Mrs. O’Neill was diagnosed with diabetes about six weeks ago. You started her on metformin 500 mg bid and gave her a schedule to work up to 1000 mg bid. You also started her on lisinopril 10 mg a day as her BP then was 160/92. Her A1C was 7.6 at that last visit six weeks ago. Today, her BP is 150/84. Her glucose log demonstrates morning fasting blood sugars of about 140 on average. She has been checking her blood pressures at home and they range from 142/88 to 160/94. She has been very conscientious about logging her BPs and her morning blood sugars. Her urine dip six weeks ago demonstrated a urine albumin of >30 and <60.
Today she comes to you in tears. She states, “I just cannot stand the metformin because after I take it each day, I end up in the bathroom with diarrhea two or three times before I can even get out to work.” She was never able to go above the 500 mg bid dose because her diarrhea increased even more when she tried it for two days. You determine that you are going to stop the metformin. She is also complaining of a dry, nonproductive cough and states, “I feel like I am constantly clearing my throat.” That started about one month ago. She has been checking her blood pressures at home and they range from 142/88 to 160/94.
Mrs. O’Neill is a newly diagnosed person with diabetes. What are some of the places you should have referred her to when she was newly diagnosed?
What baseline labs did Mrs. O’Neill need when she was initially diagnosed besides the A1C?
Mrs. O’Neill just had an eye exam about two months ago. When would her next eye exam be due?
If you have stopped the metformin, what medication(s) might you offer her now? Include the dose.
What will you do about Mrs. O’Neill’s cough?
How will you address Mrs. O’Neill’s blood pressure today?
What other medications should Mrs. O’Neill be on with the diagnosis of new onset type 2 diabetes?
What immunizations should you ensure Mrs. O’Neill has up to date?
Mrs. O’Neill, a newly diagnosed individual with type 2 diabetes, presents with medication-related concerns and symptoms. In this essay, we will address the nursing care required for Mrs. O’Neill, including appropriate referrals, necessary baseline labs, medication alternatives, management of side effects, blood pressure control, additional medications for diabetes management, and recommended immunizations.
Upon Mrs. O’Neill’s initial diagnosis, it would have been important to refer her to the following healthcare professionals:
Registered Dietitian: To provide guidance on diabetes-specific meal planning and carbohydrate counting.
Certified Diabetes Educator: To educate Mrs. O’Neill on diabetes self-management, including blood sugar monitoring, medication administration, and lifestyle modifications.
Ophthalmologist/Optometrist: To assess her baseline eye health and establish a schedule for regular eye exams.
In addition to the A1C test, baseline labs Mrs. O’Neill would have needed include:
Fasting plasma glucose (FPG): To assess her blood sugar level after an overnight fast.
Lipid profile: To evaluate cholesterol and triglyceride levels, which are essential for cardiovascular risk assessment.
Kidney function tests: Including serum creatinine and estimated glomerular filtration rate (eGFR), to evaluate renal function.
Since Mrs. O’Neill had an eye exam two months ago, her next eye exam should be scheduled annually. Regular eye exams are crucial for early detection and management of diabetic retinopathy, a potential complication of diabetes.
Considering the adverse effects experienced by Mrs. O’Neill with metformin, alternative medication options may include:
DPP-4 inhibitors: For example, sitagliptin 100 mg once daily.
SGLT-2 inhibitors: For example, empagliflozin 10 mg once daily.
GLP-1 receptor agonists: For example, liraglutide 0.6 mg subcutaneously once daily, gradually titrated to 1.8 mg.
Given Mrs. O’Neill’s dry, nonproductive cough, it is crucial to evaluate if the cough is a side effect of lisinopril. If the cough is suspected to be medication-related, discontinuing lisinopril and discussing alternative antihypertensive medications with the healthcare provider is necessary.
To address Mrs. O’Neill’s blood pressure, the following measures can be taken:
Review lifestyle modifications: Encourage adherence to a low-sodium diet, regular exercise, weight management, and stress reduction techniques.
Consider initiating or adjusting antihypertensive medications: Alternative medications such as calcium channel blockers or angiotensin receptor blockers (ARBs) may be appropriate depending on her specific clinical presentation and comorbidities.
In addition to metformin or alternative medications, Mrs. O’Neill may require additional medications to optimize her diabetes management. These may include:
Statins: If her lipid profile reveals dyslipidemia or if she has existing cardiovascular disease.
Aspirin: If she has a high cardiovascular risk or established cardiovascular disease.
To ensure Mrs. O’Neill’s immunizations are up to date, the following vaccines should be considered:
a) Influenza vaccine: Annually to protect against seasonal flu.
b) Pneumococcal vaccine: Pneumococcal conjugate vaccine (PCV13) followed by pneumococcal polysaccharide vaccine (PPSV23) for individuals aged 65 years or older.
c) Hepatitis B vaccine: If she is at risk or not already immune.
d) Tetanus, diphtheria, and pertussis (Tdap) vaccine: To ensure her protection against these diseases.
In providing nursing care for Mrs. O’Neill, a newly diagnosed individual with type 2 diabetes, it is essential to consider appropriate referrals, baseline labs, alternative medications, management of side effects, blood pressure control, additional medications for diabetes management, and recommended immunizations. By addressing these aspects comprehensively, healthcare professionals can support Mrs. O’Neill’s journey towards optimal diabetes management, enhanced well-being, and reduced risks of complications.
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