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Bakker & Mau (2012) defines a care plan as an outline of how a patient's support needs will be addressed in an individualized way according to the patient’s diagnosis. It gives a roadmap that is to be followed by both the care provider and the patient so as to improve the patient's condition. In drafting a care plan, the patient's input is necessary. This paper illustrates a care plan for a patient I once cared for during my practice. The paper will focus on type 2 diabetes mellitus, its prevalence, and the social, economic and physical impacts of the disease in the United Kingdom. Discussions on the physiological impact of the disease on individuals' quality of life and the consequences and complications of uncontrolled diabetes particularly diabetic foot ulcers, wound dressings, and its rationale and effectiveness will also be addressed.
Similarly, the theories and policies underpinning the individualized care planning process, its usefulness, strengths, and limitations will be demonstrated, and the importance of person-centred care, such as patient engagement, involvement; respect, dignity and holistic care will be analyzed. Furthermore, requisite techniques that will help individuals living with diabetes manage their illness, and prevent further ulceration as well as promote the quality of their lives will be established. The name and personal information of the patient were kept confidential by the Nursing and Midwifery Council (NMC) code of conduct (2015).
The patient was a 63-year-old man who had an established type 2 diabetes and new developed neuropathic leg ulcer, was referred to the diabetic foot clinic. He lives with his wife. The patient’s family had a history of diabetes and was 61 years old when he was diagnosed with type 2 diabetes (T2DM). His Haemoglobin (HbA1c) laboratory test result was 94mmol/l, thus indicating hyperglycaemia (Blair, 2016). HbA1c testing measures the level of glucose in the red blood cells (NICE, 2015a), and the recommended blood glucose level is 4.0 to 6.6mmol/l and below this range is known as hypoglycaemia (NICE, 2012, Diabetes UK 2015a). Baker (2011) states that this provides an insight into an individuals’ blood glucose level for 2-3 months before testing. Khan et al. (2014) assert that the higher the blood sugar, the more haemoglobin sugar level is attached. The patient’s height was 1.57m, weight 109kg, and blood oxygen level 93% and has a history of peripheral neuropathy, which causes numbness and tingling in the feet (National Health Services England NHS, 2016), and high blood pressure which was in the range of 191/129 and 200/140mmhg, as against the recommended 130/85mmhg with respect to his age, an indication of hypertension (NHS 2016). About three weeks before my visit to his home with my mentor while on community placement he also had developed an infected foot ulcer on the plantar part of his left foot, which was caused by pressure due to insufficient offloading of the area, and worsened by over-exuberant debridement of callus. He was on Sitagliptin tablet 100mg once daily and Metformin tablet 500mg daily three times a day with or after meals. (Anti-diabetic medication).
Globally, diabetes prevalence for adults between the ages of 20 and 70 was estimated to be 415 million in 2015, and 1 in 10 persons are expected to be affected by the condition by 2040, thus it is estimated that 642 million people are affected by the condition (International Diabetes Federation [INF], 2015). The estimation shows that 1 in 2 adults having type 2 diabetes is undiagnosed. The INF (2015) predicted that countries like Brazil, United States of America, Russian Federation, India, Indonesia, China, and Mexico had more than 10 million people with type 2 diabetes. Diabetes has been identified worldwide more urban area 65% than in rural area 35% (INF, 2015).
Nationally, about 4 million people in the UK are living with diabetes; it has been forecasted that approximately 549,000 people in the UK, are yet to be diagnosed with diabetes (Diabetes UK, 2017). This indicates that 1 in 16 of the UK population has diabetes that has either been diagnosed or undiagnosed; statistics indicates 183,348 people in Wales, 2,913,538 in England, 271,312 in Scotland, 84,836 in Northern Ireland (Diabetes UK, 2017). It has been suggested that about 56% of men account for the diabetic population in the UK while women constitute 44%. Diabetes prevalence in the UK has been estimated to rise to 5 million by 2025 (Diabetes UK, 2017). Additionally, Type 2 diabetes has been identified as one of the world’s most common long term condition; NHS spends about 10% yearly which is about 9 million per annum diabetes treatment (Diabetes UK, 2017).
