Short-Term and Long-Term Nursing Management of Diabetes Specific to Patient - Case Study Example

Diabetes Case Study Name University Affiliation Introduction Over the last sixty years, the incidences of diabetes have increased exponentially. Factors such as the increase in longevity, decrease in physical activity, tightening of the diagnostic criteria and increase in the waist circumference or central obesity has contributed to increased incidences of diabetes (Kirby, 2012, p. 315). Nursing plays a specialised role in the management of diabetes, including in education and care of individuals with diabetes. Such roles places nurses at the core of treatment and care of patients with diabetes. The understanding of patient needs, education requirements, and general management concerns such as the role of interdisciplinary collaboration is critical in the successful management of diabetes. In the case study, a 69 year-old named Irene Chapman who has been recently diagnosed with type-2 diabetes is presented for critique of the current care, and determination of current and future care and education needs and diabetes management strategies. In order to implement proper care for patients, the first step is to undertake an exploration of the patient’s medical history, and performing physical exams before identification of management goals and determination of appropriate plans of care (Kirby, 2012, p. 314). Appropriate cues from scenario Based on the assessment of the patient’s medical history, laboratory results and physical examination, the patient has uncontrolled and complex type-2 diabetes as indicated by such factors as HbA1C of 8.1% compared to the normal of less than 7%, besides polyuria and polydipsia. Polyuria is frequent urination while polydipsia is excessive thirst. The rise of glucose levels above the renal threshold (10-12mmol/l) contributes to excretion of glucose with the osmotic effect of glucose leading to excess water/urine leading to polydipsia (Brown and Edwards, p. 1361). The patient also has obesity, which is evident by the BMI of 37.1kg/m2 and a waist measurement of 100 cm, which is indicative of excess intra-abdominal visceral fat. Brown and Edwards, p., p (1361) assert that diabetes 2 often occur in patients above 40 years with 80-90 percent of patients overweight during diagnosis in addition to the tendency to run in families indicating genetic factors as contributory factors. The patient is unaware of her risk to diabetes despite various indicators pointing out to her being at risk. Brown and Edwards (p. 1358) indicate that during prediabetes, individuals at risk of developing type 2 diabetes have impaired glucose tolerance (IGT) with serum glucose levels of 5.6mmol/l to 6.9mmol/l, which is within the range levels of 5.5 and 6.9 mmol/L for the patient three years earlier indicating patients prior risk of developing the condition. Brown and Edwards (p. 1361) asserts that type 2 diabetes is primarily a vascular disease characterised by various disorders that include hyperlipidaemia, hypertension and hyperglycaemia. The onset is also characterised by one or more microvascular complications such as retinal, renal, and neuropathic, macrovascular complications such as coronary, peripheral vascular or neuropathic such as autonomic and peripheral complications. The patient has currently untreated hypertension indicated by blood pressure when lying for right arm 154/96mmHg and while sitting for the right arm at 140/90mmHg. The patient has hyperlipidaemia, which while being treated with atorvastatin, is not adequately controlled as indicated by the high amounts of lipids. The relatively high amounts of uric acid levels (BUN) coupled with the recent foot pain is indicative of hyperuricaemia as the build of uric crystals in the body contribute to possible Gout, in combination with peripheral neurology (Brown and Edwards, p., p, . Other indications such as the elevated urine microalbumin of 25mg/l compared to the normal range of less the 20mg/L indicate an early diabetic nephropathy. This occurs where the blood glucose levels rise over and above the capacity of the kidneys to reabsorb the glucose from the renal ultrafiltrate (Goldie, 2008, p. 17). This leads to the glucose remaining diluted and resulting to a rise in osmotic pressure and water being carried out resulting to increased volumes of excreted urine, which could indicate nocturia or polyuria. Peripheral neuropathy was also indicated in the diminished vibratory sense to the barefoot and lack of ankle reflexes besides the monofilaments only felt above the ankle. The patient further had self-care management and lifestyle deficits as evidenced in lack of adequate exercises, poor diet containing large quantities of carbohydrates and lack of a clear understanding of understanding as shown in her failure to self-monitor her glucose levels. Short term and long-term nursing management specific to patient In the case, Chapman presented with type-2 diabetes, accompanied by some complex set of cormobidities. As a nursing specialist, the most critical role to begin with is to identify the most pressing healthcare issues that the patient faces and prioritise medical care to address the issues. Overall management of the patient will require use of diverse strategies that incorporate a multidisciplinary collaborative approach. Besides education on the appropriate care, management of diabetes will also involve managing the various cormobidities using various drugs, dietary measures, weight reduction and in some complex cases, injection of insulin (Goldie, 2008, p. 14). Among the issues that need to be addressed in the short term visit include the elevated glucose levels, obesity, and hypertension, change of drugs, exercise, diet, and care