NR 601 Week 5 Standardized Procedure Worksheet

Chamberlain University NR 601 Week 5 Standardized Procedure Worksheet– Step-By-Step Guide

This guide will demonstrate how to complete the Chamberlain University  NR 601 Week 5 Standardized Procedure Worksheet  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NR 601 Week 5 Standardized Procedure Worksheet                        

Whether one passes or fails an academic assignment such as the Chamberlain University  NR 601 Week 5 Standardized Procedure Worksheet  depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NR 601 Week 5 Standardized Procedure Worksheet                        

The introduction for the Chamberlain University  NR 601 Week 5 Standardized Procedure Worksheet      is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NR 601 Week 5 Standardized Procedure Worksheet                        

After the introduction, move into the main part of the NR 601 Week 5 Standardized Procedure Worksheet      assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NR 601 Week 5 Standardized Procedure Worksheet                        

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NR 601 Week 5 Standardized Procedure Worksheet                        

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NR 601 Week 5 Standardized Procedure Worksheet

Standardized Procedures

Nurse practitioners are crucial in promoting optimum health and well-being for their populations. Nurse practitioners use their clinical knowledge, skills, and experience to diagnose patients and develop patient-centered interventions to promote recovery. This study’s primary objective is to create standardized care procedures for hemorrhoids in older adults. The paper is segmented into four core sections encompassing the identification and description of hemorrhoids, disease assessment processes, diagnostic tests, and an evidence-based management plan for this condition. Protocolized (standardized) care establishes explicit clinical pathways for managing medication interventions, ensuring that desirable treatments are administered systematically, correctly, and on time.  

Description of Hemorrhoids

The assigned topic of discussion is hemorrhoids in older adults. Júnior et al. (2020) define them as normal vascular cushions comprising connective tissue, veins, smooth muscle fibers, sinusoids, and arterioles found in the anal canal, which in pathological conditions present as venous hypertension and dilation leading to mucous discharge, edema, intense pain, thrombosis, and prolapse. Júnior et al. (2020) and Sheikh et al. (2020) acknowledge that this condition is a common occurrence in adulthood, with more than 50% of persons aged over 50 years experiencing related symptoms at some point in their lives. Age is a risk factor for hemorrhoids, which, according to Sheikh et al. (2020), contributes to the weakening of the connective tissue framework supporting the anorectal apparatus. Intra-abdominal pressures as a result of obesity, constipation, physical inactivity, chronic cough, or pregnancy also contribute to hemorrhoids development (Sheikh et al., 2020). The former factor explains the high prevalence rate of up to 50% among older adults aged over 50 years (Júnior et al., 2020; Sheikh et al., 2020). Concerning the general population, the prevalence of hemorrhoids varies across countries, with Italy and Russia registering an incident rate of 16%, while the Czech Republic, Brazil, France, Spain, and Romania recording 11%, 6%, 7%, 11%, and 10% prevalence rate, respectively (Sheikh et al., 2020). In the United States, Sheikh et al. (2020) accentuate that about 1 million new cases of hemorrhoids are reported annually in the United States, which translates to an annual incidence rate of 4.4% or 10 million people. Overall, these figures may be considerably high because most hemorrhoid cases are underreported as patients desist from seeking medical intervention due to associated shame. 

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The pathophysiology of hemorrhoids is yet to be fully ascertained. However, according to Margetis (2019), the sliding anal canal model, also known as the cushion theory, is the universally accepted explanation of hemorrhoids development. It attributes this condition to the abnormal slippage of cushions through the anal canal. In particular, Margetis (2019) cites four critical pathophysiological events that account for its development and progression. These events entail the anal cushion slippage process, cushions’ connective tissue deterioration, incomplete venous return from sinusoids to the superior (SRV) and middle (MRV) rectal veins during defecation, and blood accumulation (stagnation) in the dilated plexus (Margetis, 2019). While these events may be attributed to various factors, Margetis (2019) considers sinusoid congestion the hallmark of the onset of hemorrhoidal disease. In layperson’s terms, hemorrhoids develop from blood accumulation in the blood vessels around the lower abdomen and anus due to reduced venous return during defecation and heightened abdominal pressure. According to Margetis (2019), the impaired or dysfunctional arteriolar sphincteric mechanism, relaxed and hypertrophied connective tissue, and decreased vascular tone contribute to the accumulation of blood, underling the congestion of the sinusoids. Conversely, fibrous tissue hypertrophy and the growth of new blood vessels (neovascularization) contribute to cushion enlargement (Margetis (2019). These events account for the pathophysiology of hemorrhoids. In conclusion, the resulting venous hypertension and dilation lead to mucous discharge, edema, intense pain, thrombosis, and prolapse, which are the primary presenting symptoms of hemorrhoids.   

