Interdisciplinary Case Study of Diabetes And Bulimia
Margo is an 18-year-old high school senior attending a school in the upper Midwest preparing for her transition to college. She comes from a Catholic, conservative family of 7. Margo is the second oldest, and is closest with her older sister, Janette. Margo has type I diabetes and regularly takes Glyburide, a prescription medication taken to help control blood sugar. Psychologically, she has undiagnosed bulimia nervosa, but works very hard to hide it from her family. They are unaware of her challenges with bulimia.
Difference between type I and II diabetes
Both types of diabetes are chronic diseases that affect the way your body regulates blood sugar. Glucose is the fuel that feeds your body’s cells, but to enter your cells it needs insulin. Both types of diabetes can lead to chronically high blood sugar levels. This increases the risk of diabetes complications, such as: Hypoglycemia or KetoacidosisIf those are left untreated, it can lead to
- seizures,
- loss of consciousness,
- death, or
- damage to eyes, kidneys, the heart, or the skin.
People with type 1 diabetes do not produce insulin. People with type 2 diabetes do not respond to insulin as well as they should and, as the disease progresses, their body often does not make enough insulin.
Bulimia Nervosa
Bulimia Nervosa is a serious, potentially life-threatening eating disorder that is characterized by a cycle of binging and self-induced purging to compensate for the effects of binging. Perceptions and behaviors that dieting, control of food, and weight loss are primary concerns, frequent trips to the bathroom, signs or smells of vomiting after meals, appears uncomfortable eating around others, drink excessive amounts of water or zero-calorie drinks, teeth are discolored, unusual swelling of cheeks/jaw, frequent diets and diet fads, extreme mood swings, fluctuations in weight (both up and down, normal to large BMI, stomach cramps, non-specific gastrointestinal complaints, feeling faint/syncope, sleep problems, feeling cold all the time, dizziness, cuts or callouses across tops of the fingers, dental problems, dry skin, thinning of hair, muscle weakness, yellow skin, menstrual irregularities, and impaired immune functioning.
Co-occurring conditions
Co-occurring conditions: Substance abuse, anxiety, depression, OCD, impulsivity, self-injury, diabulimia (intentional misuse for type 1 diabetes).
Margo has been sexually active with her boyfriend and became scared when she missed her monthly menstruation cycle. It is usually irregular, but it has been 2 months since her last period. Margo decides to take a pregnancy test and finds out that she is pregnant. Margo had planned to tell her boyfriend at the football game. However, at half-time, Margo felt very dizzy. She told her boyfriend that she was going to go get some water, and on the way to the concessions stand, she collapsed.
Pregnancy when someone has type I diabetes
High blood sugar levels during pregnancy can be very harmful for the fetus. Neural tube defect (such as spina bifida) and congenital malformation of the heart are both possible when blood sugar is high. Low blood sugar also poses a threat to the fetus by limiting the amount of glucose stores, which transfers to the developing infant. This puts the child at risk for long-term conditions such as cognitive deficits, developmental abnormalities, and hypertension. If blood sugar is not controlled during the pregnancy, women are at greater risk for fetal death, pre-eclampsia, delivery by C-section, and birth weights above the 90th percentile. Babies born to women with pre-existing diabetes are also more likely to have breathing problems, jaundice, and low blood sugar levels.
The first responders
The Athletic Trainers on scene are the first responders. The first actions should be ABCs, check Margo for awareness, EMS, call 911, alert the ambulance on-site, and follow the Emergency Action Plan. Describe when EMTs should be called to the field and what their responsibilities should be. The ambulance arrived and rushed Margo to the ER. She experienced temporary loss of consciousness. The attending nurse ran tests and asked Margo a series of questions that ultimately led to the revelation of her pregnancy. Margo’s parents had been called and they were on their way to the hospital. Margo’s boyfriend had followed the ambulance from the field and was in the waiting room anxiously pacing.
