Please respond to the 2 following discussion posts separately with separate reference lists. References not to be older than 5 years.
1.[Onpaneeya Pataky] FNP 592: DQ2, Diabetes is a common illness seen in primary care. Using evidence-based practice, what screening would you need to make to ensure these patients are getting adequate care and health promotion?
Since the question is not clear, I will have to discuss both forms of diabetes mellitus – type 1 (DM1) and type 2 (DM2). 95% of all DM patients in the USA have DM2, and the prevalence is 9.4% or 28 million diagnosed, while the prevalence of DM1 is only 1.25 million cases (Golden et al., 2019). DM1 is a syndrome of disordered metabolism of proteins, fats & carbohydrates resulting in deficits in insulin secretion or action or both and ultimately hyperglycemia; by contrast, DM 2 is the abnormal secretion of insulin, resistance to insulin action in the tissues, and/or inadequate response at the insulin receptors (Golden et al., 2019).
Screening for both DM1 and DM2 includes any of these four tests, however it is recommended to confirm at least the first three with repeat testing with the same test: 1) glycosylated hemoglobin (A1C) of 6.5% or higher, 2) symptoms of diabetes including polyuria, polydipsia, weight loss) plus a random plasma glucose level of 200 mg/DL or higher, 3) fasting (at least 8 hours with no calories) plasma glucose level of 126 mg/dL or higher, or 4) two-hour plasma glucose level of 200 mg/dL or higher during an oral glucose tolerance test (OGTT) with a 75-g glucose load (Golden et al., 2019). Follow-up testing should also include fasting lipid profile, serum creatinine, eGFR, liver function tests, and spot urinary UACR (Golden et al., 2019). If diagnosis between DM1 and DM2 is not clear, a C-peptide measurement reflecting insulin production may be ordered; normal or elevated levels indicate DM2, while decreased levels indicate DM 1 (Golden et al., 2019). At diagnosis and annually thereafter, assessments for end-organ damage should be conducted, including BMI, blood pressure (including orthostatic for older adults), funduscopic eye exam, thyroid palpitation, full skin exam for acanthosis nigricans, and foot exam for diabetic ulcers (Golden et al., 2019).
Reference
Golden, A. K., Thomas, D. J., & Porter, B. O. (2019). Diabetes Mellitus. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter & D. J. Thomas (Eds.), Primary care: The art and science of advanced practice nursing – an interprofessional approach (5th ed., pp. 909-938). F. A. Davis Company.
2.[Lindsay Trent] Diabetes Mellitus is defined as “a syndrome of disordered carbohydrate, fat, and protein metabolism resulting in hyperglycemia that is caused by deficits in insulin secretion, insulin action, or a combination of both” (Dunphy et al, 2019, pg. 909). The prevalence rate of diabetes mellitus in America is approximately 9.4%, with 95% of individuals diagnosed having type 2 (CDC as cited in Dunphy et al, 2019). As advanced practice providers, it is important to understand the risk factors to increase prevention and utilize appropriate screening measures. The United States Preventative Services Task Force (USPSTF, 2021) identifies patients identified as overweight or obese as the highest risk factor, as well as older age, a family history, a history of gestational diabetes or PCOS, and certain dietary and lifestyle factors. There is also a higher prevalence among patients who are American Indian/Alaska Native, Asian, Hispanic/Latino, and Non-hispanic black; as such, providers should consider screening at an earlier age for these patients (USPSTF, 2021). Additionally, there has been a strong association with socioeconomic status, food environment, and physical environments (Hill-Briggs et al, 2020, as cited in USPSTF, 2021). All of these factors should be considered when determining screening plans.
There are several screening tests available, including random plasma glucose, fasting plasma glucose, glycosylated hemoglobin (A1C), and oral glucose tolerance tests or post load glucose levels (Dunphy et al, 2019; USPSTF, 2021). Initially, it is recommended to test for hyperglycemia in the clinic setting using a portable monitor (Dunphy et al, 2019). For continued monitoring, an A1C is ideal as it provides an idea of the average glucose levels over the previous 2-3 months and is not affected by glucose levels that may be elevated due to stress or illness (Dunphy et al, 2019; NIH, 2018; USPSTF, 2021). It helps determine the level of glycemic control and can help determine prescriiption management.
Once diabetes mellitus or prediabetes is diagnosed, ongoing education and management is needed. Lifestyle management is key, including appropriate nutrition therapy and physical activity plans as well as interventions focused on mental health, sleep, and smoking cessation (Dunphy et al, 2019; USPSTF, 2021). The Centers for Disease Control and Prevention (CDC) recommend incorporation of the National Diabetes Prevention Program (DPP) (2021). The DPP’s key component is a lifestyle change program to prevent or delay the progression of type 2 diabetes, including plans for eating healthier, how to add physical activity to a daily routine, and ways to improve coping skills (CDC, 2021).
References
Centers for Disease Control and Prevention (CDC). (2021). What is the national DPP? Centers for Disease Control and Prevention. Retrieved 2022, from https://www.cdc.gov/diabetes/prevention/what-is-dpp.htm
Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019). Primary Care, The Art and Science of Advanced Practice Nursing – An Interprofessional Approach. Davis Plus. ISBN 9780803667181
Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2020;44(1):258-279. Medline:33139407 doi:10.2337/dci20-0053
National Institutes of Health (NIH). (2018). The A1C test & diabetes. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2022, from https://www.niddk.nih.gov/health-information/diagnostic-tests/a1c-test
US Preventive Services Taskforce (USPSTF). (2021). Prediabetes and type 2 diabetes: Screening. Recommendation: Prediabetes and Type 2 Diabetes: Screening | United States Preventive Services Taskforce. Retrieved 2022, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes#citation10
