Non Majors Nancy Dentlinger Health And Social Care Essay

P is a 30-year old long-distance delivery driver from Newcastle, England. He sustained a full-thickness burn to 20% of his body while at work 3 days ago. He was exposed to a hot liquid at temperatures exceeding 180°F. The burn occurred primarily on his right arm, hand, and right side of his chest. He is currently hospitalized on a burn unit and is in stable condition. He was diagnosed with Type 2 diabetes 3 years ago following a routine optician's eye test. On presentation, background diabetic retinopathy was confirmed. He is 1.63 m tall and weighs 113 kg. P has a family history of Type 2 diabetes as his father was diagnosed 10 years ago at the age of 44. P is currently prescribed 500 mg metformin. However, since his first prescription over 2 years ago, he has not ordered any repeat prescriptions. P has experienced problems with compliance since he was first diagnosed. At presentation, he was prescribed 500 mg metformin once a day to be steadily increased to 1000 mg twice daily, but became noncompliant when he experienced diarrhea at higher doses. His lab values were shown to be; HbA1c: 12.3%, Random blood glucose: 347 mg/dl (19.3 mmol/l), Total cholesterol: 77 mg/dl (4.3 mmol/l), HDL-cholesterol: 14 mg/dl (0.8 mmol/l), Triglycerides: 56 mg/dl (3.1 mmol/l). P does not smoke and only drinks socially. P has had difficulties in accepting his diagnosis and so has failed to comply with his treatment. In addition, over the past 2 years, he has missed several hospital diabetes and ophthalmology clinics, practice diabetes clinics and a mobile retinal photography unit appointment, culminating in being discharged from the hospital diabetes clinic. He has also received a strongly worded letter from the practice diabetes clinic explaining the risks of failing to monitor and control diabetes. In addition to attendance problems, P has not tolerated his treatment with metformin. P's job as a long distance delivery driver has a huge impact on his lifestyle. He often eats in cafes and service stations at the side of the road, where the menus can be limited and high in fat. His driving also means he has long periods of inactivity. At previous clinic appointments, he has often expressed concerns about incorporating exercise and healthy meals into this schedule. This scholarly paper will describe the association of a patient who has recently received a severe burn and has pre-existing type 2 diabetes mellitus (T2DM). Unstable blood sugar will create healing difficulties from this resent burn injury. This paper will discuss the progression of a burn and diabetes, how they would relate, and how both diagnosed chronic diseases will relate.

Epidemiology & Ethiology

The lifestyle of the westernized civilization which is becoming an epidemic is creating an increase in the number of people with T2DM. Winer & Sowers, found that 20 million people have diabetes and 5 million of which still are undiagnosed in the United States (2004). People who have diabetes are more likely to develop other diseases as well because of the decreased health status and depressed immune system that is related to T2DM. Some of the diseases that effects people with diabetes are, on set of blindness, amputations, end-stage renal disease, and cardiovascular disease which accounts for more than half of the population's medical resources (Winer & Sowers, 2004). A healthy diet and more exercise incorporated into this westernized population will hopefully decrease the rising prevalence of T2DM.

Burns make up about 45,000 hospitalizations and over a million burn victims will need medical treatment each year (Nelms, Sucher & Long, 2007). Major prevention and medical care advancements have significantly reduced the number of deaths due to burns in recent decades. Burns can be caused by thermal, chemical or electrical exposure. Thermal is the most common and is the result of hot water or fire sources (Nelms, Sucher & Long, 2007). Chemical burns are related to the presents of an acid or alkali such as house hold cleaners or battery acid (Nelms, Sucher & Long, 2007). Electrical burns are caused by the current of electricity trying to become grounded by traveling through your body. When the current runs through the body bone and tissue are damaged. The severity of the damage depends on the voltage level.

The westernized life style has decreased the health status of the population and increased the risk of diabetes. Many nutrients have been diminished in this lifestyle creating a greater risk for disease. As found by Arora, vitamin D levels has been found to be a good indicator of the persons health status as well as results found that could create insulin resistance (2011). When the health status and insulin resistance is reduced the recovery from a burn will be prolonged.

