diabetes case study answers

Diabetes Mellitus Case Study (45 min)

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What additional nursing assessments should be performed at this time?

• POC glucose
• Heart and lung sounds and respiratory effort – ensure she is protecting her airway
• Assess skin and mucous membranes
• Level of consciousness and orientation

What history questions would you like to ask of the patient and/or her parents?

• Has she been excessively thirsty or hungry lately
• Has she been urinating a lot
• Has she lost weight unintentionally?
• Is there a history of diabetes in the family?
• Has she been told previously that she has diabetes?
• Does she take any medications on a daily basis?

Upon further questioning, the parents report that their daughter has been weak a lot lately. Miss Matthews reports but she’s always hot and exhausted. She reports a 10-pound weight loss over the last 2 months despite eating all the time and agrees that she has been thirsty and peeing a lot.

What diagnostic tests should be run for Miss Matthews?

• Serum glucose level
• BMP – electrolytes, anion gap, etc.
• ABG to assess for acidosis
• Urine ketones

What is an appropriate response by the nurse?

• Your daughter has Type 1 diabetes, which means that she has an autoimmune disorder that attacks the cells in her pancreas that make insulin. Type 1 diabetes typically has nothing to do with diet and lifestyle and usually has more to do with genetics.
• Your daughter’s healthy lifestyle will continue to help her control her blood sugar levels, but unfortunately, there is no cure for type 1 diabetes at this time.

What treatments do you expect to be ordered for Miss Matthews at this time?

• Miss Matthews will need intensive insulin therapy and IV fluids to counteract the ketoacidosis and bring her blood sugars down.
• She will then need to be started on long-acting insulin like Lantus and short-acting insulin-like NovoLog for correction with meals.

Miss Matthews is treated for diabetic ketoacidosis over the next 2 days and is now feeling much better. The diabetic nurse educator comes by to teach Miss Matthews how to self-administer SubQ insulin using an insulin pen. Miss Matthews says “I  can’t stand needles, isn’t there a pill I can take instead?”

What is the most appropriate response by the nurse?

Unfortunately, at this time insulin is not available in pill form. It has to be taken via injection. Otherwise, it will not work correctly.

What options does Miss Matthews have for insulin administration?

• Insulin vial with needles
• Insulin pen
• Insulin pump

Miss Matthews is able to demonstrate proper technique for glucose monitoring and self-administration of insulin with the insulin pen. Her blood glucose levels are stable between 140 and 180 mg/dL,  and the provider has said that she could go home today.

In addition to the insulin education, she has already received, what other education topics should be included in discharge teaching for Miss Matthews?

• Miss Matthews should be taught how to count carbohydrates to determine the amount of insulin required.
• She should be given a prescribed sliding scale or insulin protocol to follow.
• Miss Matthews should also be instructed on when to take her long-acting insulin and when to take regular insulin in relation to meal times. It is important that she does not take short-acting insulins without being ready to eat.
• Miss Matthews should be educated on the possibility of morning hyperglycemia due to the Somogyi effect or Dawn phenomenon, and be given suggestions to try an evening dose of insulin or an evening snack.
• The importance of follow-up appointments with her primary care provider and/or endocrinologist should be stressed. She should have her Hgb A1c checked every 3 months to start with.
• She should also be educated on foods to avoid, such as desserts and sweets, and foods that are beneficial, such as fruits and vegetables and high-quality proteins.
• Miss Matthews should carry some candy or glucose tablets with her in case of a hypoglycemic reaction.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Pediatrics Nursing Case Studies

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Mental health nursing case studies.

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Diabetes Case Study – Answers

Doug is 47 year old man admitted to your medical unit with an ulceration on his right foot. His blood glucose level is 473.   He tells you that he takes NPH (Humulin R) insulin 40 units every morning and Regular (Humulin R) insulin with each meal and at bedtime.

1) Doug said his doctor told him to keep his glucose between 100 and 150. What is the normal range for blood glucose? Why didn’t the doctor recommend that Doug keep his glucose in the normal range?

