Reflective Practice in Diabetes Care -Mismanagement of Hypoglycemia - Case Study Example

Reflective practice in diabetes care. (Mismanagement of hypoglycemia) Case study: A 65years old lady type 2 diabetic on insulin was admitted on account of episodes of hypoglycaemia.Whilst on admission she had 3 episodes of hypoglycemia so the doctor stopped her insulin resulting in hyperglycemic episodes and was managed with as required (PRN) doses of Actrapid insulin. Introduction: Diabetes is considered to be the second most threatening and wide spread condition in the world that attributes to increased mortality, next to cancer. Diabetes is a highly prevalent chronic disease. According to the Third National Health and Nutrition Examination Survey, conducted between 1988 and 1994, it is seen the prevalence of diabetes rose from 4.9% in 1990 to 6.9% in 1999. In that Type 2 diabetes is known to produce myriad of complications as metabolic complications, vision disorders, neuropathy, kidney disease, peripheral vascular disease, ulcerations and amputations, heart disease, stroke, digestive diseases, infection, oral complications, and depression, all of which has a increased mortality rate . (American Diabetes Association, 2006) Many major studies as the Diabetes Control and Complications Trial (DCCT), Kumamoto Study and the U.K. Prospective Diabetes Study (UKPDS) (1991) stress the importance of intensive blood glucose control in reducing its associated morbidity. This is achieved by tight glycemic control. This has now been accepted as standard care as it is found to reduce the degree of micro vascular damage by delaying the onset and progression of complication as diabetes is found to be a leading cause of blindness, dialysis, and lower extremity amputations. Usually as a part of treatment regimen, early diagnosis, proper self-management, improvements in monitoring, and availability of an expanded array of therapeutic regimens has become the regular treatment pattern. Specifically case of type 2 diabetes the treatment regimen is usually a combination of lifestyle management, diet regulation coupled with a hypoglycemic drug and unlike type 1 insulin comes into picture as a last option. But now early aggressive insulin therapy is becoming of greater importance in the treatment of type 2 diabetes mellitus. The American Diabetes Association and the American Association of Clinical Endocrinologists (2004) currently recommended insulin therapy when the glycated hemoglobin (A1C) levels of < 7.0% and < 6.5%, respectively. The American Diabetes Association (ADA) recommends that patients with diabetes receive care from a medical team. Working with patients and their families, these teams develop self-management and problem-solving plans that consider each patient’s cultural, social, physical, and medical needs and support the intensive glycemic control. Reflective practice on other hand is very important tool in nursing. It helps nurses to learn from past and deliver a quality care. According to Atkins and Murphy (1995), “Reflection is a deliberate process which consists of thinking about and interpreting experiences as a learning tool”. When applied to nursing, according to Johns (1995) it could be described as the ability to assess, understand and learn experientially in order to perform work more effectively and with greater job satisfaction.' The reflective practice is highly beneficial and is found to enables clinical expertise to develop towards achieving effective practice; helps in gaining a acceptable grounding of health professionals' knowledge. It helps in gaining effective personal knowledge is gained that can be shared with other health professionals. Also it allows practitioners to define contradictions between their actual practice and desired practice.( MacKinnon ,1998) Personally I believe that it is important to explore the subject on a personal level, which would help me to understand and notice points that I would have missed earlier. This would help me t ponder upon any mistakes and helps to seek an alternative. So I decided to write a reflective essay about the management of T2DM patient admitted with episode of hypoglycemia upon use of insulin. I wrote consistently, descriptively and let the work flow uncensored as advocated by Walker (Mackintosh, 1998). Reflective analysis of the case: The patient, a type 2 diabetic was 62 years lady and was on insulin treatment for last 3 months. She had a history of hyperglycemia for last 10 years and was put on a dietary and oral hypoglycemic regimen. As the level of glucose was not under control, insulin treatment. She took the insulin shots at home. She had noticed an increase in weight but had not experienced any episode of hypoglycemia. But on the particular day she had symptoms of hypoglycemia and was admitted in the hospital. On admission, again she had three episodes of hypoglycemia. Hence she was stopped from insulin. Then when the index raised up to the level of hyperglycemic and hence on monitoring her glucose level was adjusted with actrapid insulin dose. Her food pattern was monitored and the composition maintained as the standard given by dietician. Her lipid level, BP were also monitored.