Diabetes Management

Introduction

Individuals with diabetes mellitus face serious changes in their lifestyles and are exposed to several other health complications that may either be acute of chronic (Stellefson, et al., 2013). The health consequences of diabetes are devastating and may present in various ways including renal failure, loss of vision and amputations (Silverstein, et al., 2005). This leaves prevention as the best remedy for diabetes. However, if an individual has been diagnosed with diabetes, there needs to be effective management so that they can avoid complications as much as possible (Inzucchi, et al., 2012). It is this need for effective diabetes management that reveals the important role of nurses in providing care and information to patients regarding healthy actions, lifestyle and behaviors that enhance secondary prevention (Eldor & Raz, 2009). The nurses are responsible for diabetes treatment and saving the patient’s life in case of emergency complications arising from their diabetic condition. Moreover, it is their responsibility to ensure that the patient receives holistic care through physical, emotional and social rehabilitation. The main aim of this essay is to use a simulated diabetic patient diagnosed with diabetic ketoacidosis. First, the essay will give an overview of the case study, highlighting the patient’s conditions and presenting symptoms. Next, the essay will conduct a critical reflection of the case study, highlighting the health theories and models that are applicable in the condition’s management process. The penultimate section will dwell on the identification and analysis of the decisions made in diagnosis and management of the patient’s condition. Here, the essay will identify, define and apply the most appropriate clinical decision-making theory to demonstrate how they enhance the patient care process. Lastly, the essay will identify and critically outline the clinical implications of the case study and how they affect the author’s learning.

An overview of the case study

The case study involves John, a 70-year old widow that has recently been brought for assessment at the diabetic assessment unit. A week before visiting the unit, John was had some abdominal pain and vomiting. A further look at his history revealed weight loss, polydipsia and polyuria. John was accompanied by her daughter who was unsure of his father’s condition because he lived alone. She only discovered that her father was unwell when she visited. Upon viewing his father’s health condition, she resorted to take her to the hospital, and he was admitted into the ward before assessment because it was almost emergency department’s breach time. The assessment revealed John’s weight to be 74kg with BMI of 24. His urine assessment also revealed an output of 0.5-1/kilo and SP for COPD patient is 88-90%. Further assessment also revealed that John had no previous health complications except for type 2 diabetes for which he was taking metformin 500mg twice a day. He also had increased temperature exposure.

With prior information that John had been diagnosed with type 2 diabetes, I resorted to other diabetes-related conditions that could be cause his ill health- particularly diabetic ketoacidosis (DKA). DKA occurs either as a result of insulin insensitivity of the body or insulin deficiency (Shrivastava, et al., 2013). This implies that DKA can present in two types of patients namely Type 1 diabetic `or Type 2 diabetic who dare associated with insulin deficiency and insulin insensitivity respectively (Cebul, et al., 2011). Patients with DKA have an increased levels of hormones such as cortisol, catecholamines, growth hormones and glucose. Consequently, according to (Peek, et al., 2007), the patient’s blood become more acidic, causing symptoms such as vomiting, sweating, weight loss, nausea and palpations.

John looked tired, could hardly move, and reported remaining in bed for long. I performed a quick general inspection of John to have a sense of how unwell he was (Kent, et al., 2010). To do so, I introduced myself and because he was able to answer questions, I asked him how he was feeling. Upon the assessment of John’s symptoms and vital measurements, I begun preparations for a treatment plan that would be administered through the ABCDE framework (Airway, Breathing, circulation, Disability, Exposure) for treating (Thim, et al., 2012), which I considered suitable to not only address his health status but also address his biopsychosocial needs (Siegelaar, et al., 2010). Besides, I chose the humanistic model of care where I considered John as an individual with unique care needs (Ricci-Cabello, et al., 2013). Therefore, I did not have any predetermined formulaic method of treating John but instead delivered care with specific consideration to socio-cultural aspects, his unique needs and his family’s (i.e. daughter’s) considerations.

First, as recommended by Thim, et al (2012), I developed the mentality of treating problem related to John’s condition as I found them. Moreover, I needed to conduct a regular reassessment of John’s condition after the intervention to establish whether it was effective. More importantly, I communicated with the other team members on how frequent I would need John’s heart rate, oxygen saturations, respiratory rate, blood glucose and blood pressure to be measured throughout the course of ABCDE. This not only prepared them psychologically to cooperate with me but also ensured that they had all the necessary tools and equipment to conduct such assessment in a short notice.