Hypoglycemia is likely to occur when glucose levels fall below 60 mg/dL. By keeping Doug’s glucose levels slightly higher than normal (100-150 mg/dL), Doug has some leeway in case he does not keep his glucose levels completely under control. For example, if Doug was keeping his glucose level in the normal range, but something in his routine changed that effected the action of his insulin (i.e. skipped or delayed a meal), then he would be at high risk of developing hypoglycemia if his glucose levels were already close to 60 mg/dL. However, if he maintains his average glucose level at a slightly highis level (100-150 mg/dL), then his glucose levels would be less likely to fall to hypoglycemic levels if the insulin caused an altered effect.

2)      Doug’s first dose of insulin each day is given at 6am. Chart the action of his insulin throughout the day, showing where the insulin was given and where it peaks.

3) When you enter his room to check his 4 p.m. vital signs, he complains of a

headache, and he’s started sweating before you finish taking his vitals. Based on your nursing assessment, what do you suspect? How would you confirm your suspicions?

It is likely that Doug is experiencing hypoglycemia. The signs and symptoms of hypoglycemia include headache and sweating.

4) What nursing interventions should you implement?

If He remains conscious, Doug should swallow about 15 grams of carbohydrate, such as 4oz of fruit juice, 2 sugar cubes, or a commercial glucose product. If He loses consciousness before the carbohydrate can be swallowed, then glucose or glucagon must be given parenterally. After the immediate hypoglycemic crisis is treated, Doug should be given a meal or snack to prevent secondary hypoglycemia. His insulin regimen and routine should also be evaluated in order to prevent hypoglycemia from occurring in the future

5) Why do you think this incident occured at 4pm?

The hypoglycemia occurred at 4pm because of the combined effects of his R-insulin and N-insulin. The effect of the R-insulin He took before lunch was beginning to decline but were still relatively strong. In addition, the effect of the N-insulin taken in the morning was beginning to peak. The combination of both of these insulin effects caused the body to move too much glucose from the blood stream into body cells, which led to the hypoglycemia.

6) At 5 p.m. you check Doug’s glucose level before preparing his next dose of insulin. The finger stick shows that his blood glucose is currently 80mg/dL. What do you do?

80 mg/dL is lower than the 100-150 mg/dL level that the doctor recommended. Thisefore, the next step would be to skip the dose of R-insulin before dinner, document the reason why, and continue to monitor his glucose levels. It would probably be a good idea to also inform the doctor that this step has been taken. If the next dose of insulin were given despite the already low glucose levels, then Doug would be at risk to experience another hypoglycemic reaction.

7) Identify 2 possible reasons that Doug’s blood glucose dropped lower than usual.

a) He may have skipped a meal, or his meal was late in being served to his.

b) The dose of insulin He is receiving may be too high. This could be caused by several factors, including a change in his body’s insulin sensitivity, or being given an incorrect dose of insulin.

c) His body’s ability to clear insulin from his system may have decreased, possibly indicating renal impairment.

8) Explain the importance of eating regularly scheduled meals throughout the day. How would you explain/teach this to Doug?

It is important to make sure that you are eating on a regular schedule so that the insulin can work properly. Whenever you eat something, you are putting glucose in your blood that the insulin will help your body to process. But when you skip a meal, your insulin will keep trying to help your body process glucose even though the glucose in your blood has not been ‘restocked’ by food. This can put you at risk for hypoglycemia. Eating regularly can help you to keep a safe and healthy balance between the amount of insulin and the amount of glucose in your body. Plus, when you can consistently keep your glucose levels in a safe range, you lower your risk for othis complications as well.

9) You did such a good job educating Doug about his diabetes last year that after discharge he started exercising, eating nutritious meals, and lost 65 pounds. But almost 2 years after his last admission, he arrives in the ER with a blood glucose of 41. What made his glucose level go so low?

Overall, diet, exercise, and maintaining proper weight can decrease a patient’s need for insulin. Losing weight decreases the workload placed on the pancreas, allowing it to work more efficiently. In addition, it is likely that Doug has been exercising as part of his weight loss plan. Exercise can increase the utilization of insulin in the body tissues, thiseby decreasing the total amount of insulin needed by the body. Since it is likely that Doug’s body is both producing and using insulin more efficiently, then He was probably receiving more insulin than He needed. This resulted in a hypoglycemic level of blood glucose.