( Koro etal.,1998) Many Landmark trials have proven the point that tight glycemic control is the accepted standard of care to prevent or delay the onset and progression of complications with an increased emphasis on an intensive, targeted, multifactorial intervention with the level of aggressiveness of diabetic control to be tailored to the patient. These trails further emphasize the point that benefits are to be viewed from the point of view of cost, resource utilization, quality of life, and risk of hypoglycemia in individual subjects. Main stress is laid on the patient-centered approach with foci laid on a multidisciplinary team care, the concept of disease management, and the empowerment of individuals to take responsibility for day-to-day self-management through education and a supportive, collaborative approach with health care providers.( UK Prospective Diabetes Study,1991) Also it is proved that effective treatment of Patients with type 2 diabetes to maintain their glycemic control includes the usage of insulin as hyperglycemia is observed to have a variety of adverse consequences, including increased neurological ischemia, delayed wound healing and higher infection rates. It is true that even transiently elevated glucose levels can cause volume and electrolyte abnormalities, delayed gastric emptying, impaired leukocyte function, osmotic diuresis and impaired insulin responses. But the traditional and largely prevalent approach to treatment of type 2 diabetes is that of oral agent monotherapy, often in a sequential manner, slowly progressing to combination treatment and eventually insulin In contrast to type 1 diabetes, in type 2 , insulin is used at last as “last-ditch” or “last resort” use when all other avenues have been exhausted Generally Providers are reluctant to initiate insulin therapy due to “clinical inertia “and for the patients aversion to injections (Bullano etal.,2006) There are numerous studies that shows the insulin therapy being started too late in the course of this disease due to factors related to provider and patient resistance, as well as lack of awareness about potential benefits . The main reason the clinician worry bout is of hypoglycemia, weight gain, and increased cardiovascular risk. In reality, these concerns have been shown to be unfounded misconceptions .Early insulin therapy is now being advocated for improving glycemic control and reducing the risk of diabetic complications in type 2 diabetes. (U.K. Prospective Diabetes Study Group,1998) The problem is not with the insulin but with the optimal type and regimen of insulin used. Insulin therapy is commonly employed in improper dosage, frequency, or timing, and is associated with glycemic variations and increased risk of hypoglycemia. The goal with insulin treatment is to mimic normal physiology by employing it in a basal-bolus fashion, with an emphasis on duplicating the natural release of insulin when normal pancreatic function is present. This approach consists of discrete amounts of continuous ‘basal’ insulin required to maintain euglycemia in the fasting state, and ‘bolus’ insulin during times of hyperglycemia (for example, in the postprandial state). This philosophy is widely recognized and accepted in the management of type 1 diabetes and is being increasingly advocated in type 2 diabetes as well. However, the advantages offered by formal teaching through diabetes educators (nurses and dieticians) are often not fully utilized during this process. The significant point to be noted in these types of treatment is the pattern of patient centered team management that includes, at its core, physician-diabetologists, nurse educators, and nutritionists in putting the patient on “the right footing” at the outset of initiation of multi-dose insulin regimen to achieve short-term, and hopefully long-term, success. (Rosenstock etal.,2005) The main problem to be faced here is requirement of proper availability of insulin and the fear of hypoglycemia and insulin resistance. Also the use of insulin has been associated with weight gain, which in turn has been considered a major factor in insulin resistance. , but when compared to the amount of micro vascular complications it could be understood that tight glycemic control may be more important in therapeutic decision-making. Considering the co morbidity of diabetes and several cardiovascular risk factors, ADA recommends also close monitoring of blood pressure, the use of antihypertensive agents in patients with hypertension; testing for lipid disorders. (Ferranninietal., 1998) Clinicians often cite hypoglycemia as an adverse effect that might preclude the use of insulin. Indeed, in the DCCT study of type 1 diabetes, tighter control produced a risk of severe hypoglycemia three times higher than that of conventional therapy but the rates of severe hypoglycemia are quite low in type 2 diabetes. Same pattern was observed in the Kumamoto study also. (Atieaetal., 1992) But again, hypoglycemia can be a dangerous health problem with serious consequences. Clinicians caring for diabetic patients often recognize the risks associated with glycemic emergencies, such as diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic coma. It is often observed that hypoglycemia itself can represent a glycemic emergency and clinicians ideally seek to restore the diabetic patient to a euglycemic state following a bout of hypoglycemia. It is recognized that treatment of diabetes is multifaceted and needs attention in the areas of nutrition, diet, physical activity, medications, sick-day management, and ongoing evaluation for the development of complications. This complex undertaking is a challenge beyond the single-handed effort of the lone clinician. The patient requires longitudinal guidance from a group of health-care professionals who have a consistent educational message for behavior change individualized to each patient's agenda. Members of the diabetes care team include the patient and a core of providers: the physician, nurse educator, and nutritionist. The primary goal is to educate the patient and provide tools for self-care and motivation in a partnership fashion rather than adopting a paternalistic, critical, and predominantly compliance-based atmosphere. The American Diabetes Association Clinical Practice Guidelines recommend that medical nutrition therapy for people with diabetes should be individualized, with consideration given to the individual's usual food and eating habits, metabolic profile, treatment goals and desired outcomes.] It is important to use an interdisciplinary approach and try to integrate nutrition into the overall treatment plan. Intake of fiber, fruits, vegetables, and low-fat dairy products may need to be enhanced to achieve a more balanced diet in some people with diabetes. It is obvious, therefore, that every patient with diabetes needs an individual consultation with the nutritionist for assessment of current dietary patterns, habits, and cultural influences, and to incorporate preferences and metabolic co morbidities into a modified plan for the future. Patients also require ongoing education and guidance in nutrition self-management over time so that dietary changes can be made as treatment aims change and new knowledge is acquired through additional research.( Benedetti, 2002) Clinical evidence for the efficacy of a combination of oral antidiabetic agents with or without insulin use for optimal glycemic control is growing. This process has gained momentum with the fact that the inexorable progression of glycemic deterioration might be due, to an overly conservative approach with single agent use for a prolonged period. In this background the basal- bolus concept and insulin pump concept gains momentum. It is commonly accepted that hyperglycemia invites infection, retards healing, and worsens prognosis in general for inpatients with diabetes. Clinicians have been wary of attempting intensive control in the inpatient setting because of various barriers (changes in usual routine, unpredictable oral intake, missed meals and medication doses due to procedures, acute illness, etc), fear of hypoglycemia, and the notion that a brief period of relative laxity in glycemic control would not impact outcomes.( Hirsch etal.,1995) Patients with diabetes play an integral role in any treatment strategy. Lifestyle modification; goal setting; self monitoring; preventing, detecting, and treating acute complications; and using medications correctly are all important components in achieving glycemic control. This makes patient education crucial, particularly when it comes to dispelling myths about insulin therapy. The relationship between health care provider and patient is crucial to compliance. In the management of diabetes, this is more than a relationship between the patient and a single provider—it includes an entire health care team. Other factors also influence compliance. On the patient’s side, the belief that the benefits of therapy are worth the consequences, a readiness to change, memory, communication skills, literacy level, knowledge, competence, confidence, skills, and a good support system work together to influence the patient’s acceptance of therapy. On the team’s side, communication skills, the quality of information and instructions, and a willingness to identify and address barriers affect compliance. The regimen itself is also a factor; if it is difficult, costly, or has many side effects, compliance may diminish. (Koivisto,1993) In the treatment of type 2 diabetes with insulin, reluctance to inject oneself and fear of weight gain or hypoglycemia may hinder compliance. Clinicians need to explain to their patients that type 2 diabetes is progressive and that insulin will probably have to be used at some point; therefore, clinicians may need to dispel myths associated with insulin use, allay patient fears, and assure patients that insulin will likely improve symptoms, enhance quality of life, and provide a sense of well-being.” Resistance to insulin" on the part of clinicians may also be a significant provider-driven factor in compliance. Concerns regarding hypoglycemia, patients’ fear of needles, cultural health beliefs, and the time necessary to teach self-injection can all emerge as barriers to insulin use. Discharge planning, including patient education, should be initiated early in the hospital stay. After discharge, the