A long term condition (LTC) is defined as an incurable syndrome. However, some LTC can be managed through medication (Goodwin et al 2010) whereas for others, it can be managed by healthcare providers facilitating health promotional support to patients in order to self-manage their conditions effectively (examples, maintaining healthy diet and physical activities) (Hutchison & Breckon 2011). Additionally, for this assignment I will use a case study to discuss my experience about caring for a patient with type 2 diabetes in the hospital. The discussion will include the identified problems to support patients’ needs, the nurses’ contributions to promote patients’ health and well-being as well as the benefits of working alongside with a multidisciplinary team.
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According to Goodwin et al (2010) type 2 diabetes is also known as insulin resistance. The syndrome is when an individual body lacks the ability to produce sufficient insulin or the body is incapable of controlling enough blood glucose level. It is categorised as a LTC because it is incurable. Nonetheless, it can be managed depending on the individual’s conditions needs such as healthy food and regular activities, or a combination of medications and a healthy lifestyle (Diabetes UK 2012).
According to Nursing and Midwifery Council (NMC 2010) Guidance on Professional Conduct, the patient’s identity will be maintained confidential and an anonymous name (Jane) will be used. Jane 65, who has had type 2 diabetes for about two years, was suffering from kyphosis on her back. As she has not been on pharmaceutics’ therapy since her diagnosis, she was advised to maintain her weight within an ideal range. However, Jane has not been able to gain control over her weight (73 kg). She lives alone and has no close family members but she has a good relationship with her neighbours and friends. I met Jane while on placement on an aging admission ward. She was admitted via Accident and Emergency department (A&E) to an elderly ward referred by her General Practice (GP) with elevated blood glucose (11.5mmol) which was making her feel weak and was also giving her severe headaches, tiredness and recent weight gain (73.6kg). While she was admitted to A&E, her hyperglycaemia was stabilised with a dosage of metformin (500mg) (8.0mmols) prior to her transfer from A&E to the elderly ward.
Bakris (2011) suggested that nurses should carry out a comprehensive assessment on patients with type 2 diabetes as this will support the nurse to identify and address issues that can prevent and reduce problems that may affect the patients with type 2diabetes. Diabetes UK (2012), also recommended that a patient’s risk can be recognised if healthcare professionals could aid an in-depth assessment. This includes; blood glucose level, Hba1c, blood pressure, cholesterol, Body Mass Index (BMI) and waist circumference. The rationale behind the assessment is to support healthcare professionals to make an appropriate individualised care plan considering the patient’s preference (Diabetes UK 2012).
To classify any interrelated problem, the nursing assessment was to look at Jane’s medical history before the admission and to observe what her current condition looked like. The nurse along with the author admitted Jane and prior to carrying out the assessment they introduced themselves to the patient. To obtain Jane’s consent, a full detail of the information about the process was explained to her (Nursing and Midwifery Council 2010). Jane’s vital signs presented a blood pressure of 138/80 mmHg, heart rate 84, respiratory rate 16 and temperature 36 degree centigrade. While examining Jane’s nutritional assessment, her MUST stool height was (1.62cm), weight 73.6kg, and waist circumference 88cm. It was identified that she had a BMI of 27 giving her a score (0). In addition to Jane’s assessment, her fasting glucose level was stable 6-7 mmol/litre her foot showed normal to sensation, no sign of lesions on toenails and skin.
From Jane’s screening, the underlying cause for Jane’s hyperglycaemia is an increased BMI 27, this indicates overweight as (British Association for Parenteral and Enteral Nutrition 2010) recognised. Overweight is when an individual has more fat than normal in their body. However, an athlete with muscle mass or someone with swollen legs (oedema) could be overweight due to an increase in BMI (Heath & Sturdy 2009). According to Nazarko (2008) an individual with a BMI 25-30 is considered to be overweight. BMI is the most common evidence-based tool used to analyse normal weight, overweight or obese in hospital when patients come for admission. It is calculated by dividing an individual’s body weight kilogram by the square of body height (NICE 2006). Waist circumference is also a reliable tool used to recognise overweight and obesity as it provides information with regards to the distribution of excess body fat in a person’s abdomen (NICE 2006).
