Managing Type 2 Diabetes-Comprehensive Approach to Care and Prevention

The Patient assessment

Type 2 diabetes according to WHO, (2020) typically occurs in adults when the body becomes insulin resistant or does not make enough insulin. Diabetes UK, (2019) states that one in ten over 40 has type 2 diabetes, and the number of people living with diabetes in all its types in the UK has reached 4.7million. It is can occur in all age groups and is increasingly diagnosed in children, it is also associated with complications such as long-term microvascular and macrovascular which leads reduced quality of life and life expectancy (NICE, 2019).

The Orem’s nursing theory mentions that all patients have the wish to take their own care so that they feel empowered and avoid being burden of care on others (Maslakpak et al., 2018). The theory of self-care states that the nurse should establish a relationship between the nurse and client, determine what the self-care requisites of the patient are (Hagran & Fakharany, 2015). The general nursing theory of Orem has a huge influence on clinical practice, as it basically describes the need for nursing care, this need arises if a person encounters deficit that interferes with their ability to sustain self-care (Hagran & Fakharany, 2015). However, further empirical work is needed, together with realistic and practical application of the theory to practice in a way that embraces contemporary notions (Timmins & Horan, 2007)

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The self-care requisites are mainly of three types as mentioned by Orem which are universal requisites which are needs required by all people, development requisites which are situational and maturational needs and health deviation requisites which are needs raised due to specific health condition of an individual (Mendonça et al., 2017). The universal requisites are need of air, water, food, ability to effectively eliminate, activity and rest, social interaction, hazard prevention and normality promotion. The evaluation of George on the basis of universal requisites informs that he experiences no issues with breathing or drinking water and show effectively ability to manage elimination. However, due to pain perception in the joints he expresses reduced activity and express hindrance with manging effective diet as required to control his type-2 diabetic state (Dehvan et al., 2020).

Patient evaluation includes the application of theory, diagnosis, intervention and outcomes into practice and the use of theory to make recommendations on complex practice problems (Kumar,2007). Assessment was approached from a multisource viewpoint Client, family, and health-care data were used to empower George in the self-management of his diabetes which guaranteed George’s collaboration in the selection of the most suitable nursing diagnoses hence the right interventions and outcomes.

George’s currently taking metformin used to treat type 2 diabetes by improving the way the body handles insulin resulting to low blood sugar levels (NHS, 2019) alongside paracetamol for pain when required. His clinical observations were as follows: blood pressure 150/80mmHg, temperature 36.5℃ which was the normal body temperature according to NHS, pulse 80bpm, respiration rate 19, oxygen saturation 98%, weight 95kg, and blood glucose before eating was 13mmol/L using a glucometer which is used to monitor hypoglycaemic and hyperglycaemic conditions in healthcare setting (Tonyushkina & Nichols, 2009). However, they devices have a significant problem of as it is found to express the results that are usually 20% above the blood glucose level in the body which is concerning issue as it is altering care decision taken for patients (Hellman, 2012).

The national early warning score (NEWS) of George was calculated and it was identified to be zero. The advantage of using NEWS as health assessment toll is that it allows to detect and respond to any deterioration in clinical aspect of the patient which eventually helps to ensure patient safety and enhance their health outcomes (Vihonen et al., 2020). However, the limitation with using NEWS is that it needs effective engagement of experience practitioner in using it, require sensitivity analysis, needs reaction for health escalation, requires making clinical judgement and creates need of intermittent recording of patient health data which is not always possible to be managed (Kivipuro et al., 2018). Thus, this limitation leads raise recording error of health data of the patient. The glucometer is effective self-monitoring device for patients with diabetes to be used to regular keep track of their glucose level to be alert when hypoglycaemia or hyperglycaemia occurs (Vihonen et al., 2020). However, George did not keep track of his blood sugar levels because he felt too overwhelmed by his life and avoided using glucometer.

