Modeling Patient with Diabetes - Research Paper Example

I’m about to meet with a new patient. The patient is an adult male who has received a diagnosis of type 2 diabetes. This consultation is in regardsto diet and exercise in his health regimen. I am going to use the Gibbs model of reflection to discuss how I handled this consultation. Gibbs model of reflective practice: (1) Description Action Plan Feelings Conclusion Evaluation Analysis Gibbs (1998) I prepare for the consultation by reviewing the facts on Type 2 diabetes. It the most common form of diabetes. (American Diabetes 2005) My patient’s body is either not producing enough insulin or his body is not utilizing the insulin correctly. This insulin is necessary for his body to process sugar, and transfers it from his blood to his cells for energy. (American Diabetes 2005) Without this process his cells will be starved for energy or he may incur damage to his eyes, kidneys, nerves or heart. The early symptoms he was likely to have had were frequent urination, excessive thirst, extreme hunger, unusual weight loss, increased fatigue, irritability, itchiness, especially around the genitals, due to yeast infection, recurrent infections on the skin, e.g. yeast infections or boils, and blurred vision, none of which appear life threatening on their own. (American Diabetes 2005) People with diabetes have the same nutritional needs as anyone else. Along with exercise and medications (insulin or oral diabetes pills), nutrition is important for good diabetes control. By eating well-balanced meals in the correct amounts, an individual can keep his/her blood glucose level as close to normal (non-diabetes level) as possible. A diabetic’s meal plan is a guide that tells an individual how much and what kinds of food he/she can choose to eat at meals and snack times.  A good meal plan should fit in with one’s schedule and eating habits.  The right meal plan will help improve blood glucose, blood pressure, and cholesterol numbers and also help keep one’s weight on track.  Whether a person needs to lose weight or stay at a present weight, the proper meal plan can help. People with diabetes have to take extra care to make sure that their food is balanced with insulin and oral medications (if necessary), and exercise to help manage their blood glucose levels. A healthy diet is a way of eating that that reduces risk for complications such as heart disease and stroke. Healthy eating includes eating a wide variety of foods including vegetables, whole grains, fruits, non-fat dairy products, beans, and lean meats, poultry and fish. There is no one perfect food so including a variety of different foods and watching portion sizes is the key to a healthy diet. They must also their choices from each food group provide the highest quality nutrients they can find. In other words, they must pick foods rich in vitamins, minerals and fiber over those that are processed. People with diabetes can eat the same foods the family enjoys. Everyone benefits from healthy eating so the whole family can take part in healthy eating. It takes some planning but they can fit their favorite foods into their meal plans and still manage blood glucose, blood pressure and cholesterol. Losing weight and keeping it off is a real challenge for most people.  Thats why its important to begin a weight loss program with the help of a health care team, including, if possible, a dietitian.  They can help a patient find ways to decrease calories but still consume the foods they enjoy.  And they can suggest strategies to help exchange old habits for new ones. Its important to remember that losing even a relatively small amount of weight can make a real improvement in reducing the risk for diabetes and other serious conditions. Exercise is also known as physical activity and includes anything that gets one moving, such as walking, dancing, or working in the yard.  One can earn the benefits of being physically active without going to a gym, playing sports, or using fancy equipment.  When a person is physically fit, they have the strength, flexibility, and endurance needed for daily activities.  Being physically active helps one feel better physically and mentally. The first treatment for Type 2 diabetes is often meal planning for blood sugar control, weight loss, and exercising. Sometimes these measures are not enough to bring blood sugar down near the normal range. The next step is taking a medicine that lowers blood glucose levels. I’m ready with the facts about diabetes. I don’t know much about his current lifestyle at present so this consultation will consist of my asking him questions and preparing a plan that will fit with as little disruption as possible into his normal routine. I have prepared sample diets and charts which explain substitutions he should use in handling his diet. I have also gathered information about different forms of exercise he might consider. I think I am prepared, so I go into the consultation in a positive frame of mind. The first words out of the patient’s mouth once introductions have been made are, “I don’t believe the diagnosis.” I take the time to review his blood sugar levels with him. Showing him the difference between his and the normal range. The normal amount of sugar in the blood ranges from about. A good blood sugar range for most people with diabetes is from about 4 to 7mmol/l. (netdoctor 2005) This is before a meal, for instance before breakfast, or four to five hours after your last meal. Blood sugar goes up after eating, but returns to normal range within one to two hours. One’s