Case 5:

Diabetes Nursing 2 (Assignment 2)

Mary Tomy
Layla Abdul Rahman
Hana Yousef
Farah Al Hamad

Fatima College of Health Sciences/ Malmo University

Date: August 22nd, 2014

ABSTRACT

This paper will discuss the case of Mr. Mahmoud, a patient who presented to
the clinic 6 years ago with the diagnosis of diabetes type 2 and with previous
history of high blood pressure and high lipids. The patient has been negligent and
not adherent to the treatment prescribed regardless of the team efforts to
help him, he claims he is always busy with important meetings and traveling
schedules making him to forget about his health. Eventually, while on a
travel, Mahmoud had recently developed acute Myocardial Infarction (MI)
and was hospitalized due to. The incident had served as a wake-up call for
him to get up again and pay attention towards his health and body condition.
Thus, this paper aims to analyze Mahmouds case from nursing, medical, and
psychosocial aspects, and to define the problem areas in each domain,
followed by a suggestive plan of care based on the analysis. The care plan
for Mr. Mahmoud is formulated by a Multi-Disciplinary team; with a main
concern to raise the patients awareness about his health condition care and
to start up by setting his own goals. Those goals would include lifestyle
modifications as a major point expanding to glycemic control, dietary control,
weight control, and regular exercises. As well, Mr. Mahmod is advised to have
a regular schedule of follow ups and visits to the clinic.

TABLE OF CONTENT
Case descriptionpage 4
Case Analysis....page 5
The problem areaspage 8
The plan of care.page 9
Conclusion page 10
Case
reflection .......................................................................................
page 11
References..........page 12

CASE DESCRIPTION
Mr. Mahmoud is 63 years old, married, and works as a CEO in a Very
Important Company in Abu Dhabi. His line of work requires him to have many
business travels as well as long working weeks. 6 years ago, Mr. Mahmoud
was diagnosed with type 2 diabetes. In addition to his Illness, he already had
a high blood pressure and high lipids which was diagnosed 10 years ago, but
as he had no symptoms, and had a very negative attitude towards medicine
and tablets, he had refused many offerings of commencing medical
treatment. Mohammed has been prescribed with Metformin and NovoNorm.
Unfortunately and due to his negative view towards medication, he often
forgets to take his tablets. Also, He wouldnt show up to his scheduled visits
to the clinic due to his pre-occupancy with his work and high level meetings,
or because of his prolonged business travels. Mr. Mahmouds last contact to
his diabetologist was 6 weeks ago when he called from one of his business
travel destinations and had measured a blood glucose value of 18 mmol/L,
and he wanted to know what he should do. He has been offered to
participate in one diabetes education program (diabetes school). However,
he declined to participate due to his current lifestyle and his nature of work
that makes him unable to attend such programs, which implies that the said
school should give a special education programs and training sessions that
can be compatible with his current line of work and lifestyle.
During one of Mr. Mahmouds visit to Dubai two weeks ago, he had an acute
myocardial infarction, which he was treated for with coronary surgery (stent).
After the Surgery, Mr Mahmoud was discharged from the hospital with a
Long-term Sick Leave. During his hospital stay, he was found to have high
blood pressure, high blood lipids, and a high HbA1c. Hence, he has been
prescribed with insulin Humalog mix 25 x 2, tablet Metformin, one ACEinhibitor, Simvastatin and ASA. After this incidence, Mr. Mohammad has
realized that his illness has reached an extreme dangerous situation, hence
asking for an appointment with Abu Dhabis Diabetes team, who were glad to
start up a care plan for Mahmoud.