A pain assessment was executed for George using the numerical pain rating scale since George had complained of pain and numbness and rated five out ten. The pain was characterised by burning sensation and unusual tingling while patient was mobilising. This is a common complication in patients with long-term diabetes. This may possibly mean the involvement of peripheral neuropathy which develops when nerves in the body’s extremities such as feet, arms are weakened (NHS, 2019). This influences mental well-being and has been associated with depression and anxiety. The loss of feeling in his feet means he could unknowingly cause damage to his feet and fall out of lack of strength in the feet to stand effectively. Further inspection of his feet revealed plantar calluses beneath his toes which put George at a high risk of developing diabetic foot ulcer which could result into amputation (Edmonds, 2006). Further assessment of George in regard to his family at home reveals that he rarely heard from his daughter, his mother was entirely dependent on him, he oversaw the maintenance of the house and preparing meals for his mother on top of his job. He hence revealed that he feels exhausted all the time.

George further revealed that he did not pay much attention to his dietary intake. He eats whatever he likes and has a beer twice or three times a week. He did not do any physical exercise as a result, George had a partial self-care deficit. Self-care deficit occurs when the patient is unable to meet his or her own needs and nursing intervention is needed (Leeuwen & Bladh, 2016). He was able carry out some of his self-care needs however due to his poor glycaemic control as evident from his physical examination, he needs assistance in meeting the health deviation self-care deficit. The major issues presented were poor diabetic control and neuropathic pain management which are the two key care needs to be focused in framing the care plan. This affects quality of life as it could lead to limit his physical and social activities as well as raise psychological distress and wellbeing leading to more consumption of medicines (Aalaa et al, 2012).

Formulation of the care plan

Care planning for patients with long-term illness has been a policy priority for chronic disease management in a variety of health care systems. These conditions cannot be cured but they can always be managed through health promotion, medicines, education, and self-management (Davies, 2010). Care planning therefore includes assessing what the needs of the patient are, planning how best to address these needs, developing care strategies, and then assessing how effective the care will be (Raut, 2017). Promoting self-management is vital in the treatment of diabetic patients and it includes the person taking responsibility for their well-being and health alongside managing their illness with the support and assistance of nursing staff (RCN, 2019). Diabetes treatment must be individualised per patient, so the care plan should be patient-centred, be across the life span which is curial as the patient transitions through various stages of life span (American Diabetes Association, 2015).

In terms of patient empowerment, the Kaiser Permanente (KP) model is best used as it encourages patient independence as well as patient/nurse relationships. According to McCarthy et al. (2009), Kaiser Permanente (KP) model is a nature of healthcare which allows to combine key parts of care delivery and health coverage in a coordinated experience. It is unlike health insurance where care is provided based on membership whereas in this model care is provided based on the dues paid by the patients to help them avail care in both inpatient and outpatient unit to avail better well-being (Pantell et al., 2019). Schiotz et al. (2012) states that KP’s integrated health information technology framework facilitates the provision of care to the patient by facilitating the tracking of clinical indicators over time, providing electronic reminders, and providing an up-to-date summary of available relevant resources such as health education classes in promotion of self-management support for the patient. It also empowers patients to monitor their own wellbeing and care such as the ability to securely email physicians (Zhou et al, 2010). However, according to Steiner et al, (2018) the framework requires adaptation to each local context as it oversimplifies complex processes in health systems and the community.

The NHS Long Term Plan is the forward view taken by the NHS for next five years to arrange care and deliver them to the people in the community to enhance the overall health scenario of the country (NHS, 2020). The NHS Long Term plan mentions that it would implement online availability of general physician (GP) consultation and redesign the hospital support to avoid unnecessary outpatient appointment which would save trips to the hospitals, in turn, leading patient to avail care at home (NHS, 2020). Thus, such plan would impact George to avail healthcare for his diabetes management home while taking care of his own and his mother. It would save him time to invest in taking his own care while also managing the job and household activities. The NHS Long Term plan mentions to take priorities in enhancing care quality for improving patient outcome (NHS, 2020). Thus, such initiative would impact George to avail better quality care for his pain management and diabetes which would help him to lead a better life with well-being.

