Morbid obesity, poorly controlled diabetes type 2, sleep apnoea and obesity ventilation syndrome
Major Issues and Probable Intervention
Case Study-A 48 year old man with morbid obesity, poorly controlled diabetes type 2, sleep apnoea and obesity ventilation syndrome Multiple factors influence the care of patients with chronic conditions. As a Primary
Heath Care nurse, it is important that care given is prioritised based on clinical and c patient needs. Prioritisation of the patient needs for care is integral to daily nursing practice. This requires integrating and collaborating different aspects of patient needs in order to maximise care activities and the effectiveness of nursing interventions.
This case study is designed to demonstrate the integration of various principles of managing care of patients with chronic conditions. Students will be expected to analyse the case scenario, identify the care needs and from the list of identified needs discuss two COMPLEX care priorities. Please refer to the subject outline and marking
rubric when answering this question.
The purpose of this essay is for students to present a comprehensive discussion and justification identifying two (2) care priorities within a clinical scenario using the LevettJones’ Clinical Reasoning Cycle. Students are required to provide critical analysis and justification of the care priorities using appropriate academic references
Content: Critical Thinking, Reasoning and Evaluation of the Evidence
Major Issues and Probable Intervention
This study was performed to come up with a good health care procedure for Michael Anderson, a morbidly obese 48-year-old unemployed man living alone. He was previously admitted with symptoms of diabetes and was diagnosed with poorly controlled type 2 diabetes and depression. The poorly controlled diabetes predisposes him to other secondary conditions such as sleep apnea and obesity ventilation syndrome. He is currently on metformin with insulin for his type 2 diabetes and beta blockers with an angiotensin converting enzyme (ACE) inhibitor for his hypertension. He also takes a proton pump inhibitor for gastroesophageal reflux disease. He has been discharged after a 3-week admission in the medical ward. Michael had a high blood pressure; 180/92 and a staggering 102 heart beats per minute when he was discharged. He was also still obese at 165 kg.
A high blood pressure may suggest an increased blood volume(Renzaho, Bilal, & Marks, 2014). Lisinopril as an ACE inhibitor blocker lowers the blood pressure as it blocks the formation of angiotensin II (Agarwal, Sinha, Pappas, Abraham, & Tegegne, 2014). Angiotensin II would normally constrict the arteries raising the blood pressure(De Mello & Danser, 2000). Metoprolol is used to decrease blood pressure too. Its mechanism of action lies in its ability as a beta blocker(Yazici, Ozduman, Aydar, & Birdane, 2013). Insulin and metformin administration helps in the uptake of glucose from the blood as type 2 diabetes is associated with insulin resistance or deficiency (Maruthur, Tseng, & Berger, 2016). Insulin also inhibits glucose production by the liver and its excretion into the blood when present in high concentrations in the blood (Leto & Saltiel, 2012). Nexium lowers the amount of hydrochloric acid produced in the stomach by inhibiting the proton pump responsible for H+/K+-ATPase transport across the membrane in peptic cells(Lucas, Estigarribia, Darga, & Reaven, 2015). This leads to a consequent decrease in effects of gastroesophageal reflux disease associated with increased acid levels in the stomach.
Mr. Anderson’s sleep apnea may be due to excessive fatty acids in his chest muscles, attributed to his morbid obese state(Bianchi, Cash, Mietus, Peng, & Thomas, 2010). These fatty acids strain the diaphragm and the intercostal muscles resulting to difficulties in breathing and hypoxic states characteristic of sleep apnea. His hypertension could be associated with his obesity too together with obesity ventilation syndrome(Pi-Sunyer, 2002). Michael had a slightly above average weight, 95 kg., but has gained almost twice as much weight as his treatment with insulin. This shows that insulin increased intake of glucose leading to this drastic change which may imply that type 2 diabetes may have been the cause of the morbid obese state. Regular exercising and a change of diet from a carbohydrate-based to more of a protein based diet might improve his current state(Pedersen & Febbraio, 2012). This would also go a long way in relieving his depression as part of it is attributed to his low self-esteem. He feels his body weight caused him his job and family, thus detaching himself from social ties.
The incidence of a lot of fatty tissue on his neck and body due to the obese state is a problem, although not major, during a physical examination. Auscultations for lung sounds may prove difficult as the layers of fat may cushion the sounds(Ferreira et al., 2012). When looking for a pulse, a nurse may also be faced with the same problem. On next visits, he should be advised to lie on his left side as this brings the heart closer to the chest wall and heart sounds can be well heard from this position.
