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Synthisis Paper

Desiree L. Cripps

School of Nursing, James Madison University

NSG 461: Pathophysiology and Pharmocogy

Professor Samantha Leontie, MSN

April, 16, 2023

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Synthesis Paper

Disease Information

There is an interplay of disease processes that have detrimental effects on the health of

Americans. Type 2 diabetes is the most prevalent form of diabetes myelitis in the United States

and has been doubling in statistics for the last 20 years (McCance & Huether, 2014). Coronary

artery disease is the main cause of death in the United States (DynaMed, 2023). Obesity has

become a global concern affecting even children and teens that continue suboptimal lifestyle

habits into adulthood (McCance & Huether, 2014). One cannot modify risk factors such as age,

male or female after menopause, and genetics. However, one can change lifestyle to lower the

risk for these diseases by incorporating regular exercise and eating nutritious whole foods

(McCance & Huether, 2014). This paper aims to share the pathological processes of obesity,

Type 2 diabetes, and coronary artery disease, their connection, and how the nurse may serve

populations at greater risk.

Pathophysiology

Genetics and obesity contribute to developing insulin-resistant Type 2 Diabetes.

Typically, the liver, adipose tissue, and muscles receive insulin through their tissues; this helps to

process oncoming glucose. However, in Type 2 diabetes, these tissues are flawed and reject the

insulin. Excess glucose remains in the bloodstream (McCance & Huether, 2014). The pancreas

compensates by producing more insulin, creating hyperinsulinemia. Eventually, the pancreas's

islet cells malfunction, resulting in insulin insufficiency. Beta cell mass decrease and die due to

exposure to excess glucose, free fatty acids, and adipokine inflammation (McCance & Huether,

2014).
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A patient with type 2 diabetes has infections that are challenging to heal due to decreased

blood flow or neuropathy. The patient can experience changes in vision from damaged blood

vessels, retinopathy, damage, and numbness or weakness in limbs. (DynaMed, 2023). If

untreated, type 2 diabetes may lead to coronary artery disease, cerebrovascular disease, and

peripheral artery disease. A person can improve their health by losing weight through exercise,

monitoring their nutrition, and lowering blood pressure values (McCance & Huether, 2014).

Coronary Artery Disease is the reduction of the coronary artery by the accumulation of

lipid plaques inside the arterial wall (DynaMed, 2023). After the prolonged buildup of plaque on

the coronary arterial wall, atherosclerosis manifests. The pathology of atherosclerosis is

inflammatory. In time, the lining of the artery is injured by risk factors like hypertension,

smoking, diabetes, low HDL levels, and high LDL levels. The endothelial lining becomes

inflamed from injury and unable to make adequate amounts of vasodilating and antithrombotic

cytokines. Excessive cytokines such as interferon-gamma, interleukin-1, factor-alpha, CRP, and

toxic oxygen radicals are released during this aggravated response (McCance & Huether, 2014).

The compromised endothelium becomes invaded by macrophages attaching (VCAM-1) to the

injury and secretes enzymes and toxic radicals that oxidize LDL and cause more compromise to

the arterial wall. Growth factors prompt smooth muscle proliferation at the damage of the artery.

Fibrous plaques form and potentially calcify. If the plaque ruptures, it will trigger the formation

of platelets and activate the clotting cascade resulting in inadequate blood perfusion and heart

attack (McCance & Huether, 2014).

A person may not experience symptoms in the early stages of CAD. Still, with the

increase of plaques on the arterial wall, a person will develop either stable or unstable angina

(tightening of the chest wall) or, worse, a heart attack (McCance & Huether, 2014).
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In obesity, adipocytes release several hormones and cytokines called adipokines, which

serve a broad role throughout the body, including metabolism, lipid deposit, and insulin

acceptance. When a person carries excessive visceral fat, the adipocytes become defective and

malfunction in the regulation and interplay of hormones. This flaw in adipocytes stimulates

macrophages to invade, causing an inflammatory response from TNF-a and IL-1b (McCance &

Huether, 2014). The inflammation and change in adipokines, neurotransmitters, and hormones

provide optimal conditions for obesity and related disorders, Type 2 diabetes, and cardiovascular

disease. Obesity involves high levels of leptin, insulin, retinol-binding 4 protein, and ghrelin in

the blood and low levels of adiponectin and peptide YY (McCance & Huether, 2014).

The distribution of adipose tissue to the abdomen and upper body is related to several

systemic complications, metabolic syndrome, cancers, type 2 diabetes, and cardiovascular

disease, which are prominant causes of morbidity and death in our country (McCance & Huether,

2014).

