Care and Management of Diabetes - Essay Example

Care and management of diabetes Word count: 3,675words Essay outline The essay entails critically analysis of the care and therapeutic management of a patient with type 2 diabetic foot and the aim is to offer professional advice on how the patient can care the diabetic foot. In the first part, the essay has identified the epidemiology, aetiology and pathology of diabetes and the impact on the health of an individual. In the second part, the essay has critically analysed the therapeutic management practices using a case study of a Polish patient with diabetic feet and some of the therapies that have been explored include blood glucose monitoring, oral and insulin therapies, Furthermore, the essay examines the role of multidisciplinary teams in offering patient-centered diabetic care and patients with such conditions. Lastly, the paper has critically detailed the physical, psycho-social and cultural impact of diabetes on clients and their families. The essay incorporates a case study of type 2 diabetic patient with pressure ulcers in his diabetic feet and associated conditions such as unitary and bowel incontinence, but has not adequate knowledge of management and care of his diabetic feet. The essay has adhered with ethical conduct of Nurses and Midwifes since the identity of the patient has been altered to John in order to protect confidential medical information of the client. The case study has been included in the appendix. Introduction Anderson and Rubin (2000) agree with Edmonds (2013) that diabetes results from several biological, environmental and lifestyle factors that lead to abnormal metabolism and hyperglycemia. Foster and Edmonds (2013) conquers with Cheyette (2005) that diabetes is a life-long condition that is associated with high glucose in the blood since the pancreas is incapable of producing enough insulin that is essential in regulating the blood sugar levels. I agree with Cheyette (2005) that John is experiencing high sugar levels due to inability to produce enough insulin. As Anderson and Rubin (2000) have outlined, insulin initiates the signal transduction whereby the glucose will enter the bloodstream for it to be stored as energy in the muscles or converted to fat by the liver. Tuomi (2005) confirms that insulin signals the liver to convert glucose to glycogen in case the body has sufficient energy. From the analysis, I believe insufficient of insulin affects metabolism processes in the body of John. The Health Commission (2007) explains that some critical pathophysiological aspects of type 2 diabetes include impaired secretion of insulin and increased body resistance to the intake of insulin thus leading to progressive decline in pancreatic β cell insulin secretion (Cheyette, 2005). The Department of Health (2010) clarifies that there is type 1 diabetes and type 2 diabetes and both affect adults. Tuomi (2005) agrees with Cheyette that type 1 diabetes is more acute and is caused by the immune destruction of the beta cells in the pancreas that gradually diminishes insulin secretion (Cheyette, 2005). Type 1 may occur at early ages and is mainly triggered by infections, stress and genetic predisposition and insulin injections will be critical for the survival of the client. Tuomi (2005) is of a similar opinion with Health Commission that diabetes is associated with increased urination, weight loss and life-threatening ketoacidosis and if not well managed can lead to chronic hyperglycemia that eventually leads to cardiovascular diseases, kidney disease and nerve damage (Health Commission, 2007). On the other hand, I agree with Diabetes UK (2010) that type 2 diabetes as in John’s case is caused by insulin resistance and high sugar levels in the liver. I agree that Type 2 diabetes leads to decline in insulin secretion and failure of beta cells in the pancreas and some of the leading contributing factors include elderly age, obesity, genetic factors, sedentary lifestyles and conditions that lead to insulin resistance such as polycystic ovary syndrome (Department of Health, 2010). Epidemiology, aetiology, and pathology of diabetes and impact on the health of John Epidemiology Diabetes UK (2010) diabetes affects more than 3 million people and the number is expected to reach 5 million people by 2015. The cases of new diagnosis have increased rapidly from 1.4 million in 1999 to about 2.6 million in 2009. In 2008 alone, 145,000 cases were reported which translates to 400 new diagnosis each day (Diabetes UK, 2010b). Clinical estimates indicate that half million people live with undiagnosed diabetes in UK and it is estimated that about one-fifth