The Importance of a Holistic Approach in Care Management - Research Paper Example

 Introduction This essay will focus on the aspect of care on the control of blood glucose of John, a patient with diabetes mellitus type 2, whom I nursed in my year two community placement. The aim of this essay is to give a reflective account on my experience in inter-professional working and how different health care professionals influence the decisions on patient management and care delivery. The Gibbs model of reflection (Gibbs, 1998) was used because it is appropriate for this experience. This model shows that reflection on experience and learning is a cycle that does not stop. My reflection will also show how the experience is relevant to future practice. The patient’s name was changed for the purpose of confidentiality in accordance with the NMC code of professional conduct (NMC, 2004a). Aspect of Care There are many aspects of care for diabetes mellitus type 2 patients. The most important are control of blood glucose, the drug metformin (which improves insulin sensitivity) and control of blood pressure. My chosen aspect of care was the control of blood glucose through multi-faceted approaches including monitoring of blood glucose, diet, drug therapy, and improved education of patient and family. This aspect was chosen because diabetes mellitus is characterized by a chronic elevation of blood glucose concentration (hyperglycaemia) that results from defects in insulin secretion or insulin action (Levene, 2003). Intensive control of blood glucose has been found to reduce microvascular complications and is important especially in patients who are on insulin to determine dosage and to prevent hypoglycaemia. Type 2 diabetes mellitus was the disease of choice because my year two placements were in the community and many of the clients I encountered were mostly diabetic. As a result, I became interested to learn more about the disease and its management, in order to be able to provide high quality and effective care to people who have the disease and its complications in future practice. Diabetes is one of the most common chronic disorders in the UK, affecting people of all age groups (Nair, 2007). Type I is caused by an autoimmune destruction of insulin producing beta cells in the pancreas, resulting in absolute insulin deficiency which is treated with regular administration of insulin (Chambers et al, 2003). Type 2 diabetes is a progressive condition characterized by insulin resistance (Watkins, 2003) which could be due to the body’s inability to make enough insulin or to make proper use of insulin. Regardless of the type, the blood glucose levels remain high and not enough energy gets to the cells and muscles (Williams and Pickup, 2005). Type 2 diabetes can be treated using dietary modification, oral hypoglycaemic drugs, or insulin injection (Jerreat 2003). Some type 2 diabetes patients require insulin therapy to maintain glycaemic control as beta cell failure progresses (Wong, 2007). Reflecting upon my role and others’ roles in the management of care I met my patient, John, during my practice placement in a nursing home. John is a 71-year-old retired lorry driver with an English background. He is a widower with two independent children who are both involved with his care. He has type 2 diabetes mellitus with a past medical history, which includes stroke, myocardial infarction, and hypertension. His diabetes is managed using oral hypoglycaemic drugs (metformin) and insulin injections (Human Actrapid). John has difficulty speaking, chewing, and swallowing because of his stroke. Therefore, these conditions were taken with primary consideration in the management of his blood sugar levels through diet. The multifaceted aspects of the disease made the care of John a collaborative effort among members of an inter-professional team comprising of doctors, diabetes specialist nurse, nurses and dieticians (Hillson, 2002). This team approach was crucial in ensuring that optimal glycaemic control is achieved (Capaldi, 2007). I was part of the team as student nurse working under the supervision of my mentor (NMC 2004a). As a student nurse, I assisted all the members of the team and thus, I was able to work on all facets of controlling John’s glycaemic level. The doctor’s role was mainly to oversee the general health and well-being of John. After regularly reviewing John’s case, the doctor prescribes John’s drugs. The role of the doctor is very important specially when his John’s condition changes and needs adjustment in his medication or the prescription for new drugs. Another member of the team was the physiotherapist, whose role includes the assessment of John’s daily movements and activities. Normally, the physiotherapist would start by asking John questions about any difficulties he has with his movements. The physiotherapist also supports John in performing his exercises, which encompass a range of movements and muscles-strengthening exercises, and posture. The physiotherapist visits John twice a week for his exercises. Exercise was very necessary because of its main benefit of promoting the uptake and utilization of glucose in the muscle cells (Pullen, 2000). Once taken up, the blood glucose level will be lowered. Exercise also improves blood circulation and muscle tone, and helps in reducing weight. John’s previous stroke also affected John’s ability to chew and swallow with ease; therefore, a dietician was necessary to make an in-depth nutritional assessment in order to identify the proper food for him. Green and Jackson (2006) emphasize that patients should be routinely screened for malnutrition and specialist support should be given if necessary. The right diet is major factor in controlling diabetes as suggested by Cheyette (2005). Because he refused an alternative method of feeding called the percutaneous endoscopic gastrostomy, John was placed on puree diet and grade two thickened fluids. Being in a nursing home, nurses had the primary responsibility in the care of John, with the aims to ensure that optimal glycaemic control is achieved, to prevent long-term complications of diabetes, and to save lives (Porth, 