The nursing assessment determined Margo’s BP was 88/40; pulse 48; temperature 97. 3; respirations normal. What interventions do the nurses do immediately upon arriving in the ER?ABCs, taking vital signs (recording blood pressure, measuring pulse rate, respiration, temperature, and watching for any change in vital signs), administering medications if needed, prepping for surgery if necessary, setting up and priming an intravenous (IV) infusion or handing over pills for swallowing with water, if needed. If the admitted patient is already on medications, the nurse will confirm the current medication list with the patient or the family, and acquire in-hospital prescriptions and administer as needed.
The nurse will also help with any necessary medical treatment such as infections, stabilization, suturing wounds, intubation, and anything else the doctor needs. Nurses are also required to chart all patient medical history, contact information, current condition and medications, and treatment as well as update their electronic medical record throughout their stay in the ER.
Responsibilities a nurse has in the ER
This can be anything from making sure medications are given to checking on the completion and results of diagnostic tests that are ordered. Nurses may be asked to assist lab technicians in the transport of a patient to a diagnostic test (x-ray, CT, etc. ). Nurses are also in charge of notifying the doctor should the patient’s condition worsen or change.
If Margo was unconscious and had to be intubated, what are some risks associated with that? (RT). Infection, pressure ulcers, Urinary Tract Infection (UTI), injury to throat or trachea, lung complications, aspiration, and complications may increase due to Margo’s diabetes through the use of general anesthesia during the intubation process. Margo decided to tell her boyfriend and parents about her pregnancy. The doctor discussed all the options with Margo, her boyfriend, and her parents. Margo and her boyfriend wanted to continue with the pregnancy. Margo’s parents were shocked at the news of her pregnancy and took their time processing everything. They shared their support for Margo through the pregnancy.
The doctor informed Margo of all the risks associated with pregnancy and diabetes. 6 months into the pregnancy, Margo was experiencing an array of complications. Margo tried to keep her bulimia a secret, but she was hospitalized again and almost lost her baby. She did not want to take any medications while she was pregnant, but she knew she had to change to ensure the safety and health of her baby and herself. Margo was referred to an OT in mental health for help with her health management, coping skills, and help in behavioral changes that she knew were necessary. Margo was also referred to PT for the multiple musculoskeletal issues that had arisen.
The OT’s role
When a person struggles with an eating disorder, their prior roles, rituals, and occupations fade significantly. Their primary occupation becomes the eating disorder and all their thoughts and actions are centered around it. OT would help with re-establishing those previous healthy occupations and the life balance they once had. Through the use of purposeful activities, the OT would focus on 3 main goals with Margo:
- To provide a safe setting where she can engage in occupations in a multi-sensory environment,
- Health management through the control of her diabetes, eating, and engagement in healthy occupations.
- To practice habits that create and reinforce healthy roles, occupations, and beliefs/thoughts.
The OT would address the negative thoughts and beliefs by challenging the cognitive distortions through a multi-sensory environment. This may involve touching, exploring, smelling, laughing, seeing, talking, and hearing. The OT may also use Cognitive Behavioral Therapy to address, re-establish, and create new positive core thoughts in Margo about her ability to have control in her life, self-beliefs, and beliefs about food. The OT may also have Margo participate in group or individual sessions using real life activities. These activities may include: planning and preparing snacks/meals, meal pacing, grocery shopping, clothes shopping, leisure and hobby exploration, socializing with peers and pregnancy groups, goal setting, time management, developing and recognizing sensory preferences, and identifying healthy eating. The OT may also need to ask Margo about her knowledge of child rearing. OT services for Margo may also include life skills, parenting, education on child development and milestones, communication skills, money management skills, and independent living skills should Margo choose to move out of her home with her parents.
The PT’s role
PT can address aches and pains during pregnancy. There should be no modalities used, such as ultrasound or electric stimulation (or any contraindications identified by physician). The first and most important exercises for PT to address are stabilization exercises. This includes core and pelvic floor muscles that help to stabilize the pelvis and lower back during movement. The PT may also create treatment plans that take a comprehensive approach by working on pain’s typical triggers: posture, joint alignment, muscle strength, flexibility, and nerve involvement. The PT should also create an exercise plan for Margo that is safe. Some other treatments for pain that a PT might help implement are SI belts, massage (perineal massage), and education on proper body mechanics. The PT may also create a home exercise program for Margo to aid in her healthy leisure activities and lifestyle.