Mr. Anderson’s weight makes him depressed as much as he has found it hard to find work with his current weight problem making him resolve to cut on his weight. It has been shown that type 2 obesity increases the risk of depression by about 95%(Luppino et al., 2016). A support group would help him in his resolve to a better life. Being around people who feel as he does and who treat him with respect and dignity would raise his self-esteem. Loss of his family may have also contributed to his depression. Living alone and isolated could only add to his psychiatric problems. Reuniting or getting regular visits from his children might help ease the loneliness. Psychotherapy and use of antidepressant medication could also be another way of decreasing depression.
Insulin use has rendered him obese. To lose weight, he could go on a dietary management regiment scheme. He should be advised to change his diet from carbohydrate and starch based meals to protein based meals(Hawley & Dunstan, 2008). He should also be encouraged to take small meals which would rule out any excess food that would then be stored as fat deposits in the skin layers. He should also reschedule visits to a dietician to guide him on his meals(Proietto & Baur, 2004).
If the diet regulation regiment does not work well as desired, a gastric bypass surgery or gastric barding could be performed (le Roux et al., 2011). This procedure could also improve ventilation during sleep due to the weight loss associated with it, which helps reverse the sleep apnea and obesity ventilation syndrome (Sarkhosh et al., 2013). There is, however, the risk of post-operative pulmonary failure or pulmonary embolism due to this type of surgery (Deutzer, 2005). These complications may cause death and thus should be monitored closely(Ballantyne et al., 2004). Apart from restricting his diet, Michael could carry out regular exercises to reduce his weight. Exercising enables the body to burn out excess fat and with regular exercising comes a steady loss of weight(Obesity Australia, 2014).
Discussion and Further Recommendations
Michael’s case presents with a classical relationship between morbid obesity, type 2 diabetes, sleep apnea and obese ventilation syndrome. These cases relate in such a way that they seem dependent on each other. If one is cut out, the other gets eliminated in the process too. Weight loss, for example, would result in rectification of obese ventilation syndrome as well as morbid obesity. Being reunited with his family, by recreating ties with them would help him psychologically stable and reduce his depression. His loneliness and alienation may be the source of his mental problem.
Depression has been known to pose as a risk factor for the development of cardiovascular diseases including hypertension seen in Michael’s case. This would improve his hypertensive state and may lower his blood pressure. Dietary regulation would be a safer way of reducing his weight compared to surgery or exercise. It may be hard to change a diet, but it is necessary if he has to improve sooner rather than later. A combination of regular exercise together with dietary changes would be the landmark of weight loss. A moderate weight loss, in turn, would deter the secondary chronic conditions; sleep apnea and obese ventilation syndrome.
The physiotherapist therapy process can be used to help the patient to lose some weight and use of the referral to community care unit for ongoing support and follow-up, this enables the patient’s weight and clinical comorbidities to be manageable. The behavioral and cognitive therapy can be used in the treatment process.
relation to the above-stated case study,
it is clear that the subject might be suffering from obesity. As such, the
recommendations presented above can be helpful in treating the patient fully.
As a nurse practitioner, it is required that I observe all the patient details
and seek guidance from the physician so to administer the relevant intervention
plan for the patient. Additionally, it is imperative to observe the patient
history so as to come up with any assumptions for the possible pharmacological
intervention. Obesity is one of the most notorious conditions in Australia, and as such there should be
awareness programs to address its prevalence. This paper shows the worse
conditions and damaging effects that patients may suffer as a result of this
disorder of diabetes. Such individuals
are often partially handicapped due to the fact that their large weight could
also inhibit them from taking long walks or performing huge tasks. Based on
hypothesis Michael’s disorder might
have been caused by his marital issues of divorce which resulted in him having
sleepless nights and losing his job too accounted for the depression he
encountered. His large weight could have resulted from the large intake of high
energy foods and low protein food intake.
With a helpful, caring doctor and a physiotherapist treatment program he
was able successfully to recover.