of the population live with diabetes. The prevalence rates are 5.1 percent in England (2,213,138 people), 4.5 percent in North England (65,066 people), 4.6 percent in Wales (146,173 people) and 3.9 percent in Scotland (209,886 people). On average, the prevalence rate is 4.5 percent across UK. Accordingly, 15.7 of the men aged 65 to 74 years have diabetes while individuals from South Asian origin are 13 times more likely to have the disease (Diabetes UK, 2010b). Hillson (2005) outlines that most cases involve type 2 diabetes due to the ageing population, the lifestyle changes, and high number of obese people due to poor health eating habits. Diabetes UK (2010b) that this figure is alarming and points out that diabetes is an emerging health crisis and self-management among affected individuals such as John is critical in controlling the disease share a similar opinion. The Department of Health (2010) conquers with Boulton and Andrew (2005) that type 2 diabetes is most prevalent since it accounts for about 90 percent of the newly diagnosed cases while type 1 accounts for the other 10 percent of the new cases. Type 2 diabetes is common at the age of over 40 years and is high among South Asian and African-Caribbean people (Diabetes UK, 2010b). Diabetes UK (2010b) outlines that more than 6,000 people have a leg foot condition and several have received toe amputations across England. It is shocking that 80 percent of the people with amputation die within few years since amputations lower the quality of life die to foot ulcers, pain, depression and poor social relationships (Diabetes UK, 2010b). The good thing to John is that 80 percent of foot amputations are preventable through integrated foot care. Aetiology The Department of Health (2010) highlights that type 2 diabetes occurs when the beta cells of the pancreas do not produce enough insulin to regulate the blood sugar levels or when the body is resistant to insulin. As in John’s case, I am of the opinion that insulin resistance will lead to hyperglycemia and eventually diabetes. Just like John, diabetic patients may develop foot ulcers due to ischaemia or neuropathy (Foster & Edmonds, 2013). As illustrated by Hillson (2005), peripheral neuropathy will lead to abnormal foot forces thus affecting the skin of John is the disease is not effectively managed. In addition, poor vision, cerebral-vascular disease and limited joint mobility will lead to ulceration (Diabetes UK, 2010b). In this case, John’s pressure ulcers will contribute to broken skin that will lead to bacterial infections, trauma and poor feet management. The Department of Health (2010) clarifies that a person will display certain symptoms even before diagnosis since the type 2 diabetes mainly starts at adulthood unlike type 1 diabetes whose symptoms are evident even in childhood. Watkins, Amiel, Howell & Tuner (2003) points out that old age is a risk factor since individuals like John tend to gain weight and adapt sedentary lifestyle as they age, more recent work by Department of health (2010) has suggested that the disease is common to individuals aged more than 40 years. However, I believe it is worth noting that genetic factors is also a factor since hereditary pattern has been established as children whose parents are diabetic have higher chances of developing the disease as suggested by Diabetes UK (2010b). Obesity or overweight individuals with a body mass index of more than 30 has high fat levels and low metabolic thus will have high glucose levels and may develop associated conditions such as stroke (Department of Health, 2010). As in John’s case, I am of the opinion that the continuing lack of physical exercise, poor diet and sedentary lifestyles lead to overweight and limited metabolic activities thus increasing the chances of developing the disease (Diabetes UK, 2010b). Food with high cholesterol and excessive smoking increase the risks of the disease while impaired fasting glycaemia (IFG) and impared tolerance to glucose lead to higher than normal blood glucose levels (Pendsey, 2014) . On a different note, I must emphasise that bacterial infection, chemical toxins and autoimmune reactions are the primary triggers of type 1 diabetes and such clients occasionally experience low blood sugar levels unlike in the case of type 2 diabetes. Diabetic foot may cause tissue damage in the feet and legs and is a leading cause of amputations in the UK (Diabetes UK, 2010b). Pathology The World Health Organization (WHO) criteria for diabetes diagnosis is presence of symptoms like increased urination, weight loss, extreme tiredness and fasting plasma glucose (FPG) of equivalent or more than 7.0 