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Nursing Assignment: Interpreting & Analysing Medical Conditions Of Sandra Bullock


Nursing Assignment Case scenario:
Sandra Bullock, 39 years of age is seeing a GP, where you work as practice nurse. Over the past 3 weeks, Sandra has noticed significant tiredness, palpitations, and tremor. She has also noted that she is always feeling hot, ‘even when others are feeling cold’. She has lost 5 kg in weight over the past 2 weeks without any effort or exercise. She has also noticed a swelling over the front of her neck. On direct questioning, Sandra has noticed her eyelids are ‘a bit puffy’ and friends have commented that she often looks like she is ‘staring’. Sandra is a mother of 5 children and lives in suburban Melbourne. Sandra works as a Real-Estate Manager. She has been married to Frank, who is an electrician, for 18 years.

Sandra has been suffering from type 2 Diabetes and rheumatoid arthritis for the past two years. She takes metformin (APO-Metformin XR 500 mg tablet daily) and glipizide (Minidiab 5 mg half a tablet daily) to control her diabetes and Ibuprofen (APO-Ibuprofen 400 mg one table daily) for joint pain. She does not get enough opportunity to exercise and depends on “takeaway” for her lunch and eating snacks and ice cream. She states that she often forgets and does not take her medication regularly. Sandra also smokes 5-6 cigarettes daily.

Her mother and older sister were both diagnosed with T2DM in their early 50’s. Her mother also has Hashimoto thyroiditis.

Sandra is quite “stressed” about her ongoing conditions and the recent development of other symptoms.

The examination findings of Sandra are as following –

  • BMI: 29 m2 /kg
  • Blood Pressure: 140/90 mmHg
  • Pulse rate: 105 beats/min, irregular
  • Respiratory Rate: 22 breaths/minute
  • Temperature: 37.7ºC tympanic
  • SpO2: 97% on RA (Room Air)
  • A smooth, mildly enlarged thyroid gland with a bruit (increased blood flow in the thyroid gland), mild proptosis
  • eyelid retraction bilaterally
  • brisk reflexes, and a fine tremor.
  • Sandra’s blood tests reveal –
  • Full blood examination (FBE): haemoglobin: 125 g/L (reference range: 120–150 g/L)
  • White cell count: 11.5 X10^9/L (reference range: 4.0–10.0 X 10^9/L)
  • neutrophil: 8.0 X 10^9/L (reference range: 2.0–7.0 X 10^9/L)
  • lymphocytes: 0.8 X 10^9/L (reference range: 1.0–3.0 X 10^9/L)
  • Platelet: 250 X 10^9/L (reference range: 150–400 X 10^9/L)
  • Free T3 = 15 pmol/L (reference range 3.5 – 6.0 pmol/L)
  • Free T4 = 75 pmol/L (reference range 10 – 20 pmol/L
  • TSH = 0.02 (reference range 0.500 – 4.2 IU/L
  • TSH-Receptor antibody (TSH-RAB AB) = positive and significantly elevated.
  • Antithyroid peroxidase (anti-TPO) and antithyroglobulin = negative or low titre

Part 1 Questions
1. What underlying endocrine condition is indicated by Sandra’s blood test, as well as the signs and symptoms (clinical features) she is experiencing? Describe the pathophysiology of the condition. You need to explain the following aspects in this section and link them to Sandra:

1.1 Identify the underlying condition

1.2 Interpret Sandra’s blood test results and clinical features, and link back to Sandra

1.3 Include at least 4 risk factors relevant to Sandra

1.4 Explain the pathophysiology of the specific condition Sandra is suffering from, making links to Sandra throughout

1.5 Explain at least 5 complications of this condition that are relevant to Sandra

Part 2 Questions
Further blood test results reveal that Sandra’s blood glucose level (BGL) is 12.9 mmol/L [3.9-6.1 mmol/L]; HbA1c: 9% [normal<6.5%].

Sandra’s GP referred her to an Endocrinologist. Her conditions, blood test results and medications were reviewed by the specialist. Sandra was advised to stop metformin and prescribed Tab Sitagliptin (Januvia) 50 mg daily in addition to glipizide 5 mg (Minidiab) half a tablet daily. The Endocrinologist also added Tab Carbimazole 5 mg daily for managing her recently developed signs and symptoms, and the related Endocrinological condition.

2.1. Identify 4 risk factors potentially causing Sandra’s high BGL and HbA1c. Discuss how each risk factor affects BGLs and HbA1c.