Diabetes mellitus is a long-term condition caused by the inability of the pancreases to produce sufficient hormone insulin to metabolize sugars and starch (Wilmot et al., 2013). The two main types of diabetes are type 1 and type 2 diabetes (Diabetes UK, 2017). Type one diabetes is considered to affect 10-15% of all diabetic patients, and it's caused by the deficiency in insulin production because of beta cell destruction in the pancreas (Bell et al. 2015). Meanwhile, type 2 diabetes accounts for 80% of those diagnosed with diabetes; it is caused by a combination of insulin production deficiency and or body cell resistance to the action of insulin (Morrison & Weston, 2014). Glucose and insulin being the key players in diabetes mellitus, insulin is produced by pancreas and glucose is obtained from carbohydrate from the daily diet which is metabolized by body cell to produce glucose that can be used by the body (Elaine, 2015). Normally, in a healthy individual, an increase in blood sugar levels after a meal, stimulates the pancreatic beta cells to produce the insulin hormone. The hormone insulin will stimulate cells to use glucose present in the blood (Tortora, & Derrickson, 2014). When blood glucose decreases, for instance during exercise, this causes the insulin levels to fall. While insulin stimulates the uptake of blood glucose by body cells, it also facilitates the following: conversion of glucose to pyruvate (glycolysis) to produce energy; converts excess glucose to glycogen to be stored in the liver (glycogenesis) and stimulates the uptake and synthesis of fats, proteins and amino acids (Elaine, 2015).
However, this process is altered with type 2 diabetes. When the body produces inadequate insulin to be used by the body cells, insulin resistance occurs. Insulin resistant is the inability of the body cells, for example, those in muscles, liver and fat cells to respond to insulin action (Fradkin & Rodger, 2015). The triglycerides in fat cells are then broken down to produce energy thus starving the muscle cells of a source of energy and inability of the liver cells to form glycogen stores. Colbert, Ankeny, & Lee (2012) suggests that this will lead to an increase in blood glucose, reduction in glycogen stores and insufficient glucose to be used when the need arises. The two major triggers linked to insulin resistance are obesity and lack of physical activity (Haitao, Chuangang & Chunmao 2015).Type two diabetes is classed as a multi-factorial disease (Patel et al.). Some other causes include sedentary lifestyle and genetics (Hu, 2011). However, the chances of developing the condition can be reduced if the individuals engage in healthy lifestyles (Huggins, Berger & McCaffery, 2015). Furthermore, some medication such as corticosteroids, thiazide diuretics and some mental health drugs such as clozapine and olanzapine do not cause diabetes type 1 but increase the risk of developing two diabetes (Repaske, 2016).
The nursing process is a straightforward recurrent model that comprises of five important concepts of nursing: assessment, diagnosis, planning, implementation, and evaluation. The key consideration of the nursing process is that it focuses first on the patient and later considers the care that is required rather than considering what care the patient needs before looking at the patient and the implementation of the care plan. The emphasis of the nursing process is on patient assessment. The rationale is to encourage nurses to collaborate with patients in identifying potential and actual health problems.
Holistic assessment is considered as the first stage in nursing care. This process commenced by gathering vital information about the patient’s past medical history that enhanced nursing diagnosis and decision-making about appropriate interventions. During the assessment, I introduced myself and asked the patient how he would like to be addressed, and he responded by saying his name. Effective communication was used all through the process. Confidentiality was enhanced by closing the clinical room door. The Nursing Midwifery Council (NMC, 2015) states that the care of people is of paramount, treating them as individuals and giving credence to their dignity.
Consequently, the patient’s consent was gained even before the commencement of personal contact. Service procedures were clarified to him as the nurse accessed his physiological, psychological and emotional conditions by asking him if he was comfortable and required any further clarification. In responding, the patient queried the extent of time required for the ulcer on his leg to heal. I observed that he was anxious and bothered concerning his current predicament but tried to dissuade his fears intimating him on the solution to his situation. I then asked if he would like to have something of drink. This approach was necessary because NMC (2014) stipulates the protection, promotion of the health and wellbeing of those in your care, their families and carers. When the patient was asked what happened, he said that it was painless and he could recall no precipitating trauma, only becoming aware of the ulcers when he noticed fluid on the floor where he had been walking barefoot. The patient had a long history of obesity, hypertension, diabetes and chronic sub-optimal diabetes control HbA1c of 15.3%.
I noticed that the fluid was an exudate from the ulcers, and a diabetic foot screen identified the presence of sensory neuropathy in both feet. Dorsal pedal and posterior tibial pulses were detected using a hand-held Doppler. The pulses were bounding, suggesting arteriovenous shunting and autonomic neuropathy. Other systemic effects of autonomic neuropathy were evident because the patient had a history of gastroparesis (failure of the stomach to empty as a result of decreased gastric motility), postural hypotension and dry, non-sweating skin on his feet. The ulcers appeared to be superficial and infected. Therefore they were classed as grade one (Davis & Mclister, 2016). Microbiology swabs were obtained and showed moderate numbers of meticillin-resistant Staphylococcus aureus. The nurse measured and took pictures of ulcer according to local policy.