blood sugar should be less than less than 10mmol/l 90 minutes after a meal. And it should be around 8mmol/l at bedtime (netdoctor 2005). His physician would give him specific levels based on a number of factors, as these levels vary depending on the person. But his skepticism persists. It’s at this point that I realize the patient is in denial. From my training and experience I know this is normal for someone faced with a life threatening illness. And I realize that instead of being a simple process of giving and receiving information I must also initiate a dialogue that will help this man cope with the information he is going to have to process. I’m sympathetic to the man’s concerns, but I now feel a sense of urgency at getting him to see the necessity for the plan I have tentatively designed for his treatment. His alarm at the diagnosis is perfectly apparent to me, and I react in a calm and professional manner as we continue with the interview. I inform him that the disease is more common than most people realize with diabetes mellitus affecting approximately 5 % of the population. Type 2 diabetes (non-insulin-dependent diabetes mellitus) accounts for 85-90 % of patients with diabetes mellitus. (American Diabetes 2005) He was surprised by these statistics. I further explain that Type 2 diabetes is becoming increasingly common because more people are living longer (diabetes prevalence increases with age). It is also being seen more frequently in younger people in association with the rising prevalence of childhood obesity. Although type 2 diabetes still occurs most commonly in adults aged 40 years and older, the incidence of disease is increasing more rapidly in adolescents and young adults than in other age groups. I include these facts not to alarm him, but rather to let him know that he is not alone in facing this disease. I explain to him that early symptoms of diabetes do not appear life threatening, and individually they are not. Many of them mimic symptoms of less serious diseases, or even appear to be reactions to stress. The risks of diabetes are the damage done to body organs as it functions without a proper level of sugar. I am relieved at this point to see that he is at least listening and paying attention to my words. I briefly discussed the symptoms of diabetes as listed at the beginning of this paper and he acknowledged being troubled by them. He seemed to feel they were just part of the aging process. I ask a lot of questions about his life style, which is rather sedentary. His diet is casual with little attention to the value of the foods he eats. He is perhaps 16 kilos overweight, and will definitely need to lose this. His responses indicate that for the most part he appears to eat whatever strikes his fancy. He does however, like fruits and vegetables as well as meat, and potatoes, and desserts. These areas will require a great deal of attention. And I know that his difficulty in accepting his disease will have a bearing on the success of the program I will recommend. His physician would make the determination of how often he would check his glucose level, but I reviewed with him the process he was using. Normally if one’s diabetes is treated or a special diet (Type 2), he should measure his blood glucose levels once or twice a week, either before meals or 90 minutes after a meal. He should also do a 24-hour profile once or twice a month. (netdoctor 2005) This means measuring glucose levels before each meal. And I reiterated that his blood glucose should be measured any time he feels unwell or thought his blood sugar level is too high or low. With time and experience he will learn to notice it. At this point I ask if he has a significant other in his life. They usually tend to appear at this consultation to obtain information. My patient has arrived alone. As it turns out he is married, but she was unable to take time from work to attend the meeting today. The fact that he is not dealing with this alone is good, he will hopefully have someone to help him in following the regimen. His wife does most of the cooking however, and at some point it will become necessary to discuss in detail with her the manner in which she prepares meals and the foods she uses. We continue talking. Gradually he seems to be less resistant and more participatory in the discussion. He explains that he comes home from a desk job and tends to relax in front of the television or read a book. He and his wife attend church services on a regular basis, which may offer another source for support. Occasionally he putters about in his small garden. I explain to him that exercise need not be a great deal of exertion, but that a daily walk or bicycle ride would do him an immense amount of good. A regimen of exercise for at least 30 minutes at least 5 days per week is most likely to provide better overall health, report a normal weight, and have no physical impairments. (I add that while losing weight initially might not be difficult, it can be more difficult to maintain the weight loss. He seemed aware of this acknowledging that he had been battling that problem for some time. At this point I make a particular point to mention to him that it is entirely possible to handle his diabetes with diet and exercise modifications, and that if he successful using those there might be no need to use insulin. That prospect seems to encourage him. The patient appears to have no adverse reaction to consulting with other health care professionals in regard to his disease. His trepidation over the original diagnosis seems to have alleviated