against cormobidities. The fasting glucose levels have increased since the patient’s diagnosis with impaired glucose tolerance where her fasting glucose levels were 5.5 and 6.9mmol/L to current levels at 9.9mmol/L compared to the normal range of 3.6 to 6.0 mmol/L. This is an indication of worsening glucose control or poor glucose control. Priority should be placed on ways to control glucose levels. Control of the high glucose levels in the patient is a priority issue that needs to be addressed. Besides weight loss and an increase in the physical activity, bringing the glucose levels to normal would also require medication (Goldie, 2008, p. 17). Patients with diabetes are often at an increased risk of cardiovascular disease and thus it is recommended that patient with diabetes and who are above 40 years take cholesterol lowering drugs such as statin or low dose aspirin in case there is no contraindication in order to prevent formation of thrombus (Goldie, 2008, p. 17). Considering that Chapman is above 40 years, she was already put on statin medication. Nonetheless, from the assessment, it is indicated that despite the control of hyperlipidaemia with the atorvastatin, the total lipid levels are significantly high. This is likely attributed to the poor diet and lack of exercise. The currently untreated hypertension for instance, is an issue of concern and the recommended treatment for hypertension in diabetes patients is angiontension converting enzyme (ACE) inhibitor such as enalipril (MIMS, 2013, p. 1). Since the patient is not currently of hypertension treatment drugs, control of hypertension should be prioritised. The patient also has a deficit in self-care management and lifestyle deficits. This is evident by the fact that even after being advised to lose weight, she has been unable to lose weight over the years. The patient’s diet, which includes excessive intake of carbohydrates including pasta and bread are potential contributors to her inability to lose weight coupled with inadequate exercises. In order to address the problem, change of diet to reduce the amounts of carbohydrates is recommended. This will be achieved by connecting the patient to a dietician for advice on appropriate diabetic diet. The patient is recommended to reduce her carbohydrate intake as she awaits an appointment with a dietician for advice on appropriate diabetics’ diet. Weight management and weight loss for obese patients as is the case is crucial in the improvement of metabolic control. This can be achieved by referring the patient to a dietician and educating the patient on the need to reduce the large portions of carbohydrates including pasta and other carbohydrates. The patient lacks understanding on the cause of diabetes as evident in her view that she does not understand why she has diabetes despite the fact that both her parents had diabetes 2. Similar lack of knowledge on diabetes is indicated when the patient asserts that since the GP knows that her blood glucose levels are high, there is no need of monitoring. The patient also lacks knowledge on self management as evident by her lack of understanding of the significant of various symptoms. For instance, the patient has had episodes of nocturia, which is indicative of hyperglycaemia associated with the large intakes of Italian pastries and pasta meals. Other symptoms associated with hyperglycaemia that are evident in the patient include common experience of lethargy. The patient experience of foot pain is a possible indication of peripheral neuropathy. This is a significant risk to the patient and she is required to be given advice on appropriate care to prevent possible damage from poorly fitting shoes especially when exercising. This indicates that the patient requires being educated on the risks. The patient further asserts that she experiences excessive thirst, which is indicative of polydipsia. The patient erroneously associates her symptoms of lethargy with her nocturia. The occurrence of polydipsia and nocturia is attributed to a rise in the levels of glucose in the blood leading to an overwhelming of the renal glucose threshold leading to dilution of urine and resulting to polyuria, polydispsia, and dehydration besides elevation of potassium and sodium retention. The patient’s ongoing treatment has been glicazide (Diamicron) 80 mg each morning although she was forced to stop the medication due to feeling of dizziness, agitation and sweating. These symptoms are indicative of hypoglycaemia, which is a side effect of the drug, and are suggestive of the need for a medical review to another hyperglycaemic lowering drug. Other short term nursing management issues that need to be addressed is the issue of feeling of dizziness, agitation and sweating, which is indicative of hypoglycaemia, associated with the drug glicazide (Diamicron) 80 mg and which necessitated that it be discontinued. According to Kirby, 2012, p. 315 (p. 32) the ability to prescribe and adjust the medication of patients with diabetes is an invaluable asset in caring for the patients. This is especially the case of patients with cormobidities as evident in the case. Subsequently, a medical review to an alternative drug to address hyperglycaemia, such as Metfformin a biguanide should be undertaken. According to Kirby (2012, p. 316) metformin is now the first line of drug for treating diabetes as it reduces the hepatic glucose production while contributing to improvement in insulin resistance without leading to hypoglycaemia, besides lowering the HbAIC results by 1%. The drug is suitable unless there is specific contraindication such as liver disease or severe renal disease (Kirby, 2012, p. 316). Among the evident issues that the patient is currently experiencing and which should be