Nevertheless, BMI has some weakness; it is not suitable for individuals with excess body fat or muscle mass as it does not differentiate between excess body fat and muscle mass (Heath & Sturdy 2009). Diabetes UK (2012) argued that using BMI alone to calculate a patient’s height and weight would not identify overweight or obesity. However, the combination of BMI and waist circumference will help classify an overweight or obese person, and for this reason Jane’s waist circumference was measured because it is the best way to measure abdominal fat distributed around her waist as suggested by Diabetes UK (2012).
Regardless BMI and waist circumference screening tool was used to classify Janes’ overweight, however, according to Ashwell et al (2012) studies have proved waist to height ratio screening tool a better way of identifying overweight or obesity in adult than BMI and waist circumference. As a result nurses should consider using waist to height ratio as a screening tool to recognize overweight or obese patients with diabetes. This is because the tool measures the ratio of an individual waist to his or her height (Ashwell et al 2012).
Jane’s height and weight was measured using stadiometer and clinical scale, nevertheless, the use of stadiometer to measure Jane’s height was comparatively weak (BAPEN 2010). Jane is a 65 year old woman with a small kyphosis on her back and according to Hirani & Aresu (2012) the result for an elderly with this condition may impair their actual height resulting to false reading. This is because some people grow older with distort height like kyphosis, this as such will result in the individual to losing his or her real height. Kyphosis is a deformity of an individual’s back which can lead to hunched back due to a deviation of a spinal curvature from its normal shape (Kado et al 2013). Therefore the use of demispan measure tool could be an evidence based practice to consider when a patient’s actual height is distorted. As a result this might have worked for Jane as she has a small kyphosis on her back and the NMC (2010) emphasized that nurses should use their clinical knowledge, skills and judgement to classify factors that could impair individual’s height.
Consequently, Jane’s hypoglycaemia is partly dependant on her overweight; therefore the main nursing intervention that needs to be targeted is Jane’s weight loss as it will lead to long term benefit for her. This is because overweight can cause hypoglycaemia, overweight is also associated to inadequate exercise and unhealthy eating behaviours considered to be primary factors contributing in the rising prevalence of type 2 diabetes and if not well managed, it could also lead to other complications such as obesity, heart attack or stroke (Diabetes UK 2012). As a result an effective weight management can improve Jane’s wellbeing using nursing problem solving approach.
According to Barrett et al (2010) nursing problem solving approach is about understanding the individual as a whole person. Therefore, using the problem solving approach means nurses have to link the individual’s illness to factors that could affect their disease. These involve psychological, emotional, social environment, spiritual and time and if there’s any of these identified then it should be addressed as they form part of the individual’s well-being (Wade 2009).
Knol et al (2006) states depression is common in people suffering from type 2 diabetes. Knol et al (2006) also recognised that thirty seven percent of those people with a medical history of depression are prone to have type 2 diabetes. Evidently, Jane during her initial assessment mentioned that she had little knowledge on dietary due to lack of motivation and her dietary history reveals having unhealthy food such as ready meals and dessert while away with friends. Consequently, this has had an impact on her psychological wellbeing. She also recognised excesses carbohydrate intake and her normal dinner meals consist of pasta whereas during the day she often has rice with homemade sauce as well as walking exercise 10-15 minutes twice in a week.
However, the nursing team worked with Jane to determine if Jane’s overweight was caused by her not complying with her dietary advice, as a result she agreed that a referral to a dietician and diabetes specialist nurse was her concern and this was made to deliver meal plan as well as maintain her physical activity. This is the best practice as suggested by NMC (2006) that nurses must work together with their patient to ascertain the patient’s understanding about risk associated with overweight. This is because if Jane’s food pattern is left unattended it may lead to further ill health problems such as obesity, stroke and heart disease (Thomas 2008). The United Kingdom Progressive Diabetes Study (UKPDS 1990) recognised the majority of people with type 2 diabetes have ill health complications associated with their long term condition.