somewhat as our discussion progressed. I gave him copies of information (sample diets, exercise regimens and their specific benefits) and asked him to return in a week’s time with his wife. Knowing his dietary preferences and daily habits I am more likely to develop a plan that will suit his lifestyle. It’s time now to evaluate my interview with this patient and decide what I might have missed or how better I might have conducted my interview. I should have been more prepared for his denial. I had all the statistics and background information, but I also know that denial is a common reaction. (ABOUT 2005) Yet I was surprised by that reaction. While the patient initially responded with resistance because of his disbelief, with information he became more open to the possibility. I know from experience that it will be necessary for him to devise a coping mechanism in order to deal with the illness. Because of his willingness to participate in the discussion I am hoping that taking an active role in the treatment, and I hope that complying with my recommendations will be the positive method he will choose. But I also know that the changes, while minor will require permanent adjustment to his life, and that can be difficult to adjust to. Depending on how well he achieves this, and success in maintaining a diet and weight loss, he may face depression if he continues to have problems. This causes me some alarm. I am grateful that I came with the facts and statistics about diabetes however. They seemed to alleviate some of his concerns. Because of his lack of acceptance of his disease I did not emphasize at this time the severity of complications and possible development of other conditions relevant to the diabetes. They include: Three out of four diabetes-related deaths are caused by heart and blood vessel (cardiovascular) disease. People with diabetes are 2-4 times more likely to have heart disease than persons without diabetes. Even people with type 2 diabetes who do not have heart disease have an increased risk of having a heart attack. People with diabetes also tend to have other risk factors for heart disease including obesity, high blood pressure, and hardening of the arteries (atherosclerosis). (FDA 2005) I would like to discuss these issues at the next meeting when his wife will be in attendance. There is no way I can accurately predict the possibilities of potential depression, but I make a note that the patient may wish a psychiatric consultation in the future should his mood or behavior undergo changes. And I make a note to discuss that privately with his wife and his physician. One of my concerns is how agreeable his wife will be to adjust her cooking styles to meet his dietary requirements, especially since she also works. People with diabetes must maintain a healthy weight and eat a diet that is low in fat, (particularly saturated fat), low in sugar, low in salt, high in fruit and vegetables (at least five portions a day), high in starchy carbohydrate foods, such as bread, chapatti, rice, pasta and yams (these should form the base of meals). In other words, the diet consists of foods that all of us should eat. There are no foods that people with diabetes should never eat. (Delia) And there is no need to cut out all sugar. But, like everyone, people with diabetes should try to eat only small amounts of foods that are high in sugar or fat, or both. If one has diabetes, one can eat cakes and biscuits sparingly, as part of a balanced diet. I make a note to request the presence of a nutritionist who can give more specific suggestions, and recipes. Considering the patient’s denial of his condition I still feel the consultation went well. This patient will require the intervention of a nutritionist, as well as, monitoring for depression and weight loss. Involvement of his wife will be critical to his success at achieving weight loss, and developing an exercise program. Society allows ill patients to assume a new status, designated in sociological terms as “sick role”. This role allows him both some expectations and responsibilities. The sick person is exempt from “normal” social roles.  An individual’s illness is grounds for his or her exemption from normal role performance and social responsibilities.  This exemption, however, is relative to the nature and severity of the illness and the more severe the illness, the greater the exemption. Exemption requires legitimization by the physician as the authority on what constitutes sickness.  Legitimization serves the social function of protecting society against malingering (attempting to remain in the sick role longer than social expectations allow, usually done to acquire secondary gains, or additional privileges afforded to ill persons. Secondly, the sick person is not responsible for his or her condition. An individual’s illness is usually thought to be beyond his or her own control. A condition of the body needs to be changed and some curative process apart from the person’s will power or motivation is needed to get well. (Christopoulos 2005) It is the responsibility of sick person to try and get well. The first two aspects of the sick role are conditional upon the third aspect, which is recognition by the sick person that being sick is undesirable. Exemption from normal responsibilities is temporary and conditional upon the desire to regain normal health. Thus, the sick person has an obligation to get well. (Diligio 2005) The obligation to get well involves a further obligation on the part of the sick person to seek technically competent help, usually from a