Navigating the Complexities of Diabetes Mellitus

Introduction

The purpose of this case study analysis is to systematically and deeply explore the issues associated with the assessment, interventions, and management of patients with life-shortening illnesses of Diabetes Mellitus. Diabetes is a disease condition where the body's ability to produce or respond to the hormone insulin is paralyzed, resulting in abnormal body metabolism of carbohydrates and increased blood glucose levels (Mohammed, 2014). The disease condition expresses in two ways; type 1 diabetes, a chronic condition with impaired metabolism where the pancreas produces little or no insulin, and type 2 diabetes is presumed a chronic condition where the body's blood sugar processes are affected. This paper will consider Patient TX, who is a 58-year-old lady with a complex diabetic condition. The case study will explore the prognosis and prevalence of this chronic disease, as well as its anatomy and physiology. It will also extrapolate the disease's possible physical and psychological symptoms, as exemplified in the patient TX.

Case Presentation

TX is a 58-year-old Russian lady referred to the clinician for pharmacotherapy assessment and diabetes management. TX's medical condition reveals a type 2 diabetes diagnosed in 2003, asthma, coronary artery condition and hypertension.

TX's diabetic condition is currently under treatment with the admission of premixed preparation of 75% insulin lipspro protamine suspension of 33 and 24 units before breakfast and before supper, respectively. The patient confesses to being taking insulin adjustment occasionally upon notice of high blood glucose count. The other routine medication projected for her treatment includes intake of fluticasone metered-dose inhaler, salmeterol for two puffs daily, naproxen twice daily, enteric-coated aspirin, furosemide, potassium chloride, fluvastatin, and diltiazem. The other medications prescribed for her to consume only when needed include furosemide for swelling, albuterol for breath shortness, and sublingual nitroglycerin for chest pain. The patient has no known drug allergies and denies using alcohol, nicotine, or any recreational drugs.

TX's major complaint at the moment is the increased asthma exacerbations and the need for prednisone therapy. In the last round of prednisone therapy, she confesses to having experienced high blood glucose readingsin the range of 250 to 400 mg/dl, regardless of a massive decrease in her intake of carbohydrates. She explained that she had increased the frequency of taking fluticasone, albuterol, and salmeterol to four or five times on the days when she had flare-ups. Moreover, we noticed that her spouse was not financially stable, making her depend entirely on the Social Security check. Hence, this reduced her ability to buy salmeterol and fluticasone as recommended, subjecting her to only taking albuterol and prednisone for any acute asthma exacerbations.

Finally, TX reports maintaining a healthy diet of substantialy three meals a day with additional snacks before dinner and before bedtime. In this case, she ensures that she takes a heavy breakfast and supper. She reports being cautious of her carbohydrates intake for each meal. However, it's unfortunate that she has not merited a routinely physical exercise due to her asthmatic condition and the adverse cold weather for the past few months.

Discussion and Literature Findings

Prevalence and Prognosis

Diabetes is on the rise worldwide. According to the World Health Organization statistics, about 422 million people globally have Diabetes, and most of them are in low and middle-income countries (Zhou et al., 2016). Consequently, an estimated around 1.6 million deaths that occur globally are directly attributed to diabetic conditions annually. Statistics hold that the number of cases and prevalence of Diabetes have been increasing over the past few decades. As of 2017, the global prevalence of adults with Diabetes stood at 8.8 percent of the world population, with an anticipated further increase to 9.9 percent by researchers in 2045. The percentage figure reflects a population of 424.9 million people with Diabetes, with an approximated increase to 628.6 million people by 2045 (Cho et al., 2018). Considering the age brackets, global diabetes prevalence stands at the percentages of 5, 10, 15, and 20 respectively for the age groups ranging between 35-39, 45-49, 55-59, and 65-69. When interpreted on the global scaling, the statistics imply that Diabetes is virulent for middle-aged people between the ages of 40 and 59 years, which is believed to have adverse economic and social consequences for the world.