Background Physiology

Insulin is a hormone secreted by the pancreas which helps in metabolizing carbohydrates and storing glucose in the cells for energy. Insulin also helps utilize fat, minerals and protein once eaten. Diabetes has a wide spread affect across the body because of the importance of insulin in supplying the cells, tissues and organs with nutrients. This why many other diseases can develop with diabetes and how healthy lifestyle changes are beneficial. The body functions are regulated through endocrine gland secretions, while digestion is facilitated by the help of exocrine gland hormones (Mahan, Escott-Stump & Raymond, 2012). Insulin is released into the blood by beta cells in Islets of Langerhans found in the pancreas (Mahan, Escott-Stump & Raymond, 2012). Insulin is released when blood sugar levels are high to help the cells absorb glucose to help lower blood sugar levels. When blood sugar levels are low in the blood, glucagon is released by the pancreas which released stored glucose to raise blood sugar levels (Mahan, Escott-Stump & Raymond, 2012). Insulin acts as a key to allow cells to receive glucose by binding to cell surfaces by insulin receptors (Praveen, Sahoo, Khurana, Kulshreshtha, Khadgawat, Gupta, Dwivedi, Kumar, Prabhakaran, & Ammini, 2012). Exterior insulin receptors are on the outside of the cells and help insulin bind to the cell. The interior insulin receptors send a signal to glucose transporters to receive glucose. Once blood sugar levels have decreased the glucose transporter goes back into the cell and the receptors empty (Mahan, Escott-Stump & Raymond, 2012). Glucose production is decreased from non-carbohydrate sources such as protein when the liver releases glucose into the blood (Mahan, Escott-Stump & Raymond, 2012). Insulin affects fat by creating and stopping the breakdown of fat in certain situations. Insulin can stimulate protein creation affecting muscle growth and creating fat from simple sugar which become triglycerides (Mahan, Escott-Stump & Raymond, 2012).

Skin is the largest organ of all the organ systems and is a main source of protection from pathogens and stability. The skin is so important because of how quickly it can send a message to the brain of the sensation of touch, re-growth from minor to severe injuries, and heals wounds. The first layer of the skin is called the epidermis comprised of stratified squamous epithelial cells (Mahan, Escott-Stump & Raymond, 2012). The epidermis is made up of five sublayers; stratum corneum, stratum licidum, stratum granulosum, stratum spinosum, and stratus basale forming the outermost layers of skin (Mahan, Escott-Stump & Raymond, 2012). Normal skin production and death involves the removal of this epidermis layer over several weeks to bring new skin to the surface (Mahan, Escott-Stump & Raymond, 2012). The second layer is the dermis anchoring the epidermis to the body. The dermis provides the most protection and contains hair follicles, blood vessels, sweat glands, nodes, and blood vessels (Mahan, Escott-Stump & Raymond, 2012). The skin also regulates body temperatures through shivering and sweating. The skin helps maintain the body's chemical balance through absorption of chemical such as oxygen and carbon dioxide and excretion through sweat (Mahan, Escott-Stump & Raymond, 2012). The skin also helps regulate fluids from the protective layer between bodily organs and the environment. The skin becomes more sensitive from the regeneration of new tissue over the wound and is aged more rapidly. The skin provides the sensation of being cold, hot, sense of touch, pain, and pressure (Mahan, Escott-Stump & Raymond, 2012).

The normal functions of insulin bring glucose into the cell and the many functions of the skin help the body stay in a healthy state. When these functions are disrupted the entire body can be affected. When the normal function of insulin and glucose are disrupted such as the case in T2DM, the body is at a suppressed immune state creating an opportunity for other diseases or infections to coexist. When the skin is compromised such as in a burn the main functions of the skin are disrupted. Temperature regulation is disrupted, fluids are lost from the wound, and pathogens have an entrance into the body increasing the risk of infection.