It is important to use evidence to support clinical decisions during the implementation of nursing care. According to Titler, (2008) evidence-based approach is the careful, explicit, and judicious use of existing best evidence in combination with professional experience and patient values to guide health care decisions. As a result, evidence-based practice aims to substitute practice as normal, with practice driven by rigorous result-oriented studies, and preferably randomised controlled trials. It also aims to make practice a less arbitrary, and to bring it to a higher degree of transparency and aligned with attempts to identify best practices in nursing and other disciplines (Baumann, 2010). Evidence-based guidelines include recommendations for how healthcare practitioners can take care of patients with specific conditions (NICE, 2008). The recommendations used in the nursing intervention below show that the development process was appropriately rigorous and involved an explicit evaluation of the validity of evidence. The guidelines were clearly defined and tended to be applicable to the patient in the clinical scenario.

In order to support George to maintain glycaemic control, nursing intervention according to NICE, (2019) will include efficient blood glucose management and maintenance of HbA1c at or below the target value set for the person by educating him on how to check his blood sugar and interpret the results and how often he needs to check his blood sugar. He is also to be supported in making consulting with the dietitian to develop education about diabetic diet to be followed to develop enhanced self-care in controlling diabetes, encouraging George to part in physical exercise as exercises decrease blood glucose level and increase the demand for glucose in the cells which lowers blood sugar levels (Leontis, 2019). George is also to be made aware about the way he can remember to take his medication for diabetes control as the medication such Metformin acts in effective control of blood sugar level. The desired health outcomes include the patient will demonstrate how to monitor his blood sugar and interpret the results; patient will create a daily menu that addresses his diabetic needs. See appendix for further details.

In regards, to neuropathic pain management, nursing interventions will include physician-prescribed anti-inflammatory drugs intake and relaxation therapy (Kumar, 2007). Relaxation therapy helps to reduce response to stress, reduces skeletal muscle contraction and decreases the sensation of pain (Baird and Sands, 2004). George is to be referred to the foot protection services such as Diabetology, Podiatry, Diabetes specialist nursing for further assessment (NICE, 2015). Furthermore, the nurse is recommended to provide George information about diabetic foot problems which includes a clear explanation of the person’s foot problem, footwear advice, foot emergencies and who to contact in case of raised problem (NICE, 2015). The desired outcomes will include patient showing their knowledge of foot care, and the patient will also show how to conduct a physical examination and take care of their feet on a regular basis. The patient will also ensure that the skin and nails are kept clean and maintained by the patient (Aalaa et al, 2012). I think that it is important to include these recommendations while making George’s care plan however inclusion of George’s preferences in his care. See appendix for a detailed evidence-based care plan for George regarding managing his type 2 diabetes.

Reflection on Nursing decision

Reflective practice in nursing requires a period of careful thinking, looking back, evaluating oneself and ones’ practice to improve future practice (Bulman & Schutz, 2013). Refection includes the explanation, interpretation, and assessment of practical knowledge to help you make sense of it (Murdoch, 2019).

Therefore, on reflection my nursing experience in providing patient care I learnt that gathering patient information and history provided me with a comprehensive description of the patient, it helped me to focus on the patient’s needs at that moment as well as possible needs that may need to be addressed in the future. I also learnt the importance of interactive communication between the patient and the nurse as this ensures that patients take part in planning their care to ensure their continued well-being and should be supported by the nurse, based on evidence-based written information. Therefore, it is important as a student nurse to work in a professional manner, abiding by policies, codes of conduct set by the NMC, GP and hospital trust.

As a student nurse still in training, my learning needs to develop in patient assessment and planning include confidence while interviewing the patient and carrying out assessment as I noticed this affected my performance, I was very nervous and kept making mistakes while talking. Another learning need is to be more familiar with existing current written evidence or guidelines for different health conditions by conducting more research.