10) Doug’s doctor switches him from insulin to glipizide (Glucotrol) 5 mg bid. What are the 2 mechanisms of action for this medication?

·        Stimulate the pancreas to release more insulin.

·        Increases peripheral use of glucose, while at the same time decreasing the liver’s production of glucose.

11) How often and at what times should Doug take his gucotrol every day?

He should take his gucotrol 30 minutes before breakfast, and 30 minutes before supper.

He should take the medication before breakfast and before supper because doing so helps absorption of the drug and, ultimately, plasma levels. Taking it in the morning and in the evening will also help to maintain a more constant level of the drug in his system throughout a 24-hour period. In addition, if He took the medication but did not eat anything as the drug began to work, then He would be at risk for hypoglycemia because his pancreas would be producing additional endogenous insulin whether or not his blood glucose levels are being increased.

13) Does Doug have type I or type II diabetes? How do you know?

Doug has type II diabetes. If He had type I diabetes, then he would not be able to stop taking exogenous insulin because his body would be completely unable to produce endogenous insulin. Since He has type II diabetes, his body is able produce some endogenous insulin, so the doctor was able to prescribe glipizide to help increase the effect of his endogenous insulin.

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Clinical pearls, case study: a woman with type 2 diabetes and severe hypertriglyceridemia sensitive to fat restriction.

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Deborah Thomas-Dobersen; Case Study: A Woman With Type 2 Diabetes and Severe Hypertriglyceridemia Sensitive to Fat Restriction. Clin Diabetes 1 October 2002; 20 (4): 202–203. https://doi.org/10.2337/diaclin.20.4.202

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L.S. is a 52-year-old Caucasian woman who was diagnosed with type 2 diabetes in 1988. She developed hypertriglyceridemia 3 years later and hypertension 9 years later. Other medical problems include obesity and diverticulosis. She presents now for screening to determine eligibility for a clinical research protocol using once-daily insulin.

Physical exam reveals a height of 64 inches, a weight of 181 lb, a body mass index of 31 kg/m 2 , and a waist circumference of 40 inches. Blood pressure, well controlled on 20 mg lisinopril (Prinivil) daily, is 104/70 mmHg.

Laboratory results reveal a fasting lipid panel as follows: total cholesterol 214 mg/dl, triglycerides 940 mg/dl, direct HDL cholesterol 24 mg/dl, an invalid LDL cholesterol unobtainable because of the hypertriglyceridemia, and a free fatty acid of 1.1 mEq/l (normal range 0.1–0.6 mEq/l). Hemoglobin A 1c (A1C) is 9.5%, and fasting blood glucose (FBG) is 304 mg/dl. When called to discuss the finding of severe hypertriglyceridema, the patient commented that she had previously had fasting triglycerides as high as 3,000 mg/dl.

L.S. is currently taking metformin (Glucophage), 1,000 mg twice daily, and glipizide (Glucatrol XL), 10 mg twice daily, to control her blood glucose. She is also on gemfibrizol (Lopid), 600 mg twice daily, for hypertriglyceridemia and estradiol (Estraderm) for menopause (topical estrogen does not induce hypertriglyceridemia).

What nutritional modification would be effective in rapidly lowering serum triglycerides when the patient is at risk of pancreatitis?

What treatment strategies can be employed to lower triglycerides, and how effective are they?

How can nutritional modifications improve insulin resistance?

Type 2 diabetes carries a two- to fourfold excess risk of coronary heart disease. The most common pattern of dyslipidemia in patients with type 2 diabetes is elevated triglycerides and decreased HDL levels. 1 Although coexistent increases in small, dense LDL cholesterol particles—not the triglycerides themselves—may be responsible for the increase in cardiovascular risk, hypertriglyceridemia poses a significant burden on society. 2  

In type 2 diabetes, characterized by insulin resistance and insulin deficiency, the pathophysiology of hypertriglyceridemia is an increased hepatic production of triglycerides as well as a decreased lipoprotein lipase activity leading to slower breakdown of VLDL cholesterol and chylomicrons. 3 The American Diabetes Association (ADA) Clinical Practice Recommendations list serum triglycerides ≥400 mg/dl and an HDL level <45 mg/dl for women as indicative of high risk of coronary heart disease. 1  

By both ADA and National Cholesterol Education Program (NCEP III) guidelines, the first goal for this patient is to lower triglycerides to prevent pancreatitis, which not only can result in hospitalization, but also is potentially lethal. 4 Although L.S. is already on the maximum dose of gemfibrozil, her triglycerides are still inadequately controlled.