patient should be followed closely to ensure that the acute problem has resolved and that the patient has made a successful transition to the outpatient environment. Thus after reviewing the volume of research it would be effective to compare the understood material with our practice. The treatment of patient with insulin sounds to be correct as from the literature it is understandable that insulin therapy has now a days become the routine initial process. The episodes of hypoglycemia are again nothing to be worried, considering the patients age and the fact that she has self administered insulin. And the initial steps taken to maintain the glucose level as euglycemia also seems logical. But as the sugar level increased the administration of insulin under close monitoring becomes important. Also the process of checking and controlling BP and lipid profile also sounds to be important in the given time.( American Diabetes Association,1998) The important part would be advising the patient and counseling patient at the time of discharge regarding the steps to be taken, precautions to be maintained, the diet plan to be taken care of and the hypoglycemic symptoms to be watched for. Conclusion: This report is thus in line with Schon's (1987) suggestion that there are two aspects to problem solving of practitioners. The first shows the practitioners as using technical means to solve structured problems. The second is more user-friendly and involves the practitioner improvising, inventing or testing new strategies for problem solving. I believe that reflective practice is essential for the problem-solving process to occur. The personal knowledge I gained has been shared with colleagues and led to a change in practice. This exercise highlighted how difficult it is to maintain good glycaemic control and gave some insight into the time management required to maintain the regimen. Using the reflective diary allows an analysis of actions and feelings, enhances learning skills and gives opportunities to view issues more clearly from the patient's perspective. The diabetes is a condition that has to be closely monitored for. Treatment of type 2 diabetes with insulin again calls in for a close monitors after effects as any possible cause or episode of hypoglycemia occurring. Also while treating such condition close monitoring of the patient becomes necessary to watch for any changes closely. References: 1. American Diabetes Association. Outpatient Diabetes Mellitus Consensus Conference Recommendations. Diabetes Care. 2006;29(suppl 1):S4-S42. Abstract 2. AACE Diabetes Guidelines -- 2002 Update. EndocrPract. 2002;8(suppl 1):40-82. 3. State of Diabetes in America, American Association of Clinical Endocrinologists, 2003-2004. Available at: http://www.stateofdiabetes.com/. Accessed December 21, 2007. 4. Koro CE, Bowlin SJ, Bourgeois N, Fedder DO. Glycemic control from 1988 to 2000 among U.S. adults with type 2 diabetes. Diabetes Care. 2004;27:17-20. Abstract 5. UK Prospective Diabetes Study (UKPDS). VIII: Study design, progress and performance. Diabetologia. 1991;34:877-890. Abstract 6. Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes. Diabetes Care. 2005;28:2948-2961. Abstract 7. Bullano M, Fischer MD, Grochulski WD, Menditto L, Willey VJ. Hypoglycemic events and glycosylated hemoglobin values in patients with type 2 diabetes mellitus newly initiated on insulin glargine or premixed insulin combination products. Am J Health Syst Pharm. 2006;63:2473-2482. Abstract 8. Rosenstock J, Dailey G, Massi-Benedetti M, et al. Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care. 2005;28:950-955. Abstract 9. Atkins S, Murphy K (1995) Reflective practice. Nursing Standard 9(45): 31-37 10. Johns CC (1995) The value of reflective practice for nursing. Journal of Clinical Nursing 4(1): 23-30 11. MacKinnon M (1998) Providing Diabetes Care in General Practice, 3rd edn. Class Publishing, London. 12. Mackintosh C (1998) Reflection: a flawed strategy for the nursing profession. Nurse Education Today 18: 553 13. Schon DA (1987) Educating the Reflective Practitioner. Jossey-Bass, San-Francisco. 14. U.K. Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 353:837–853, 1998. 15. Ferrannini E, Haffner SM, Mitchell BD, Stern MP: Hyperinsulinaemia: the key feature of a cardiovascular and metabolic syndrome. Diabetologia 34:416–422, 1999. 16. Atiea JA, Luzio S, Owens DR: The dawn phenomenon and diabetes control in treated NIDDM and IDDM patients. Diabetes Res Clin Pract 16:183–190, 1992. 17. Benedetti MM, Hamburg E, Dressler A, Zieman M, for the 3002 Study Group: Lower incidence of nocturnal hypoglycaemia in patients with type 2 diabetes treated with insulin glargine compared with NPH insulin, given as a combination regimen with oral agents (Poster). Presented at the 38th annual meeting of the European Association for the Study of Diabetes. Budapest, Hungary, September 1–5, 2002. 18. Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care 1995; 18:870-8. 19. Koivisto VA. Insulin therapy in type II diabetes. Diabetes Care 1993;16(Suppl 3):29-39. 20. American Diabetes Association. Hospital admission guidelines for diabetes mellitus. Diabetes Care 1996;19(Suppl 1):S37. Read More