Relationship between Clinical Manifestations, Laboratory and Diagnostic Studies and Medical Diagnoses need cite

People with T2DM may or may not experience symptoms related to diabetes. Diabetes is a chronic lifelong progressive disease that usually starts affecting the body long before it is diagnosed. Many of the risk factors related to T2DM are; family history of the disease, aging, obesity, inactivity, and ethnicity (Mahan, Escott-Stump & Raymond, 2012). Many of these risk factors can be prevented through nutrition education and increased physical exercise. A small decrease of 5-10% in body weight can help bring glucose levels back to normal in a person with pre-diabetes (Mahan, Escott-Stump & Raymond, 2012). Insulin resistance causes decreased clearance of glucose from carbohydrates causing high glucose levels in the blood (Mahan, Escott-Stump & Raymond, 2012). Insulin resistance can be caused by the shape of insulin, signal problems, not enough insulin receptors, or malfunctioning glucose transporters (Mahan, Escott-Stump & Raymond, 2012). As insulin resistance increases the pancreas can not keep up with the demand, blood glucose levels continue to rise and diabetes is diagnosed. Individuals at high risk or over the age of 45 should be tested for T2DM. If a person at high risk shows normal glucose levels they should be tested again every three years using one or a combination of these tests; A1C, FPG, or two hour OGTT (Mahan, Escott-Stump & Raymond, 2012). A1C is the gold standard in testing for T2DM. A1C is glycosylated hemoglobin test which measures the glucose level in the body over a long period of time, the proteins attach to the glucose in a non-enzymatic way showing a weighted average of plasma glucose concentration (Mahan, Escott-Stump & Raymond, 2012). T2DM is unique in that it can be prevented and help in treatment through a lifestyle of healthy food choices and physical activity. Maintenance of weight and increased physical activity can prevent or delay T2DM in many individuals (ADbA, 2001). Lifestyle changes including preventing weight gain and maintaining weight loss through physical activity is important along with medical management. Whole grains improve sensitivity to insulin and dietary fiber's ability to increase insulin sensitivity and secretion are associated with decreased risk of diabetes (Mahan, Escott-Stump & Raymond, 2012). As the disease progresses beta cells will be lost, exogenous insulin and medication will be needed to control glucose levels. Insulin will be needed faster and at a much higher rate with a chronic illness such as a full thickness burn (Mahan, Escott-Stump & Raymond, 2012).

The percentage of the body affected by the burn and the burn depth determines the classification of the burn; superficial, partial thickness, deep partial thickness or full thickness (Nelms, Sucher & Long, 2007). The symptoms will vary with the classification of the burn. The response to the burn of severity, treatment and recovery depend on the victim's pre-burn health status, nutrition status, and age (Nelms, Sucher & Long, 2007). Sunburn is a superficial burn of the top layer of epidermis, which will turn red and heal quickly. Partial thickness deep burns into the epidermis and dermis which will be open, weeping, and painful (Nelms, Sucher & Long, 2007). Full thickness burns can affect all layers of the skin, muscle and tissue all the way to the bone. The diagnostic measurement used to determine the percentage of the body that has been affected by the burns is the rule of nines method. The rule of nines divides the body up into portions each combined creating nine percent (Nelms, Sucher & Long, 2007). This rule of nine is helpful in quick estimation of the amount of surface area that has been affected to administer medication and fluids.

Many different clinical manifestations are found for T2DM and burns but the most common are obesity and fire respectively. The diagnoses for T2DM is done through lab values the gold standard uses A1C. The diagnoses for the degree of burn depend on the physical examination of the wound. In the case study P had T2DM and a full thickness chemical burn. This is an uncommon type of burn that was received while he was working as a truck driver. Since his burn was a full thickness burn it will be deep and need time to heal. During this period of healing he will need to make sure it is clean so that infection does not set in. His uncontrolled T2DM will cause an increased immune suppression situation allowing an opportunity for his wounds to become infected. Along with education on how to clean and take care of the wound special attention will need to be taken in educating him on his immune suppressed state.