With triglycerides in this range, she should be alerted immediately to the fact that any alcohol, even that found in over-the-counter cold remedies can trigger pancreatitis until her serum triglycerides are brought down to a safer range (<500 mg/dl). In addition, a single high-fat meal can also trigger pancreatitis.

A severely restricted fat intake (<10% of daily kcal) can effectively bring down serum triglycerides by 20% per day until triglycerides are <500 mg/dl. A diet in which fat is so severely restricted usually brings about weight loss as well. A loss of 2.5 kg body weight would bring an expected 15–20% decrease in serum triglycerides. In addition, aerobic exercise can help to lower serum triglycerides by 10–15%. 2  

Interventions to further decrease serum triglycerides to <200 mg/dl, increase HDL to 45 mg/dl, and decrease LDL to <100 mg/dl should be attempted to decrease the risk of coronary heart disease.

At the first clinic visit, L.S. was advised of the risk of pancreatitis and advised to forego any alcohol and to adhere to severe fat restriction until she has a fasting serum triglyceride level <400 mg/dl. She and her husband are both from the South, and their traditional Southern fare used quite a bit of salt pork, which deleteriously augmented the saturated as well as total fat in her diet. She had been advised to “watch her weight” when her triglycerides were in the 3,000 mg/dl range, but she had been unable to follow that recommendation.

Between clinic visits, L.S. was given written information about a low-fat (10% of kcal) diet, including lists of foods to restrict and foods to encourage until a more thorough meal plan could be developed based on an assessment of her previous dietary patterns. She was advised that this was a short-term, severe dietary change. She had already instituted an exercise program, walking for 1 hour, five times a week regularly.

Two weeks later, when L.S. returned to clinic after following the suggested fat restriction, her lab results showed the following lipid profile: serum total cholesterol 193 mg/dl, serum triglycerides 355 mg/dl, direct HDL cholesterol 32 mg/dl, and LDL cholesterol 90 mg/dl. Her A1C had dropped to 8.8% with no change in therapy for her diabetes, and her FBG was 158 mg/dl. Her fasting free fatty acid level was 0.7 mEq/l. Her weight had dropped by 3 lb.

At this visit, medical nutrition therapy (MNT) was initiated, and the patient was put on 10 units of 75/25 insulin before dinner.

Six weeks later, her A1C had dropped further, to 7%, her FBG was 110 mg/dl, and her weight was down another 2 lb. Her lipid profile was as follows: total cholesterol 181 mg/dl, triglycerides 299 mg/dl, direct HDL cholesterol 32 mg/dl, and LDL cholesterol 89 mg/dl. Her fasting free fatty acid level was now 0.6 mEq/l, the upper level of normal. Meal plan records showed that she was consuming ∼1,500 kcal/day and getting ∼25% of daily kcal from fat.

Commonly, controlling hyperglycemia leads to a decrease in triglycerides. 1 However, in this patient, the clearing of serum triglycerides, the restricted saturated fat, and the weight loss had a substantial impact on improving glucose tolerance without adding further diabetes oral agents. Studies have shown that dietary fat, primarily saturated fat, has adverse effects on insulin sensitivity. 5 Restricting fat intake, especially saturated fat, resulted in a better metabolic profile in regard to both glucose tolerance and fasting serum triglycerides.

Lifestyle changes had been recommended previously; why was L.S. successful this time when she hadn’t been before? The patient offered the following comments when asked this question.

“I was handed written information, but concern about the numbers (hypertriglyceridemia) was never conveyed.”

“They tell you what you need to do, but not how or why to do it.”

“No one sat down and talked with me. I never received individualized attention.”

“If my triglycerides were potentially harmful, why did they not see me sooner than 3 months? Three months was the usual time between visits and again they conveyed no concern.”