mmol/l or plasma glucose of equivalent or more than 11.1 mmol/l at two hours after a 75g oral glucose load (OGTT) (Diabetes UK, 2010b). As the case for John, the body produces inadequate insulin or develops insulin resistance thus leading to high blood glucose. John must understand that insulin stimulates conversion of glucose to energy and synthesis of amino acids and fat (Diabetes UK, 2010b). Pendsey (2014) is of similar argument with Barnett & Kumar (2004) that the pathophysiologic defect entails three disorders that are peripheral insulin resistance in muscle cells, increased glucose production by the liver and altered pancreatic insulin secretion. As the case for John, I am of the view that the glucose will then fail to enter target cells and accumulate in the bloodstream thus causing hyperglycemia thus eventually causing the insulin resistance syndrome (Hillson, 2005). Therapeutic management practices Barnett & Kumar (2004) outlines one of the therapeutic management practices for John as the education on the routine preventive podiatry care, Boulton, Cavanagh and Rayman goes further to suggest that patients must use appropriate footwear in order to minimise pressures on foot and breaking of the skin. I believe that John is expected to check his feet on a daily basis and report any puffiness, pain, colour change, numbness or swellings that do not heal (Boulton and Andrew, 2005, p 880). Pendsey (2014) is of the idea that well-fitting and comfortable shoes will reduce friction and ease John’s mobility, similar opinion is stressed byWhitmore (2010) that hygiene is essential since John must carefully clean and moisturise his dry skin on daily basis in order to avoid skin breaks (p 882). My take is that John must receive education on the dangers of skin removal and possible complications such as colour change and swelling that may lead to limited mobility. Furthermore, I believe it is important to use sun block on the feet and have a first aid kit that will be used in dressing the sore places of the feet. Hillson (2005) has outlined that diabetic physician tests the foot sensation using 10 g monofilament, and Boulton, Cavanagh and Rayman (2006) goes further to provide that physicians must inspect possible deformities and risks of ulceration due to the pressure ulcers, loss of sensation and unexplained swollen feet. In this case, John should be offered an antibiotic treatment of clarithromycin 500 mg twice a day for seven days. Boulton and Andrew (2005) explain that vascular surgeon will determine the need for angioplasty due to the significant peripheral vascular disease since ischaemia candelay his healing (p 14). In this case, I believe the surgeons are expected to conduct surgeries such as tendon lengthening and tenotomy or reconstruction in order to heal ulcers and finally amputation in cases of uncontrolled pain and debilitating ulceration. John will be provided with specialist footwear and casts in order to relive pressure and facilitate the healing of the plantar foot ulcers (Department of Health, 2001). A majority of the authors conquer that diabetes can cause long term complications such as sexual dysfunction, nerve damage and blindness, thus patients like John need therapies on blood glucose monitoring and therapies that will reduce the glucose levels to normal (Barnett & Kumar, 2004). Diabetes UK (2010b) maintains that patients like John are responsible for self-care and blood glucose monitoring, and Hillson (2005) expands the scope of self-monitoring to ensure the attainment of target level of 48 mmol/mol which is set for type 2 diabetic patients. I am of the opinion that the team should conduct a renal monitoring for albumin creatinine ratio and glomerular filtration in ordr to educate John on how to monitor possible kidney damage. John must receive diet therapeutic lessons to attain weight loss and improve glycaemia control (Whitmore, 2010, p 881), and available options include calories restrictions, using carbohydrates with low glycaemic index, and reduction in fat intake (Department of Health, 2010). In this case, I advice that John to maintain a normal blood sugar levels of 4-7 mmol/L (millimoles per litre) before the intake of meals and 7-10 mml/L aftet meals (Hillson, 2005). John was placed on a balanced diet that included high fibre, low fat, starchy, fruits and vegetables in order to control blood glucose levels and promote his healthy lifestyle. In this case, the nurses discouraged John’s Polish culture of high carbohydrate foods in order to prevent high blood pressure (Whitmore, 2010, p 884). NICE guidelines requires recommendation anti-diabetic Metformin drug so as to delay