I then went ahead to prepare for a further assessment by putting in place the necessary diabetes drug charts, observation charts and a notebook. John was now ready for further assessment. This was in line with Nancy Roper’s authorship on demands and problems of care, the scholar highlights that based on the diagnosis and identification of the patient’s health needs, there needs to be an elaborate plan of care that not only addresses the patient’s situation but also considers the patient’s bio-psychosocial needs are addressed using the professional privileges, powers and resources that nurses have (Ricci-Cabello, et al., 2013). This would ensure that the patient shows positive response to treatment and becomes part of the treatment process through patient-centered care.

Critical reflection of the case study

John’s condition initially underwent a slight evolution considering that he could still complain of constipation and severe pain on his left plank. John’s constipation persisted for some time although with little intense, and he was still not physically mobile. As result, a decision was made to increase his ambulation stimuli by helping him to sit on the bed and ensuring that he gets ambulated twice a day for 15 minutes. John responded positively to this intervention by experiencing less pain that he experienced before. John’s reduced physical mobility necessitated further ambulation, although he did not display any hypoglycemia symptoms but displayed more frequent chest movement.

Even though based on my observations John’s evolution was satisfactory especially due to the implemented interventions, I must acknowledge that I failed to properly consider the patient’s treatment plan. Part of the reason for not effectively adhering for John’s treatment plan was that it was made up of technical medical prescriptions and drug procedures that I could hardly understand and effectively implement. For example, I found it challenging to conduct skin hydration assessment and skin stimulation. Moreover, despite the importance of team cooperation, the team did not cooperate enough to yield satisfactory results. Some tests were not delivered in time and this delayed the entire process of administering DKA interventions However, despite all the challenges, I still managed to provide a successful care to John.

The patient’s history brought to attention various problems and care needs that could be integrated into a comprehensive intervention plan and daily assessment of that plan to rehabilitate and help John recover. Observably, John responded positively to the interventions and adopted some of the healthy behaviors that were recommended for him. To this end, one important realization is that to effectively implement the Humanistic Model of care (Cara, et al., 2016), practitioners must work within a multidisciplinary team, especially it is essential for a proper development and adoption of humanistic and individualized nursing actions. Therefore, I proposed a closer and team-driven examination of John’s case, whereby a team of nurses from different departments within the diabetes care pathway discussed and implemented care decisions.

Apart from poor compliance with therapeutic prescriptions, another problem that poses a challenge to diabetes treatment and interferes with the efficacy of drug therapy is treatment interruption (Stellefson, et al., 2013). The patient’s treatment process can be interrupted by the practitioner’s lack of knowledge on existing scientific evidence and lack of proper communication skills for engaging with the patient (Silverstein, et al., 2005). Furthermore, in the diabetic care context, there sometimes exists a diversity of cultural values that can contribute to cultural distance between the patient and the care giver. This distance can contribute to the patient’s resistance to certain treatment plans or advice or cause a misunderstanding between the practitioner and the patient with regards to certain elements of the treatment plan (Inzucchi, et al., 2012). Consequently, it is important for practitioners to consider the context of treatment and be able to modify some of their fundamental values if they are likely to interfere with the treatment process. For instance, when interacting with John, I noticed his negative attitude towards some of his family members that he say had abandoned him at his time of need and through my experience and adequate training, I was able to manage the situation by informing him that only his daughter would be involved in the care process in case a family input is required. This was in line with Stellefson, et al’s (2013) assertion that nurses should approach the patient with the mentality that everybody needs to be heard and recognized together with their values because through recognizing those values that the caregiver can deliver a humanistic care.

An analysis of decision-making issues

Following the ABCDE framework, John’s case presented several decisions that needed to be made to improve his health. First, during the Airways assessment, I assessed John’s ability to speak and listened to his breathing for any additional sound. Besides, I inspected his mouth. I noticed a noisy breathing and immediately performed a jaw thrust to secure his airway (Eldor & Raz, 2009). I also called for a standby airway adjunct in case his breathing deteriorated (Peters & Laffel, 2011).