Assessment

Over and above diagnostics tests, a comprehensive assessment of the patient’s presenting symptoms, social and family history, and an in-depth physical examination are paramount to diagnosing. According to Jakubauskas and Poskus (2020) and Wang et al. (2023), common subjective findings (symptoms) consistent with hemorrhoid encompass rectal bleeding, prolapse (a feeling of a lump around the anal region), itching, mucus discharge after bowel movements, and throbbing pain that might be experienced several hours after a bowel movement. Patients also report feelings of tissue prolapse, mild fecal incontinence, and the presence of painless external skin tags. Moreover, Jakubauskas and Poskus (2020) note that a careful history examination is necessary to correlate the presenting symptoms with hemorrhoids or to make a differential diagnosis. In particular, the examiner should inquire about an individual’s obstetric history to establish the presence of episiotomies, instrumental delivery, and perineal tears for female patients and perianal trauma for men. Equally, the examiner should question patients about their defecation habits (assess for signs of prolonged sitting and strain during defecation) and history of polyps, cancer, and inflammatory bowel disease (IBD) (Jakubauskas & Poskus, 2020). These variables constitute pertinent subjective data associated with hemorrhoids.   

A comprehensive physical examination is necessary to establish pertinent objective data consistent with hemorrhoids. This condition’s primary physical exam indicator is the presence of a perianal thrombosis, which, according to Jakubauskas and Poskus (2020), appears as a tender, firm purple nodule. Besides a thrombosed external hemorrhoid, the examiner should take note of a tender lump to palpation and observe the presence of ulcerations and bloody drainage on the hemorrhoids, and skin tags. Following a general physical exam, Jakubauskas and Poskus (2020) suggest that the examiner should proceed to perform a digital rectal examination to establish the presence of a distal rectal mass, anorectal fistula, fissures, and abscess. This procedure is essential for differentiating these pathologies from hemorrhoids (Jakubauskas & Poskus, 2020). Furthermore, Jakubauskas and Poskus (2020) and Picciariello et al. (2021) suggest that medical professionals should also perform an examination of the anal canal and rectum with an anoscope (anoscopy) to visualize the left lateral, right anterior, and right posterior cushions to establish the extent of prolapse and for differential diagnosis. Picciariello et al. (2021) assert that an anoscopy is essential for examining internal hemorrhoids, rectal masses, or fissures. A physical exam corroborates subjective findings and helps establish a preliminary diagnosis pending a diagnostic test for confirmation.

  Nurse practitioners in California are required to work in collaboration with a physician. In particular, physicians supervise nurses as they practice. Nurse practitioners must have an agreement with a physician who leads their practice. California nurse practitioners collaborate with physicians in certain circumstances, such as developing new care models for integrated collaborative patient care and education. Unlike in California, nurses in the District of Columbia and 22 other states in the country, including New Hampshire, Washington, Oregon, Wyoming, Nevada, Iowa, Arizona, Montana, Massachusetts, and Maryland, have approved full practice status, which means that they can practice without physician supervision, undertaking case management, including assessment, diagnosis, interpretation of diagnostic tests, and prescription of medications (American Association of Nurse Practitioners [AANP], 2024). However, they may require prompt surgical consultation in the management of grade IV internal hemorrhoids, which require surgical intervention (Perry, 2022). The idea is that nurses’ scope of practice varies across states, meaning they may require physician supervision or practice independently depending on local regulatory requirements.      