absorption of sugars in the bloodstream and thus is the initial treatment that is the available treatment in cases of this nature (NICE 2006). Smoking cessation is advisable for people with type 2 diabetes in order to minimise risks of cardiovascular diseases and health care professionals must monitor the smoking status of the diabetic patients (Hillson, 2005). Role of inter-professional teams in management of diabetes Leading nursing authors like Pendsey (2014) and Hillson (2005) conclude that effective care and management of type 2 diabetes requires inter-professional teams that comprise of dieticians, physicians, nurses, social workers, physical therapists, vascular surgeons, kinesiologists and pharmacists who are expected to offer client-centered healthcare (Diabetes UK, 2010b). In the initial assessment, I believe the multidisciplinary team will calculate the body mass index (BMI), check smoking status and involve the patient in discussing measures of self-monitoring of the glucose levels. More important is that the diabetic physicians will advice John on oral plasma glucose lowering treatments and urine glucose monitoring (Hillson, 2005). Hillson (2005) claims that poor management of diabetes will lead to acute complications such as blindness, nerve damage, amputation of the foot and renal failure, different authors share the same predicaments and thus a inter-professional team is best suited in offering systematic and evidence-based care that will lower sugar levels and avoid thus complications (Nair, 2007a, p 232). Vascular surgeons play a leading role in avoiding renal failure and dealing with urinary incontinence thus improving the overall quality of life enjoyed by the diabetic patient. In this case, the team of professionals will limit risks of further complications such as cardiovascular diseases, blindness and amputation thus leading to high wellbeing of John and his family (Hillson, 2005). Nursing and Midwifery Council (2008) reminds of the need of the team to follow the national guidelines and policies on the insulin therapies and further treatments that relieve the acute symptoms. National Institute for Health and Clinical Excellence recommends that patients like John who has foot ulcer to receive care under multidisciplinary team within 24 hours in order to avoid ulceration and receive insulin dosages, the same procedures are observed by the Department of Health (2010). In the case of John, I conquer that inter-professional teams will facilitate coordination of the therapeutic care and ensure collaboration in monitoring the changing conditions of the diabetic foot. According to the National Service Framework (2001), individuals admitted with diabetes in healthcare facilities are expected to receive adequate and quality care thus will improve their medical outcomes. Vora and Buse (2012) outlines some medical professionals that form the team as Tissues viability nurse will engage in routine assessments so as to avoid instances of feet amputation and will offer the required advice on the care of the feet. Diabetes UK goes further to highlight that nutritionists should monitor the body mass index, the physical health changes and prescribe the right diet for John in order to avoid obesity and overweight thus enhances isk of cardiovascular diseases (2010b). I am convinced that Dieticians have a critical role to play in assisting John’s family with advice and education on the right insulin regimen and providing social and emotional support in order to avoid stress and depression (Vora and Buse, 2012). With John’s case, diabetic nurses offers critical information in glycaemia control through explanation of the causes of type 2 diabetes, self-care therapies including glucose monitoring and care of the diabetic feet. In this case, the team will provide medical nutrition therapy that is geared at meeting the blood glucose targets such as eating the right servings of carbohydrates (Diabetes UK, 2010b). In addition, John’s case requires the input of physiotherapies who will provide information on the purpose of physical activity and guidelines for the physical exercises depending on the nutrition (Hillson, 2005). In this case, some advisable moderate exercises such as jogging, leisure cycling and golfing are critical. For instance, I would advise John not to walk barefooted or open the blisters since this will lead to wounds. Likewise, diabetic nurses will educate John on how to wash his feet in lukewarm water and how to minimise the pressure of the soles on his feet while walking (Pendsey, 2014). From the medical diagnosis, John has a unitary and bowel incontinence and I expect nurses to help him with