2.2 Discuss the three medications Sandra is prescribed by the Endocrinologist. Include in your answer the action, complications, relevant side effects and relevant nursing considerations linked to Sandra’s situation.

2.3 Explain five complications that Sandra could experience if her blood glucose level (BGL) and HbA1c remain high.

2.4 Identify and briefly discuss four preventive measures Sandra could use to reduce her risk of developing complications related to T2DM.


Introduction to the case scenario of nursing assignment
The thyroid is a gland in the neck and has the form of a butterfly. The thyroid gland produces hormones that control some essential processes of the body, such as metabolism. If the thyroid hormone levels are low or too high, thyroid disease is said to occur (Elbers & Germany, 2018). Hyperthyroidism is an endocrine disease in which the T4 and T3 thyroid hormones are higher than their normal ranges, the thyroid-stimulating hormone levels are lower, and the rankings of T3 and T4 hypothyroidism are lower. The thyroid-stimulating hormone level is higher than normal values (Elbers& Germany, 2018).

The aim of this study is to interpret and analyse the medical conditions of Sandra Bullock and understand the risk factors, complications, and related aspects of the patient.

1. PART 1
1.1 Identification of underlying conditions
The endocrine condition of Sandra is hyperthyroidism. Hyperthyroidism is initially diagnosed with high T3 and T4 and low TSH (Thyroid stimulating hormone). Sandra’s blood test shows that levels Free T3 = 15 mol/L are too high based on the reference range 3.5 – 6.0 pmol/L); Free T4 = 75 mol/L increased from 10 – 20 mol/L and TSH = 0.02, which is little compared to the normal range 0.500 – 4.2 IU/L. Sandra's clinical manifestations that include palpitations, trembling, tiredness, heat or cold sensitivity, and swelling on the face of the neck, termed goiter, may corroborate this (Guerri et al., 2019).

1.2 Interpretation of blood test reports
The initial stepwhen TSH is insufficient helped to identify that the patient is having hyperthyroidism, followed by high free T4 and T3 levels. For Sandra, T4 is raised by the normal range of (10 – 20) pmol/L, Free T3 = 15 pmol/L by the reference range of 3,5 – 6,0 and TSH =0.02, which is low compared to the usual range of content of 0.500–4.2 IU/L by the normal range of content (Guerri et al., 2019). Because Sandra's condition is hyperthyroidism, the levels should either be low or negative.TSH-Receptor (TSH-RAB AB) antibody is equivalent to positive and substantially higher. Thyroid stimulant immunoglobulin (TSI) attaches to receptors that stimulate and generate thyroid hormones such as T3 and T4, making them high and low in hyperthyroidism.

On the other hand, hyperthyroidism increases the total number of white blood cells, along with small decreases in the total number of neutrophils and lymphocytes linked with the thyroid gland's involvement in metabolism and blood cell propagation. InSandra’s scenario, White cell count levels are raised: 11.5 x10^9/L, Neutrophil: 8.0 x 10^9/L, leading to elevated thyroid hormones, Lymphocytes. The impact of the enlarged thyroid is also relatively low: 0.8 X 10^9/L. T3 hormonesare the precursor of normal-B cell development, thereby affecting the lineage of blood cells, which results in a little reduction in lymphocyte numbers. Furthermore, hyperthyroidism is not linked with red blood cell and platelet dysfunction but rather with hypothyroidism (Brown et al., 2018). This validates Sandra's typical Full Blood Examination findings.

Hyperthyroidism is linked with an increase in baseline metabolic rate. This explains why Sandra would drop 5kg in two weeks despite no regular exercise. When thyroid hormones T3, T4, and TSH produce cardiac output and left ventricular hypertrophy, the increase in heart output supports a 105-beat/minute rise in heart rate and the irregular effect to enhance palpitations, tiredness, and exercise intolerance. Increased thyroid hormones are linked with increased extra-ocular fat and muscles in the eyes' orbital volume, producing unilateral and bilateral protrusion of the eyes (Aylward, 2021). This explains the clinical characteristic of Sandra's moderate proposal and bilateral eyelid retraction, making Sandra’s eyes a little puffy in appearance and constantly starring. Again, the smooth and slightly enlarged thyroid gland is caused by the synthesis of thyroid hormones that make goiter easier to develop.