2005). Nursing care was also designed to be within the framework of patient self-care to enable them to take control of their own care (Walsh, 2002). The nurses performed a crucial role in managing his medication. To facilitate this, they offered John some advice on the important of complying with his oral anti-diabetic drugs and insulin injections. They also ensured that John was informed at every stage of his treatment. This was to promote concordance with his medication and to achieve effective care. The nurses worked in partnership with John and his family; informing them on the care of diabetic patients and advising on the diet that John needs to follow in order to control his diabetes. Nurses also advised John on the need for regular exercise and coordinated with the physiotherapists who usually help in carrying out with this aspect of care. As a student nurse, I was involved in almost all areas of nursing care for John. I assisted in most of the procedures towards managing his blood glucose levels that were carried out by the different healthcare professionals. Each day, before the procedures performed by the different team members, I take and record John’s vital signs. These include temperature, pulse, respiration, and blood pressure. I always introduce myself to John as a student (NMC 2002), and then I explain the procedures to allay his anxiety and to gain his consent. After I take the vital signs, I report any observed abnormality in the vital signs to the nurse immediately. The values are recorded promptly and accurately in the observation chart in accordance with NMC (2005). If there were any causes for concern, the nurse will then inform the doctor. The doctor reviews the case, and if he recommends a prescription, it was my role to fax the information to the pharmacist for filling up the prescription. Blood glucose increases if the food eaten by a diabetic was high in sugar. To control the sugar content of the food that John was taking in, I coordinated with John and his family on this matter. I informed him of other alternatives to what they normally bring for John like cakes, sweets and chocolate which are high in sugar, and therefore are restricted foods for John. Persons with diabetes need a more structured diet to prevent hyperglycaemia (Lemone and Burke, 2004). I agree with Walsh (2002) that whole meal bread, fruits and vegetables should be substituted for refined carbohydrates that are found in sugar, cakes, and sweets. Diabetes UK (2006) recommended that patients with diabetes should aim to maintain their blood sugar levels at 4-6mmol/L pre-prandial and not above 10mmol/L two hours post-prandial. It is further emphasized that foods with high soluble fibre content help to lower insulin secretion, reduce low-density lipoprotein and improve glucose tolerance. I also advised John, together with the nurses, on the importance of eating regular meals. Delaying or missing meals will promote the breakdown of body fat and the development of hypoglycaemia (Nair, 2007). Intensive glycaemic control reduces the rate of micro and macroalbuminuria and the manifestations of diabetic nephropathy (Gross et al, 2005). For anybody who is on a puree diet, malnutrition is very probable. Thus, John’s body mass index (BMI) was regularly measured as part of the assessment of his nutritional status and risks of becoming malnourished. I assisted in taking the measurements, so with his eating and drinking needs. During these activities, I always made sure that he maintained his privacy and dignity by closing the door, using appropriate equipment and demonstrating a caring attitude toward him. John and his family were also given information on how to recognize the symptoms of hypoglycaemia and hyperglycaemias attack such as restlessness, hunger, sweating, and decrease in conscious level such as lethargy (Lemone and Burke, 2004). They were advised what needs to be done in case of an attack. Another role I took as a member of the team was to be involved in observing and participating in the administration of medicine safely and effectively under the supervision of a registered nurse at all time. The administration of his drugs was done in accordance to the guideline set out by (NMC, 2004b p6) which state that “be certain of identity of the patient to whom the medicine is to be administered.” These I frequently carried out by using the following steps the right medication, right person, right time, right dose, and right route. A very important function in the chosen aspect of care was the monitoring John’s blood sugar level, which was carried out each morning after the nursing handover, and whenever it became necessary. Each reading was reported to the nurse in charge, documented immediately in his nursing note, and countersigned by the nurse. Depending on his blood sugar level, and as prescribed by the doctor, the correct insulin dose will be drawn up. Prior to administering the insulin, John was informed to gain his consent and under supervision, I administered the insulin safely using the correct route (subcutaneous). When giving injections, I always make sure that I rotated the site of the injection. According to Davies-Lyons (2003) the best site for injection is into the thigh, buttocks or abdomen. This I normally do to avoid tissue inflammation or poor absorption of the insulin. Working with an inter-professional team enhances learning by students (Nolan, 1998) because students working directly with qualified role models enables them to ask for explanations regarding procedures and seek out new approaches therefore developing their confidence (Morgan, 2005). In my case, I was grateful for the opportunity to learn from seasoned health professionals. I learned that an interdisciplinary approach works best in the management of a disease that requires a multifaceted treatment approach. Analyzing this experience, it made me realize the key roles of nurses in the management of patients with diabetes. Primary care and responsibility in informing patients on how to control their disease rest with the nurses. The experience also allowed me to see the benefits of a holistic approach to patient care, where