basic roles such as emptying the bowel and emotional support. He is also catheterized and doctors must keep observing his changing medical condition in order to prescribe further measures of controlling the problem (Department of Health, 2010). John’s case requires a multidisciplinary team since team members will work depending on their areas of expertise in providing holistic care of the diabetic feet and preventing other accompanying diseases. Hillson (2005) asserts that inter-professional team is associated with higher accountability and better decision-making and fosters good self-care in the clients. Indeed, I agree that inter-professional team will lead to higher professional satisfaction and improved health outcomes for the diabetes patients like John. Physical, psycho-social and cultural impact Walsh (2002) discusses various physical, psycho-social and cultural factors that will influence the health of John such as belief systems and expected social support from the family members. Hillson (2005) agrees with Walsh (2005) and mentions the physical characteristics such as diabetic feet and bowel incontinence as leading impairments to patient’s movements. Although John is admitted in rehab to improve his mobility, I am of the belief that the pressure ulcers on his diabetic feet are painful and will cause discomfort even while sleeping. In this case, Tuomi (2005) and Hillson (2005) require patients like John to take the necessary measures in self-care therapies of the feet in order to avoid amputation. The course has enabled me understand that diabetic foot is associated with cold feet, poor blood pulses and thin skin that may eventually change colour (Hillson, 2005). Anderson and Rubin (2000) dwells on the psychology of diabetic patients and point out that John is likely to be concerned about his poor health and the change is likely to cause eating disorders in trying to reduce weight and adapting to healthier lifestyles such as tobacco cessation. Hillson (2005) conquers with the proposition and offers emotional support and counseling as the most appropriate solution that will facilitate the uptake of healthier lifestyle since psychological anxiety has the potential of causing severe depression on the patient. In addition, John’s family can cause fear and frustration among family members as they will be worried about the burden of taking care of John and the financial cost implications (Walsh, 2002). In the case of John, I believe nursing professionals are expected to further coordinal and meaningful client-nurse therapeutic relationships that are based on mutual trust, cooperation and empathy. Walsh (2002) asserts the psychosocial impact on John may include emotional disturbances and anxiety. In this case, lifestyle interventions are essential for John and will include frequent contacts with diabetic nurses, behavioural modeling, and empowerment in order to engage in self-care activities such as blood glucose monitoring and care of the diabetic feet (Tuomi,2005). Structured educational interventions will assist John with manuals on diabetic foot care and emotional balance in order to cope with the disease. Walsh (2002) and Tuomi (2005) points out some negative cultural beliefs on diabetic feet that may affect John’s attitude towards his condition. The two authors agree that John may be socially excluded by friends since some people perceive the disease as contagious (Walsh, 2002; Tuomi, 2005). In this case, I suggest structured educational interventions will assist John to adjust his cultural beliefs and perceive diabetes as a lifestyle disease that is manageable. John may also be worried about his siblings developing the disease and thus psychotherapies will enable him to cope with the disease (Hillson, 2005). Diabetes UK (2010b) outlines that genetic factors contribute to development of type 2 diabetes, and his siblings will have higher chances of developing the disease thus social support and information must be provided to the family. Furthermore , John is experiencing social denial and may encounter social exclusion if adequate emotional support is not availed by his immediate family. Diabetes will hinder his social relationships and alter his personal beliefs thus affecting his psychological wellbeing (Hillson, 2005). Outcomes To evaluate John’s progress in self-care of the diabetic feet and controlling the blood glucose level, John was discharged from the health facility and was tasked with self-monitoring of blood pressure, blood sugar levels, self-feet care and observation of associated complications. John received several documents on diabetes on the symptoms, causes and associated