Advanced Diagnostic Skills in Diabetes - Case Study Example

Advanced Diagnostic Skills in Diabetes Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Name Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Instructor Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Date Introduction My patient has been presented with typical diabetic symptoms of polyuria, polydpsia and lethargy among others while my task is to examine the patient and then present my consultation style, assessment skills and tests that I will use according to the latest and guidance models. Polyuria, polydpsia and lethargy are but signs of diabetes mellitus. Notably, diabetes mellitus is a chronic illness and requires continuing medical care compounded with ongoing patient self management and support to prevent any acute complications that may arise in future. The National Institute for Clinical Excellence, 2008 (NICE) guidelines are based on the World Health Organization (WHO) definition of diabetes, that diabetes is a disease that is characterized by high levels of plasma glucose and usually puts the individual patient at a risk of many microvascular complications. As a nurse, there exists a large body of evidence that provides a wide range of interventions I would employ in order to improve diabetes outcomes. These available standards of care are supposed to help me as a clinician to with the relevant components of how to care for a diabetic patient, the general treatment goals and the necessary tools required evaluating the quality of care that I give. This paper is a reflection of the different decisions that I made as regards to my patient and how I arrived at the different decisions. i. Presenting complaint and reason for attendance The patient comes to me with typical symptoms of diabetes mellitus which include polyuria, polydpsia and lethargy among others. The first step in attending to the patient is diagnosis. According to NICE Guidelines (2008), some patients cannot be clearly identified as having either type 1 or type 2 diabetes mellitus. Moreover, clinical presentation and disease progression may vary considerably from patient to patient. However, the disease may become more obvious with time. In the case of my patient, it is evident that the symptoms exhibited are of type 2 mellitus. For many decades now, the diagnosis of diabetes was largely based on plasma glucose criteria (NICE Guidelines 2008). It was either the fasting plasma glucose (FPG) or the 2-h value in a 75 grams glucose tolerance test (OGTT) (). The World Health Organization (WHO) also maintains these criteria. (Hillson 2008). In 2009, however, another taste for diabetes was recommended. It is called the AIC test and ha greater convenience as compared to the FPG test since fasting is not required and has a greater pre-analytical stability. For my case, I would consider applying this test as it is also characterized by less day-to-day perturbations especially in periods of illness and accumulated stress. As the rule is with most tests of diagnosis, it is also essential that I repeat the diagnostic test of diabetes so as to rule out any laboratory error unless my test comes out clear on clinical grounds or there are classic symptoms of diabetes exhibited by the patient. My diagnosis should be based on the confirmed test. This is to mean that if my patient meets the AIC test then he should be considered to have diabetes. For diabetes, screening is usually carried out by the same tests for diagnosis (Bicescu 2010). ii. History of presenting complaint By use of a symptom analysis tool it is important for me as a nurse to examine and evaluate the history of my patient. For instance, most cardiovascular complications associated with diabetes are brought about by a current or former history of drinking and especially smoking. If in any case the patient is a smoker, then he should be advised to stop the habit and I should also offer him support to help facilitate the process (Scottish Intercollegiate Guidelines Network (SIGN)). This will be helpful in minimizing general health risks that are associated with smoking and those that accelerate the impact of diabetes disease. It should also be noted by the nurse if the patient is presenting the complaint for the first time (Bicescu 2010, p81). For the patient with polyuria and polydpsia, he may be in want of considerable hydration because of the thirst associated with such symptoms. Severe dehydration may necessitate hospital admission even if it is first instance complaint. Whether the symptoms have lasted for a long duration before diagnosis is also an important factor. It will help me as the nurse to approximate the minimum duration of the disease itself (Hillson 2008). iii. Associated symptoms My patient has typical diabetic symptoms of polyuria, polydpsia and lethargy. Type 2 diabetes is commonly associated with other side symptoms like a rise in the blood pressure of the patient, the blood lipid levels are disturbed and there is always the tendency that the patient may develop a condition known as thrombosis (NICE Guidelines, 2008). It is also prudent that as a nurse, I should look at other accompanying risks that it carries for instance the coronary artery disease which could result in multiple heart attacks. It may also be associated with the peripheral artery disease that is characterized by complications such as gangrene and claudication (Home et al 2009). Basically, diabetes is associated with a wide range of vascular risk factors and varied complications therefore its management and care must draw from a lot of areas. Because of the above reasons, the level and degree of care in diabetes is characteristically complex and time-consuming. According to SIGN 2010, there is also need for me as a professional health worker to identify any accompanying psychological problems. From research and study, it is evident that depression is also a side symptom in diabetes. As a nurse I should therefore asses the