Diagnostic Tests

Medical practitioners can perform various diagnostic tests, including anoscopy, total colonoscopy, digital rectal examination, and complete blood test to confirm preliminary differential diagnosis. Anoscopy is one of the diagnostic tests performed in older adults who are suspected of having hemorrhoids. According to Jakubauskas and Poskus (2020) and Picciariello et al. (2021), an anoscopy is essential for visualizing the left lateral, right anterior, and right posterior cushions to establish the extent of prolapse and for differential diagnosis. Equally, it is instrumental in examining internal hemorrhoids, rectal masses, or fissures (Picciariello et al., 2021). In particular, an anoscopy allows the diagnosis of internal hemorrhoids or fissures and rules out the presence of rectal masses. A total colonoscopy might also be performed if there are uncertainties in the diagnoses. According to Jakubauskas and Poskus (2020), it is recommended for older adults (over 45 years) who have not been screened for colorectal cancer, with a history of polyps, cancers, or IBD, and those presenting with atypical symptoms, including blood-stained stool and significant changes in defection habits. A digital rectal examination should also be performed to determine the presence or absence of anorectal mass, scar, stenosis, and patency of the sphincter tone (Jakubauskas & Poskus, 2020). A complete blood test is also recommended to rule out anemia. Conversely, Soeseno et al. (2021) suggest performing a stool occult test for mild cases in earlier stages of development to rule out infections. The expected abnormal results include the presence of an anal lump, bleeding hemorrhoids, anal fissures, non-patent anal sphincter, bleeding after bowel movements, skin tags, and anal ulcerations, which are the pertinent indicators of hermorrhoids.

Management

Hemorrhoid management encompasses pharmacological and nonpharmacological interventions. Prescription therapy used as part of the first-line treatment of hemorrhoids in older adults includes oral flavonoids such as chrysin 400 mg once daily because of its anti-hemorrhoid properties and its capacity to improve vascular function while decreasing vascular resistance, according to Razdar et al. (2023). Although flavonoid therapy is superior to calcium dobesilate, Changazi et al. (2020) note that oral calcium dobesilate 0.5 mg once daily may be used as a second-line treatment for hemorrhoids if patients react to the first-line medication. Vahabi et al. (2019) also recommend topical treatments such as glyceryl trinitrate 0.2% for pain management, particularly following a hemorrhoidectomy surgery. Pharmacotherapy in hemorrhoid treatment is mainly used to reduce pain and constipation.

Hemorrhoids are best managed using nonpharmacological interventions. Perry (2022) considers a treatment regimen comprising increased fiber and adequate fluid intake as the first line of treatment for this condition. While this treatment approach entails the primary plan for managing hemorrhoids, case management varies according to disease severity levels. In particular, Perry (2022) notes that grade I and II hemorrhoids can be effectively managed through banding, sclerotherapy, and infrared coagulation. Complicated cases, including instances in which patients present with large III and IV hemorrhoids are often referred for surgical intervention (Perry, 2022). These operative treatments, encompassing sclerotherapy, rubber band ligation, and infrared coagulation, are highly recommended for patients that are allergic to hemorrhoid treatment-related medications. Other relevant treatment modalities entail cryotherapy, radiofrequency ablation, hemorrhoidectomy, plication, Doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy. Overall, patients must seek doctors’ guidance to determine the treatment plan.

The post-treatment plan encompasses patient education centered on adherence to the prescribed treatment regimen and recommended lifestyle changes, discussion of indications for referral, and expected client follow-up. Ektov et al. (2020) indicate that the predicted client follow-up depends on the adopted treatment. For example, a client presenting with persistent or recurrent symptoms should be referred for surgical intervention after initial treatment. It might also entail starting the patient on drugs if lifestyle and dietary modification had been considered. Conversely, indications for referral include hemorrhoids unresponsive to treatment, severe bleeding, anemia, rectal prolapse, and absence of specialized care in a facility. Most importantly, patients must be advised to adhere to the prescribed treatment regimen and recommended lifestyle changes.  