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In addition to this, the role of the dietician is to identify problems relating to an individual’s nutritional status and once identified the dietician working in partnership with the individual will then formulate meal plan that adapt to the person’s needs and preferences (British Dietetic Association 2012). Department of Health (2005) emphasised that nurses should empower patients with long term condition so that the individual is capable to manage and live with their disease effectively. NICE (2008) also suggested this method of approach as the best practice as it helps the individuals to manage their condition.
According to Thomas (2008) weight loss through dietary can be defined as a reduction of less food intake to that of the energy used by an individual. Therefore the dietician along with the nursing team main target was how Jane would lose weight through dietary behaviour change and in order to achieve this she was seen a day after her admission. The initial approach considered was the motivational interview based on providing a solution to a suitable diet. Motivational interviewing is a collaborative patient centred approach in a form of supporting a person’s motivation to encourage and empower patients’ behaviour change (Resnicow & Mcmaster 2012). This is to maintain the patient’s autonomy based on his or her needs for their condition and that any decision made is eventually up to the patient (Resnicow & Mcmaster 2012).
Jane agreed having a motivational interview and had the opportunity to discuss her dietary plan with the main focus on the types of food she likes as mentioned above. In order for Jane to have an appropriate balance diet, the dietician and the nursing team worked with Jane by setting a realistic goal. This is because for an individual to lose weight involves time and encouragement to achieve his or her goals effectively and therefore the best practice is setting an appropriate goal that suits Jane (Thomas 2008). It was difficult to set a short term goal for Jane as she was unable to maintain weight loss due to lack of motivation and therefore a long term goal was set with smaller intake of caloric food so that Jane could gradually lose weight and also improve her glycaemic control (Diabetes UK 2012).
Jane was offered the importance to a strict diet and she was provided food such as fish, vegetables, low starchy food per day; a reduction of low sugary food was put in place. She was also encouraged to drink two litres of water daily. Her daily food intake was recorded to meet her dietary care plan needs as (Lang & Froelicher 2006) recommended. Moreover, Jane during her admission was subjected to weight monitoring and repeating her ‘MUST’ screening progress for any changes in her BMI (BAPEN 2010).
Jane following a regular monitoring, on her fifth day on admission was still considered overweight; however, evidence shows a minimal improvement of 900gms weight loss. A risk of any physical complications of diabetes was low and no episode of hyperglycaemia. Her symptom of severe headaches and tiredness was now resolved and she was more excited to go home.
Following Jane’s outcome of her dietary care plan, if Jane can be convinced to increase her physical activity her need for hypoglycaemic drug will be minimised. This is because the combination of dietary and an increase in physical activity on a regular basis is recommended to be more effective for an individual to achieve weight loss in a long term goal (NICE 2006). As such Jane’s care plan was reviewed with the nursing team prior to discharge and from her assessment it was recognised that she does not need a psychological referral but to improve her knowledge with regard to her type 2 diabetes so that she can self-manage her diabetes successfully.
Even though Jane was suffering from kyphosis, physically she was fit to increase her physical activity and following the discussion how significantly an increase in exercise can have positive effect on glucose management, Jane agreed to walk each day in the mornings 20 – 25 minutes.
After reviewing Jane’s dietary and physical options, a discussion about the need to continue metformin helped to improve her glycaemic control; therefore she was prescribed 500 mg twice a day. Metformin is an oral drug to lower glucose level in the blood. Jane will benefit from taking metformin as it is associated to weight loss this will prevent her from gaining more weight (NICE 2009). Other oral anti-diabetic agent such as thiazolidinedious and sulphonyureas were not recommended due to an increase of body weight caused by these agents.
Prior to discharge Jane was informed about the importance of community nurse. The nursing team liaised with the community nurse for a regular monitoring of Jane’s glucose level as well as her weight. NMC (2010) highlighted that consent must be given to Jane before involving a community nurse thus it is the right of an individual to confidentiality and consequently is a must for a nurse to respect this.
To sum up, Jane’s dietary plan did not make much significant changes in her weight, however, on discharge she was educated to continue recording her daily food and drinks intake, regular exercise, to closely monitor glucose level for symptoms of hyperglycaemic or hypoglycaemia. Further information about getting support from educational programme such as DESMOND was discussed with Jane. She was also given information leaflets which were easy to read as supporting interventions to help increase her knowledge about how to self-manage her diet.
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