Holistic Assessment and Management of Diabetes Mellitus - Essay Example

?Holistic Assessment and Management of Diabetes Mellitus Introduction Effective nursing care involves different processes which eventually secure improved patient outcomes. This paper will discuss the holistic assessment and management of a diabetes mellitus patient. The patient in this case is a middle-aged 52 year old man, married with four grown-up children. He works in a highly stressful job, is overweight, does not exercise, wears glasses all the time due to blurred vision, has recently been experiencing erectile dysfunction, has mood swings, and is depressed at times. His cholesterol is high, as is his blood pressure. He is on Lipitor 80mg at night, has no foot ulcers or skin sores. He is also on metformin and sulfonylureas for his blood glucose maintenance. He does his best to comply with his regular medication, mostly his oral anti-diabetic medicines. His HbA1C is however persistently rising and he may need to be put on insulin for the next few months if his blood sugar would not be managed better. He has a strong support system through his wife and children. He is also intelligent and has a good understanding of his disease, however he is in denial about the long-term complications which may relate to his disease. This paper will discuss the appropriate and effective nursing management of this patient, considering mostly the importance of holistic assessment, self-management, and team approach in securing improved patient outcomes. Body The regulation of blood sugar levels are based on negative feedback which seeks to secure homeostasis for the body (Matthews, et.al. 2008). Blood glucose levels are monitored by the pancreas, mostly through cells called the Islets of Langerhans. In instances where the blood glucose would decrease near or below threshold levels, especially during exercise or prolonged lack of food, the Alpha cells of the pancreas discharge the hormone glucagon (Matthews, et.al. 2008). Glucagon’s impact on the liver cells allows for an increase in the blood glucose levels. Glucagon transforms glycogen into glucose through the process of glycogenolysis. Glucose is subsequently introduced into the bloodstream, thereby leading to higher blood sugar levels (Brill 2011). As blood sugar increases due to the introduction of glycogen or through the normal process of food ingestion, another hormone – insulin – is released from the beta cells of the pancreas (Brill 2011). Insulin allows the liver to convert the glucose into glycogen through the process of glycogenesis, thereby prompting majority of the body’s cells to use glucose found in the blood transported through the GLUT4 transporter (Powell 2007). This process would then lead to decreased blood sugar levels. As insulin attaches to the receptors found on the surface of the cells, the GLUT4 transporters bind to the plasma membrane through exocytosis. This would assist in the diffusion of glucose within the cell (Powell 2007). Glucose enters the cell and through phosphorylation, it is transformed into Glucose-6 Phosphate. This process helps maintain the concentration gradients, allowing glucose continued entry into the cell (Woodruff and Saudek 2005). The insulin gives the signal to the different systems, allowing metabolic controls to be maintained. In the case of Diabetes Mellitus type 1, non-production or insufficient production of insulin causes high blood glucose levels; and type 2 is often caused by a reduced responsiveness to insulin by the body tissues (Dubois and Bankauskaite 2005). There is insulin resistance, in other words. If unmanaged, diabetes, would persistently cause blood sugar levels to rise, with the glucose remaining within blood circulation, not absorbed or delivered by the cells (Dubois and Bankauskaite 2005). It can then lead to a variety of complications. The deficiency of insulin or the insensitivity of the receptors to insulin has a major role to play in the manifestation of diabetes. Individuals ingest and digest carbohydrates and through the actions of the enzymes within the digestive tract are eventually broken down to monosaccharide glucose, which is an energy source for the body (Polisena, et.al. 2009). With the application of normal processes mentioned above, the levels of glucose in the body can be managed. In instances however where insulin is insufficient or where the cells do not respond well to insulin, the glucose is often not absorbed by the cells and not stored by the liver and muscles. The overall impact would be persistently high glucose levels which can lead to different metabolic issues including acidosis (Woodruff and Saudek 2005). Where the blood glucose levels reach beyond the 9-10 mmol/L levels, this is beyond renal thresholds. Reabsorption within the renal system is often not complete and the same glucose in the urine is retained (Gardner 2011). Under these conditions, osmotic pressure would prevent the reabsorption of water, thereby leading to higher urine production and higher fluid loss. The decreased volume in the blood is usually replaced through osmosis with fluids within the cells leaving the body compartments (Gardner 2011). This can cause dehydration and excessive thirst. For which reason, diabetic patients often experience polyuria and excessive thirst. Patient Management The management of this patient would require various interventions, primarily weight loss, reduction of stress, reduction of his cholesterol levels, reduction of his blood pressure, increase of his physical activity, and management of his food intake. Ultimately as well, the goal for this patient is to reduce his HbA1c levels to acceptable levels (6%-7%). Lower blood sugar levels would also