Conclusion

Hemorrhoids are a common occurrence in adulthood, with more than 50% of persons aged over 50 years experiencing related symptoms at some point in their life. To make a definitive diagnosis, nurses should be aware of pertinent subjective and objective findings relevant to hemorrhoids. The former encompasses symptoms such as rectal bleeding, prolapse, itching, mucus discharge after bowel movements, and throbbing pain that might be experienced several hours after a bowel movement. Conversely, the latter entails the presence of a perianal thrombosis, ulcerations and bloody drainage on the hemorrhoids, and skin tags. Equally, they are advised to perform a comprehensive assessment of the patient’s presenting symptoms, social and family history, and an in-depth physical examination and conduct diagnostics tests to simplify the differential diagnosis process. Most importantly, they must understand that hemorrhoid management encompasses pharmacological and nonpharmacological interventions.

References

American Association of Nurse Practitioners. (2024). Practice information by state. AANP. https://www.aanp.org/practice/practice-information-by-state

Changazi, S. H., Bhatti, S., Choudary, A., Sr, Rajput, M. N. A., Iqbal, Z., & Ahmed, Q. A. (2020). Calcium dobesilate versus flavonoids for the treatment of early hemorrhoidal disease: A randomized controlled trial. Cureus, 12(8). https://doi.org/10.7759/cureus.9845

Ektov, V. N., Николаевич, Э. В., Somov, K. A., Алексеевич, С. К., Kurkin, A. V., Васильевич, К. А., Muzalkov, V. A., & Александрович, М. В. (2020). Treatment options for chronic hemorrhoids. Journal of Experimental and Clinical Surgery, 13(4). https://doi.org/10.18499/2070-478X-2020-13-4-353-361

Jakubauskas, M., & Poskus, T. (2020). Evaluation and management of hemorrhoids. Diseases of the Colon & Rectum, 63(4), 420-424. https://doi.org/10.1097/DCR.0000000000001642

Júnior, C. W. S., de Almeida Obregon, C., e Sousa, A. H. D. S., Sobrado, L. F., Nahas, S. C., & Cecconello, I. (2020). A new classification for hemorrhoidal disease: The creation of the “BPRST” staging and its application in clinical practice. Annals of Coloproctology, 36(4), 249-255. https://orcid.org/0000-0002-0304-9999

Margetis N. (2019). Pathophysiology of internal hemorrhoids. Annals of Gastroenterology, 32(3), 264–272. https://doi.org/10.20524/aog.2019.0355

Perry, K. R. (2022, May 31). Hemorrhoids treatment & management. Medscape. https://emedicine.medscape.com/article/775407-treatment

Picciariello, A., Tsarkov, P. V., Papagni, V., Efetov, S., Markaryan, D. R., Tulina, I., & Altomare, D. F. (2021). Classifications and Clinical Assessment of Haemorrhoids: The Proctologist’s Corner. Reviews on Recent Clinical Trials, 16(1), 10–16. https://doi.org/10.2174/1574887115666200312163940

Razdar, S., Panahi, Y., Mohammadi, R., Khedmat, L., & Khedmat, H. (2023). Evaluation of the efficacy and safety of an innovative flavonoid lotion in patients with haemorrhoid: A randomized clinical trial. BMJ Open Gastroenterology, 10(1). https://doi.org/10.1136/bmjgast-2023-001158

Sheikh, P., Régnier, C., Goron, F., & Salmat, G. (2020). The prevalence, characteristics and treatment of hemorrhoidal disease: Results of an international web-based survey. Journal of Comparative Effectiveness Research, 9(17), 1219–1232. https://doi.org/10.2217/cer-2020-0159

Soeseno, S. W., Wahyudi, P. A. E., & Febyan, F. (2021). Diagnosis and management of internal hemorrhoids: A brief review. European Journal of Medical and Health Sciences, 3(5), Article 5. https://doi.org/10.24018/ejmed.2021.3.5.1014

Vahabi, S., Beiranvand, S., Karimi, A., & Moradkhani, M. (2019). Comparative study of 0.2% glyceryl trinitrate ointment for pain reduction after hemorrhoidectomy surgery. Surgery Journal (New York, N.Y.), 5(4), e192–e196. https://doi.org/10.1055/s-0039-3400532

Wang, L., Ni, J., Hou, C., Wu, D., Sun, L., Jiang, Q., & Fan, W. (2023). Time to change? Present and prospects of hemorrhoidal classification. Frontiers in Medicine, 10. https://doi.org/10.3389/fmed.2023.1252468

Week 5 Case Study: Type 2 Diabetes Mellitus 

Week 5 Case Study: Type 2 Diabetes Mellitus 

Case studies are essential tools that help learners apply knowledge to solve patient cases similar to those found in the clinical setting. This paper will examine the subjective and objective data in the case study and develop diagnoses and a management plan for the patient. I will also apply national guidelines in the management of the patient’s primary and secondary diagnoses.  In addition, I will identify appropriate health promotion and disease prevention interventions for the patient based on the diagnosis. Lastly, I will apply polypharmacy knowledge in medical reconciliation for this case study.   