Agarwal, R., Sinha, A. D., Pappas, M. K., Abraham, T. N., & Tegegne, G. G. (2014). Hypertension in hemodialysis patients treated with atenolol or lisinopril: A randomized controlled trial. Nephrology Dialysis Transplantation, 29(3), 672–681. https://doi.org/10.1093/ndt/gft515
Ballantyne, G. H., Svahn, J., Capella, R. F., Capella, J. F., Schmidt, H. J., Wasielewski, A., & Davies, R. J. (2004). Predictors of prolonged hospital stay following open and laparoscopic gastric bypass for morbid obesity: Body mass index, length of surgery, sleep apnea, asthma and the metabolic syndrome. Obesity Surgery. https://doi.org/10.1381/0960892041975460
Bianchi, M. T., Cash, S. S., Mietus, J., Peng, C.-K., & Thomas, R. (2010). Obstructive sleep apnea alters sleep stage transition dynamics. PloS One, 5(6), e11356. https://doi.org/10.1371/journal.pone.0011356
De Mello, W. C., & Danser, A. H. (2000). Angiotensin II and the heart : on the intracrine renin-angiotensin system. Hypertension, 35(6), 1183–8. https://doi.org/10.1161/01.HYP.35.6.1183
Deutzer, J. (2005). Potential complications of obstructive sleep apnea in patients undergoing gastric bypass surgery. Critical Care Nursing Quarterly, 28(3), 293–299.
Ferreira, P., Pereira, D., Mourato, F., Mattos, S., Cruz-Correia, R., Coimbra, M., & Dutra, I. (2012). Detecting cardiac pathologies from annotated auscultations. In Proceedings – IEEE Symposium on Computer-Based Medical Systems. https://doi.org/10.1109/CBMS.2012.6266358
Hawley, J. A., & Dunstan, D. W. (2008). Overweight and obesity in Australia. Medical Journal of Australia. https://doi.org/letters_020608_fm-4 [pii]
le Roux, C. W., Bueter, M., Theis, N., Werling, M., Ashrafian, H., Lowenstein, C., … Lutz, T. a. (2011). Gastric bypass reduces fat intake and preference. AJP: Regulatory, Integrative and Comparative Physiology, 301(4), R1057–R1066. https://doi.org/10.1152/ajpregu.00139.2011
Leto, D., & Saltiel, A. R. (2012). Regulation of glucose transport by insulin: traffic control of GLUT4. Nature Reviews. Molecular Cell Biology, 13(6), 383–96. https://doi.org/10.1038/nrm3351
Lucas, C. P., Estigarribia, J. a, Darga, L. L., & Reaven, G. M. (2015). Insulin and blood pressure in obesity. Hypertension, 7(5), 702–706. https://doi.org/10.1161/01.HYP.7.5.702
Luppino, F., de Wit, L. M., Bouvy, P. F., Stijnen, T., Cuijpers, P., Penninx, B., … Review, A. S. (2016). Overweight, Obesity, and Depression. Archives of General Psychiatry, 67(3), 220–229. https://doi.org/10.1001/archgenpsychiatry.2010.2
Obesity Australia. (2014). Obesity : A National Epidemic and its Impact on Australia. Obesity Australia.
Pedersen, B. K., & Febbraio, M. a. (2012). Muscles, exercise and obesity: skeletal muscle as a secretory organ. Nature Reviews Endocrinology, 8(8), 457–465. https://doi.org/10.1038/nrendo.2012.49
Pi-Sunyer, F. X. (2002). The obesity epidemic: pathophysiology and consequences of obesity. Obesity Research, 10 Suppl 2, 97S–104S. https://doi.org/10.1038/oby.2002.202
Renzaho, A. M. N., Bilal, P., & Marks, G. C. (2014). Obesity, type 2 diabetes and high blood pressure amongst recently arrived Sudanese refugees in Queensland, Australia. Journal of Immigrant and Minority Health, 16(1), 86–94. https://doi.org/10.1007/s10903-013-9791-y
Sarkhosh, K., Switzer, N. J., El-Hadi, M., Birch, D. W., Shi, X., & Karmali, S. (2013). The impact of bariatric surgery on obstructive sleep apnea: A systematic review. Obesity Surgery. https://doi.org/10.1007/s11695-012-0862-2
Yazici, H. U., Ozduman, H., Aydar, Y., & Birdane, A. (2013). Effects of metoprolol and nebivolol on exercise blood pressure in patients with mild hypertension. The Scientific World Journal, 2013. https://doi.org/10.1155/2013/608683