depression levels of my patient. This can be assessed by use of simple questions regarding mood and enjoyment of day to day activities (Home et al 2009). It is worth noting that some symptoms of diabetes will occasionally overlap symptoms associated with common psychological problems (SIGN 2010). I should thus take full note of any general psychological distress that is related to diabetes. If present, then I will be obliged to offer the necessary interventions. One appropriate psychological intervention as proposed by the NICE guidelines is group or individual counselling on glycaemic control. This type of intervention has been proved to significantly reduce psychological distress in patients with diabetes mellitus type 2 (NICE guidelines 2010). iv. Current health status A nurse must also put into consideration the current health status of the patient. Normally, persistent hyperglycaemia is the hall mark indication of diabetes mellitus. A thorough clinical assessment and detailed evaluation of the patient will give the nurse an opportunity to assess the patient’s health status and provide better quality health care (NICE guidelines 2010). There are specific symptoms that suggest the development and severity of diabetes and must be looked into. They include facial puffiness, dysuria, angina, pedal edema, claudication, gangrene and amputation (Cavan 2010).Moreover, in considering the current health status of the patient, the nurse must look at aspects of sensory impairment such as pain, disturbances in the dark and gait instability (Wu & Shah 2007). I must also assess whether there is the presence of any infections such as skin infections, dental infections pulmonary tuberculosis as well as genitourinary infections. Accordingly, a deeper evaluation of any possible causes of secondary diabetes is essential so as to determine the stability of the patient (Ashwell et al. 2008). v. Past medical and surgical history If the patient has been on dual therapy for instance, a nurse should consider starting insulin therapy instead of administering other oral drugs to control the blood glucose levels unless the nurse is strongly justified that he/she should not do so (Ashwell et al. 2008). As a nurse, I must also consider whether the person has been on any previous blood pressure therapy. Blood pressure is supposed to be measured at least annually if the patient has never been diagnosed with hypertension or renal disease (Pouwar & Hermans 2009). The very first visit of the patient is when the nurse must take into account the full medical history of the patient. For my case here, the medical history entails symptoms of diabetes which are polyuria, polydipsia and lethargy. I must also look out for weight loss, generalized weakness, peri arthritis, any signs of delayed healing of ulcers and visual disturbances (Home et al 2009). I should also note any previous history of ketosis, any coronary events as well as pancreatic diseases (Fowler 2007). Since my patient has a history diagnosis of diabetes, there is need that I review the control of the blood pressure and the past medications he has used. Changes ought to be made only when there is poor management of the disease or where the current medications are not appropriate or do not reduce the metabolic problems or the microvascular complications (NICE Guidelines 87 2010). Here, it is also prudent for me to offer lifestyle advice and add medications if there is no notable improvement (Fowler 2007). vi. Drug history The patient is at a high cardiovascular risk if he has the following aspects of drug history: heavy drinking and intense smoking. If the drinking has been extremely excessive in the past, then I am likely to diagnose the patient with secondary diabetes (Thistlewaite 2003). On the other hand, if the drinking is currently excess, then the patient is most likely to gain weight and face a greater risk of hypoglycaemia especially when glucose lowering medication is administered (Fowler 2007). vii. Allergies It is important to assess and see whether the patient has nay allergic reactions to specific drugs. My patient for instance, should be advised to bring all his drugs during any clinical appointment (Thistlewaite 2003). Drugs such as steroids, thiazides and oral contraception’s have the effect of worsening insensitivity to insulin through allergic reactions (Hawley & Zierath 2008). This may in turn precipitate hyperglycaemia. Other drugs I should factor our are beta-blockers which may reduce warning of diabetic symptoms and thus could also worsen the lipid profile (Hillson 2010). viii. Social history Social history is one of the most important and the most neglected aspect of a patient’s history. It includes factors such as education and the occupation of the patient. Both ought to be detailed in a manner that the patient understands (Hillson 2010). Assessing the conditions of his occupation is important because it might the cause of the disease. For instance, diabetic patients are often not allowed to drive passenger carrying vehicles (Wu & Shah 2007). The diagnosis may also carry significant financial implications. Assessing the family circle and his dependants should not be ignored. As a nurse I should consider the patients history as well. The patient must be advised to engage in energetic activities such as athletics, football, martial arts (Yadav 2009). Importantly, he ought to refrain from hazardous activities like sky diving and underwater diving (Yadav et al., 2009). Others include accommodation and smoking habits (Yadav 2009). ix. Patient ideas, concerns and expectations The patient’s status may also raise various concerns. If the patient is for instance visually impaired, then the nurse must offer a device or an adaptation that will take into account the individual needs of the patient. The injector given to him must be one that he can be able to use successfully even on his own (Chan & Abrahamson 2003). The main aim of diabetes care is to see to it