each team member contributed effectively in the management of John’s condition by assisting him to come to terms with having a long-term condition. The effectiveness of this approach underscores the fact that sickness has to be managed from different avenues. Disease management should not focus only on the pathology but also on other possible causes. This is very true in type 2 diabetes, which is triggered more by lifestyle rather than physiological elements. Involving the family in management was also a good approach since I felt that the initial anxiety and pessimism expressed by John’s family became more positive because they participated in his care with much zeal. As a student nurse, my workload during this placement was heavy because I have to be assisting each member of the team, aside from directly taking care of the patient and his needs. Nevertheless, the benefits of learning outweighed the disadvantages. Because of what I learned and experienced first-hand, I have developed more confidence in practice. This confidence enabled me to provide a level of nursing care to John that was equivalent to my stage of training. In future practice, I will continue to work in partnership with other health professionals, patients and their families to help manage disease and rebuild patient confidence in controlling their ailments. The proposed care has to be holistic, that is, encompassing the whole person including the physical, psychological, social, and spiritual aspects of the patient. The care of people with any disease should be based on a patient-centred approach that involves a careful assessment of the patient and the application of appropriate pharmacological and non-pharmacological therapies. Reflection on the relevance of this learning to future practice Working within an inter-professional team has given me the opportunity to look at nursing as part of a large framework aimed at providing care and relief for patients. Based on this experience, I have come to view an interdisciplinary approach towards disease management as an effective tool in increasing the effectiveness and efficiency of nursing care. With different specialists working on different aspects of patient care, the burden of decision-making by nurses, on areas for which they have not trained on, eases. The different team members will also learn from each other, and such learning will be put to benefit patients and when handling other cases. On reflection, this experience has enabled me to make sense of clinical work and look at ways in which I can improve and strengthen my own practice. Participating in the inter-professional team working on John’s care has enhanced my knowledge on how and why different health care professional contribute towards the care and management of diabetes mellitus. Primarily, I learned of the different roles that each member of the team play in the management of diabetes. Through this, I was able to understand the different effects of the disease and the importance of the aspect of care, management of blood glucose levels, in controlling the diabetes. Secondly, through this experience, I understood the importance of involving the patient and his family in his care. For me, a person is on his way to healing when he understands that he has to be a primary contributor to the management of his sickness. Patients should wish to be healed in order for the healing process to progress. The importance of the support of family members in the healing process was also demonstrated in this experience. Finally, I learned that nurses are the links that join doctors, therapists, health professionals, patients. Nurses are the constant presence in the healing process. This I was able to see clearly with this experience. More than anything else, my experience has strengthened my conviction that nursing is a noble profession. On the technical side, I learned the importance of education for the patient in managing his condition. Patients should always be informed of their choices for treatment and for the procedures that they may have to undergo. Here, the role of the nurse is to help the person understand the nature of their illness. The nurses also need to address personal, cultural and religious preferences and the patient’s lifestyle. “Considerations for cultural needs of the individual are important and should form an integral part of the educational process” (Perry, 2002 p45). As an educator, nurses must carefully determine what the individual needs to know and find the time when they are ready to learn. Effective communication skills are especially important when informing patients of their conditions and options. At all times, the nurse needs to create an environment of trust, so that the patient feels valued, understood, involved, and accepted. Evidence suggested that nurses could improve chronic care by communicating effectively with patients and helping them to understand their illness and concordance with medication and treatment regimens (Bodenheimer et al, 2005). The experience has taught me to view care of patients using a combination of personal and holistic approaches. All learnings I hope to bring along with me in my future dealings with my future patients. Conclusion The aspect of care chosen for John, a patient with type 2 diabetes was the control of his blood glucose level. This aspect of care was managed by an inter-professional team comprising of a doctor, physiotherapists, dietician, nurses and myself as a student nurse. The management of his diabetes was easier when he and his family were involved in controlling his sugar levels. Generally, the experience showed me the importance of a holistic approach in care management. This experience underscored the importance of nurses as a bridge between the health care experts and the patient in the process of care management. References Bodenheimer, T, MacGregor, K & Stothart, N 2005, ‘Nurses as leaders in chronic care’, British Medical Journal, vol. 330, no. 7492, pp. 612-613. 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Wong, LM 2007, ‘Barriers to insulin starts for type 2 diabetes’, Practice Nursing, vol. 18, no. 3, pp. 127-130. Read More