Assessment 

The case study depicts, Mr. Jones, a 60-year-old African American male who comes for a scheduled six months’ follow-up visit for Hyperlipidemia and weight loss. In the previous visit, he was educated on lifestyle interventions, and he reports that he has been adhering to the dietary and exercise recommendations. He presents with new concerns of increased fatigue for the past ten weeks. He also reports that he attends a health club 3-4 times a week and walks on the treadmill for at least 30 minutes, but he has not lost any weight, and he has actually gained 7 pounds. Mr. Jones does not understand what he is doing wrong and request for more health education and suggestions to help in weight loss. He further reports that exercises make him hungrier and thirsty and is requesting for further assessment for his fatigue. The patient also reports frequent waking at night to pass urine, and the urinary frequency has increased during the day in the past two months. He, however, denied having painful micturition, dribbling and sexual dysfunction. Mr. Jones has a past medical history of Hyperlipidemia and osteoarthritis. He is currently on: Simvastatin, 10 mg OD, Tylenol 500 mg 2 tabs in the morning for knee pain and daily multivitamin, and turmeric.   

He reports drinking 1-2 beers daily and was a former smoker who quit five years ago. Vital signs include, BP 119/77, pulse 80, respiration 16, regular, height of 5’9.5″, and weight of 210 pounds. Examination of the head revealed hair thinning distribution across the crown.  A Complete blood count (CBC), urinalysis, complete metabolic panel (CMP), serum lipid profile, and EKG were conducted.  

Abnormal lab results include: 1+ glucose, Hemoglobin A1c- 6.9%, TC-202 mg/dl, LDL- 134 mg/dl, VLDL- 36 mg/dl, HDL-32 mg/dl, and Triglyceride- 225 mg/dl. The EKG showed the presence of normal sinus rhythm. 

Assessment  

Primary Diagnosis: Type 2 Diabetes Mellitus; ICD 10: E11. 9  

Pathophysiology: Type 2 Diabetes Mellitus develops when there is impaired or inadequate secretion of insulin by the beta cells of the pancreas and peripheral tissue resistance to insulin (Zaccardi, Webb, Yates & Davies, 2016). Insulin resistance is attributed to high levels of free fatty acids and proinflammatory cytokines in the blood plasma, which results in increased hepatic glucose production, increased breakdown of fat, and reduced glucose transportation into the body’s muscle cells (Zaccardi et al., 2016). The impairment causes hyperglycemia or elevated blood glucose levels, which results in the typical diabetes symptoms of polyphagia (excessive hunger), polydipsia (acute/increased thirst), and polyuria (excessive urine production) (Zaccardi et al., 2016). Other common symptoms of Type 2 Diabetes Mellitus include weight loss, fatigue, blurred vision, and paresthesia in the lower extremities.  

Pertinent positive findings: Pertinent positive findings of Type 2 diabetes in the case study include, increased urine production, increased thirst and hunger, nocturia, and fatigue. Diagnostic values of Hemoglobin A1c level of 6.9%, 1+ glucose on urinalysis, elevated total cholesterol, triglyceride, LDL, and VLDL levels are also pertinent positive findings (Zaccardi et al., 2016).  Pertinent negative findings: Pertinent negative findings include weight loss, lower extremities paresthesia, blurred vision, and random blood glucose of 135 mg/dl (Zaccardi et al., 2016). Rationale for the diagnosis: I made a primary diagnosis of Type 2 Diabetes mellitus based on the presence of the typical clinical presentation of Diabetes, that is, excessive hunger, increased thirst, and increased urine production (Zaccardi et al., 2016). Besides, Hb A1c level of 6.9%, which is above the normal range 4-5.6% suggests that the patient has Diabetes. Type 2 Diabetes was also the most likely diagnosis since the patient has a history of Hyperlipidemia, which could be causing resistance of body tissues and muscle cells to insulin as well as increased hepatic production of glucose that eventually result in hyperglycemia (Zaccardi et al., 2016). 

