Diabetes Management

Collaborative posts
• Read the SOAP notes constructed by your course colleagues.
• Review the ‘P’s (Plans) posted by your peers from your Nurse Practitioner role perspective. From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their ‘P’(Plan).
• Post a response individually to each of them that expresses your advanced practice nursing role perspective of their ‘P’.
Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse practitioner did your peer develop a ‘P’ that aligns with EBP/CPG guidelines and/or the foundational basic sciences, etc.?
Please be sure to validate your opinions and ideas with citations and references in APA format. (short reply, at least 150 words each).
Peer #1 E. J.
Subjective
The patient is a 64-year-old Hispanic male with diabetes. He reports that his morning capillary blood sugar readings are between 150 and 190. The patient has an intermittent burning sensation in his feet. He walks a couple of miles three to five times per week. He wears glasses and his last eye exam did not reveal any problems. The patient consumes 75 – 100 gram of carbohydrates per day. He takes 1,000mg of metformin twice a day and glipizide 5mg daily.
Objective
The patient is 6’2” tall, weighs 200 lbs, BP was 118/72, pulse was 72, respiratory rate was 17 and his Hgb A1C was 7.4. The patient had a normal heart rhythm, no murmur or gallop and his lung sounds were clear. Monifilament testing did not reveal any decreased sensation in his feet.
Assessment
The patient has an elevated morning glucose level, as well as an A1C level that indicates this patient’s diabetes is not being properly controlled. The burning sensation in the patient’s feet could be an indication that he has diabetic nerve pain.
PLAN:
Therapeutic
Given that the patients diabetes is not being controlled with the current therapeutic treatment, it is necessary to adjust it. The patient is currently taking the maximum dose of metformin which is 2,000mg per day (Straight Healthcare, 2022). The patient’s glipizide can be increased to 20mg/day going up by 2.5mg every two weeks (Straight Healthcare, 2022). If the patient does not respond to the increase in glipizide then additional medications may be necessary. Dipeptidyl-peptidase 4 (DPP-4) inhibitors can be added to stimulate the release of insulin while blood sugar levels are rising (Mayo Clinic, 2020). Thiazolidinediones, such as Avandia and Actos, improve insulin sensitivity (Mayo Clinic, 2020).
The patients diabetic nerve pain can be treated with an antidepressant (Mayo Clinic, 2020a). The American Diabetes Association recommends duloxetine as a first line treatment (Mayo Clinic, 2020a). Diabetic nerve pain can also be treated with pregabalin, which is also recommended by the American Diabetes Association (Mayo Clinic, 2020a).
Education
The patient should be educated on the signs and symptoms associated with diabetes. Diabetic neuropathy should be explained to the patient. The patient should be encouraged to exercise regularly in order to improve cardiovascular health (Mayo Clinic, 2020a). Diet is an important part of diabetes management. The patient appears to be suffering from the dawn phenomenon and should avoid carbohydrates at bedtime. It is important that the patient take his medication consistently and see healthcare providers regularly.
Collaboration
The patient should see an internist, endocrinologist, ophthalmologist, and dietician.
References
Mayo Clinic. (2020a, January 21). Diabetes care: 10 ways to avoid complications. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-management/art-20045803
Mayo Clinic. (2020b, March 3). Diabetic neuropathy – diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/diabetic-neuropathy/diagnosis-treatment/drc-20371587
Mayo Clinic. (2020c, October 24). Diabetes treatment: Medications for type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/in-depth/diabetes-treatment/art-20051004
Straight Healthcare. (2022). Sulfonylurea dosing. https://www.straighthealthcare.com/sulfonylurea-dosing.html#metaglip

Peer #2 J.G.
Diabetes Management
Subjective: The patient is a 64-year-old Hispanic male and presents today in the office for his scheduled diabetes medication management. His blood sugars in the mornings have ranged between 150-190 and the patient states that he takes his daily medications. The patient maintains an active lifestyle, walking a couple miles between 3-5 days a week and keeps his carbohydrate intake of 75-100 grams a day. He states his last eye exam was routine and wears his reading glasses as needed. He states that he takes 1000 mg of Metformin BID and 5 mg of Glipizide once daily. The patient does report that he does have intermittent burning sensations in his feet.
Objective: Patient’s Ht 6’2”, Wt. 200 points. BP 118/72. Pulse 72. RR 17. HgB A1C 7.4. Upon assessment patient’s lungs are clear and has a regular heart rhythm, no murmur or gallop noted. Monifilament testing does not reveal any decrease in sensation in his feet.
Assessment: Based on the patients’ A1C of 7.4 from earlier labs and his morning blood sugars, his diabetes is poorly managed. Patient symptoms of burning sensations in his feet are indicative of diabetic neuropathy.
PLAN:
Therapeutics: The patient’s daily medications are not sufficiently getting better control of his blood sugar levels. The maximum dose for Metformin is 2,550 milligrams a day. Making adjustments is necessary at this time, his Metformin can be increased every couple of weeks with a maximum dose of 2,550 milligrams a day (Arcangelo et al., 2017). Initially his Metformin should be increased to 1,500 milligrams and it is imperative that a follow up be completed to make sure his A1C and HgB are trending in the right direction. Metformin’s effects are typically reached within 24-48 hours so a follow up should be stressed. Research has shown that diabetic neuropathy discomfort can sometimes be managed with medications for seizures, antidepressants and antiarrhythmics but at this time I would recommend starting him on Gabapentin.
Consultation: At the next follow up visit my goal would be to ensure that the patient is making improvements with lab work and that the dosage change in his Metformin and Gabapentin have been beneficial for the patient. I would continue to encourage the patient to monitor his carbohydrate and sugar intake as well as continue any exercise regimen. At this time my only recommendation is that the patient see an endocrinologist for the proper management of his diabetes and neuropathy in his feet.
Reference:
Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics vbk://9781496374066