eventually reduce his blurry vision and possibly his erectile dysfunction. It is important also for this patient’s blood sugar to be kept at relatively normal levels, in effect, hyperglycemia and hypoglycemia has to be avoided through the religious intake of his current anti-diabetic medications (Rother 2007). For this patient, the importance of weight loss cannot be overemphasized. The weight loss would resolve various issues which are exacerbating his health condition. It would decrease his cholesterol, reduce his blood pressure, and also help eventually reduce his blood sugar levels (Al Nozha, et.al. 2004). The patient’s diet would have to be modified. There is a significant amount of discussion on the effective diet needed for these patients. Most times, the recommended diet is one which is high on fiber, mostly soluble fiber, and low in fat (saturated fat). Total caloric intake for this patient has to be set at a rate lower than what he is actually taking now (Al Nozha, et.al. 2004). About 60-70% of his caloric intake can be allocated to carbohydrates. Some studies however recommend lower levels (Ripoll, et.al. 2011; Funnell and Anderson 2004). When considered for the patient, he said that he would likely find it hard to reduce his carbohydrate intake to those recommended levels. In his initial diet adjustment, it would likely be best to start him at 70% carbohydrate levels. As his confidence and commitment to his diet would improve, then his carbohydrate intake may be decreased further. This is part of the empowering process for the patient, giving him the independence to decide on his diet and what changes he can actually be involved in (Funnell and Anderson 2004). Much care must also be undertaken in order to reduce excessive energy intake. Complex carbohydrates can also be recommended for this patient. This would include whole grain: wheat bread, brown rice, oat bran, corn meal; fruits like oranges, apricots, grapefruits, and prunes; vegetables like broccoli, cauliflower, eggplant, carrots, onions, lettuce, celery; legumes (Ripoll, et.al. 2011). The timing of the meals is also as important as what meal is taken. For this patient, it is important to determine his blood sugar levels at certain times of the day, especially when he would take his meals and when he would take his diabetic maintenance. A blood sugar level of below 6 mmol, a long-acting carbohydrate is recommended before he would sleep at night in order to prevent hypoglycemia at night (Ripoll, et.al. 2011). It is also best to advice the patient to reduce his alcohol intake in order to prevent any complications. It is also important for him to not take any alcohol on an empty stomach because alcohol can sometimes inhibit hunger pangs and eventually lead to hypoglycemia. The patient’s diabetic diet has to be planned with the patient. A suggested plan would have to be discussed with the patient, with goals set for the entire plan and for specific parts of the plan (Funnell and Anderson 2004). The target weight and HbA1c levels must also be discussed with the patient. The plan must be based on realistic goals and collaboratively undertaken with the patient. It is important for the patient to be an active participant in his diet plan in order to secure his cooperation and compliance (Funnell and Anderson 2004). He can indicate what type of foods he would prefer to take, substitutions he can make, cooking options he can consider, as well as other lifestyle diet changes he can realistically participate in. Studies also emphasize the importance of educating diabetic patients about their diet. Discussing their disease, how it affects them, and what needs to be done to manage their blood glucose levels is an important aspect of the health education process. The more the patients understand about their disease, the more they would know the adjustments they can make in order to manage their blood sugar levels (International Diabetes Federation 2006). Patients declare that with health education, they are aware of what food they can indulge on, and how much they can take in excess. They also become aware that they may need to make adjustments later in their food intake if they are to indulge in certain foods at some point during the day (International Diabetes Federation 2006). As the patient is already overweight, there is a need to implement measures, including those already mentioned above, for the patient to lose weight. A low carbohydrate or low fat caloric diet is usually recommended in the short-term period for these patients, and in this case, highly appropriate for this patient (Alberti, et.al. 2005). Physical activity and behavior modification is also an important component of his weight loss and weight loss maintenance. The significance of managing body weight in reducing the complications related to diabetes is an important aspect of effective patient management (Grundy, et.al. 1999). Nutrition recommendations would usually initiate with the evaluation of energy balance as well as weight loss techniques. Due to the impact of obesity on insulin resistance, weight loss is a significant objective for patients with diabetes (Norris, et.al. 2005). However, long-term weight loss can be a significant challenge for most patients. The central nervous system has a crucial role to play in managing energy input and output. The short-term studies indicate that moderate weight reduction among patients with type 2 diabetes seems to be linked with lower insulin resistance, with better measures in cholesterol management and blood glucose management, as well as lower blood pressure (Klein, et.al. 2004; Norris, et.al. 2004). The longer-term researches indicated unexceptional weight loss and HbA1c levels (Norris, et.al. 2004). Based on evidence, clearly structured and intense programs for patient education, personalized counseling, decreased fat intake, and increased physical activity are interventions which help secure long-term weight loss (Franz, et.al. 2002). Exercise and physical activity alone can lead to modest weight loss. These activities must be encouraged as they help increase insulin sensitivity and is eventually beneficial for long-term weight loss maintenance (Franz, et.al. 2002). The most favorable nutrient distribution for weight loss has not been fully established. Meal replacements however seem to offer a more specific amount of energy for patients. These meal replacements used once or twice a day are taken in lieu of regular meals and have been known to lead to significant weight loss (Bantle, et.al. 2008). Weight loss medications may be beneficial for the patient in order to assist him in losing weight (Bantle, et.al., 2008). Such medications must however be combined with lifestyle changes in order to ensure prolonged and sustained outcomes towards weight loss. Diabetes management is based on primary, secondary and tertiary prevention (International Diabetes Federation 2006. Primary prevention mostly includes the health education of the general public and those who have a high risk of developing this disease. Bantle et.al. (2008) discusses that for those who have a high risk of developing this disease, there is a need to secure a specific and a well-planned program which would highlight lifestyle changes, including weight loss and regular physical activity, as well as reduced caloric intake. Those at high risk for developing diabetes are also encouraged to increase their dietary fiber and whole grain intake. Secondary prevention for diabetes would now include the management interventions for this patient. Secondary prevention measures would include a diet of carbohydrates which would include fruits, vegetables, legumes, and whole grains (Bantle, et.al. 2008). The importance of monitoring carbohydrate intake is also a necessary part of the management of the diseases, with levels based on glycemic control. The utilization of the glycemic index may also secure benefits in terms of preventing excess energy intake for the patients (Grundy, et.al. 1999). It is also important to remind the patients that the intake of sugar alcohols and sweeteners is safe for as long as the person’s intake is based on the recommendations of the Medicines and Healthcare products Regulatory Agency (MHRA). The management of blood glucose in order to reach normal or relatively normal levels is the main aim of diabetes management. Nutrition interventions which decrease postprandial blood sugar considerations are significant under these conditions, especially as dietary carbohydrates have a major impact on postprandial glucose quantities (Bantle, et.al. 2008). Having low carbohydrate meals may be an effective approach in decreasing postprandial glucose. However, foods with carbohydrates are also needed for energy, vitamins, and minerals. In effect, these foods are crucial requisites of the diet for diabetic patients (Bantle, et.al. 2008). For the management of diabetes, it is important to consider insulin dose and secretion in relation to the carbohydrate content of meals. Various methods can be applied in order to evaluate the nutrients found in meals. In the evaluation of pre and postprandial glucose levels, various patients can apply experience in order to assess and attain postprandial goals for different foods (Bantle, et.al. 2008). Fiber-rich foods have been mentioned above as beneficial for diabetic patients. These foods include fruits and vegetables and they are important sources of vitamins, minerals, and other nutrients which can promote the patient’s health (Nordmann, et.al. 2006). Allowing fiber-rich foods also assists in ensuring palatability for diabetic patients, with the larger variety of foods which the patient can take in. Sweeteners have been discussed also in relation to diabetic patients. Evidence has been presented indicating that dietary sucrose does not cause the rise of blood sugar more than the usual amounts of starch converted in the dietary system (Bantle, et.al. 2008). Therefore sucrose and sucrose-containing foods for patients with diabetes need not be limited. Sucrose can nevertheless be substituted for other carbohydrates within the diet if it is integrated into the planned meal, and it is sufficiently compensated with insulin or any other medication which would reduce blood glucose levels (Mayer-Davis, et.al. 2004). In addition, nutrients taken in with sucrose also have to be considered in order to prevent excess energy intake. For patients with diabetes, fructose can cause lower postprandial glucose response as it replaces sucrose in the diet (Bantle, et.al. 2008); however, this favored response is moderated by concerns on fructose negatively impacting on plasma lipids (Franz, et.al. 2002). This is why the use of fructose as a sweetener among diabetics is not favored. Naturally occurring fructose in fruits, vegetables, and other foods is however recommended for diabetics. In terms of dietary fat intake, the recommendations include saturated fat of less than 7% of total calories with the use of trans-fat significantly minimized (Bantle, et.al. 2008). Dietary cholesterol also needs to be limited to less than 200 mg daily. The main goal in the intake of dietary fat among diabetics is on controlling saturated fatty acids, trans fatty acids, as well as cholesterol in order to decrease the patient’s risk for cardiovascular disease (Stern, et.al. 2004). Saturated and trans fatty acids have a significant impact on the LDL cholesterol levels among