CASE ANALYSIS
Nursing analysis
Mr. Mahmoud was diagnosed with diabetes for the last 6 years and he was
not finding time to visit his doctor and see diabetes Educator for the proper
management of diabetes. In diabetes management, it is primarily a chronic
illness that requires lifestyle adjustments and long-term prevention
strategies to ensure maintenance of health, (Complete Nurses Guide to
diabetes a care, chapter 17, and page 236) where the patients required to
take-up an equal share of responsibility in management along with the
diabetes care team. Diabetes educator plays as important a role as
treatment itself. In Mahmouds situation, he was non-compliance with taking
his medication, follow up and many times he was offered diabetes selfmanagement education and he was declined from the participation. Due to
his nature of job he was not able to follow as instructed and many times he
missed the medications and not changed his life styles. He has a skeptical
attitude, towards the medicine, where he wants good results with low inputs,
low awareness, and lives for today and wants short term benefits. His
attitude was controlling diabetes with average involvement, irregular follow
up and was not following healthy diet. Now Mahmouds health conditions
became more complex, he had myocardial infraction and treated with
angioplasty. He decided to change his life style and to actively participate
with the diabetes care team.
Mahmouds medical histories are significant of non- adherence to medication
and follow up in clinics. He has multiple comorbid conditions, including
hypertension, coronary artery disease, and type2 diabetes. His current
medications include Humalog mix 25 x 2, tablet Metformin, one ACEinhibitor, Simvastatin and ASA. Mahmouds metabolic level is not well
controlled and the study has been suggested that HbA1c acts as an
independent and continuous risk factor for macro vascular disease and to

aim for an HbA1c < 7% (53 mmol/l), but to be more cautious in patients with
underlying and pre existing CVD. (The Text book of Diabetes, 4th edition,
Chapter 57, Page 970)
It is important that the person with diabetes shares in any decisions about
treatment or care as this improves the chance of jointly agreed goals being
adopted following the consultation.
(The text book of diabetes, Chapter 57, page 327). Diabetes education plays
an important role in managing such chronic and complex case behavior
change. Tailoring the interventions to the age and culture of the patient and
include his wife, adult children or care giver may increase the effectiveness
teaching outcome. By incorporating training in self- directed goal- setting,
problem solve problems, respond to physical and self-management
challenges throughout the period of his chronic illness, and make and sustain
changes in his own behavior improves outcomes resulting from education.
(Complete Nurses Guide to diabetes care, chapter 16, page227).
A formal educational assessment needs for Mahmoud before start diabetes
education session. Developmental age, cultural influences, health beliefs and
attitudes, diabetes knowledge, self-management skills and behaviors,
readiness to learn, health literacy, family support and relevant medical
history. It is also equally important to find out what areas the he wishes to
learn or causes the greatest concerns or worries (Complete Nurses Guide to
diabetes care, chapter 16, 224, 225) and framing information to meet
Mahmouds identified goals to divide in to short and long term goals.
Medical analysis
Following MI incidence, time is the crucial for starting thrombolytic therapy such as
Streptokinase or urokinase (Complete nurses guide to diabetes care, 2009). However, it has been
proven that early administration of thrombolytic therapy preserves cardiac function but the risk
of bleeding may remain present after these type of therapies, which are used mainly in centers
where angiography service is not available (Complete nurses guide to diabetes care, 2009).
Diabetic patients with MI who suffer from signs of current ischemia despite medical therapy
should be considered for myocardial revascularization by PCI (percutaneous coronary
intervention) or CABG (coronary artery bypass graph), PCI is usually used for single vessel
disease while multiple vessel disease often requires CABG (Complete nurses guide to diabetes
care, 2009). After discharge from hospital, the main goal of glycemic management after MI is to
prevent mortality, recurrent MI, heart failure, arrhythmias and progression of coronary
atherosclerosis controlling myocardial function (Banerjee, 2012). High blood glucose can happen
at this time because of electrolyte imbalance and elevation of fatty acids which can cause
arrhythmias, in addition to chronic hypoglycemia which can increase the risk of myocardial