In previous attempts to encourage this patient make lifestyle changes, the compliance approach was used, but the benefits of self-care, the costs of not complying, the susceptibility to pancreatitis and cardiovascular disease, and the severity of such elevated triglycerides were not conveyed. A referral to an educator, time spent in assessing eating patterns and teaching alternatives, and more frequent visits or follow-up serve to convey the importance of recommended lifestyle changes. MNT coupled with an empowerment approach through which patients are the primary decision makers is important.

Although lifestyle changes are always recommended as first-line therapy, the approach to helping patients achieve these lifestyle changes in busy office practices is too often insufficient. A new Medicare benefit effective January 2002 allows patients with diabetes access to insurance coverage for MNT. Evidence-based research shows that MNT provided by a registered dietitian experienced in the management of diabetes is clinically effective. 6  

Reducing dietary fat improves body weight, which in turn improves glucose tolerance and hypertriglyceridemia. 7 – 9  

There is evidence that saturated fat may elevate plasma glucose by way of increasing insulin resistance.

MNT for hypertriglyceridemia may be divided into three parts:

  1. When fasting triglycerides are ≥1,000 mg/dl, restrict dietary fat to 10% of kcal until fasting triglycerides fall to <500 mg/dl.

  2. For fasting triglycerides between 1,000 and 500 mg/dl, a ) reduce saturated fat to <7% of energy and dietary cholesterol to 200 mg/day; b ) increase viscous (soluble) fiber to 10–25 mg/day; c ) encourage modest weight loss (5–7% of body weight); and d ) increase physical activity. 10 Monounsaturated fats or carbohydrates can be used to substitute for the decrease in saturated fats.

  3. For fasting triglycerides <500 mg/dl, encourage weight loss and a decrease in simple sugars in addition to the above reduction in saturated fat.

Deborah Thomas-Dobersen, RD, MS, CDE, is a professional research assistant and certified diabetes educator in the Endocrinology Department of the University of Colorado Health Sciences Center in Aurora.

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• Diabetes & Primary Care
• Vol:24 | No:06

Interactive case study: The elderly and type 2 diabetes

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Diabetes & Primary Care ’s series of interactive case studies is aimed at all healthcare professionals in primary and community care who would like to broaden their understanding of diabetes.

The care of older people with type 2 diabetes is complicated, as the prognosis and appropriate treatment goals vary greatly between individuals. The three mini-case studies developed for this issue of the journal take us through the basic considerations of managing type 2 diabetes in the elderly.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve our knowledge and problem-solving skills in diabetes care by encouraging us to make evidence-based decisions in the context of individual cases.

Readers are invited to respond to the questions by typing in your answers. In this way, we are actively involved in the learning process, which is hopefully a much more effective way to learn.

By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Marianne , who is 71 years old, has type 2 diabetes but lives a very active life, with little in the way of comorbidities. However, despite treatment with metformin 1000 mg twice daily, her glycaemic control has deteriorated in recent years.

Mike is 78 years old and has long-standing type 2 diabetes. Six years ago he suffered a myocardial infarction. He takes a range of medication to address his hyperglycaemia, hypertension and low mood. He lives alone, but uses a stick to walk and receives practical help from his daughter. Recently, he has been experiencing shakiness and sweating after gardening, and dizziness on standing. His BP is 117/58 mmHg and HbA 1c is 51 mmol/mol.

Claire is an 81-year-old who lives in a care-home. She has Alzheimer’s disease and long-standing type 2 diabetes. A stroke 4 years ago left her with unilateral weakness, and she has frequent lower urinary tract infections and episodes of urinary incontinence. For her hyperglycaemia, hypertension and various other health concerns, she is taking over a dozen medications. A review of her diabetes is due.

The health and care needs of each of these people differ greatly. By working through their case studies, we will consider the following issues, and more:

• Agreeing glycaemic targets in the elderly.
• Assessment of frailty and the importance of a holistic approach to managing diabetes in the elderly. 
• Choice of medications and concerns over hypoglycaemia.
• Deintensification and simplification of medication regimens.

Click here to see the case study.

Q&A: Lipid management – Part 3: Triglycerides and use of non-statin drugs

Diabetes distilled: impact of metformin timing on glucose and glp-1 response, diabetes distilled: diabetes-related foot ulcers – detailed advice for primary care, conference over coffee: diabetes and obesity within multiple long-term conditions, lada – assessing diabetes in a non-overweight younger person, challenges and opportunities in reducing risk of diabetes-related cardiovascular disease: making every contact count, diabetes distilled: pneumonia hospitalisation associated with long- and short-term risk of cardiovascular mortality.