patients. Among non-diabetics, decreasing saturated and trans fatty acids can effectively reduce total and LDL cholesterol levels in the blood. Decreasing saturated fatty acids can also decrease HDL cholesterol (Stern, et.al. 2004). The recommended dietary fat intake for patients with diabetes is actually similar to patients with preexisting cardiovascular disease as the two groups carry similar health risks (American Diabetes Association 2008). For protein, recommendations for diabetic patients evidence suggests that the usual protein intake must be adjusted. For diabetic patients, ingested protein can lead to a higher insulin response which would not increase plasma glucose levels (Bantle, et.al. 2008). In effect, protein must not be used to manage nighttime hypoglycemia. Good protein sources are also recommended for diabetic patients with sources including meat, poultry, fish, eggs, cheese, and soy. The dietary intake of protein for patients with diabetes is likened to the general population, which is usually not more than 20% of energy intake (Herman, et.al. 2005). Studies on healthy individuals and among diabetic patients indicate that glucose from ingested protein does not lead to higher plasma glucose; however it causes increased blood insulin reactions (Gannon, et.al. 2001; Franz, et.al. 2002). Problems in protein metabolism may also be attributed to insulin deficiency and insulin resistance, however these aspects are often remedied following blood glucose management processes (Guogeon, et.al. 2000). Among older patients, including the patient being evaluated for this study, energy restriction and increased physical activity may be beneficial. Their energy requirement is lower as compared to their younger counterparts. A decreased energy intake must therefore be planned (Bantle, et.al. 2008). Nevertheless, multivitamin supplementation is appropriate for these patients, especially as their diet intake needs to be decreased (Brown, et.al. 2003). As their energy intake is decreased, they may be deprived of the essential nutrients and vitamins they need for normal functioning. Among the obese older adults, there is a need to lose weight with levels reaching 5-10% of their body weight (Brown, et.al. 2003; Miller, et.al. 2002). Physical activity is essential as a means of satisfying the loss of lean body mass which can be seen along with energy restriction. Exercises can help manage the decline in the general capacity which is apparent with age. Physical activity can also prevent and help manage the risks relating to atherosclerosis; it can also decrease age-related deterioration in the body mass (Zinman, et.al. 2003). Exercise can also reduce centralized obesity as well as increase insulin sensitivity (Day 2012). However, it can also expose the patient to musculoskeletal injuries and hypoglycemia. It is therefore important for any physical activity or exercise to be monitored. In the case of this patient, he has to be guided on the physical activity he can actually engage in (American Association of Diabetes Educators n.d). The health education process would therefore include recommended exercises for the patient. These exercises would have to be based on what he can safely do and what he can actually actively engage in (American Association of Diabetes Educators n.d). Patient preferences in exercise and other physical activities is often the best course of action especially as most individuals find it difficult to engage in exercise, and this patient is no exception (Day 2012). Nevertheless, patient preferred activities and exercises can help improve compliance. Some patients may prefer to play a sport, or prefer to walk or jog daily or only on weekends (Day 2012). Regardless of their preferences, it is important to highlight that any form of exercise would be a significant contribution to their well-being. It is also important to consider possible injuries which may befall these patients during exercise and physical activity, especially among older adults. Exercises and physical activities may lead to falls, bruises, scrapes, and other physical injuries (Eastman n.d). Due to diabetic neuropathies, these patients may not be able to feel any injuries they are already suffering. It is important for regular assessments on possible injuries and wounds to be determined for these patients. Early treatment is crucial because wound healing is often slow for these patients (Eastman n.d). Prolonged healing can also lead to gangrene and eventually to amputations. Amputations are common interventions for diabetic patients (McIntosh 2007). Therefore efforts must be ensured to avoid any injuries befalling these patients. The support of the patient’s family is an important element of successful diabetic management. In the patient’s case, he has a strong family support system. The family support system would be a useful tool in terms of the patient’s weight loss process (Hardtke n.d). Possible discussions on what the entire family can do in order to help the patient lose weight and make lifestyle changes can be opened up with them. The lifestyle changes can include adjustments in the family’s diet and in their general attitude and behavior (Hardtke n.d). The patient would not feel isolated from his family due to his condition and the lifestyle changes he needs to make. In other words, the patient would feel less alone if he can diet and lose weight with his family (Funnell and Anderson 2004). Under these conditions, the patient’s socialization process with his family and friends would still be maintained. Emotionally, he would be less prone to the risks of isolation and depression which are often associated with chronic disease sufferers (Goldney et.al. 2004). As he would