Pathophysiology

T2DM is characterized by beta cell and insulin resistance failure (Mahan, Escott-Stump & Raymond, 2012). Insulin levels in the body could be normal, decreased or elevated but because of decrease sensitivity to insulin resistance occurs starving the cells of nutrients. The starving cells signal to the pancreas to produce more insulin so that they can receive the nutrients they need this creates an over production and hyperglycemia occurs. This is when most people are diagnosed. Hyperglycemia is witnessed by elevated blood glucose readings after a meal caused by insulin resistance creating an elevated fasting glucose concentration (Mahan, Escott-Stump & Raymond, 2012). Liver glucose production is then elevated from decreased insulin secretion causing increased fasting blood glucose. Increased abdominal fat increases free fatty acids to the liver creating an increase in which in turn creates insulin resistance and cellular sensitivity.

The severity of the burn will determine the level of treatment that will need to be administered. The rapid fluid shift, fluid accumulation, and inflammation cause the shock after receiving a server burn (Nelms, Sucher & Long, 2007). The first step in treating a burn will be re-stabilization from the shock by administering fluids. After re-stabilization and fluid administration, the wounds will need to be cleaned and covered in most cases. Several conditions can present secondary to the burn itself such as; hypoxia from the decreased oxygen in a fire, carbon monoxide from a fire decreasing oxygen availability in the body from the binding of CO to oxygen, and the body's inability to regulate its temperature (Nelms, Sucher & Long, 2007). Patients' physiological response to burns is through the metabolic stress process (Nelms, Sucher & Long, 2007). Metabolic stress alters hormone status which will causes an increase in substrate and decrease carbohydrate, protein, fat, and oxygen utilization (Nelms, Sucher & Long, 2007). Hypermetabolism increased metabolic activity rate, catabolism metabolic pathways, altered immune and hormonal response will all change as a response to the severe burn (Nelms, Sucher & Long, 2007). Respiratory complications are common in burn patients from either the smoke or chemicals breathed in during the burn incident or by fluid resuscitation, inflammation and infections (Nelms, Sucher & Long, 2007). After trauma such as a burn, increased protein is needed not only to rebuild damaged tissue but also from protein lost in exudate. Burn patients are prone to developing an infection because of the depth of a full thickness burn penetrating all levels of the skin creating an increased energy and protein need (Greenwood, 2009). According to the study by Steinstraber, et. al., further research on the affect of protein on wound healing will hopefully create new methods of creating healing (2010). Acute-phase protein mobilization found in the liver which are changed in response to the burn injury increase the loss of lean body mass and increase negative nitrogen balance during the inflammatory response after a burn incident (Nelms, Sucher & Long, 2007). An increase in free fatty acids is also seen from an increase in lipolysis from increased catecholamines and cortisol circulation. The increase of these substances in the body increases the ratio of glucagon to insulin, correlating with hyperglycemia during metabolic stress (Nelms, Sucher & Long, 2007). The initial response to metabolic stress will increase glucose production and epinephrine, which decreases insulin release (Nelms, Sucher & Long, 2007).

The increased glucose production and decreased insulin release in a normal person with a burn would create increased blood sugar levels. With a person with uncontrolled T2DM who already has a high A1C of uncontrolled T2DM will have even higher levels of blood sugar levels after receiving a burn. This increased glucose production initially after a burn will need to be taken into consideration when controlling a T2DM patient blood sugar levels. After metabolic stress and the initial shock decreases the blood sugar levels will become more regular to his normal condition. Since he has not been controlling his blood sugar levels he will need to figure out what his normal blood sugar levels will be. He will need to change his diet initially to provide enough energy and protein to promote healing and defend against infection. After the initial healing and risk of infection has decreased he will need to change to a diet which will help stabilize his blood sugar levels.

Implications and Expected Prognoses/Outcomes

Prognoses of the T2DM disease depend on the degree of blood sugar control the patient has while living with the disease. The slower the disease progresses the better control the patient has and the better their prognoses will be (Mishra, Son, & Arnzen, 2012). Education on methods a patient can use to help control their blood sugar will increase their likelihood of a better prognosis. Progression of uncontrolled T2DM can lead to many diseases such as; end-stage renal disease, neuropathy, diabetic retinopathy, cardiovascular disease and even cancer (Mahan, Escott-Stump & Raymond, 2012). The progression of these diseases will in crease the patient's morbidity and mortality rate severely if high blood sugar levels are not controlled. A blood glucose reading of higher than 100mg/dL is uncontrolled and correlated with further development of disease states (Seshasai SR, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, et al. 2011). Obesity related T2DM has been shown that a decreased diastolic function is present increasing the risk of early heart failure (Shah AS, Khoury PR, Dolan LM, Ippisch HM, Urbina EM, Daniels SR, et al., 2011). This is why early prevention is the key to preventing progression into a further chronic disease. As the person loses beta cells the severity of the disease will increase.

