HSNS 367 Nursing Practice: Complex Integrated Care Assignment

Question:

Describe the pathophysiology of the chosen complication.

Discuss the assessment and diagnostics of this complication.

Discuss the treatment and management of this complication.

Demonstrated ability to review the literature and select appropriate sources.

Demonstrated ability to appraise and analyse the literature .

Sample Draft Solution:

Introduction

Diabetes Mellitus (DM) is a metabolic disorder. It is characterized by hyperglycemia that generates due to disequilibrium in insulin secretion and/or insulin action. The pathological hallmark of DM encompasses vasculature leading to microvascular and macrovascular complications. The microvascular complications like nephropathy and retinopathy accelerates the chance of developing macrovascular complications, which promotes atherosclerosis and eventually leads to the development of cardiovascular disease, peripheral vascular disease and stroke (Marieb & Hoehn, 2015). The following essay aims to highlight the pathophysiology associated with macrovascular complications of diabetes followed by assessment and diagnostic criteria. At the end, the essay will explore common treatment and management principles underlying macrovascular complications of diabetes.

Macrovascular complications: pathophysiology

According to Chilelli, Burlina and Lapolla (2013), the main pathological mechanism in macrovascular complications in DM mainly involves atherosclerosis. Atherosclerosis results from chronic injury or inflammation of the wall of arteries present in the coronary or peripheral vascular system. Inflammation the walls of the arteries cause oxidation of the lipids from low-density-lipoprotein particles under the action of angiotensin II. The oxidized lipid particles accumulate in the endothelial walls leading to narrowing (Bullock & Hales, 2016). The activation of the inflammatory pathway causes stimulation and proliferation of macrophage and attraction of T-lymphocyte at the site of inflammation. The activated T-lymphocyte induces proliferation of smooth muscle in the arterial walls and simultaneous collagen accumulation leading to thickening of arteries. The arterial inflammation leads to narrowing of the arterial walls throughout the body and thereby increasing the chance of cardiovascular accident (Chilelli, Burlina & Lapolla, 2013).

Chawla, Chawla and Jaggi (2016) highlighted the pathophysiology underlying the inflammation in diabetes and subsequent development of macrovascular complications in details. According to Chawla, Chawla and Jaggi (2016), hyperglycemia provokes monocyte adhesion to the arterial cells. These monocyte adhserion triggers type 1 hypersensitivity reaction, promoting the accumulation of the primary mediators of hypersentivity and thereby causing thickening of the arteries. Increase blood glucose level activates matrix-degrading enzyme metalloproteinase, which cause plaque rupture and arterial remodelling leading toe thickening of the arteries. Diabetes also increases the secretion of the primary inflammatory mediators like C-reactive protein, plasminogen activator inhibitor and interleukine-6 that cause activation of macrophage and thereby leading to the development of inflammatory reaction under the influence of protein kinase C (PKC) pathway.

Another underlying pathophysiology behind the development of the macrovascular complications include increased rate of platelet adhesion and hypercoagulability (Zhang et al., 2014). Impaired nitric oxide generation, free radical formation in the platelets and altered calcium regulation promote platelet aggregation cause hypercoagulability. Increased levels of plasminogen activator inhibitor type 1 impair fibrinolysis in patients with diabetes. The combination of these cause increased level of platelet coagulability which in turn cause vascular occlusion and cardiovascular events in type 2 diabetes (Zhang et al., 2014).

Chawla, Chawla and Jaggi (2016) stated that hyperglycemia and insulin resistance are main reasons behind the development of macrovascular complications of diabetes. Development of diabetes is inherently associated with hyperglycemia. However, insulin resistance develops years before hyperglycemia and during the course of time becomes clinically significant. Obesity plays an important role in the development of insulin resistance (common among the people with type 2 diabetes). The release of free-fatty acids, inflammatory mediators and reactive oxygen species increases the chance of systemic inflammation and thereby leading to the development of atherosclerosis.

Assessment and diagnostics

The study conducted by Donaghue et al. (2014) highlighted that assessment of macrovascular complication of diabetes should start after the age of 10. The main screening methods that are used to highlight the marcrovascular complications include testing the lipid profile of the individual after every 5 years along with the annual tabulation of blood pressure. Truong, Maahs and Daniels (2012) highlighted that for type 1 diabetes (T1D) individuals, with no significant family history of early cardiovascular disease or individuals who are over 12 years of age, should undergo proper screening of glycemic level after every 5 years. If T1D have family history of cardio-vascular disease then fasting lipid profile must be used as screening tool for the detection of macrovascular complications. If lipid screening is found to be abnormal, annual screening is recommended. For type 2 diabetes (T2D), lipid profile must be done after every 2 years if lipid content of the blood is found within the permissible range (Truong, Maahs & Daniels, 2012).

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Other hallmarks apart from blood lipid concentration, which can be used to detect the tendency of developing macrovascular complication, include microalbuminuria. Donaghue et al. (2014) stated that microalbuminuria is confirmed via analysis of two or three samples for a period of three to six months. Persistent microalbuminuria is found to predict the end stage of the renal failure, which in turn increases the chance of developing macrovascular disease. Donaghue et al. (2014) highlighted that loss of nocturnal dipping on round the clock blood pressure monitoring is regarded as the early marker for the assessment diabetic renal disease which simultaneously precedes towards microalbuminuria leading the renal hypertrophy and subsequent development of macrovascular complications.

In the domain of selection of the proper assessment and diagnostic tool for the detection of macrovascular diseases (MVD) in diabetes, Papa et al. (2013) conducted a population based study. 1199 diabetic cohort from outpatient department were selected on the basis of their cardiovascular history and other medical and hospital records (cardiac index, brachial index, duplex ultrasonography of the carotid and lower limbs, computed tomography angiography and peripheral arteriography). Over the selected group of individuals, Papa et al. (2013) conducted standardized procedure for the assessment of macrovascular complications. The analysis of the results indicated that the phenotypic heterogeneity is associated with different types of macrovascular complications among type 2 diabetes patients. They are also found to have different metabolic syndrome. Depending on this phenotypic heterogeneity, the development of the diagnostic tools and therapeutic strategies for MVD must be selected (Papa et al., 2013).

Park et al. (2015) highlighted that the diagnostic method that can be used for the detection of MVD include bronchial artery ultrasound for the detection of flow-mediated dilation. Other diagnostic test for the detection of arthrosclerosis, include cardiac catheterization, angiogram and echocardiogram. These tests help to analyze the position where exact thickening of the arteries have occurred (Park et al., 2015). Truong, Maahs and Daniels (2012) highlighted the importance of cardiovascular imaging in the diagnosis of MVD, a non-invasive imaging helps to analyze the involvement of heart and vasculature in diabetes.

Treatment and management

The main foundation of care for the treatment and effective management of MVD complications among diabetic patient include proper patient education, nutritional planning, physical activity, smoking cessation and psychological care.