complications and recommended action in controlling the symptoms. John also received healthy balanced diet information and was informed on the importance of attending to regular check-ups. John also received a glucose monitor and his immediate family was provided with information on how to provide social and emotional support. In this case, multidisciplinary team was engaged in the care and patient confidentiality and human dignity was incorporated in the care (Nursing and Midwifery Council, 2008). Conclusion Blood glucose control is essential in the management of diabetes and associated complications such as high blood pressure, nerve damage, visual impairment, diabetic feet, and sexual dysfunction. From the analysis, poor diets that contain high cholesterol, smoking, hereditary factors, obesity, and sedentary lifestyles increase the risk of type 2 diabetes. Diabetic foot care entails multidisciplinary approach for all diabetic patients and John must receive antibiotic regimen according to the national protocols. The multidisciplinary team will comprise of diabetic nurse specialist, radiologist, diabetic physician, podiatrist, vascular surgeon and orthotist since the three pressure ulcers could be symptoms of spreading infection and swollen feet. In this case, the team must offer rapid referral according to his need and provide both verbal and written education, contact numbers and guidelines of self-care of the diabetic feet. John has bowel and unitary incontinence thus intensive glycaemic control will reduce development of diabetic kidney disease. Accordingly, John is at risk of losing eyesight due to high risk of retinopathy thus community support and training in use of low vision aids will improve his welfare. Reference list: Anderson, B.J and Rubin, P.R. 2000. Practical psychology for diabetes clinicians. New York: Hamilton. Barnett, H & Kumar, S. 2004. Obesity and diabetes. London: Ashgate. Boulton, M and Andrew, J.M. 2005. “Management of diabetic peripheral neuropathy”, Journal of clinical diabetes, January 2005, Vol 23, Issue 1, pp 9-15. Boulton, M.A., Cavanagh, P.R and Rayman, G. 2006. The foot in diabetes. New Jersey: John Wiley. Cheyette, C. 2005. “More education needed on weight and insulin”, Journal of practice nursing, Vol 16, Issue 4, pp 166-170. Department of Health. 2001. ‘National Service Framework for diabetes: standards available from:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/1988 36/National_Service_Framework_for_Diabetes.pdf [Accessed 18 May 2014]. Department of Health. 2010. Health survey for England 2009. London. DH. Diabetes UK. 2010b. Treating diabetes with insulin. London: Diabetes UK. Foster, A.V & Edmonds, M.E. 2013. Diabetic foot care: case studies in clinical management. New Jersey: John Wiley. Health Commission. 2007. Managing diabetes: improving services for people with diabetes. London: Commission for Healthcare Audit and Inspection. Hillson, R. 2005. Diabetes the complete guide: the essential introduction to managing diabetes. London: Vermillion. Nair, M. 2007a. Nursing management of the person with diabetes mellitus: part 2”, British journal of nursing, Vol 16 (4): pp 232-234. National Institute for Health and Clinical Excellence. 2006. Guidelines manual on diabetes management. London: NICE. Nursing and Midwifery Council. 2008. The code: standard for conduct, performance and ethics for nurses and midwives. London: NMC. Pendsey, S. 2014. Contemporary management of the diabetic foot. Philadelphia: Jaypee Brothers Medical Publishers. Tuomi, T. 2005. “Type 1 and Type 2 diabetes: what do they have in common”, Journal of diabetes, Vol 54, Issue 2, pp 540-545. Vora, J and Buse, J.B. 2012. Evidence-based management of diabetes. Harley: TFM Publishers. Walsh, P.J. 2002. Watson’s clinical nursing and related sciences. London: Bailliere Tindall. Watkins, P.J., Amiel, S.A., Howell, S.L & Tuner, E. 2003. Diabetes and its management. London: Blackwell Publishing. Whitmore, C. 2010. “Type 2 diabetes and obesity in adults”, British journal of nursing, Vol 19 (14): pp 880-886. Appendix: Case study John is a 72 years patient of polish descent with antibody disease and had a elapse in August 2013. John had type 2 diabetes, capal tunnel and AfDVT in February. Prior to admission, he was mobilized with Zimmer frame. John has urinary and bowel incontinent and is catheterized. He has three pressure ulcers on his left foot and has been seen in clinics before by vascular surgeons. John is admitted to rehab to improve his mobility and manage his incontinence. Despite being seen numerous times in clinics, John is not well informed on how to care for his foot as a diabetic. Read More