damage (Banerjee, 2012). Therefore, appropriate medical management should

focus on balancing hypoglycemia episodes and hyperglycemia in addition to
initiation of cardiac treatments.
MI stimulates a series of metabolic changes, including increased secretion of hormones such as
catecholamine, glucagon, and cortical substances, all of which worsen the uncontrolled diabetic
state and possibly jeopardize non-ischemic parts of the myocardium (Ryden &Malmberg, 2003).
Furthermore, the clinical condition of the patients post MI is very variable,
and they may eat little or more, after acute patient may need insulin therapy
temporarily to control their high blood glucose levels. The results of the recent DIGAMI study
(1999) suggested that treating patients with intensive insulin at least 3 months following the
infarction can reduce the mortality. Also, the use of daily subcutaneous insulin injection as
determined by the clinical state of the patient has been shown to be practical and feasible, and to
lead to improved glycemic control (Malmberg, 1999). However, other scientific papers suggest
that the idea of insulin being of extra benefit than oral anti diabetics is not proved beyond doubt,
oral agents if used should preferably include insulin sensitizers like metformin and glitazones
(Banerjee, 2012).
It is clear that aspirin is of equal benefit in diabetic and non-diabetic patients, the meta-analysis
of the Antiplatelet Trialists Collaboration Group (1994) included 47000 patients (10% diabetics)
and reported a crucial benefit of aspirin therapy in diabetic patients at an increased risk for
vascular disease. As well, the use of additional anti-platelet agents has been advocated, and,
specifically, clopidogrel showed its efficiency (Complete nurses guide to diabetes care, 2009).
Moreover, dyslipidemia is a significant cause of MI and mortality in diabetic patients (Laakso,
1997). As a result, aggressive management of low-density lipoprotein (LDL), high- density
lipoprotein (HDL), and total cholesterol, but also triglyceride is important (Laakso, 1997). Statin
therapy in particular, has a great effect, showing 27-40% reductions in LDL-cholesterol in all
placebo- controlled trials, and subsequent decreases in occurrence of cardiovascular events and
mortality by 25 to 42% in persons with and without diabetes or previous acute coronary
syndrome (Laakso, 1997). This benefit extends to those with already controlled LDL-cholesterol
fractions (Laakso, 1997). Dietary modification and addition of statins are, recommended as firstline management guidelines for lipid control in diabetic patients or those with confirmed CVD
(Manely, 2000).
Hypertension is well-known to be associated with diabetes, hence, lowering blood pressure
produces huge benefits in these population, and BP targets (130/80) mm/hg have been changed
specifically in diabetic population to prevent disabling and fatal complications in the form of
nephropathy, retinopathy, and vascular events (Whelton, 2005) . Several large randomized
trials, sub-studies and meta-analyses which include patients with diabetes have shown that
angiotensin-converting enzyme (ACE) inhibition in diabetics with acute MI is associated with
larger reductions in short-term mortality and occurrence of congestive heart failure than in nondiabetic patients (Pahor ,2000). An important beneficial effect on micro vascular disease was also
demonstrated in the UKPDS study, where blood pressure was controlled by beta-blockers or

angiotensin-converting enzyme inhibitors. (UK Prospective Diabetes Study (UKPDS) Group,

1998).
In the discussed case of Mr. Mahmoud, he has been prescribed with the following medicine after
going through coronary angiography (CAG) with stent: metformin, Humalog mix insulin ACE
inhibiter simvastatin and aspirin. He needs to comply with his medicine to reach a better
generalized health condition.
Psychosocial Analysis