George’s care plan for his care needs was based on evidence-based information, was very effective. It was followed by both the nurse and George hence the goals were met. However, to ensure improvement in care for the patient is by improving access to care by making sure that there are no delayed treatments and providing them with all important contacts of the multi-disciplinary teams involved in their care. In additional to the above the role of a nurse as a care giver in supporting patients with long term conditions live well is by supporting the patient in making healthy choices and directing them to useful sources of information. Furthermore, nurses should play an active role in providing advice, educating, and training patients with long term conditions in managing their condition, to know when to seek medical help or self-manage their symptoms with guidance from health professionals (RCN, 2020).

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Conclusion

In conclusion George’s assessment using Orem’s model of nursing and other assessment tools revealed that he had a self-care deficit in managing his diabetes requiring nursing intervention to ensure his continued well-being. Self-management of blood glucose is key to patient adherence to pharmacological treatment and motivates the patient to make appropriate changes in their lifestyles for their well-being.

Nursing intervention included evidence-based information that the Patient consented to as well as safe-netting measures such as consultations with diabetic foot specialist, dietician, relaxation therapies to help the patient manage their condition.

References

Aalaa, M., Malazy, O.T., Sanjari, M., Peimani, M. and Mohajeri-Tehrani, M. (2012). Nurses’ role in diabetic foot prevention and care; a review. Journal of Diabetes & Metabolic Disorders, [online] 11(1), p.24. Available at: https://doi.org/10.1186/2251-6581-11-24 [Accessed 16/11/2020].

American Diabetes Association (2015). 1. Strategies for Improving Care. Diabetes Care, 39(Supplement 1), pp.S6–S12.

Baird, C.L. and Sands, L. (2004). A pilot study of the effectiveness of guided imagery with progressive muscle relaxation to reduce chronic pain and mobility difficulties of osteoarthritis. Pain Management Nursing, [online] 5(3), pp.97–104. Available at: https://doi.org/10.1016/j.pmn.2004.01.003 [Accessed 2 Feb. 2020].

Baumann, S.L. (2010). The Limitations of Evidenced-Based Practice. Nursing Science Quarterly, 23(3), pp.226–230.

Bulman, C. and Schutz, S. (2013). Reflective practice in nursing. 5th ed. Hoboken: Wiley-Blackwell.

D'Aiuto, F., Gable, D., Syed, Z., Allen, Y., Wanyonyi, K.L., White, S. and Gallagher, J.E., 2017. Evidence summary: The relationship between oral diseases and diabetes. British dental journal, 222(12), p.944.

Davies, N.J. (2010). Improving self-management for patients with long-term conditions. Nursing Standard, [online] 24(25), pp.48–56. Available at: doi.10.7748/ns.24.25.48.s53 [Accessed 2 May 2020].

Dehvan, F., Nasif, F.Q., Dalvand, S., Ausili, D., Dehkordi, A.H. and Gheshlagh, R.G., 2020. Self-care in Iranian patients with diabetes: A systematic review and meta-analysis. Primary Care Diabetes.

Diabetes.co.uk. (2011). Type 2 Diabetes - 90% of People with Diabetes have Type 2. [online] Available at: https://www.diabetes.co.uk/type2-diabetes.html [Accessed 3 Nov. 2020].

Diabetic foot problems: pre Diabetic foot problems: prev vention and ention and management management NICE guideline. (2015). [online] Available at: https://www.nice.org.uk/guidance/ng19/resources/diabetic-foot-problems-prevention-and-management-pdf-1837279828933 [Accessed 15 Nov. 2020].

Downey, C.L., Tahir, W., Randell, R., Brown, J.M. and Jayne, D.G. (2017). Strengths and limitations of early warning scores: A systematic review and narrative synthesis. International Journal of Nursing Studies, [online] 76, pp.106–119. Available at: https://www.sciencedirect.com/science/article/pii/S0020748917302109.

Eastern Illinois University (2018). Why Is Evidence-Based Practice in Nursing so Important? [online] Eastern Illinois University Online. Available at: https://learnonline.eiu.edu/articles/rnbsn/evidence-based-practice-important.aspx [Accessed 24 Nov. 2020].

England, N. (2012). NHS England » National Early Warning Score (NEWS). [online] England.nhs.uk. Available at: https://www.england.nhs.uk/ourwork/clinical-policy/sepsis/nationalearlywarningscore/ [Accessed 11 Nov. 2020].