Excessive body mass is foundational to the pathogenesis of insulin resistance—

disproportionate visceral adipose tissue causes defective adipocytes. The faulty adipocytes

contribute to the dysfunction of metabolism, lipid storage, and insulin acceptance. The invasion

of macrophages causes inflammation. Free fatty acids, Cytokines TNF-a and IL-6 contribute to

insulin resistance, lipid imbalance, and formation of atherosclerosis. The dysfunction of B-islet

cell compensation of the pancreas and insulin resistance leads to type 2 diabetes. Low HDL, high

LDL, and type 2 diabetes contribute to arterial wall trauma in coronary artery disease (McCance

& Huether, 2014).

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Treatment of the Disease

Pharmacologic Treatment

Metformin is an anti-diabetic medication in the Biguanide class (Hazard & S Sanoski,

2019). It is the first-line therapy for type 2DM (DynaMed, 2023). It works by lowering glucose

production in the liver and the assimilation of glucose in the intestine. Metformin helps tissues to

accept insulin to achieve stable glucose levels. Metformin is taken orally with food, 500-2000mg

daily. The nurse educates the patient on the importance of taking their Metformin medication

simultaneously every day. Side effects can be bloating, diarrhea, nausea, and vomiting. The

adverse impact would be Lactic Acidosis. Metformin may lower Vit D levels (Hazard &

Sanoski, 2019).

Glipizide (Glucotrole), and Glyburide (Diabeta) are Anti-diabetics in the Sulfonylureas

class (High Alert). Sulfonylureas activate insulin secretion from the pancreas and enhance the

acceptance of insulin at tissue receptors, thereby decreasing blood glucose. These drugs also

contribute to lowering glucose production in the liver. Standard dosing with Glipizide is oral, 5 -

40 mg daily. Elderly patients start conservatively at 2.5 mg. Glyburide (Diabeta) oral, 2.5mg

daily. Elderly patients start lower with 1.25mg daily. The nurse educates the patient on the side

effects of drowsiness, headache, constipation, diarrhea, nausea, and vomiting. Photosensitivity

can affect the skin nurses should instruct patients to use sunscreen. Hypoglycemia may occur—

adverse effect Aplastic anemia. The nurse will discuss hypoglycemia signs with the patient,

teach the patient to drink orange juice, and notify the doctor. The patient should avoid alcohol

(Hazard & S Sanoski, 2019).

Atorvastatin (Lipitor) is an HMG-CoA Reductase Inhibitor/Statin. It treats cardiovascular

disease and patients with diabetes to reduce cholesterol and dyslipidemia by obstructing the
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enzyme HMG-CoA reductase from the construction of cholesterol. The daily dosage is 10-20 mg

orally. Side effects include confusion, headache, blurred vision and sexual dysfunction,

insomnia, chest pain, edema, and arthritis. An adverse impact is Rhabdomyolysis. The nurse

educates the patient not to drink more than 200ml of grapefruit juice a day and encourages the

patient to comply with the diet and exercise regime. The patient should be aware to notify the

provider of adverse pain or muscle disturbances (Hazard & S Sanoski, 2019).

Lisinopril is an Angiotensin-Converting Enzyme Inhibitor. Ace inhibitors stop the

conversion of angiotensin I to angiotensin II. Additionally, Ace inhibitors help preserve

vasodilatory prostaglandins, maintaining systemic vasodilation and lowering hypertensive blood

pressure. Lisinopril is prescribed for heart failure and post-myocardial infarction. The dosage is

10-40 mg oral daily. Side effects are cough, vertigo, and hypotension. An adverse effect is

Agranulocytosis. The nurse should monitor the patient's blood pressure and pulse before

administration. Educate the patient to avoid salt in their diet. Additionally, the patient should

change positions slowly to prevent hypotension (Hazard & S Sanoski, 2019).

Liraglutide (Saxenda) is an Anti-diabetic medication. It is for weight loss in obese

patients who experience one comorbidity, such as Type 2 diabetes. This drug releases insulin to

rebalance high glucose levels. It also decreases appetite, supporting lower calorie consumption

(Hazard & S Sanoski, 2019). Liraglutide is administered subcutaneously, 0.6mg, daily. Side

effects include headache, tachycardia, rash, diarrhea, and nausea. Adverse effects are thoughts of

suicide, thyroid cell tumors, and pancreatitis. The nurse will educate the patient not to double a

dose. The medication pen is kept refrigerated. Nausea is the most common side effect of

Liraglutide patients (Hazard & S Sanoski, 2019).