start to lose weight, his body image would improve and this would encourage him further to continue to lose weight. The fact that he has the support of his family throughout the process would also help secure improved outcomes (Goldney et.al. 2004). The health education process would therefore also have to include the family. Their risk for developing diabetes has been increased by the diagnosis of their family member. Their diet as a family implies affectations which have impacted on the father, which may also eventually manifest in their future physiology if no changes are made (Joslin and Kahn 2005). Teaching the family about their risks and the changes they can implement in their diet is an important aspect of health education and empowerment. This process would also clarify to the family what they can and cannot eat, how much they can eat, and the impact of all these foods on their body. Instructing the family about the importance of exercise and physical activity can also be beneficial for the patient (Joslin and Kahn 2005). The family can actually plan activities which they can all take part in. In the process, not only would they help their diabetic family member lose weight, they too can make lifestyle changes in their own lives. Healthy habits can therefore be borne from these activities. The family’s participation can also reduce the burden of the disease. As a chronic care patient, the diabetic would likely need care during times when he would be suffering from hyperglycemia or hypoglycemia. During these instances, the burden of the disease on the family would be heaviest, especially on the primary caregiver (Watson 2005). With grown up children, the burden of care would likely fall mostly on the wife. The burden of care giving would likely be more significant as the disease would progress (Watson 2005). Hence, it is important to gain the support of other family members in order to reinforce the emotional and physical tolerance of the primary caregiver. This is not a significant issue for the family which has strong ties with each other. As Muslims, they are very much involved in patient care, including the administration of medications for the patient, and similar interventions (Alzaid 2012) The patient’s erectile dysfunction is also attributed to the patient’s diabetes. Impairments in the nerves, blood vessels, and muscle function can cause the dysfunction (Sinclair 2009). Normally oral medications can be taken in order to resolve this dysfunction, however the medications available can also cause cardiovascular issues (Sinclair 2009). This patient carries this risk especially as he is obese and has hypercholesterolemia. It is important for a consultation with the attending physician to be undertaken in order to manage this medical issue (Sinclair 2009). The physician would likely consider milder medications which can help resolve his dysfunction. The patient’s blurry vision is also attributed to his diabetes. Blurry vision is caused by the high blood sugar levels draining fluid from the tissues, including the eyes (Fong, et.al. 2004). This condition is also known as diabetic retinopathy. This blurry vision has to be managed and treated in order to prevent damage to the blood vessels around the eyes and to prevent the formation of new blood vessels around the retina (Mayo Clinic, 2012). Decreasing blood sugar levels would help resolve this condition. The assistance of the healthcare team is one of the most important elements of diabetic management. The healthcare team would include the attending physician, in this case, the endocrinologist, also the nurse, the dietitian, and the physiotherapist/trainor (McDowell, et.al. 2007). The endocrinologist would be the primary medical caregiver for the patient. He would be directing the patient’s care, including his medication intake, medical interventions, surgical options, diagnostic examinations, as well as related health teachings (McDowell, et.al. 2007). The nurse assists in the monitoring of the patient, including his assessment, and health education. The nurse would assist in the administration of due medications, and the monitoring of the patient’s vital signs, and blood glucose levels (Clark, 2004). The physiotherapist would be involved in the establishment of an exercise plan for the patient and possibly his family. This therapist would likely assist in the first few weeks where the exercises and other physical activities would be initiated (Clark, 2004). He would guide the patient and the family members on safe and appropriate exercises, including warm up procedures, sports, cardiovascular exercises, and cooling down activities (Nagi and Gallen, 2010). The dietician would help in the planning of the patient’s diet. This diet would have to be made in consultation with the client and his family, especially the wife who is the primary caregiver (Huang, 2010). Suggestions on food preparation and diet adjustments can be discussed with the dietician. A list of possible recommended foods and meals can also be drawn out by the dietician (Huang, 2010). Conclusion Based on the above discussion, it is apparent to note that the patient’s condition calls for a major lifestyle change. These changes mostly include adjustments in food and physical activity. Changes in eating habits and the increase in physical activity can help reduce the patient’s blood sugar, his cholesterol and his blood pressure. His blurred vision and erectile dysfunction can also be managed better with the application of the abovementioned interventions. These interventions are also meant to be carried out with the assistance of the patient’s family as well as the health care team. 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