Furthermore, statistics imply that the diabetic condition has threatened the low and middle-income countries for the best of times, with an estimate of around 77 percent of the people living with Diabetes globally living in such countries. Moreover, this data by the International Diabetes Federation (IDF) Diabetes Atlas 2017 shows an estimated 352.1 million individuals of the global population being at the risk of Diabetes or the prediabetes phase. The anticipated figure indicates a possible rise of the diabetes cases to 531.6 million people by 2045. The IDF indicated that the global numbers of Diabetes have continuously increased from 151 million by 2000 to about 285 million in 2009 and a further 382 million in 2013 (Saeedi et al., 2019). These figures correspond with the international consortium reporting that shows a worldwide prevalence increase of 4.3 percent in 1980 to about 9.0 percent in 2014 for men and a similar increase from 5.0 to 7.9 percent for women. Insofar, as indicated in the IDF statistics, Diabetes less more or less affects both sexes in similar measures, where men get affected more than women at the younger ages. Still, women surpass men at the higher age groups. The international consortium estimated that the number of adults with diabetic cases globally had an increasing trend from 180 million individuals in 1980 to about 422 million in 2014. Among some of the reasons given for the upward trend, statistics keenly noted that a 28.5% increase was true prevalence.

In contrast,the population growth and aging population triggered 39.7%, and a further 31.8% was due to the interactions of the factors mentioned above. Other than aging and growth of the global population, the global obesity pandemic has also emerged as a primary factor contributing to the rising incidences of Diabetes (Bluher, 2019). Based on the international consortium estimates on millions of adults with diabetes mellitus between 19980 and 2014, there has been a shift from the European countries towards Asian countries, Mexico, and Egypt, which have reported high population growth in the past few decades. The latter can be related to the World Health Organization (WHO) Global Health Observatory report of 2016 that indicated higher obesity and overweight prevalence in the United States and Gulf countries, which are possible risk factors of Diabetes (WHO, 2017). On the other hand, countries within Indian, China, and Asian horizontals, albeit showing a lower prevalence of overweight and obesity, were also noted to be a hotbed of Diabetes. These regions have exhibited the highest incidence of Diabetes in recent years. For instance, China was found to exhibit 10.9% of diabetes cases on its adult population, representing close to 100 million individuals. However,almost two-thirds of its population is yet to be diagnosed. Between 2000 and 2016, there was an estimated 5% percent increase in premature mortality resulting from Diabetes, which increased significantly from 2010 to 2016 in the middle-income countries.

As of 2019, statistics showed that approximately 463 million adults aged between 20 and 79 lived with Diabetes, which is expected to rise to 700 million by 2045. Accordingly, those with type 2 diabetes are increasing, with most cases in low and middle-income countries, with 79% of the adult population submerged into this pandemic. On health expenditure reports, Diabetes has caused at least 760 billion U.S dollars of health expenditure in 2019 alone for the adult population. It's also recorded that more than 1.1 million minors and adolescents also live with type 1 diabetes, and additional 20 million live births are also being affected during pregnancy. As of now, about 374 million individuals are at an increased risk of contracting type 2 diabetes. Owing to its population, China is currently the country with the largest cases of this condition globally, with about 116 million people suffering from this medical condition. Among these cases, 88.5 million individuals have been diagnosed with type 2 diabetes. China is closely followed by India, which records 65.9 million and U.S 28.9 million individuals with type 2 diabetes, and all prevalence shows a slightly higher male than females (6219 comparing to 5898 cases per 100,000). However, statistics showed that the highest prevalence of Diabetes is within Mauritius, Marshall Island, and New Caledonia, but the rates have generally increased across many countries due to obesity. It's predicted that the prevalence will continue to the future, and the African region is expected to exhibit a 143 percent increase in diabetic cases between 2019 and 2045.

The United States has the fourth-highest prevalent cases of Diabetes. According to a CDC report, about 34.2 million people (10.5 percent) of the U.S population have Diabetes; the cases represent 26.9 million diagnosed, among which 26.8 million are adult population and 7.3 million undiagnosed (Centers for Disease Control and Prevention, 2020; Cho et al., 2018). The prediabetes statistics stand at 88 million individuals aged 18 years and above, representing about 34.5 percent of the U.S. adult population. Nonetheless, 24.2 million people aging 65 years and above are also reported to have prediabetes conditions. According to the National Diabetes Statistics Report 2020, during the 1999-2016 periods, the age-adjusted prevalence of the total diabetes cases significantly increased in the adult-aged from 18 years and above. These prevalence cases were estimated at 9.5% from 1999-2002 and a 12.0% between 2013 and 2016.