Nursing diagnosis according to Carpenito-Moyet (2009), is a clinical judgment about an individual, community or family reaction to actual or potential health challenges. This means that potential and actual problems are acknowledged and labeled in the nursing diagnosis. After the investigation, the patient was diagnosed with neuropathic foot ulcer which is a damage of nerve fibers in people with diabetes (Gérard 2013). The North American Nursing Diagnosis Association (2009), highlighted that a nursing diagnosis is usually referred to as an identification of a problem. This phase of the nursing process is implicitly used to identify and address patients' needs.
Generally, planning nursing care involves setting goals that set standards in care evaluation. These goals may be adapted post nursing intervention implementation. Some factors such as the culture of nursing, the context or the patient, may influence modification of the process after a while. The plan was to decrease pressure on the wound edges in addition to the reduction of bacterial load. The care was planned to cover a period of 2 to 4 weeks so that all the clinical signs of the infection were treated. The dressing of patient’s wounds was also planned.
During the Implementation stage, I used an appropriate course of antibiotics which was prescribed by the doctor. I administered the antibiotics to the patient according to the guideline of the National Institute for Health and Care Excellence (NICE, 2015) and local policy. A blend of autolytic and sharp debridement was decided to be the most suitable procedure for eliminating necrotic tissues and slough from the location of the sore. The relevance of debridement was to help define the severity of an ulcer as well as decrease pressure on the wound edges in addition to the reduction of bacterial load (Haycocks & Chadwick, 2012). A report also suggests that regular sharp debridement is required to accelerate wound healing (Brown, 2013). However, there seems to be no indication that one method of debridement is more practicable than any other (Haycocks & Chadwick, 2012).
In addition, the patient's wounds were dressed every two days by deploying a hydro fiber dressing containing silver since there was observable evidence of ongoing wound infection, in addition to odor, copious, exudate and heat, redness (Haycocks & Chadwick, 2012. The justification for this treatment method was that silver kills a wide-range of wound bacteria, thereby stimulating an antimicrobial environment (Brown, 2013). The hydro fiber element of the dressing absorbs copious quantities of wound exudate and bacteria thereby creating a soft, cohesive gel that conforms easily to the wound surface, enabling a moist wound healing environment to be maintained which is required for the removal of slough (Brown, 2013). The treatment continued over a period of two weeks until clinical signs of infection were treated.
Because the ulcer was no longer clinically infected, the dressing was swapped with a hydro fiber dressing which does not have silver so as to aid autolytic debridement without damaging newly formed tissue, as well as to maintain a moist wound environment which enhances healing (Chardwick &Maccardle, 2016). The patient was recommended and supplied with an off-loading shoe and was further advised to keep his feet dry and bearing only minimal weight. He was then reviewed jointly by the podiatrist and diabetes specialist nurse so as to optimize his diabetic control in conjunction with treatment. It was observed that total ulcer healing took place in six weeks.
Constant medical check-ups were done periodically in the diabetic clinic by diabetology consultants, specialist nurse, and dietitians so as to address modifiable risk factors and enhance concordance with treatment. The nurse ensured a comprehensive wound evaluation, frequent follow up with the podiatrist involving close foot inspection and screening with the aid of the diabetic foot screening tool NICE (2015), treatment of callus and nail pathologies, as well as provision of off-loading insoles and specialist foot wear (Jarret, 2013 ) was carried out.
During the initial assessment the ulcer was first classed as active foot disease; at the point of healing, it was re-classified as being at high risk of developing serious foot complications and was managed according to national guidelines (NICE, 2010).
Furthermore, the patient was provided with written and verbal information on the importance of carrying out checks on their feet daily. He was advised to watch out for signs such as abnormality in his legs. The rational is because the presence of neuropathy is usually not taken serious, reinforcing the idea that the absence of pain can still be problematic. The nurse demonstrated that therapeutic communication was used to gather information on the patient's diet. The wife mentioned that the husband does not comply with his diet due to his cultural food. This was resolved by the nurse. Broome (2006), emphasizes that competent nurse must develop cultural sensitivity, by being aware and utilizing matter related to culture and ethnicity to respond and improve the situation. Also, the patient was given an emergency contact number for diabetic foot clinics. Jarret (2013), contends that providing patients emergency number to contact in case of emergency is crucial for patient safety.