that the person enjoys life to the fullest without much disturbance from the disease. Even though it is devastating to be diagnosed with diabetes, the patients expect that the nurse will be able to provide both sympathetic and practical support through the whole process (Burant 2012). The patient needs to fully understand what the disease means for them and what may happen in the future (Hillson 2008, p 28). The major expectation of the patient is therefore that the care given to them is able to return them to almost as close as a non-diabetic state (Hillson 2008, p 31). x. Physical examination and documentation This is the most crucial area of patient management. As a nurse, I ought to perform a full clinical examination and document down the findings in a coherent and accurate manner. Important aspects of physical examinations include: State of consciousness:-if the patient is in an impaired conscious level, the nurse must urgently consider diabetic ketoacidosis and also take note of the high risks of strokes and heart failures (Kanavos 2012). Personality and psychological features:-the attitude and the personality of the patient will help the nurse to know whether the patient will be able to cope with diagnosis of diabetes and his ability to manage his own care (Ockleford et al., 2011). General observations: - during physical examination, it is important for the nurse to look out for clues of secondary diabetes such as pancreatic diseases, thyrotoxicosis among others. If the patient also suffers from congenital rubella, then there is likelihood that he will have heart disease, deafness or cataracts (Davies et al., 2008). The assessment of weight and height is also essential. While type 1 diabetes patients are generally underweight, type 2 patients are often obese and heavy. Moreover, skin infections are a common feature of diabetes. Other physical aspects include dehydration, thyroid enlargement, lymph node enlargement just but to mention a few (Krentz 2004). The nurse must also examine the pulse, venous pressure, heart sounds, apex, look for signs of oedema, lying and standing blood pressure and importantly take note of lower limb pulses (Hillson 2008, p 18). In addition, I will also take note of the rate of respiration, chest expansion, breath sounds and sputum. People with diabetes may have asthma and restrictions in airflow to the lungs (Katsilambros et al., 2011). All the findings will then be summarized in a medical record that will help in drawing up the management and treatment plan. xi. Impression-differential diagnoses In diabetic patients, differential diagnosis is very common. It forms part of the conditions that may manifest themselves as symptoms of diabetes disease when it is not actually diabetes. For instance, a condition known as prostatism is also known to cause urinal frequency (Mogensen 2007). The nurses must make sure that they do not mistakenly misdiagnose the two. Accordingly, polyuria, polydipsia and lethargy are rare conditions of diabetes insipidus and should not be confused by any professional nurse (Russel & Khan 2007). More importantly, it is very rare that diabetes mellitus and diabetes insipidus will occur together (Hillson 2008) and a nurse must always take note of this. When a patient is subjected to compulsive water drinking, he or she may also produce urine much frequently and should not be mistaken for diabetes. Another condition is also the renal glycosuria which often comes about due to a low renal threshold for glucose (Nathan et al., 2006). As a result, it allows glucose to spill into the urine. Even though the condition exists, it is rare and usually inherited (Nield et al., 2007). Therefore, it is important for me as a nurse to assess and document the patient’s condition in a correct and accurate manner. Because such patients suffer much frustration from being incorrectly labelled as diabetic, there is a possibility that they may be undergoing a lot of psychological stress (Ashwell et al., 2008). It then becomes crucial to let the patient understand what is going on and have their blood glucose concentration correctly measured for affirmation (Kanavos et al., 2012). xii. Working diagnosis and management plan-pharmacological and non-pharmacological a) Pharmacological management This entails the use of drug choices. In the treatment and management of diabetes mellitus disease, the optimal goals for me as a nurse should be to control the levels of glucose in order to prevent microvascular and macrovascular complications (Nathan et al., 2006). Normally, the immediate purpose of lowering the blood glucose levels of my patient is to provide relief from primary symptoms such as polyuria, lethargy, nocturia as well as blurred vision (Burant 2012). It is also aimed at preventing complications such as renal failure, otherwise known as retinopathy and also foot ulcerations. High blood glucose levels are usually one of the main symptoms of diabetes (Burant 2012). It is important that I concentrate on lowering the blood sugar levels of my patient as it contributes largely in the reduction of micro vascular as well as the macro vascular complications (Chan & Abrahamson 2003). Several studies have supported the use of intensive glycaemic control and in particular by using predefined HbA1c which intensely lowers blood sugar levels Reducing blood glucose levels also reduces the levels of mortality in diabetic patients, especially if it is applied in the early stages of diabetic diagnosis. Glycaemic control in diabetes disease also targets at reducing micro vascular morbidity and larger cardiovascular risks such as heart attacks and fatal heart failure (Burant 2012). Moreover, the interventions I apply should be aimed at increasing the incidences of hypoglycaemia which is an increase in the levels of insulin in the body (Bastaki 2005). Issues of weight gain and weight control must also be put into consideration (Hawley & Zierath 2008). One pharmacological intervention is