besides, elderly patients (such as Mrs. R.H.) may be considered important risk factors for this clinical condition, since such people usually have a decrease in the quality of nutrition. Due to comorbidity, it becomes necessary to use a large number of medications that can have an adverse effect on peristaltic activity (Schuster, Kosar, & Kamrul, 2015). The second risk factor in this situation is the patient’s gender since this symptom more often occurs in women (unmodified risk factor), especially in the case of decreased physical activity, which is noted in the presented clinical case. Somatic neurological and cardiovascular diseases, as well as psychological trauma and depressive spectrum disorders, are also important predisposing factors. Per clinical guidelines for elderly patients who suffer from constipation, the primary and necessary measure is lifestyle modification, in particular, dietary correction (increase in plant fiber content), as well as physical activity. Still, since the latter factor does not have a significant evidence base, then for the patient with joint disease, this recommendation can be overlooked (Mounsey, Raleigh, & Wilson, 2015). To soften the stool, it is possible to use a remedy such as polyethylene glycol, which increases the water content in the intestinal lumen and to identify the cause of heartburn to determine adequate treatment and reject aluminum-containing antacids, which can also provoke constipation.

In the presented clinical situation, Mrs. R.H. has both subjective and objective signs that indicate the presence of a problem such as constipation. Firstly, this is a feeling of bloating in the abdomen, as well as a change in the usual pattern of the act of defecation, which has become straining and prolonged, as well as a significant increase in the intervals between bowel movements (sometimes once a week, even though previously the regularity of this action was daily). Besides infrequent bowel movements, there are other symptoms that this patient does not experience at the time of the clinical examination. This is because the duration of symptoms is relatively short (about one month), and in more severe cases, symptoms such as anorexia and weight loss, as well as psychological and neurological disorders, in particular irritability, general weakness, dizziness, and headaches, especially in cases of prolonged attempts to defecate.

A symptom such as anemia can be a manifestation of nutritional deficiency, especially in cases where the patient avoids foods high in iron in the diet, especially in the case of underlying diseases such as inflammatory bowel disease. Also, tumors (especially those located in the cecum) are very often accompanied by paraneoplastic anemia, which was excluded in this clinical situation (Schuster et al., 2015). Therefore, in the absence of severe diseases of the cardiovascular system (for example, heart failure) and chronic kidney disease, due to the short duration of the clinical symptoms of constipation, a sign such as anemia is unlikely in this situation.

Case Study 2

National epidemiological data indicate that there are significant ethnic and racial differences in the prevalence of several chronic medical conditions in the United States, including type 2 diabetes. The most vulnerable to this disease are Native Americans such as Mrs. C.B., which belongs to the Winnebago Indian Tribe, as virtually one in three adults have either prediabetes or an advanced clinical picture of the disease (Chatterjee, Khunti, & Davies, 2017). Besides, other minorities, including African Americans, Pacific Islanders, and Hispanics, are also at higher risk than the Caucasian population. As for the clinical manifestations, in the presented clinical situation Mrs. C.B. has characteristic subjective symptoms such as increased urination, especially at night, as well as severe thirst, which forces to consume a large number of fluids, which is associated with an increase in osmotic pressure in the blood due to the high content of glucose molecules (Qaseem, Barry, Humphrey, & Forciea, 2017). Also, weight gain is an indirect sign of type 2 diabetes, and symptoms such as weakness and numbness of the foot are characteristic of neuropathy, which plays a vital role in the onset of diabetic foot syndrome. Besides, the most crucial objective sign of impaired carbohydrate metabolism is a significant increase in fasting plasma glucose, which significantly exceeds the threshold required for the diagnosis of diabetes mellitus.

One of the severe problems that arise in patients with diabetes mellitus is the increased risk of bacterial infections in cases of insufficient glycemic control. At the same time, respiratory bacterial infections (such as lower lobe pneumonia, one of the most common pathogens of which is a microorganism such as Streptococcus pneumoniae) can occur in patients even with normal plasma glucose levels. Such patients often require hospitalization, since they have a higher risk of severe infection and hospitalization in intensive care units, as well as possible significant fluctuations in serum glucose levels and the occurrence of hyperglycemia (Chatterjee et al., 2017). Achieving an adequate level of this indicator is not an easy clinical task. It may require additional use of insulin since the dose adjustment of glucose-lowering tablet drugs rarely brings any benefits. The mechanisms of increasing glucose levels are the release of stress hormones, in particular glucocorticoids, which play an essential role in the regulation of the inflammatory process and immunosuppression, preventing hyperallergic reactions in response to a bacterial pathogen.

In the presented clinical situation, Mrs. C.B. needs a comprehensive diabetes management plan that includes two main areas. The first one will be the highest possible lifestyle modification (culturally sensitive), which should consist of increased physical activity and, even more critically, adherence to a diet that contains the minimum amount of saturated fat and carbohydrates. The main foods in Mrs. C.B.’s vegetables and lean protein sources (such as chicken and fish) should become available to lower both glucose and serum cholesterol levels (Qaseem et al., 2017). The second direction should be adequate pharmacological therapy, which is based on evidence-based medicine data and will be the most effective and safe for this patient. Such a drug for initial treatment should be considered Metformin, which should be prescribed at a dosage of 500 milligrams (1 tablet) per day, with further correction depending on possible side effects and efficacy (Inzucchi, 2017). This medication makes it possible to reduce the level of insulin resistance of peripheral tissues and increase the capture of glucose molecules from the blood plasma, as well as reduce the production of this substance in the liver during gluconeogenesis. If this drug is not sufficient or the patient has severe side effects, clinicians should use second-line medicines (for example, sulfonylurea derivatives) or a combination of the latter with Metformin.

References 

Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The Lancet389(10085), 2239-2251.

Inzucchi, S. E. (2017). Is it time to change the type 2 diabetes treatment paradigm? No! Metformin should remain the foundation therapy for type 2 diabetes. Diabetes Care40(8), 1128-1132.

Mounsey, A., Raleigh, M. F., & Wilson, A. (2015). Management of constipation in older adults. American Family Physician92(6), 500-504.

Qaseem, A., Barry, M. J., Humphrey, L. L., & Forciea, M. A. (2017). Oral pharmacologic treatment of type 2 diabetes mellitus: A clinical practice guideline update from the American College of Physicians. Annals of Internal Medicine166(4), 279-290.

Schuster, B. G., Kosar, L., & Kamrul, R. (2015). Constipation in older adults: stepwise approach to keep things moving. Canadian Family Physician61(2), 152-158.

 
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