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Orlistat (Xenical) is a peripherally acting anti-obesity agent. It is a lipase inhibitor that

obstructs fat from being metabolized. The dosage is 120 mg orally three times a day with a meal.

Side effects are oily stools, stomach pain, and nausea—adverse effects are kidney or liver

complications. The nurse should encourage the patient to continue the low-calorie diet and

exercise plan. The nurse educates the patient to eat some fat when taking Orlistat; however, not

exceed 30% of daily fat intake (Drugs.com, 2023).

Role of the Nurse

The nurse must be aware of cultural, social, and psychological factors involving patients

with Type 2 diabetes, CAD, and obesity. Minority populations tend to have increased rates of

type 2 diabetes and its associated disorders. To provide culturally competent care, the nurse can

communicate in the same language using a qualified healthcare interpreter (Caballero, 2018).

The nurse can discuss the patient's perception of their daily habits and beliefs about their health.

By respecting and listening to the patient, the nurse can recognize disparities and connect the

patient to appropriate resources. Initiating clear communications between the patient, nurse, and

care team is the foundation for patient success (Caballero, 2018).

Patient compliance with medication, diet, and exercise treatment is essential for optimal

outcomes. Some patients experience barriers that the nurse must consider from a non-judgmental

perspective. Low SES connects to the development of Type 2 diabetes and cardiovascular

diseases (Caballero, 2018). The nurse should remind the provider of any adjustment to treatment

plans with finances in mind. The nurse considers food insecurity when expecting a patient to

change diet. Cultural preferences require tailored nutritional education provided by a dietician.

Depression is frequent in someone diagnosed with type 2 diabetes, impacting medication and
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exercise adherence. The nurse can start a discussion by asking basic depression screening

questions to the patient to assess for appropriate resources (Caballero, 2018).

Women of Latin and African cultures may perceive having extra body weight as healthy.

Education to patients should be respectful of their perceptions of body weight. Since a gym may

not be the preferred way to exercise, the nurse can consider ways for a person to enjoy exercise

within their social norm. A Latina may like to dance, or African American may prefer to play

basketball. Nurses can inspire patients to incorporate exercise routines within their community

(Caballero, 2018).

A patient's religion can influence their perception of developing a disease. A person can

feel they brought on ill health by sin or that disease is a punishment. The nurse can help to

encourage the patient to be forgiving, explain how diabetes occurs, and learn about how to

manage Type 2 diabetes to improve their health. Nurses should consider holy observations such

as Ramadan. Every year for one month, Muslims fast during sunlit hours. Dehydration and

hypoglycemia are concerns; protocol management is available for Muslim patients. The nurse

will address any religious beliefs with her patient that may impact care (Caballero, 2018).

Conclusion

Obesity is genetically and environmentally influenced, reaping a cascade of pathology leading to

type 2 diabetes, dyslipidemia, cardiovascular disease, and more. A person should adhere to their

pharmacologic treatment to create balance within their body. While additionally incorporating

positive habits such as whole foods nutrition and regular exercise to improve health outcomes.

The nurse plays a vital role in listening to a patient's perception of their health and providing

culturally competent non-biased care for the best health outcomes.

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References

Caballero AE. (2018) The "a to z" of managing type 2 diabetes in culturally diverse populations.

Front Endocrinol (Lausanne). 9:479. doi:10.3389/fendo.2018.00479.

Drugs.com. (2023, February 24). Xenical: Uses, dosage & side effects guide. Retrieved April 12,

2023, from https://www.drugs.com/xenical.html#uses

DynaMed. Diabetes Mellitus Type 2 in Adults. EBSCO Information Services. Accessed April

12, 2023. https://www.dynamed.com/condition/diabetes-mellitus-type-2-in-adult

DynaMed. Coronary Artery Disease (CAD). EBSCO Information Services. Accessed April 11,

2023. https://www.dynamed.com/condition/coronary-artery-disease-cad

DynaMed. Obesity in Adults. EBSCO Information Services. Accessed April 10, 2023.

https://www.dynamed.com/condition/obesity-in-adults

Hazard Vallerand, A., & Sanoski, C. A. (2019). Davis's drug guide for nurses (16th ed.). F. A.

Davis Company. American Association of Colleges of Nursing. (2017, April 26). Nurse

Faculty Shortage. http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-

shortage

McCance, K. L., & Huether, S.E. (2014). Pathophysiology: The biologic basis for disease in

adults and children (7th ed.). Elsevier.