Anatomy and Physiology

The anatomy or the pathophysiology of Diabetes mellitus is related to the body insulin levels or the body's ability to utilize insulin. Arguably, type 1 diabetes results from lacking insulin in the body, while type 2 diabetes is due to peripheral tissues resisting the effects of insulin (Esser et al., 2020). In relation to the case presentation above, it’s convincing that the anatomy and physiology of Diabetes can be well described through prior understanding of the pancreatic endocrine functions. The pancreas has a cluster of pancreatic cells known as Langerhans' islets, which secrets hormones like insulin, glucagon, somatostatin, and pancreatic polypeptide. The pancreatic endocrine function involves insulin secretion from the beta cells and glucagon secretion from the alpha cells in the pancreatic islets. These are the two most common hormones that regulate glucose metabolism rates in the body. On blood regulation, (Esser et al., 2020) observed that the average blood glucose for an individual should be between 70 to 120mg/dl and is only maintained through negative feedback in the body. From the latter statement, the implication as of the related case is that when the blood sugar level shoots higher, insulin plays a role in lowering it, especially after meals. Alternatively, when the blood sugar gets too low from a lengthy break between meals, glucagon raises it. In other words, insulin is attached to the insulin receptors on blood capillary walls, removing excess glucose from the plasma and storing excess glucose through lipids and glycogen.

On the other hand, glucagon within the liver cells causes glycogen breakdown when the blood sugar level is low, thus releasing glucose monomers to the bloodstream (Ho, 2019). In this way, we are bound to allude that diabetes mellitus is a condition with disordered metabolism and dysfunctional hyperglycemia resulting from insulin deficiency or inadequate insulin secretion and resistance. Type 1 diabetes is due to the destruction of pancreatic islet B cell in the autoimmune process and cannot produce insulin. The beta cells are the only cells that help the body manufacture the hormone insulin; thus, their destruction would hinder the body's ability to regulate the blood sugar level. In most cases, the latter condition of type 1 diabetes is usually eminent among the minors and young adults, and could equally account for the 5 percent of the total population diagnosed with diabetes globally.

On the other hand, type 2 is considered the most common, contributing to 95% of diabetic cases, and is the most common form of Diabetes in adults. It’s believed to be caused by multi-factorial complications that include environmental and genetic elements that impact beta cells' functioning and affect tissue insulin sensitivity. For type 2 diabetes, either the cells ignore the insulin, or the body cannot produce enough insulin as the body requires. Its onset is typically characterized by insulin resistance,a disorder where the cells are not using the insulin effectively; hence, as the need for insulin increases, the pancreas loses its ability to produce it gradually.

Generally, when there is higher glucose build up in the bloodstream instead of getting into the cells, its attributes to other health complications such as heart diseases, kidney damage, and nerve damages. Hence, Diabetes is considered one of the leading causes of kidney failures and non-traumatic lower-limb amputations, and blindness among adults.

Physical and Psychological Symptoms

The physical symptoms of Diabetes are many and can vary depending on the amount of sugar level in the blood. Most of the symptoms are explicit in type 1 diabetes, where they appear so quick and are severe. However, for type 2 diabetes, I realized that the symptoms are not severe and may not be experienced (Xu et al., 2020). As observed from the case above, some of the early symptoms of Diabetes that are related to high blood sugar levels include frequent urination and dehydration. Dehydration in the body also causes increased thirst and high water consumption, some of the physical indicators of the diabetic chronic condition.

Moreover, absolute or relative insulin deficiency exposes an individual to weight loss, which is believed to occur despite an increase in appetite; hence weight loss and increased appetite are among the physical symptoms of diabetes mellitus. Again, some of the diabetic untreated cases usually complain of frequent fatigue, through which nausea and vomiting can also be witnessed as additional signs of Diabetes. Frequent infections such as infections of the skin, bladder, and vaginal areas are common in individuals with untreated or poorly managed diabetic conditions. Another significant symptom is a possible blurred vision, which can result from fluctuation in blood glucose levels. Still, the most severe one is coma or lethargy, which is caused by high glucose levels (Xu et al., 2020). There are also instances where the skin darkens in areas where the body creases, a condition referred to as acanthosis nigricans. Finally, acetone or fruity sweet breath odor and numbness of the feet or hands are other possible symptoms. The above symptoms occur across men and women; however, other unique symptoms are unique to either men or women. For instance, men experience erectile dysfunction or impotence, retrograde ejaculation, low testosterone count, decreased sex drive, and sexual dysfunction.