Because hyperthyroidism leads to too much thyroid hormone release, it turns muscle fiber to become weak and may break down too fast. Muscle anxiety is therefore reported in individuals with endocrine hyperthyroidism (Mammadkhanova&Azizova, 2020). In addition to a rise in hormones, the diastolic pressure is reduced while systematic pressure is raised and the blood vessels are relaxed; This suggests Sandra’s blood pressure of 140/90 mmHg (Ishchuk, 2018). Hyperthyroidism causes the respiratory traction to stimulate and may lead to dyspnea during exercise, making Sandra respiration rate 22b/min. If excess thyroid hormones are generated, all those hormones produced by the thyroid gland cannot be used by the physiological body's processes. This increases the temperature and causes heat-sensitive and often sucking, so the tympanic temperature of 37.7oC is slightly higher (Ishchuk, 2018).

1.3 Some of the risks that Sandra may be exposed to hyperthyroidism
Being a female, increases Sandra's chance for the illness. As women have ten times the risk of this disease than males, and hence this may be a risk factor.

Another risk factor for Sandra to acquire the underlying illness may be the family history of thyroid disease. This may be accurate since the mother had a history (Caon, 2021). Family history of the patient shows autoimmune disabilities such as Type 1 diabetes that the mother and sister are diagnosed with type 2 diabetes.

Currentautoimmunediseases such as diabetes may raise the chance of hyperthyroidism. Sandra has type 2 diabetes, owing to the high insulin resistance of circulating insulin hormones. This causes the thyroid tissue to proliferate and increase its size, resulting in hyperthyroidism (American Thyroid Association, 2021).

Finally, her age, pregnancy history and stressful lifestyle as well as the unhealthy eating habits can add up to the risk factor of the patient.

1.4 Pathophysiology
Hyperthyroidisms are usually the consequence of the absence or loss of thyroid gland control over thyroid hormones. When thyroid hormone levels are excessive, hypermetabolism is caused, and the stimulating effects of the hormones are increased. This subsequently stimulates the body's sympathetic nervous system, and the sympathetic nervous system is over-stimulated, producing gonadal and hypothalamus hormones. Therefore, the excess thyroid hormones raise the receptor's adrenergic and activate the cardiac system; this leads to tachycardia, increased stroke volumes, heart output that causes palpitations and tremors, and blood flow that leads to hypertension (Khan & Majid, 2021). This ultimately leads to a negative balance of nitrogen, lipid depletion, and human nutritional insufficiency, which leads to hyperthyroidism which is the complications of this disease.

1.5 Complications
Heart issuesare an important complication of a person with hyperthyroidism. Excess thyroid hormones impact the heart function via raising heart rate, thus leading to palpitations,

and affecting the heart rhythm termed atrial fibrillation (Kennedy-Malone, 2018).Brittle bones (osteoporosis) may make someone weak and brittle, if hyperthyroidism is left untreated. Excess thyroid hormones prevent calcium ions and other minerals from entering the bones, which makes the bones weak.Besides, eye issues may arise from Grave's ophthalmopathy and can cause eye problems in futurethat will cause the eyes to swell and bulge. Hormones are linked with the development of extra-ocular fat and muscles in the eye's orbital volume, resulting in unilateral and bilateral eye outgrowth (Kennedy-Malone, 2018).Thyrotoxicosis is a crisis that causes hyperthyroidism to be inadequately handled. When given incorrectly, symptoms may increase, leading to fever and fast pulses, including delirium (Kennedy-Malone, 2018).The excess release of thyroid hormone leads to menstrual and fertility problems that impact metabolism and endocrine system proliferation. This consequently causes over-stimulation in the sympathetic nervous system, therefore modifying gonadal and hypothalamus-pituitary hormones (Kennedy-Malone, 2018).

2. Part 2
2.1 Risk factors

The major four risk factors are as follows-

Stresscan be one of the risk factors, as Sandra's present state of hyperthyroidism is continuously strained. Repeated bouts of stress in diabetes patients may induce hyperglycemia. Itcauses a fast rise in the counterregulatory hormonal epinephrine and cortisol production by changing the emotional and physiological processes (Ighodaro, 2018). As per Sandra’s HbA1c test,it was noticed that the results denoted higher level of BGL in blood. It can be noted here that increase cortisol and epinephrine production leads to growth in the inflammatorycytokine’s circulation, often produce resistance to peripheral insulin and generation of hepatic glucose and increase in BGLs.

Poor adherence to medication may be another risk factor; occasionally, Sandra forgets to take medication. Proper adherenceto medication is linked to improved managementof intermediate-risk factors and frequent hospitalizations (Jannoo& Khan, 2019). HbA1c test result may fluctuate owing to BGL fluctuation.