A full thickness burn will most likely cause long term scarring where as partial thickness burns normally would not cause scarring. Silver sulfadiazine cream and silver nitrate are both topical agents used to manage infections in burn wounds (Nelms, Sucher & Long, 2007). Many other treatments are also used to treat the wound such as; cleaning, debride, and dressing the wound. Full thickness burns need to be closed through grafting or skin substitutes (Nelms, Sucher & Long, 2007). According to the study by Al-Ibran, Rao, Fatima, Irfan, Iqbal & Khan, Staphylococcus aureus was found to be the organism that caused the most infections in burn patients (2011). Collogen dressings for wounds, studied by Singh, Gupta, Soni, Moses, Shukla and Mathur, found that collogen dressings have somewhat improved the healing time of wounds. However, further research needs to be done to see if it would be an effective treatment for all types of burn wounds (2011).

A possible treatment for T2DM patients with burns is the use of glutamine supplementation. Glutamine supplementation was found to decrease the mortality rate and infection level of burn patients (Pattanshetti, Powar, Godhi, & Metgud, 2009). Treatments for burns are dependent on the degree and type of burn inflicted.

Summary

The association of T2DM and burns is related by the patient's pre burn health status and control of diabetes. If the patient is in poor health or nutrition status before the burn incident, the process of providing adequate nutrition for the patient once the burn occurs will be more difficult. The status of the blood sugar control from A1C tests will provide information to the health team treating the patient with T2DM and burn. If the patient has uncontrolled T2DM resulting in chronic high blood sugar levels, the patient will be at risk for developing other complications during the healing process. T2DM patients also have reduced immune systems and with uncontrolled blood sugar levels this reduction will decrease even more. The control of the T2DM patient's blood sugar levels to remain as stable as possible throughout the healing process is important for a fast recovery of the burn. The education component during the patient's recovery from the burn on how the stabilization of their blood sugar levels and A1C will affect their recovery is very important.

The case study patient who has T2DM and a full thickness burn will have a more difficult time healing because of high blood sugar levels. People with T2DM are asked to check their The stabilization of his blood sugar levels is crucial for his full recovery from the burn, so he will need to have education on not only how to properly care for his burn wounds but also how to control his blood sugar levels. Since he has refused to receive education about his diabetes in the past this education component will most likely be difficult. Telling him the risks of not controlling his blood sugar and the prolonged recovery of his burn wounds hopefully will create an incentive for him to receive some education. Working with him to combine his doctor appointments for his burns and counseling with the dietitians might also help him be able to attend both visits since he is on the road often as a truck driver. Hopefully, this burn will be a wake up call for him to start taking care of himself and control his T2DM.

Self Reflection

This case was an interest for me because I have had personal experience with a severe burn. My dad is a retired fire fighter and during a grass fire he was burned severely from trying to save a fellow firefighter from the engulfing flames. He received 3rd degree or full thickness burn over 40% of his body. He received burns on both arms, both thighs, and buttocks using the rule of nines, discussed previously, would equal 40%. He was rushed to the Oklahoma Burn Center for treatment and had several grafts done for the full thickness burns. He does not have T2DM and it took him many years to recover from the burns. I would image how much more difficult it would be for someone who has uncontrolled T2DM to recover from a burn. Years after recovery his skin is still sensitive and he has had multiple skin cancer spots removed from the areas that was burnt. So a person with T2DM who already has an increased risk of cancer, risk will increase with a burn. The person who has received a burn and has T2DM two risk factors for skin cancer should watch for signs of skin cancer closely.

Citations take off (-)

Al-Ibran, E., Rao, M. H., Fatima, K., Irfan, S., Iqbal, M. S., & Khan, M. (2011). Current

bacteriological profile in fire-burn victims and their associated mortality at the

burns centre, karachi-pakistan. Pak J Med Sci, 27(4), 789-792.