Health experts support that diabetic patients also exhibit mental and mood symptoms through diabetic distress that causes depression and anxiety. The symptoms of depression are ubiquitous with diabetic individuals, which can be an attributive cause of low mental health status for people with Diabetes. Hence, some of the possible signs include feeling sad or depressed, inability to sleep, waking up early, and losing appetite. The other signs include lack of interest or fulfillment of joy in daily activities, tiredness and lack of energy, feeling of guilt and worthlessness, and suicidal thoughts. Emotional distress is also widespread where an individual might be constantly worried about their blood glucose levels and the risks of developing more diabetic complications. Moreover, there are also feelings of anger about their chronic conditions and guilt when unable to manage their diabetic conditions.

Assessment, Examinations & Health interventions for diabetes management by MDTs

Generally, the health professionals' tests used to diagnose Diabetes and prediabetes include the fasting plasma glucose test, A1C test, and random plasma test. The fasting plasma glucose test can be is usually applicable for both diabetes and prediabetes conditions. It involves measuring the blood glucose after at least 8 hours without food or eatingto help detect these chronic cases. The hemoglobin A1C test is also used to test and confirm both prediabetes and Diabetes but can be done without fasting (chambers & Ryder 2018). Another applicable test for diagnosing diabetes is the random plasma glucose test, where the physician checks the blood sugar levels without considering the time for the patient's last meals. The test, along with symptoms assessment, is used to diagnose Diabetes only. The final diagnosis method is the oral glucose tolerance test. For this test, the doctor measures the blood sugar after fasting 8 hours without eating and two hours after drinking a glucose-containing beverage. This test is also suitable for diabetes and prediabetes diagnosis.

Altogether, in reference to the American Diabetes Association Standard framework, the current multidisciplinary teams have been aligned to some standard provisions on managing diabetes cases during patient treatment, which are supported with evidence based practice. In this regard, the first medical assessment consideration on the standards is improving care and promoting health for the populations. The first recommendation for diabetes and population health is that treatment decisions are timely and based on evidence (NICE, 2018). Besides, these decisions should be collaboratively made with the patients based on their preferences, prognosis, and comorbidities. The other recommendation is to align diabetes management with the chronic care model and emphasize interactive production between the informed activated patient and the proactive care team (NAO, 20115). The final recommendation is that the care system should assure team-based care, decision support tools, patient registries, and community involvement to actualize the patients' needs. On tailoring treatment for social context, the first recommendation is that the care providers assess the patient's social context, including food insecurity, financial barriers, and housing stability, to use this information in making treatment decisions The other recommendation is that patients should be referred to the local community facilities when the resources are available. The final recommendation is to provide patients with self-esteem support by the health coaches, community health workers, and navigators as appropriate (Kings, 2011). The second assessment and examination for MDTs testing to diagnose are on classification and diagnosis of Diabetes. The first concern is on a diagnostic test for Diabetes, and the standard care recommends that all people, testing should begin from 45years. Another recommendation is that for type 2 diabetes and prediabetes testing in the asymptomatic stage, individuals should be considered, especially adults of any age that are obese or overweight and those who exhibit diabetic risk factors. Again, for risk-based screening for both type 2 and prediabetes, it should be considered after the onset of puberty for children who are overweight or obese and those with risk factors. The other recommendation is that patients with prediabetes and type 2 diabetes should also be treated with other cardiovascular disease risk factors. Finally, repeated tests should be done at intervals of three years for those who test normal. For prevention or delay of type 2 diabetes, the first recommendation is annual monitoring of the type 2 diabetes development.

Additionally, lifestyle recommendations like referring the diabetic patient to an intensive behavioral lifestyle interventional program to achieve and maintain a 7percent loss of the initial body weight (RCN, 2016) . Based on patient reference, interventions through technology may be ideal in preventing type 2 diabetes. For pharmacological interventions, metformin therapy is recommended for those with Diabetes to help prevent diabetes type 2. Finally, on preventing cardiovascular disease, screening for and treating diabetic modifiable risk factors for cardiovascular disorders is recommended since prediabetes is positively associated with cardiovascular risks.