Mr. Mohamed faced difficulties obtaining a proper glycemic control over his
diabetes due to his busy lifestyle. His position as CEO implies a huge effect
over his health and follows up in clinic. People with diabetes face major
stressors or crises at different points during the course of their disease. They
often struggles to adapt and cope effectively with stressors and crises , which
might be reflected in new or existing social and emotional difficulties that
can further affect individuals efforts to maintain self-care behaviors,
glycemic control and overall quality of life (Peyrot M, 1999). It was
mentioned by Peyrot (1999) there are four phases representing different
stressors or crises warrant particular mention: 1) Onset of diabetes, 2) Health
maintenance and prevention, 3) Onset of complications, and 4)
Complications dominate. Treatment approaches and support by the
treatment team typically differ across these phases.
Often, individuals may respond to stressors in one of two ways. One is when
individuals operate in high levels of conciseness with a renewed interest in
their self-care practices, thereby demonstrating self-controlled coping
strategies. Other is when they approach their self-management with a more
pessimistic attitude, reasoning that there is nothing they can do to control
the progression of their diabetes and related complications so any action on
their part feels unproductive or pointless. Mr. Mohamed is considered to be
with those individuals who presents self-controlled coping strategies but that
is seen only after he had MI and he contacted his diabetes care team to
schedule an appointment for him although he used to miss clinic visits
previously and follow ups.
Fatalistic thinking is a type of coping based on emotions, inhibits a persons
motivation to perform self-care behaviors. Individuals expressing a fatalistic
type of attitude toward their diabetes self-management perform less
recommended behaviors which will result in diminished self-care, higher

hemoglobin A1C values and poorer quality of life (Welch GW, 1997). In a
mediation model, anger coping style promotes poor glycemic control in
diabetes patients by provoking greater diabetes-related distress. Other
associated factors may influence the response to stressors.
Acute stress in the general population typically results in an increase in heart
rate, vasoconstriction in the peripheral vascular system, and elevated levels
of skeletal muscle activity (Thorne S.E, 2001). Stress also causes increased
production of pituitary hormones, catecholamines, corticosteroids, and
suppression of insulin release. These actions serve to increase glucose levels
in the blood (Thorne S.E, 2001). Stress in diabetic individuals has also been
traditionally viewed as a hyperglycemic stimulus.
Lifestyle changes are considered as an important factor in addition to
medical interventions in the management of diabetes (Thorne S.E, 2001).
Patient participation is important in the management of diabetes. In addition
to lifestyle changes, patients are expected to practice self-monitoring of
treatment and to be actively involved in other aspects of prevention and
delaying of complications, such as proper foot care. All these may appear to
be crucial to the patient and this can impact negatively on the overall feeling
of wellbeing. This is very important for Mr. Mohamed since he stated the
health care has problems to realize that he is not able to follow the advice
that are given to ordinary people. This reflects a need for a patient centered
approach when planning the care for Mr. Mohamed. We need to considered
his busy stressful lifestyle and to discuss treatment options that are suitable
for him especially that he recently had myocardial infarction.

PROBLEM AREAS
Cardiovascular disease (CVD) is the leading cause of mortality in type 2
diabetes mellitus (T2DM), and modifying cardiovascular risk through lifestyle
intervention and pharmacologic therapy is paramount. The common
conditions coexisting with type diabetes (e.g. Hypertension and
dyslipidemia) are clear risk factors for CVD, and diabetes itself confers
independent risk. Numerous studies have shown the efficacy of controlling
individual cardiovascular risk factors in preventing or slowing CVD in people
with diabetes (Standards of diabetes care, 2013).

So we need to focus on Mahmouds Diabetes self-management strategies to

keep blood glucose normal, normal blood pressure, normal lipid levels by
educating to incorporate nutritional management, physical activity, using
medications safely, monitoring blood glucose and other parameters and
interpreting and using the results for self-management decision making,
preventing, detecting, and treating acute complications and chronic
complications, developing personal strategies to solve psychosocial issues
and to promote health and behavior change.