- (Al-Ibran, Rao, Fatima, Irfan, Iqbal & Khan, 2011) YES

Pattanshetti, V. M., Powar, R. S., Godhi, A. S., & Metgud, S. C. (2009). Enteral

glutamine supplementation reducing infectious morbidity in burns patients: A

randomised controlled trial. Indian J Surg, 1(71), 193-197. doi: 10.1007/s12262-

009-0056-x

- (Pattanshetti, Powar, Godhi & Metgud, 2009) YES

Singh, O., Gupta, S. S., Soni, M., Moses, S., Shukla, S., & Mathur, R. K. (2011).

Collagen dressing versus conventional dressings in burn and chronic wounds: A

retrospective study. Journal of cutaneous and aesthetic surgery, 4(1), 12-17.

- (Singh, Gupta, Soni, Moses, Shukla & Mathur, 2011) yes

Steinstraber, L., Jacobsen, F., Hirsch, T., Kesting, M., Chojnacki, C., Krisp, C., &

Wolters, D. (2010). Immunodepletion of high-abundant proteins from acute and

chronic wound fluids to elucidate low-abundant regulators in wound healing.

Research Notes, 3(335), 1756-5000.

- (Steinstraber, Jacobsen, Hirsch, Kesting, Chojnacki, Krisp & Wolters, 2010) YES

Arora, C. P. (2011). Role of vitamin D in modulating gestational diabetes. Biopolymers

and cell, 27(2), 85-92.

(Arora, 2011)

Winer, N., & Sowers, J. R. (2004). Epidemiology of diabetes. The journal of clinical

pharmacology, 44(4), 397-405.

(Winer & Sowers, 2004) no

Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krause's food and the

nutrition care process. (13 ed., Vol. 1, pp. 675-710). St. Louis, Missouri: Elsevier

Saunders.

(Mahan, Escott-Stump & Raymond, 2012) no book

American Diabetes Association (ADbA): Nutrition recommendations and interventions

for diabetes: A position statement of the americal diabetes association. Standards

of medical care in diabetes-2011 (Position Statement), Diabetes Care 34(Suppl1):

S11, 2011. NO

Seshasai SR, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, et al.

Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med.

Mar 3 2011;364(9):829-41.

(Seshasai SR, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, et al., 2011) NO

Shah AS, Khoury PR, Dolan LM, Ippisch HM, Urbina EM, Daniels SR, et al. The effects

of obesity and type 2 diabetes mellitus on cardiac structure and function in

adolescents and young adults. Diabetologia. Apr 2011;54(4):722-30.

(Shah AS, Khoury PR, Dolan LM, Ippisch HM, Urbina EM, Daniels SR, et al., 2011) No

Nelms, M., Sucher, K., & Long, S. (2007). Nutrition therapy and pathophysiology.

Belmont, CA: Thomas Brooks/Cole.

(Nelms, Sucher & Long, 2007) no book

Greenwood, J.E. Burn injury and explosions: an Australian perspective. Eplasty. 2009

Sep 16; 9: e 40.

(Greenwood, 2009) yes used

Mishra, N. K., Son, R. Y., & Arnzen, J. (2012). Towards automatic diabetes case

detection and ABCS protocol compliance assessment. Clinical Medicine and

Research, 10 (3), 106-121.

(Mishra, Son, & Arnzen, 2012) yes

Praveen, E., Sahoo, J., Khurana, M. L., Kulshreshtha, B., Khadgawat, R., Gupta, N.,

Dwivedi, S. N., & Kumar, G., Prabhakaran, D., and Ammini, A. C., (2012).

Insulin sensitivity and β-cell function in normoglycemic offspring of individuals

with type 2 diabetes mellitus: Impact of line of inheritance. Indian journal of endocrinology & metabolism, 16(1), 105-111.

- (Praveen, Sahoo, Khurana, Kulshreshtha, Khadgawat, Gupta, Dwivedi, Kumar, Prabhakaran, & Ammini, 2012)yes