Hagran, A and Fakharany, E (2015). Critique of Orem’s theory. J. Middle East North Afr. sci, 1(5), 12-17]. (p-ISSN 2412- 9763) - (e-ISSN 2412-8937). [online] Available at: http://www.jomenas.org [Accessed 30 Nov. 2020].

Hellman, R. (2012). Glucose meter inaccuracy and the impact on the care of patients. Diabetes/Metabolism Research and Reviews, 28(3), pp.207–209.

Kivipuro, M., Tirkkonen, J., Kontula, T., Solin, J., Kalliomäki, J., Pauniaho, S.L., Huhtala, H., Yli-Hankala, A. and Hoppu, S., 2018. National early warning score (NEWS) in a Finnish multidisciplinary emergency department and direct vs. late admission to intensive care. Resuscitation, 128, pp.164-169.

Kumar, C.P. (2007). Application of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman with Diabetes. International Journal of Nursing Terminologies and Classifications, [online] 18(3), pp.103–110. Available at: https://doi.or/10.1111/j.1744-618X.2007.00058.x [Accessed 3 Nov. 2020].

longtermplan.nhs.uk 2020, NHS Long Term Plan Diabetes, Available at: https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/ [Accessed on: 1 April 2021]

Maslakpak, M.H., Shahbaz, A., Parizad, N. and Ghafourifard, M., 2018. Preventing and managing diabetic foot ulcers: application of Orem’s self-care model. International Journal of Diabetes in Developing Countries, 38(2), pp.165-172.

McCarthy, D., Mueller, K. and Wrenn, J. (2009). Kaiser Permanente: Bridging the Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology. [online] Available at: www.commonwealthfund.org [Accessed 20 Nov. 2020].

Mendonça, S.C.B.D., Zanetti, M.L., Sawada, N.O., Barreto, I.D.D.C., Andrade, J.S.D. and Otero, L.M., 2017. Construction and validation of the Self-care Assessment Instrument for patients with type 2 diabetes mellitus. Revista latino-americana de enfermagem, 25.

Morris, D. (2019). Assessing and managing the diabetic foot in primary care. [online] www.independentnurse.co.uk. Available at: https://www.independentnurse.co.uk/clinical-article/assessing-and-managing-the-diabetic-foot-in-primary-care/216316 [Accessed 24 Nov. 2020].

Murdoch, M. (2019). How to reflect on your practice. [online] Nursing in Practice. Available at: https://www.nursinginpractice.com/professional/how-to-reflect-on-your-practice/ [Accessed 6 Dec. 2020].

National Institute for Health and Clinical Excellence (2008). How NICE clinical guidelines are developed National Institute for Health and Clinical Excellence. [online] Available at: https://www.nice.org.uk/guidance/cg177/documents/osteoarthritis-update-stakeholder-lists-and-how-to-register2. Accessed 20/11/2020

NHS Choices (2019). Hyperglycaemia (high blood sugar). [online] NHS. Available at: https://www.nhs.uk/conditions/high-blood-sugar-hyperglycaemia/ [Accessed 13 Nov. 2020].

NHS Choices (2019). Metformin. [online] NHS. Available at: https://www.nhs.uk/medicines/metformin/ [Accessed 2 Dec. 2020].

NHS Choices (2019c). Overview - Peripheral neuropathy. [online] NHS. Available at: https://www.nhs.uk/conditions/peripheral-neuropathy/ [Accessed 5 Dec. 2020].

Nursing and Midwifery Council (2015). Read The Code online. [online] Nmc.org.uk. Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/.

Pantell, M.S., Prather, A.A., Downing, J.M., Gordon, N.P. and Adler, N.E., 2019. Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes. JAMA network open, 2(5), pp.e193933-e193933.

Raut, G. (2017). Care plans | RCN. [online] Rcni.com. Available at: https://rcni.com/hosted-content/rcn/first-steps/care-plans.