Claire Davies answers questions on triglycerides and non-statin drugs.

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Administering standard-release metformin 30–60 minutes before meals may lead to improved postprandial glycaemic control.

21 Aug 2024

Review and guidelines highlight opportunities for primary care to really make a difference.

25 Jul 2024

The interactions between diabetes, obesity and long-term conditions, including cardiovascular disease, chronic kidney disease and cancer.

23 Jul 2024

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Pathophysiology

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According to McCance and Huether (2019), 9.3 % of the adult population in the United States is affected by Type 2 diabetes mellitus.  Risk factors for developing Type 2 diabetes are family history, hypertension, obesity, and increased age.  Lifestyle choices, genetic factors, and environmental factors combined can all contribute to the development of Type 2 diabetes mellitus. One main issue leading to Type 2 diabetes is insulin resistance in peripheral tissues specifically the muscle, liver, and adipose tissue (McCance & Huether, 2019).

Alpha cells and beta cells are islet cells that are found in the pancreas.  The beta cells are responsible for creating insulin and the alpha cells are responsible for creating glucagon.  The increasingly high glucagon levels cause blood glucose levels to increase leading to the stimulation of gluconeogenesis and glycogenolysis (McCance & Huether, 2019).  Due to the decreased reactiveness of the alpha cells to glucose, the glucagon secretion begins increasing as well.  Amylin which is a beta-cell hormone is responsible for repressing the alpha cells release of glucagon (McCance & Huether, 2019).  In Type 2 diabetes the cells begin to become insulin resistant. This means the needed glucose is unable to get inside of the cells which causes it to accumulate in the blood.  In this case, the insulin receptors are abnormal or missing causing glucose to be locked out of the cells.

The beta cells attempt to keep up with the increased demand for insulin but eventually lose the ability to produce enough.  The beta cells begin to decrease in number and size and eventually fail due to exhaustion (McCance & Huether, 2019).  This leads to hyperglycemia which is the buildup of glucose in the bloodstream.  In an attempt to compensate for hyperglycemia, the pancreas will produce more insulin.  The pancreas will eventually reach exhaustion and no longer be able to compete with the body’s increased demand for insulin.

Our GI hormones (gut hormones) contribute to diabetes & insulin resistance as well.  Ghrelin is a hormone made in the stomach and pancreatic islets that control food intake.  Insulin resistance has been associated with reduced levels of ghrelin.  Incretins are released from the GI tract to increase insulin release, regenerate the beta-cell and provide a barrier to beta-cell damage (McCance & Huether, 2019).  Studies show the incretin glucagon-like peptide 1, (GLP-1) depicts a decrease in beta-cell responsiveness in type 2 diabetes (McCance & Huether, 2019).

Due to hyperglycemia and the current lack of insulin polyphagia, polydipsia and polyuria are classic signs that appear while recurrent infections and visual changes occur later on.  If hyperglycemia continues to progress without treatment microvascular complications such as nephropathy, neuropathy, and retinopathy can occur along with macrovascular complications: cerebrovascular disease, coronary artery disease, and peripheral artery disease (McCance & Huether, 2019).

According to the American Diabetes Association (2015), there are four ways to diagnose Type 2 diabetes

• Glycated hemoglobin (A1C) test: Diabetics diagnosed using this test will have an A1C of 6.5% or higher
• Random blood sugar test: Diabetics diagnosed using this test will have a blood sugar of > 200 mg/dL
• Fasting plasma glucose (FPG): Diabetics diagnosed using this test will have a FPG of 126 mg/dL or higher
• Oral glucose tolerance test (OGTT): Diabetics diagnosed using this test will have an OGTT of 200 mg/dL or higher.

American Diabetes Association. (2015, January 1). 2. Classification and Diagnosis of Diabetes. Retrieved from https://care.diabetesjournals.org/content/38/Supplement_1/S8.

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2019).  Pathophysiology: the biologic basis for disease in adults and children  (8th ed.). St. Louis, MO: Elsevier.