addressed in the long-run include weight control, self-care and management of diabetes, lifestyle changes, glucose control among others. In the long-term, the patient needs to be educated on ways to care and manage the disease through control of carbohydrate intake and loss of weight using both a dietary therapy and exercise. The patient also needs to know the need to undertake continuous monitoring of her glucose levels and the potential benefits that this may contribute to her overall health by identifying potential risks to increased glucose levels in her blood. Also, the patient should be made aware that she should also not let her glucose levels to go very low as this portends significant risk to her health especially when using intensive blood glucose control. This is supported by various researches that indicate that attempts by patients with type 2 diabetes to lower their glucose levels to the near normal levels using intensive blood glucose control while benefiting some patients is also accompanied by various risks including increased mortality (Kirby, 2012, p. 316). The patient should be advised on ways to control her glucose levels including through reducing intake of carbohydrates and taking smaller portions of carbohydrates such as bread and pasta (Kirby, 2012, p. 316). The patient has also been taking atorvastatin (Lipitor) 10 mg daily for the treatment of hypercholesterolemia although she still has hyperlipidaemia, which is possibly related to diet related fatty liver metabolic schedule.. The determination and selection of appropriate medicines that do not negatively impact on other existing condition or which may increase the risk for other conditions is also crucial. For instance use of regaglinide or sulphonylurea may reduce postprandial elevations of sugar that are attributed to intake of carbohydrates but may also lead to weight gain (Kirby, 2012, p. 316). Identifies and prioritises an extensive range of education needs that are both nursing and case specific Nursing plays significant role in the education of patients with diabetes within the hospital care setting and beyond (Kirby, 2012, p. 315).The nurse practitioner (NP) model and the clinical nurse specialist (CNS) models are applicable to the management of chronic diseases such as diabetes and they create enhanced patient-provider relationships where education is provided within the context of disease management (Goldie, 2008, p. 17). Nurses play a pivotal role in the coordination and delivery of diabetes self-management education. This is especially crucial considering the view that ongoing management of diabetes should be part of an education program to improve patient’s knowledge and clinical outcomes (Kirby, 2012, p. 315). Nurses are required to combine education and management in the delivery of care. Education to patient is prioritised to reflect the complexities and contexts of a patient, which includes their own range of education needs. Nurses have a role beyond the educator role, which is to holistically assess the patient’s needs with understanding of the role of the patient in the maintenance and improvement of their own well being (Kirby, 2012, p. 315). In this context, and in this case, the patient has insufficient knowledge on various aspects of diabetes self care management, including weight reduction and diet and exercise regimen, and does not understand why some aspects of self-management such as glucose monitoring is crucial in diabetes self management. The patient also needs to be educated on possible complications and risks and how to identify them and take necessary precautions. For instance, despite the patients high fasting glucose levels and overweight, the patient has been unable to reduce weight and glucose levels through dietary changes since she has continued to consume very high levels of carbohydrates. In collaboration with a dietician, the nurse should advise the patient on an appropriate diet that is low on carbohydrates. The patient should be made aware of the role of glucose control in her health outcomes and the relation of obesity and excess glucose that is accompanied by intake of large portions of high level carbohydrates such as pasta and bread. The patient thus requires being educated on the need for dietary control through reduction of portion sizes and using a notebook records the snacks and food intake. The patient should also be made aware of the relationship between regular exercise and the lowering of her blood pressure and levels of glucose and its relation to the control of diabetes. Another significant area of self-management care where the nurse should educate the client is on detecting possible deterioration in her health and understanding various symptoms. For instance, an understanding of the past episodes of nocturia that was associated with Italian pastries would help the patient identify alternative diet that is healthier and better suited to management of her condition. The patient also needs to be educated on possible risk of complications that may result from the condition. For instance, the patient has a need to be educated about foot care and the importance of foot care considering her inability to feel light touch of the monofilament of her foot and the reduced sensitivity that accompanies diabetes. The patient would be educated on the inability to feel a light touch of the monofilament as evident in the loss of sensation from the peripheral neuropathy was an indication that the patient should be vigilant in checking her feet for signs of lesions that may be contributed by poorly fitted footwear that may be worn during exercise (Goldie, 2008, p. 17). This would be demonstrated to the patient her inability to feel the light touch of the monofilament. The