Schiøtz, M., Strandberg-Larsen, M., Frølich, A., Krasnik, A., Bellows, J., Kristensen, J.K.,

Shah, M. (2015). Compare and Contrast of Grand Theories: Orem’s Self-Care Deficit Theory and Roy’s Adaptation Model. International journal of Nursing Didactics, [online] 5(1). Available at: http://dx.doi.org/10.15520/ijnd.2015 .vol5.iss01.28.39-42 [Accessed 7 Nov. 2020].

Steiner, J., Bellows, J. and Gottlieb, L. (2018). Interventions to Address Basic Resource Needs in Kaiser Permanente: A Care Continuum and an Outcomes Wheel. The Permanente Journal. [online] Available at: https://www.ncbi.nlm.gov/pmc/articles/PMC6207439/ [Accessed 4 Jun. 2020].

The Royal College of Nursing. (2019). Education, prevention and the role of the nursing team | Diabetes | Royal College of Nursing. [online] Available at: https://www.rcn.org.uk/clinical-topics/diabetes/education-prevention-and-the-role-of-the-nurse. Accessed 19/11/2020

The Royal College of Nursing. (2020). Self-care | Public Health | Royal College of Nursing. [online] Available at: https://www.rcn.org.uk/clinical-topics/public-health/self-care [Accessed 6 Dec. 2020].

Timmins, F & Horan, P (2007). A critical analysis of the potential contribution of Orem’s (2001) self-care deficit theory to contemporary coronary care nursing practice. Available at: https://journals.sagepub.com/doi/pdf/10.1016/j.ejcnurse.2006.03.006 Accessed on 23/11/2020

Titler, M.G. (2008). The Evidence for Evidence-Based Practice Implementation. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK2659/# [Accessed 24 Nov. 2020].

Tonyushkina, K. and Nichols, J. (2009). Glucose Meters: A review of technical challenges to obtaining accurate results. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769957/ [Accessed 14 Nov. 2020].

Type 2 diabetes in adults: management ype 2 diabetes in adults: management NICE guideline. (2019). [online] Available at: https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493. Accessed 17/11/2020

Vanroy, J., Seghers, J., Bogaerts, A., Devloo, K., De Cock, S. and Boen, F., 2017. Short-and long-term effects of a need-supportive physical activity intervention among patients with type 2 diabetes mellitus: A randomized controlled pilot trial. PloS one, 12(4), p.e0174805.

Vedsted, P., Eskildsen, P., Beck-Nielsen, H. and Hsu, J. (2012). Self-Management Support to People with Type 2 Diabetes - A comparative study of Kaiser Permanente and the Danish Healthcare System. BMC Health Services Research, 12(1).

Vihonen, H., Lääperi, M., Kuisma, M., Pirneskoski, J. and Nurmi, J., 2020. Glucose as an additional parameter to National Early Warning Score (NEWS) in prehospital setting enhances identification of patients at risk of death: an observational cohort study. Emergency Medicine Journal, 37(5), pp.286-292.

World Health Organization (2018). Diabetes. [online] Who.int. Available at: https://www.who.int/news-room/fact-sheets/detail/diabetes [Accessed 3 Nov. 2020].

Zhou, Y.Y., Kanter, M.H., Wang, J.J. and Garrido, T. (2010). Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients. Health Affairs, 29(7), pp.1370–1375.

quality quality quality quality quality quality quality

What I feel I did best in this assignment was:

I feel I carried out extensive research to obtain evidence-based information and current written literature regarding assessing and planning for type 2 diabetes as a long-term condition.

What I found most challenging in this assignment was:

There is a lot of important information about caring for type 2 diabetes patient which presented a challenge as I had to decide what to include in the essay and what to skip over.

The aspects of the module that helped me most in this assignment were:

The lectures on nursing models and caring for diabetic patients as well as assignment tutorials that were held by Kathy,

The feedback from previous assignments that helped me most in this assignment was:

Be less descriptive in writing my essay and adopt analytical writing.

What I will do differently in my next assignment will be:

Be more in touch with the lectures in areas I do not understand


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