The patient needs were met in that the patient was able to attain a decreased pressure on the wound edges in addition to the reduction of bacterial load. The needs were met since the care considered activities of daily living during planning on how the patient was going to cope with his mobility and treatment; the Roper, Logan, and Tierney model. The Roper, Logan & Tierney (2000) is a nursing model that discuss the activities of daily living. It is one of the frequently used nursing models in assessment and admission documentation. The activities of daily living model aim to promote maximum independence through a holistic assessment which will lead to suitable intervention to support independence in those areas that may be impossible or difficult to be carried out by the individuals themselves. The application of this model of this model centers around patient's involvement not only on admission but also as an approach to challenges they face and their resolution. It also acts as a yardstick on how the patient could be supported to learn about their problems, cope, adjust and improve the health challenges they may be facing. This model is used as a cognitive approach to assess and plan care for patients. The use of this model means nurses must deepen their knowledge and understanding as such a widespread tool requires competence in its application. There is also a nursing model that emphasizes on the significance of therapeutic relationships (king, 1981). This model centers on the ability of humans to engage in meaningful interaction directed towards a common goal. The importance of good communication skills to build beneficial interactions which will allow care goals to be attainable instead of a checklist that covers some aspects of patient assessment has been identified (king, 1981).
Also, Neuman and Fawcett (2012) developed a nursing model that considers a person as having important resources with lines of defence or resistance that changes due to socio-cultural, physiological psychological, developmental and spiritual variables. This model suggests that if a person experiences extremes of any of this variables, resisting their effects may be difficult and this can lead to the person experiencing ill-health. For instance, the patient having a supportive family, and with an effective relationship with the nurse is likely to recover quickly from a leg ulcer than a patient with no support. Each of these models has specific relevant aspects of care. This means that a combination of selective aspects of each of the model will help the nurse to provide holistic and context specific care plan. For instance, a care plan that incorporates aspects of Roper-Tierney-Logan, Neuman, and King may provide a holistic and comprehensive care plan that considers an assessment of the patient’s physical symptoms, setting goals for the patient and initiating a therapeutic relationship to promote suitable intervention and further assessment if required. Even though these models have long existed in nursing practice, they are still debated. Bakker & Mau (2012) argues that incorporating the opinions of a partner in care is paramount when developing nursing models as it best reflects professional nursing practice. This brings to light an approach that encourages the consultation of both the patient and multidisciplinary team when developing nursing models.
The patient was suffering from Diabetes type 2. It is a metabolic disease characterized by chronic hyperglycaemia and long-term disturbances in carbohydrate, lipid, and protein metabolism inducing chronic progressive dysfunction and failure of visual, nervous, renal, cardiac, and blood vascular systems. The care plan was centered on addressing the development of an infected foot ulcer on the plantar part of the patient's left foot. The condition was caused by pressure build up due to insufficient offloading of the area and worsened by over-exuberant debridement of callus.
Agreeing on a care plan is the major thread of chronic disease management. A comprehensive care plan allows service users to be proactive so as to ensure their needs are met. The patient was made aware of the positive impact of normal blood glucose, undertaking exercise, taking his prescribed medication and living a healthy lifestyle through health education. The patient’s family was also involved in the process as appropriate. By educating the patient and his wife about their health condition and the ways to prevent further complication resulting to the better outcome being achieved, reduce GP appointments and emergency admission. Also, planning ahead of the crisis and whom to contact is a way of limiting unplanned admission. Educating patients on how to self-manage their condition will reduce disease progression (Mostrom & Blumberg, 2012). This is beneficial to the service users, public and the NHS as a better quality of care will be experienced, job satisfaction will be increased, and savings will be efficient.
In summary, it is worth noting that the provision of holistic care is underpinned by a comprehensive nursing care plans. The care planning process is paramount to person-centered care, and as it allows nursing staff to put in place appropriate intervention and work collaboratively with other healthcare professionals, patients and relatives achieve a better outcome thus improving the quality of life. Diabetes self-management minimizes complications and gives the affected individual better understanding of their medical status thus promoting patient outcome. For type 2 diabetes glucose control remains the main emphasis of self- A care plan is a process of planning care to meet the needs of a patient management. Lifestyle modification such as healthy diet and exercise and some other life adjustments such as quitting smoking, in combination with medication is also known to be beneficial (Colbert et al., 2012). The patient was educated on self-management and the need for behavioral change such as healthy diet eating, physical exercise at least 30mins every day, wearing appropriate foot wear and care, keeping medical appointments and reviews, sticking to the medication regime.
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