patient also needs to be educated on diabetes 2 in general including the risk factors and the causes as she suggests that she is unaware of the causes and argues that she does not take sugar and thus did not expect that she would get diabetes 2. Patient should be educated on lifestyle changes that she should make and the reasons for making the changes including the possible risks in failure to change her lifestyle. For instance, the patient should be made aware of the increased risk of other complications such as stroke due to obesity and thus the need to exercise and take a diet low in carbohydrates to reduce her weight. Section 3 Interdisciplinary care needed for the patient identified in the case study as well as the role of the nurse within this team An important aspect in caring for the patient is ensuring that continuity of care and vital pathways of communication are open. Collaboration with other members of the healthcare team is crucial to achieve holistic care of the patient. According to Kirby (2012, p. 315) the number of community and primary healthcare professional that assume responsibility for the review, monitoring and management of patients with diabetes has increased tremendously in the last six decades. The patient requires interdisciplinary care with the nurse playing significant role within the team. The nurse plays specialised role in the education and care of patients with diabetes (Kirby, 2012, p. 315). Diabetes management is undertaken by a multidisciplinary team that consist of an endocrinologist or diabetes specialist, general practitioner, dietician, diabetes nurse educator, psychologist, exercise physiologist, and a podiatrist. The goals of such a team is to reduce the diabetes symptoms and help improve the well being of the patient besides prevention of acute complications of hyperglycaemia and delay of the onset of complications. Diabetes educator plays various roles including new diagnosis, and self-management education to the patient. Patients may be referred to diabetes educators in cases where the HbAic levels are less than 8%, onset of complications, hypoglycaemic episodes, and in dealing with psychological, social, medical or adjustment changes. Other circumstances include in change in management such as medications and insulin commencement, prior to planned surgery, incase of difficulties in the management of diabetes. According to Brown and Edwards (1363) a patient may be referred to a dietician in case medical nutritional therapy is indicated, obesity, complications, changes in medication, sudden gain or loss of weight. Endocrinologist on the other hand may be required where the HBAic is persistently less than 8% despite the intervention by diabetes dietician or educator, in review of pharmacological management and in case of existing complication requiring review. An ophthalmologist or optometrist also plays a role in care of diabetes patients. For instance, within one year of diagnosis, patient should be referred for comprehensive eye examination and every two years in case the patient does not have diabetic retinopathy and every year in case of diagnosis of diabetic retinopathy (Brown and Edwards, p., p. 1363). A psychologist is crucial in case a patient is having difficulties adhering to treatment, difficulty implementing changes in behaviour or lifestyle changes, besides other aspects such as depression, HbAic of less than 8%, cognitive difficulties among other factors. Considering the patients history of inability to make appropriate changes in lifestyle, the involvement of a psychologist in the multidisplinary team is crucial. An exercise professional is also crucial in the management of diabetes as part of the diabetes management team. The exercise professional assists the patient in identifying an appropriate exercise program. The exercise professional takes into cognisance the conditions that may affect a patients activity levels such as musoloskelteal conditions. A podiatrist is another crucial team member especially in the diagnosis and addressing issues such as high risk foot evident in signs such as foot ulceration, neuroathropathy, peripheral neuropathy, peripheral vascular disease, foot deformity. Others include nephrologists, in case of impaired renal function and vascular surgeon in cases where there are symptoms and signs of ischaemia, carotid bruits and arterial ulceration (Brown and Edwards, p., p, p.1363). From the foregoing, it is evident that care of patients with diabetes 2 requires understanding the risks and progression of diabetes and the various comorbidities and approaches to reduce them. Nursing plays a specialised role in the management of diabetes, including in education and care of individuals with diabetes. Such roles places nurses at the core of treatment and care of patients with diabetes. The understanding of patient needs, education requirements, and general management concerns such as the role of interdisciplinary collaboration is critical in the successful management of diabetes. References Kirby, Mike. 2012. Sixty years of diabetes management in primary care. British Journal of Diabetes & Vascular Disease Lowey, A. 2005. Drug treatment of type 2 diabetes in adults. Nursing Standard, 20, 11, 55-64. Dowman, J, Tomlinson, J., Newsome, P. 2010. Pathogenesis of non-alcoholic fatty liver disease. Q J Med: 103: 71-83 Wilding, H. 2007. The importance of free fatty acids in the development of type 2 diabetes. Diabetic Medicine, 24, 934-945. Goldie, Linda. 2008. Diabetes management in primary care. Practice Nurse, 36(1) 14-17. MIMS. 2013. MIMS Full prescribing information: Enalapril. MIMS. Brown, Di. and Edwards, H. Brown and Edwards, p., p medical surgical nursing: Assessment and management of clinical problems. Read More