The fourth standard provided is on comprehensive medical evaluation and assessment of the comorbidities. The first concern is on patient-centered collaborative care (RCN, 2020). The first recommendation is to use a patient-centric communication style that uses strength-based language, active listening, patient reference and beliefs, numeracy and literacy assessments, and possible barriers to care that should optimize patient outcomes on quality health. Again, it's also recommended that diabetes care be managed by the multidisciplinary teams derived from the primary care physicians, physician assistants, nurses, dietitians, subspecialty physicians, exercise specialists, dentists, pharmacists, and mental health professionals and podiatrists. On the same, for comprehensive medical evaluation, the first recommendation is a complete medical evaluation of the patient on the initial visit to confirm diabetes and diabetes classification, evaluate complications and possible comorbid conditions, review previous treatment and risk control, begin patient engagement and develop a plan for continued care (CQC, 2018). The other recommendation on this standard assessment is a follow-up visit that should include most components of the initial medical evaluation like the medical history, assessed medication-taking behavior, intolerance or side effects, laboratory evaluation, and physical evaluation to assess the attainment of metabolic targets and A1C as well as self-management practices and assessment of risk factor complications.

Further on autoimmune diseases like cancer, it's recommended that screening the patient of type 1 diabetes is prioritized for celiac disease and autoimmune thyroid disease. For cognitive impairment or dementia condition, it's recommended that people with a history of such medical conditions administer intensive glucose control are not likely to remediate the deficits. Thus, treatment should be channeled to avoid hypoglycemia.

The Nursing Process Model

The nursing process model is a systematic care approach that uses fundamental principles of critical thinking, evidence-based practice recommendations, a client-centered treatment approach, and nursing intuition (NMC, 2010). Its core purpose is to identify the clients' status of care and actual or potential health complications to establish the plans of meeting the identified needs and deliver specific nursing interventions that correspond to the patient's needs. The framework is organized in five main sequential steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step that involves critical thinking and data collection from the patient or primary caregivers (Martin et al., 2019). Diagnosis follows next, which deploys the formulation of diagnosed assessment information by deploying clinical judgment to plan and implement adequate patient care. According to Maslow's Hierarchy of Needs, the nursing diagnosis is the priority order of basic psychological needs, safety and security needs, love and belonging, self-esteem, and finally, self-actualization needs (Petro-yun, 1988). The next stage involves formulating the goals and outcomes that directly influence the patient care towards the appositive outcome. The next stage is the implementation step that involves doing the actual nursing intervention as per the care plan. The final stage is the evaluation that is vital for the positive patient outcome. This is where the caregiver assesses or evaluates the desirability of the intervention using the outcomes.

Social & Economic Impacts of Diabetes for Patients and Immediate Family

According to Weaver et al. (2014), Diabetes has many social and economic impacts on the patient and immediate family. Generally, it attributes a considerable health burden to the patient and family. Insofar, there are both direct costs, indirect costs, and intangible costs associated with this chronic condition. The direct costs include medical costs associated with consultation, dedication, investigation, hospitalization, management, complication treatment, health programs, and non-medical costs like time dedicated to care and transportation costs (Bansode and Jungari, 2019).. On the other hand, indirect costs of diabetes include the man-days lost, depression, social insecurity, low productivity, and disability payment.

Conclusion

Diabetes mellitus is a type of metabolic disease that causes rise in sugar levels in a persons body. It’s a condition that arises when one’s body fails to make enough insulin or cannot effectively use the available insulin. From a general perspective, Diabetes proves to be a severe chronic condition that threatens the world. Given its economic and social implications discussed, the forecasted trend of Diabetes would be uncontrollable, with its burden hitting majorly on both low and middle-income countries. Although there are many types of Diabetes, the most common types of Diabetes mellitus are type 1 and type 2; type 2 seems to be the most common in adults with a 95 percent representation of the whole prevalent population. Type 1 is caused by problems in the immune system while type 2 is caused by genes or age. Being that obesity and overweight are the most risk factors, it's thus prudent that attention towards personal diet and weight watch is given attention, especially with patients exposed to such conditions.

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References

Bansode, B. and Jungari, S., 2019. Economic burden of diabetic patients in India: a review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 13(4), pp.2469-2472.