Secondary Diagnosis: Hyperlipidemia ICD 10: E 78. 5   

Pathophysiology: Hyperlipidemia occurs when there is a disturbance in the metabolism of lipids resulting in elevated serum concentrations of non-polar fats. Most cases of Hyperlipidemia are caused by genetic polymorphism, along with dietary and lifestyle factors. Single and multiple gene mutations result in primary Hyperlipidemia. It is characterized by either excessive production or ineffective clearance of triglycerides, very low density lipoproteins (VLDL) and low density lipoproteins (LDLs) or underproduction or increased clearance of high density lipoproteins (HDLs) (Karanchi & Wyne, 2019). This results in elevated serum levels of LDLs and triglycerides and low levels of HDLs. Sedentary lifestyle, excessive alcohol consumption, cigarette smoking, diabetes mellitus, and hypothyroidism are major causes of secondary Hyperlipidemia (Karr, 2017). Conditions that suggest possible Hyperlipidemia include high blood pressure, angina, heart attack, and stroke.  

Pertinent positive findings: Pertinent positive findings of Hyperlipidemia include, weight of 201 pounds, and a serum lipid profile having high levels of TC- 202 mg/dl, LDL- 134 mg/dl, VLDL- 36 mg/dl, triglycerides- 225 and low HDL levels- 32 mg/dl (Karr, 2017).  

Pertinent negative findings: Pertinent negative findings include elevated blood pressure and chest pain/angina (Karr, 2017).  

Rationale for the diagnosis: I made a secondary diagnosis of Hyperlipidemia based on the serum lipid levels, which revealed high levels of Total cholesterol, LDL, VLDL, and Triglycerides. A low HDL level also pointed to Hyperlipidemia. The ideal serum lipid levels include, Total cholesterol <200 mg/dl; LDL < 100 mg/dl; VLDL 2-30 and HDL > 60 mg/dl (Karr, 2017). He has a medical history of Hyperlipidemia, takes beer daily, and had a history of smoking, which increased the risk of developing Hyperlipidemia. Besides, type 2 DM patients with mild hyperglycemia commonly have mild hypertriglyceridemia caused by excessive production of TG-lipoproteins in the liver linked with decreased HDL cholesterol levels (Karr, 2017). 

Plan 

Diagnostics: Lab test (#1): Hemoglobin A1c level after every three months. 

The American Diabetes Association recommends that the Hb A1c test should be done every three months for monitoring the patient’s response to treatment. The Hb A1c is done regularly to monitor the prognosis of Diabetes and help in determining the hypoglycemic agents to use for a patient to achieve glycemic control.  

Lab test (#2): Serum Lipid Profile after 4 weeks. 

Miller (2019) recommends that a Serum lipid profile should be done four weeks after initiation of treatment to facilitate in evaluating the response to hyperlipidemia treatment. It will further guide in developing the patient’s treatment plan, especially when determining if the dose of lipid-lowering agents should be increased or decreased and whether to change the therapy to a higher intensity medication.  

Medications         

Medication (#1) –  

Type 2 Diabetes mellitus- Metformin 500 mg twice daily dose for 4 weeks. Take the drug with meals, swallow the whole tablet, and do not crush, chew, or cut. Drug refill after every four weeks. 

Rationale: Metformin is an Antidiabetic drug in the class of Biguanides. It is the drug of choice in the management of Type 2 Diabetes since it has no side effects of causing weight gain and hypoglycemia (American Diabetes Association [ADA], 2019). Metformin acts by decreasing gastrointestinal glucose absorption and hepatic glucose production and increases the sensitivity of target cells to insulin. It helps in improving Hemoglobin A1c, and lipid levels reduce the risk of macrovascular complications in obese patients and promote weight loss (ADA, 2019). It would be my treatment of choice since the patient is overweight; hence, it will help in managing weight and prevent long-term diabetic macrovascular complications.  