by the use of Metformin which has the effect of decreasing hepatic glucose production and may improve peripheral glucose disposal. It also suppresses appetite and thus promotes weight reduction (SIGN 2010). I could also use Sulphonylureas which increases endogenous release of insulin from the pancreatic β cells. This group of drugs include medicines such as acetohexamide and tolazamide although they are now rarely used in the United Kingdom (SIGN 2010). In particular, I will consider administering Sulphonylureas in my patient’s case since they are considered as first line oral agents in patients who are not generally overweight and those that have contraindications with metmorfin (NICE 2006). One other recommended group of drugs is the thiazolidinediones and react in the body by increasing the insulin sensitivity of the whole body by activating the nuclear receptors and also circulating free fatty acids in the subcutaneous adipose tissue (SIGN 2010). The Rosiglitazones can also be administered as they are effective in lowering the HbA1c hence reducing the blood glucose levels. Moreover, peptidase 4 inhibitors may also be administered orally so that the activity of enzyme DPP-4 which on the other hand prolongs the actions of endogenous glucagon (SIGN 2010). Notably, there is the most effective way I could employ and this is basically starting insulin therapy. A continued metformin therapy lowers Bb1Ac and reduces weight gain. The patient can lose up to 3.7 kilograms and also reduces the risk of heightened levels of hypoglycaemia (Hawley & Zierath 2008). Oral metformin therapy must be continued once insulin therapy has been initiated. This maintains and improves efforts of glycaemic control (World Health Organization, 2011). b) Non-pharmacological management Non-pharmacological interventions do not necessarily involve the administration of drugs and medicines. They include non-drug choices. As a nurse I should put into considerations factors such as initiating and maintaining good therapeutic relationships. A good relationship must be established between diabetic patients and their health care professionals. This involves agreements of individual targets for care, clinic consultations and the resulting prescriptions (World Health Organization, 2011). In insulin therapy for instance, I ought to discuss with the patient the benefits and risks of insulin therapy and when the control of blood glucose remains or becomes inadequate. It also includes offering education to a patient who requires insulin about using an injection device so that they may find it easy to use when they are at home (NICE 2008). The various non-pharmacological choices could include options such as weight management, exercise and good dietary habits (Nield et al.,2007). Exercise and good eating habits can help the patient to prevent and manage diabetes. It also improves blood glucose and reduces the risk of complications such heart attacks and strokes (Nield et al.,2007). Physical activity and health eating are key lifestyles to diabetes management. As a nurse I could collaborate with other health care providers like a dietician or diabetes educator to help my patient. I must particularly advise my patient to start intense exercise and change his diet (Nield et al.,2007). xiii. Referral, follow-up and safety netting These are the final stages of diabetes management. Nurses and the patients are supposed to assess the effectiveness of the management and treatment plan in glycaemic control (World Health Organization, 2011). The nurse must importantly consider self-monitoring of blood glucose levels even while back at home. The patient could be referred for special care if the case is chronic. For follow-up purposes, it is important that a collaborative therapeutic alliance is formulated between the nurses and the families of the patient and other members of the health care team. This helps in adequate provision of the necessary support and services in all aspects of diabetic management (Thistlewaite 2003). When developing the referral and follow-up plan, considerations should be given to the age of the patient, school or work schedule, their conditions, as well as physical activity, their social situation back at home and the cultural factors that may bring complications to the diabetic conditions (World Health Organization, 2011). Moreover, the presence of other medical conditions must also be considered. Patients who need special follow-up are those at home, in employment, at school and those in correctional institutions. Care should be aligned with the WHO and NICE standards of care for diabetes (World Health Organization, 2011). Conclusively, safety netting should also be considered. It refers to a consortium of safety net hospital systems which come together to address concerns related to the care of diabetes patients (Yadav et al.,2009). It especially concerns those patients that are unable to pay their bills. The programme can be funded by the government or may include private professionals who come together to provide free and low cost care to poor patients (Ashwell et al.,2008). A good care planning system is that which the patient will be fully engaged in the process of diabetes management. It is an essential feature of safety netting. References Ashwell , S.G, Stephens, J.W, Witthaus, E, Home, Pd, & Bradley, C. (2008). Treatment satisfaction and quality of life with insulin glargine plus insulin lispro compared with NPH insulin plus unmodified human insulin in people with Type 1 diabetes. Treatment Satisfaction and Quality of Life with Insulin Glargine Plus Insulin Lispro Compared with NPH Insulin Plus Unmodified Human Insulin in People with Type 1 Diabetes. Available from http://digirep.rhul.ac.uk/items/cfa4257d-eaa9-6492-f9f8-6e224761c664/4/. Bastaki S.(2005) Review: diabetes mellitus and its treatment; department of pharmacology, faculty of medicine and Health Science. 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