Blüher, M., 2019. Obesity: global epidemiology and pathogenesis. Nature Reviews Endocrinology, 15(5), pp.288-298.

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2020. Accessed at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf on Jan 25, 2021.

Cho, N., Shaw, J.E., Karuranga, S., Huang, Y., da Rocha Fernandes, J.D., Ohlrogge, A.W. and Malanda, B., 2018. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes research and clinical practice, 138, pp.271-281.

Esser, N., Utzschneider, K.M. and Kahn, S.E., 2020. Early beta cell dysfunction vs insulin hypersecretion as the primary event in the pathogenesis of dysglycaemia. Diabetologia, 63(10), pp.2007-2021.

Mohmmed, S.A.J., 2014. Knowledge and Attitude of Diabetes Mellitus Patients towards their Life style in GabirAbualiz Center, Khartoum State, Sudan (Doctoral dissertation, University of Gezira).

Saeedi, P., Petersohn, I., Salpea, P., Malanda, B., Karuranga, S., Unwin, N., Colagiuri, S., Guariguata, L., Motala, A.A., Ogurtsova, K. and Shaw, J.E., 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice, 157, p.107843.

Weaver, R.R., Lemonde, M., Payman, N. and Goodman, W.M., 2014. Health capabilities and diabetes self-management: the impact of economic, social, and cultural resources. Social Science & Medicine, 102, pp.58-68.

Xu, H., Du, X., Xu, J., Zhang, Y., Tian, Y., Liu, G., Wang, X., Ma, M., Du, W., Liu, Y. and Dai, L., 2020. Pancreatic β cell microRNA-26a alleviates type 2 diabetes by improvingperipheral insulin sensitivity and preserving β cell function. PLoS biology, 18(2), p.e3000603.

Zhou, B., Lu, Y., Hajifathalian, K., Bentham, J., Di Cesare, M., Danaei, G., Bixby, H., Cowan, M.J., Ali, M.K., Taddei, C. and Lo, W.C., 2016. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4· 4 million participants. The Lancet, 387(10027), pp.1513-1530.

Chambers, C., and Ryder, E. 2018. Supporting compassionate healthcare practice: understanding the role of resilience, positivity and wellbeing, London: Routledge.

CQC. 2018. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 11 (Need for consent). UK: Care Quality Commission. [online] Available at: < https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-11-need-consent#guidance-links > [accessed 30th June, 2020].

Kings Fund. 2011. Making shared decision-making a reality: No decision about me, without me. [online] Available at: < https://www.kingsfund.org.uk/publications/making-shared-decision-making-reality > [accessed 15th May, 2020].

Martin, ML., Heron, S., Moreno-Walton, L. and Strickland, M. 2019. Diversity and inclusion in quality patient care: your story/our story? A case-based compendium. 2nd ed. Cham, Switzerland: Springer International Publishing. [online] Available at: < https://anglia.primo.exlibrisgroup.com/permalink/44APU_INST/16n1f1b/cdi_askewsholts_vlebooks_9783319927626 > [accessed 11th July, 2020].

NICE. NG.-108. 2018. Decision-making and mental capacity (NICE Guideline 108). National Institute for Health and Care Excellence (NICE). [online] Available at: < https://www.nice.org.uk/guidance/ng108 > [accessed 30th June, 2020].

NMC. 2010. Standards of proficiency for pre-registration nursing education. London: Nursing and Midwifery Council. [Online] Available at: < https://www.nmc.org.uk/standards/standards-for-nurses/pre-2018-standards/standards-for-pre-registration-nursing-education/standards-of-proficiency-for-pre-registration-nursing-education/ > [accessed 11th July, 2020].

Petro-Yura, H., Walsh, MB. 1988. 5th Ed. The nursing process: assessing, planning, implementing, evaluating. Norwalk, Connecticut: Appleton & Lange.

RCN. 2016. Principles of safeguarding. UK: Royal College of Nursing. [online] Available at: < https://rcni.com/hosted-content/rcn/first-steps/principles-of-safeguarding > [accessed 30th June, 2020].

RCN. 2020. Principles of nursing practice. UK: Royal College of Nursing. [online] Available at: < https://www.rcn.org.uk/professional-development/principles-of-nursing-practice > [accessed 30th June, 2020].