Medication (#2):  Hyperlipidemia: Atorvastatin/ezetimibe 40 mg/10 mg once daily take during bedtime. This is a combination drug of Atorvastatin, a statin, and Ezetimibe, an LDL-lowering drug. Atorvastatin is a high-intensity statin that is recommended in patients with known Diabetes and a 10-year estimated risk of Atherosclerotic Cardiovascular Disease (ASCVD (Miller, 2019). I will change the statin therapy from Simvastatin, which is a moderate-intensity statin to Atorvastatin. The drug will help in lowering the total cholesterol level and increased HDL levels. It will also help in lowering the risk of developing ASCVD. Ezetimibe acts by inhibiting the absorption of cholesterol at the intestine brush border (Miller, 2019). The ADA recommends the prescription of LDL-lowering therapy in Diabetic patients with an LDL cholesterol level greater than 70 mg/dL.  

Education: 

Diagnoses: I will inform the patient about his diagnosis of Type 2 Diabetes, and since it is newly diagnosed, I would provide counseling and inform him that the condition can be effectively managed through lifestyle modification and adherence to the drug regimen. I will also inform him of the secondary diagnosis of Hyperlipidemia, which has persisted despite exercising and taking a lipid-lowering agent due to the underlying condition of Diabetes. In addition, I will teach him on self-management of Diabetes at home to help lower the risk of microvascular and macrovascular complications. I will educate him on foot-care, including how to clean, dry, and inspect his feet for ulcers, which result in diabetic foot (ADA, 2019). Besides, I will demonstrate to the patient how to conduct a self-blood glucose monitoring, how to interpret the results, and instruct him to record the daily blood sugars to monitor if the condition is improving or worsening. Furthermore, I will inform Mr. Jones that his condition will require frequent monthly check-ups by a health provider for further monitoring of his blood sugars, Hb A1c levels, weight, and evaluation of complications (ADA, 2019). 

Medications. 

Medications will play a significant role in achieving glycemic control and lowering total serum cholesterol levels. I will educate the patient that the Metformin medication acts by decreasing the blood sugar levels to maintain glycemic control and also helps in promoting weight loss. He will be educated on the side effects of Metformin, including causing gastrointestinal disturbances such as flatulence, nausea, vomiting, and diarrhea.  

I will also educate him that Atorvastatin/Ezetimibe acts by lowering cholesterol levels of triglycerides and LDLs. I will inform him to take the drug in the evening to increase its efficacy since most cholesterol is synthesized when there is minimal dietary intake (Karr, 2017). I will further guide him through the side effects of Atorvastatin/Ezetimibe, such as abdominal pain, nausea, muscle weakness, coughing, dizziness headache, and muscle pain.  

Diet. 

Diet modification will play a significant role in achieving glycemic control, lowering cholesterol levels, and promoting weight loss. Nutritional counseling will focus on caloric restriction and modest restriction of foods having simple sugars such as processed foods and saturated fats (Walton et al., 2019). I will recommend a Mediterranean-style diet which has a low-carbohydrate content with less than 50% of daily calories coming from carbohydrate sources (Walton et al., 2019). Mediterranean diet has been effective and in achieving glycemic control. I will further recommend him to increase his consumption of whole grains, fruits, and vegetables since they contain fiber, which helps in clearing LDLs and VLDLs from the body (Walton et al., 2019). In addition, I will advise the patient to limit his alcohol consumption since it has a high caloric content and increases the risk of developing Diabetes comorbid conditions such as hypertension.  

Exercise. 

Patients with type 2 Diabetes mellitus benefit from increased physical activity. Aerobic exercises enhance insulin sensitivity and can help improve glycemic levels. Physical activity lasting more than 150 minutes a week, in combination with dietary modification, has been associated with a great reduction in HbA1c (ADA, 2019). I will recommend the patient to engage in daily physical exercise such as walking and jogging for at least 30 minutes daily to facilitate weight loss. I will also recommend him to enroll in a facility-based exercise training program where he will be guided by a professional to help him with exercises as per his abilities and desired results (Karr, 2017).  