CARE PLAN
A multi-disciplinary team approach is required for Mr. Mahmoud,
Diabetologists, cardiac team, clinical dietitian, and psychologist and diabetes
educator. Diabetes and cardiovascular disease is a chronic disease. Such
chronic disease management for an individual necessarily varies over time
with adjustments based on changes in patients symptoms and fluctuations
in the disease process (Loring KR, Holman H 2003). The diabetes team needs
to work to together with Mahmoud to review the program of care including
the management goals and targets at each visit.
Screening for diabetes complications should be individualized in older adults,
but particular attention should be paid to complications that would lead to
functional impairment. (Diabetes care 2013). A range of interventions has
been proposed to reduce the macrovascular complications of diabetes for
Mahmoud, including lifestyle modification, weight reduction, dietary changes
and regular exercise.
Life style modifications
Individualized exercise recommendations are required for Mahmoud, engage
in moderate intensity exercise regimens because the possibility of
unrecognized CAD and he should be educated for typical symptoms of
Myocardial infraction. Since Mahmoud was not exercising regularly initiate
exercise at low level and gradually increase and maintain normal body
weight.
Glucose Control
It has been suggested to aim for an HbA1c < 7% (53 mmol/mol), with safely
taking medication and maintain fasting blood glucose 5 -7mmol/l and post
prandial level <10mmol/l.

Hypertension
Blood pressure goal for Mahmoud is to maintain <130/80mmhg. Life style
modification, weight reduction and limit salt intake. Assess for
contraindications of ACE inhibitors for severe cough, angioedema,
hyperkalemia, and hypotension. Experimental studies have clearly
demonstrated a reduction in atherosclerosis with RAS inhibitors with a
possible superiority of ACE inhibitors compared to ARBs in T2DM.
Dyslipidemia
It suggested to reduce LDL levels below 2.5 mmol/L with some more recent
evidence suggesting enhanced benefits if LDL is lowered < 2
mmol/L,triglycerides < 1 mmol/L and HDL > 1 mmol/L according to pre
-existing CVD and risk.
Stress
Mr. Mahmoud needs to be provided with tools and methods to overcome and
adapt with the daily stress that he encounter related to his busy work nature.
He might be referred to a psychologist who can provide him with strategies
to cope with the work stress as well.
Planning for continued care
We need to plan Mahmoud follow up and continuity of care to secondary
prevention of macro and micro complications and promote quality health
well-being .There is a critical need for ongoing, intensive, multi risk factor
management is required including reinforcement of glucose control, measure
BP each visit and maintain <13/80mmhg, regular physical activity 30
minutes per day, A1C tested two to three times per year if meeting goal,
continue medical nutrition therapy, self-monitoring blood glucose, maintain
normal weight, LDL cholesterol tested every 6 months.

CONCLUSION
In conclusion, nobody doubts anymore that there is diabetes pandemic in
the world (Complete Nurses Guide to Diabetes Care, 2009). And, the vast
majority of persons who develop diabetes have type 2 diabetes. Further,
there is no sign of a crest or a plateau in diabetes complications progression
at all. It is associated with a galaxy of complications that conveniently can be

divided into micro and macrovascular complications (Complete Nurses Guide

to Diabetes Care, 2009). The macrovascular complications are what kill the
patients, the heart attacks and strokes. They occur even before the diabetes
has become clinical grade, and they are now the target of antidiabetic
interventions, not just the glucose (Complete Nurses Guide to Diabetes Care,
2009). Recently, ordinary treatment programs have been overly focused on
glucose outcome measures as the measure of diabetes control. However, in
order to have a better control of the complications development on the
longer term, it is highly demanded to develop programs and methods to
guide the patients to be on the right path in their treatment to prevent
diabetes type 2 complications development (Complete Nurses Guide to
Diabetes Care, 2009).

CASE REFLECTION
Mahmouds case is a very realistic case that occurs usually when a person
spends the vast majority of his time and effort on his professional life and
forgets his health and wellness despite the healthcare professionals efforts
to guide him to the right track. The case helped us to realize that the
patients own perspective of his body health is the main point to start from
when coming to start education sessions. As a diabetes education team,
setting goals and objectives for his own health is the initial step to start with;
then, the patient along with the diabetes team can start the care plan.
Another essential point that was highlighted to us in this case is the patients
continuity of care and regular follow ups as a prove of his compliance.

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