physician. The sick person is also expected to cooperate with the physician and other health professionals in the process of trying to get well. (Diligio 2005) Wellness principles include several areas. An individual must maintain a healthy body by eating well balanced meals and exercising regularly and making responsible decisions concerning sex, alcohol, drugs and tobacco. (Delia 2005) One must be aware and accept ones own feelings and emotions and learn to cope with problems that arise in everyday life. And a person must gain personal satisfaction and fulfillment through their occupation. They must be open to new concepts and ideas and having a curiosity to seek out new experiences. An individual must establish a positive relationship with, and an appreciation of the animate and inanimate world. A person must have an ability to foster interpersonal relationships that are comfortable and do not harm others. One must look within and explore ones values and beliefs in order to discover a source of inner strength and serenity. (Wellness Centers 2005) All of these issues must be addressed in order to facilitate good health in any person, but they are especially necessary in someone facing a chronic illness. My conclusion is as follows. This patient has an excellent prognosis to live a happy and healthy life if he follows the recommendations laid out by his physician and team of health care professionals. There is no cure for diabetes (One Touch 2005), but with proper maintenance his condition need not worsen. As with any chronic or life threatening illness the attitude with which he approaches his treatment is the key to success. In particular with this type of illness and treatment program his full participation and compliance is required for the treatment goals to be met, and to ensure that his treatment needs will not escalate. This patient must come to full acceptance of his disease. Care must be taken to ensure that he does not continue in his present state of denial or become depressed by that awareness or the changes to his lifestyle. His family, friends and co-workers must become participants in his new health regimen, and encourage him to follow the treatment plan. Because he has a legitimate illness he has assumed a “sick role” and certain conditions will now exist in his life as a result. He will need more frequent monitoring by his physician, but as part of the terms of that role he is also expected to attempt to improve his health. In this patient’s case that will consist of following the directives for diet, and exercise, and learning to accurately monitor his own glucose levels. None of these tasks are outside the range of his abilities. It is imperative that this patient lose weight. Of all the treatment goals this is the one most likely to prevent an escalation of his illness. In order to do that he must follow the recommendations made by his team of health care professionals. Once the weight is lost he will have to maintain the weight recommended by his physician for the remainder of his life in order to stabilize his condition. My action plan for this patient follows. At our consultation next week (with his wife present) a nutritionist will go over diet recommendations and food substitutions in detail with the patient. The nutritionist will make suggestions as to specific items, and questions the couple might have. One area the nutritionist will cover in detail is portion size, as many people simply eat too much of any one thing. I will recommend that this patient begin an exercise program of walking, gardening or bicycle riding, or some similar level of exercise regimen of for at least 30 minutes at least 5 days per week. (One Touch, 2005) More would be even better, but this is an excellent beginning. I will again evaluate the patient’s mental state at the next consultation and will make a recommendation based on that as to how I feel he is coping with his illness. I will also include the wife in this discussion, asking how she feels he is handling the awareness of his condition. If necessary I will inform his physician that I feel he should be assessed for depression. Because this patient is still not in full acceptance of the diagnosis I do recommend monthly check ups by his physician and also with his health care team to ensure that he is at least attempting to comply with the treatment plan. If necessary his employer should be fully informed to facilitate all treatment goals. The patient’s wife should be requested to attend the first follow-up meeting as well, in case any more questions or concerns have arisen. The patient’s own responsibility in regaining his health must be made apparent to him. None of us can help him if he is unwilling to put out the required effort. Until he is in a position of complete acceptance we, his health care professionals and his wife, must take up some of the responsibility and be a constant source of encouragement and support. At the same time we cannot allow him to abuse the “sick role” into which he has been placed, nor enable to play that role for sympathy, or use it as an excuse to avoid his own responsibilities. Regular appointments with his physician will be scheduled at the physician’s order, in addition to my recommendations. Any subsequent orders the physician makes will of course be worked into this treatment plan. I will do everything possible to create a plan adapted for this patient. Ultimately its success will be determined by the choices he makes and the actions he takes to comply with the plan. 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