The next decision-making point was in on the breathing assessment. Keeping in mind that his oxygen saturation should have been between 94-98% (Shrivastava, et al., 2013). An assessment of his breathing system revealed a 100% oxygen saturation, meaning that he did not need any oxygen saturation. Nonetheless, I kept him on an upright position to maintain and regularly conducted an oxygen saturation assessment to ensure they remained maximized.

Circulation

Next, I needed to assess John’s circulation through pulse and blood pressure assessment. His heart rates were 135, Blood pressure is 100/60mmHg. This necessitated the administration of fluids ensure that his circulatory volume was restored, clear ketones and help him achieve a balanced electrolyte (Peek, et al., 2007). Therefore, as recommended by Peek, et al (2007), I administered NaCl 0.9% or Hartmann’s solution as an initial intervention to resuscitate his fluid.

Disability

I assessed John’s disability by assessing whether his pupils were equal, reactive to light and whether they were in the right size (Siegelaar, et al., 2010). Also, having known that John had been diagnosed with type 2 diabetes, I was aware that he was at high risk of DKA and therefore it was appropriate to measure his capillary blood glucose levels straightaway (Ricci-Cabello, et al., 2013).

As mentioned earlier, John was conscious at the time of his admission, but it was important formally record his level of consciousness for monitoring during the treatment (Quinn, et al., 2006). Nonetheless, his consciousness necessitated no action/intervention. However, his consciousness was constantly monitored.

Exposure

Despite John’s condition at the time he presented at the hospital, I that he was routinely exposed to ensure that I was not missing out on anything. Therefore, we took the urine and assessed it for any evidence of infection or for presence of ketones. Consequently, a urinalysis showed glucose and ketones. I reassessed John’s urine after intervention to monitor his progress.

A key element of care that was significantly evident during this decision-making process was the multicultural context within which John was receiving care to enhance the delivery of nursing care. Particularly, the multicultural context of this case reveals why the practitioners must coordinate their actions to effectively deliver type 2 diabetes care (White, et al., 2009). Within any care setting, practitioners are often faced with the dilemma of prioritizing either their well-being or that of their patients (Osborn, et al., 2010). However, with a better understanding of what John does with his illness and his perception of treatment, practitioner can recognize the patient’s right to care decision-making and give him the autonomy of taking part in his own care (Johnson, et al., 2008). Therefore, when handling John, it was imperative to respect his dignity, let him open, maintain his confidentiality and recognize the care choices he makes.

Against this backdrop, I have analyzed some of the most effective skills that a practitioner would need to let John effectively participate in his own care. Meanwhile, it is important to note that these skills work based on the principle of mirror effect, whereby their effectiveness depend on the caregiver’s professional behavior. This implies that form a theoretical point of view, the patient’s motivation to participate in care significantly impacts on the quality of nursing outcomes (Nam, et al., 2011).

The first important skills for enhancing John’s participation in his own care is nurses’ critical thinking skills. According to Nam, et al (2011), good critical thinking skills are key to effective decision-making within the clinical context. Nurses must be aware of the key decision-making criteria and the various internal or external variables to consider such as the work environment, personal experiences, creativity, self-learning capabilities and their thinking abilities (Tao, et al., 2010). Furthermore, according to Nam, et al (2011) good decision-making skills entails understanding one’s attitudes and ability to manage stressful situations.

It is only possible to decide when the scenario that requires decisions presents with different choices to make, whereby the practitioner must carefully gather and consider pieces of information before deciding on what to do (Peterson, et al., 2008). This implies that when making clinical decisions, nurses need to consider the advantages and disadvantages of each option before selecting the desired one. Nevertheless, Peterson, et al (2008) claim that the decision-making process does not only stop there but instead involves an evaluation of the results to determine whether it was really the best decision to make. This is a fundamental step in critical thinking.