Poor lifestyle is a risk factor. Sandra does not have time to exercise and often eat fast food. Lifestyle regulates type 2 diabetes; and hence this also raises the risk ofhyperglycemia since quick meals include many calories, similar to a high-fat diet deteriorating the HbA1c reports. The endocrine physiology, therefore, finds it challenging to control blood sugar levels at high caloric.

A poor sedentary habit is a major risk.Exercise regulates blood sugar levels, for example, by combining aerobic exercise with strength training such as yoga and weightlifting. Smoking is also a risk factor since tobacco includes nicotine that affects the efficacy of insulin,and its proper suctioning is necessary to maintain the BGL level(Lee & Choi, 2019).

2.2 Medications
The three important medications are as follows-
Sitagliptin (Januvia) 50 mg daily is the drug used in the treatment of a diabetic condition. This medicine is essential as it helps manage diabetes. Sitagliptin in Sandra will be used alongside diet and exercise and, additional medicines are recommended to her with type 2 diabetes to decrease blood sugar (the state of blood sugar being too high because the body does not make or properly utilise insulin) (Brix et al., 2020). The frequent side effects of this medicine are headache, increased neutrophils, hypoglycemia and infection of the high respiratory tract. Before beginning the course of this medication, Sandra must know these adverse effects.

Glipizide (Minidiab 5 mg half a tablet daily) is a pill that works that will help Sandra in reducing the blood glucose by producing insulin (a natural chemical necessary to break down sugar in the body) and enabling the body to effectively utilise insulin. If Sandra is allergic, the medication should not be provided (Buchan &Andersson Burnett, 2019). Sandra should be informed of the adverse effects of drug-like constipation, dizziness, blurred visionand allergic skin responses. Educating her about healthy diet, personal hygiene and exercise is important. Sandra need to compliant with medication and meals.

Carbimazole is a medication that will help Sandra in the the treatment of an overactive thyroid (hyperthyroidism). It depresses thyroid hormones.The thyroid regulates such things as heart and body temperature (Kitahara et al., 2020). Mild gastric disturbances, hair loss, skin rashesare all side effects of this medication that Sandra may face. Sandra needs to report fever, sore throat, dark urine, hyper or hypoglycemic reactions. Nurse should monitor TSH levels before and during therapy.

2.3 Hyperglycemia complications
The five Hyperglycemiacomplications are as follows-
High levels of blood sugars can stimulate blood vessel damage and heart function control, therefore associated with an increased risk of stroke, blood vessel reduction, heart disease, and high blood pressure (Bahn et al., 2021). Heart and blood vessel diseases are also common. Nerve damageeffects that kill nerve endings owing to excessive sugar levels for a long period result in tingling and numbness and occasionally pain. The renal condition, excessive blood glucose levels, causes damage to the small filters of the kidney. The kidney function is hindered when filtering units are damaged, leading to kidney failure (Anderton&Chivers, 2016).

Slow healing is another consequence of hyperglycemia since it reduces blood circulation across the tissue when blood sugar is elevated. This means that the nutrients are not properly given to the damaged tissues and delayed recovery. High injury to the eye; blood glucose levels contribute to a disease called diabetic macular edema, which may impair sharp vision later if poorly managed and lead to partial or total blindness (Ma & Liu, 2018).

4.4 Preventive action
Sandra needs to stop smoking. Smoking is linked to lung cancer, heart disease, and emphysema that may make Sandra worse. Tobacco also represents an additional risk factor since tobacco includes nicotine, which can affect the efficacy of insulin. Sandra should reduce her diet's sugar and processed carbohydrates (Kocher & Meisel, 2018). Often takeaway meals with high amounts of calories similar to a fat diet aggravate the issue. She should be given sugar-free foods to ensure blood glucose levels are maintained lower. Sandra should also try to reduce her BMI by her weight. High-calorie levels become challenging to control blood sugar levels in endocrine physiology. Sandra should also frequently work out; physical activity will help keep the disease from worsening. Type 2 diabetes exercise regulates blood sugar levels, for example, by combining aerobic exercise with strength training like yoga and weight lifting (Babu et al., 2018).

3. Conclusion
Hyperthyroidism is the underlying condition of Sandra. Since she has type 2 diabetes, by changing her lifestyle, she needs to prevent such problems. Besides, she should also guarantee medication adherence, stop smoking, regular exercise, and consume healthy and balanced nutritional foods to enhance the quality of life.

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