Warning Signs for diagnoses and medications 

I will teach Mr. Jones to recognize symptoms of hypoglycemia, including sweating, blurred vision, sweating, excessive hunger, confusion, and headache. I will instruct him to take a high carbohydrate snack or drink to manage the hypoglycemic symptoms.  

Referral 

Specialty practice or service: Endocrinologist to review the treatment plan and provide specialized monitoring to the patient by assessing complications of Diabetes (ADA, 2019).  

Referral (#2): Ophthalmologist 

To assess for microvascular complications such as retinopathy and cataracts through fundoscopy and guide their management (ADA, 2019). 

Follow up: Follow-up appointment will be scheduled after four weeks in the Diabetic clinic. In the follow-up visits, the patient will have a repeat of Hemoglobin A1c and serum lipid levels to monitor his response to treatment (ADA, 2019). The test results will determine if the drug dosage will be modified. Drug refills will also be done on this visit.   

 Assessment of comorbidities   

The patient is at risk of developing comorbid conditions that are associated with Diabetes, such as cancer of the pancreas, liver, colorectal, and bladder. The risk of cancer in diabetic patients is linked to the common risk factors in cancer and type 2 diabetes, such as obesity, old age, and physical inactivity. It is also related to diabetes-related factors, including the underlying pathology of diabetes and diabetes medications (ADA, 2019). The recommended diagnostic tests for this patient will include sex and age-appropriate cancer screenings such as colonoscopy and Digital rectal exam for prostate cancer.  He will also be recommended on lifestyle interventions that will help lower the risk of developing cancer such as reducing alcohol consumption, engaging in physical activity, and taking a balanced diet (ADA, 2019).  

Medication Cost 

1. 1. Metformin 500 mg (generic, Glumetza): Monthly cost – $1720.11 (Good Rx).
2. Atorvastatin/Ezetimibe (Liptruzet) 40 mg:/10 mg Monthly cost- $174.92 (Drugs.com).

Total monthly cost- $1,895.03 

Mr. Jones medications monthly expenses are $1766.23. Luckily, the medications are covered by most private insurance covers and government insurance, such as Medicare. Hence, if the patient has medical insurance, he will not have to cater for the expenses. I did not modify the treatment plan due to the high costs since Mr. Jones is a business executive and is likely to have medical insurance. Medication pricing websites such as Drugs.com and Good RX provide clinicians with reliable information on drug prices and guide them on the selection of drugs that a patient is likely to afford. The websites are a great tool to use in my future practice to estimate the total monthly costs that patients will incur and compare them with their financial status.   

Conclusion 

In conclusion, the patient in the case study had a primary diagnosis of Type 2 Diabetes and a secondary diagnosis of Hyperlipidemia. I prescribed Metformin as the primary hypoglycemic agent and Atorvastatin/Ezetimibe to lower serum cholesterol levels and help reduce the risk of developing ASCVD.  The patient will have a repeat of the Hemoglobin A1c levels after every three months and a serum lipid profile every four weeks to monitor the patient’s response to the drug therapy. The patient was educated on the mechanism of action, benefits, and side effects of the drugs as well as self-management and lifestyle interventions, including diet and physical exercises to help in managing Diabetes and Hyperlipidemia. Mr. Jones will be referred to an endocrinologist and ophthalmologist for multidisciplinary management and assessment of diabetes complications.  

References 

American Diabetes Association. (2019). Standards of medical care in diabetes—2019 abridged for primary care providers. Clinical Diabetes, 37(1), 11-34. 

Karanchi, H., & Wyne, K. (2019). Familial Hyperlipidemia Type 2a. In StatPearls [Internet]. StatPearls Publishing. 

Karr, S. (2017). Epidemiology and management of Hyperlipidemia. The American journal of managed care, 23(9 Suppl), S139-S148. 

Miller, M. (2019). ACC/AHA lipids & ASCVD guidelines: 2018 update. Metabolism-Clinical and Experimental, 99, 116-118. 

Walton, C. M., Perry, K., Hart, R. H., Berry, S. L., & Bikman, B. T. (2019). Improvement in Glycemic and Lipid Profiles in Type 2 Diabetics with a 90-Day Ketogenic Diet. Journal of Diabetes Research, 2019.999 

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, 92(1084), 63-69.