According to the ethical principles and practice guidelines by National Institute for Health Care and Excellence (Simmons, et al., 2010), John deserved to be treated with respect and dignity based on the humanistic approach to nursing. Since patients come from different geographical and cultural backgrounds, and multicultural approach to nursing care is key to patient satisfaction, positive outcome and good health. Patients may react differently right from the point where they are given the diagnosis report. For instance, the patient may react in denial or may develop more intensified reactions when they think of the permanent constrain, costs, and side effects of the disease (Chiang, et al., 2014). Consequently, the patient might consciously or unconsciously recourse, especial when they experience stereotypical judgment. However, Flint & Arslanian (2011) observe that such reaction may be more eminent when the practitioner fails to recognize and appreciate the patients’ culture. Therefore, it is important to encourage John’s participation and eliminate any element of social prejudice/stereotyping by integrating various aspects of care such as religion, socioeconomic class and language. These elements of culture influence the patient’s beliefs, rules and value of life and must therefore be incorporated into the care pathway to encourage them to commutate their needs and adhere to treatment plans (Flint & Arslanian, 2011). Through this, John can be encouraged to be open and communicate his needs to be addressed by the caregiver. Ultimately, John will develop a sense of responsibility and autonomy to his care and play a central role in determining the direction of care given to him.

Summary of Implications

Stewart et al (2011) argue that a treatment plan and its development process should be effective enough to make the patient develop and interest on it and acknowledge its importance. Moreover, a practitioner should take time to reflect on the patient’s needs, their response to care and any necessary intervention that would promote the achievement of positive treatment outcomes (Stewart, et al., 2011). More importantly, according to (Epstein & Street, 2011), taking time to reflect on the patient’s needs enables the practitioner to develop effective strategies for informing the patient more about their illnesses, the necessary healthy behaviors that could improve their health and well-being and invite them to take responsibility over their well-being (Tuil, et al., 2006). This implies that when caring for John, the caregiver must constantly adjust their professional skills and attitudes to inculcate efficiency and confidence in their relationship with John. This would create an opportunity for the caregiver to work together with John and his daughter in restoring John’s health while still abiding by the NMC (2015) guidelines on culturally adopted care.

The provision of nursing care does not only entail gesture of compassion and professionalism. As a nurse, it is also my responsibility to justify every care decision I make and adjust my attitude to an effective implementation of those decisions. Regarding this, Richards, et al., (2015) argue entering the nursing profession can be considered as an art as it is a science. It entails the exploration, deliberation on, and careful implementation of care intervention that are deeply rooted in ethics, values and beliefs (Stewart, et al., 2011). As required by the NMC (2015) nursing guidelines, I should treat John with respect and dignity, maintain confidentiality and interact with him in an atmosphere of free of choice where he can autonomously participate in his healthcare. This not only based on professional guidelines but also on moral grounds – as taught by Florence Nightingale that nurses must develop and maintain a professional attitude that contributes to better patient outcomes (Richards, et al., 2015).

John deserve a professional nursing care that is delivered in a cyclical cognitive process which entails identifying, defining, analyzing and applying previous care experiences and combining them with existing practice evidence to develop a robust intervention plan that would give superior health outcomes (Brown, et al., 2008). Through the humanistic research model, it is easier to conduct a systematic analysis of the relationships between factors that must be considered to deliver effective care interventions for type 2 diabetes (Cara, et al., 2016). More importantly, the success of restoring John’s health depends on the caregiver’s ability to meet his expectations and health needs.

As a diabetic patient, John might have been under stress and anxiety during his hospitalization. According to Cara, et al (2016) patients might be filled with anxiety and stress during hospital admission due to many multifaceted and complex reasons and without the caregivers’ knowledge. For instance, John’s inability to interpret the technical language used by practitioners during care might have caused some anxiety as he would not have known what was going on. This calls for the nurse to develop a close relationship with the patient and regularly informing them of their health situation at different stages of the care pathway.

Conclusion

Effective diabetes management involves a mix of conversations about non-pharmacologic, pharmacologic and self-management interventions that are tailored to the health needs of every patient. When these conversations are incorporated into regular nursing practice, they can maximize the possibilities positive treatment outcomes and reduce the risk of drug side effects while encouraging patient involvement in care. This implies that nurses must balance both the long-term and short-term risk of care to encourage patients int medication adherence and cope with the burden of diabetes. Furthermore, providing effective care to diabetes patients require shared decision-making among health professionals, patients and their families so that care plans are culturally adopted to incorporate patients’ needs and preferences.

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