This study will focus on the causes and effects of the long term condition type 2 diabetes. How the condition is diagnosed will be explored along with different treatments and the impact treatments may have on the patient. As well as this psychosocial impacts of type 2 diabetes will be explored, in relation to the patient's family and friends. In agreement with the Nursing and Midwifery Council, (NMC) Code of Professional Conduct (NMC, 2005) concerning safeguarding patients, no actual names or places will be revealed. This is why the named patient will be known as Megan.
The patient being described is a seventy year old lady who lives in a flat in the city centre with her husband Ron. Megan has had type 2 diabetes for 15 years, which has been poorly controlled by medication and diet. Megan's diabetes has now progressively worsened and she has been commenced on a self-managed insulin therapy plan. As well as care from her husband Ron, Megan is also registered with the community nursing team and her local general practitioner and she attends a regular diabetic clinic. Megan has recently suffered a hypoglycaemic attack during a shopping trip, and received treatment in hospital. Megan responded to treatment but was admitted due to a high temperature.
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Diabetes Mellitus has two principle classes, type 1 and type 2; approximately 90% of people with diabetes suffer from type 2, (Burden 2003a). Type 1 diabetes is characterised by the destruction of the Beta cells. The islets of Langerhans within the pancreas contain two types of cells, alpha cells and beta cells. Alpha cell secrete glucagon and beta cells secrete insulin. Patients with type 1 diabetes do not have this insulin production often due to the destruction of the beta cells. Type 1 diabetes is therefore treated with insulin. Type 1 diabetes is a catabolic disorder characterised by a lack of insulin, raised blood glucose levels and a breakdown of body fats and proteins. The lack of insulin in the body of type 1 patients means they are prone to the development of Ketoacidosis, (Porth, 2002).
Type 2 diabetes usually develops when the body no longer produces adequate insulin or when the body resists insulin action. The resistance to the insulin stimulates further insulin secretion from the beta cells to overcome the demand to maintain a normoglycemic state. Over time the response from the beta cells decline due to exhaustion. Type 2 usually occurs in the over 40's and is initially diet and exercise controlled, however, due to the decline in insulin production the patient may eventually need insulin therapy. The insulin resistance has been attributed to increased intra-abdominal fat; approximately 80% of type 2 sufferers are overweight. Obese people have an increased resistance to insulin action and an impaited suppression of glucose production, (Porth, 2002). The initial approach to the treatment of type 2 diabetes should take into account the underlying pathophysiology of the disorder and target a reduction in insulin resistance through modification of causative lifestyle habits, along with pharmacologie intervention, (Roman, R et al 2008).
The signs and symptoms of diabetes appear more rapidly in type 1; type 2 may go undiagnosed for some time due to the slow onset, (Diabetes UK, 2000). The most common signs and symptoms of the disease are; glucosuria, polydipsia (exsessive thirst), polyuria (passing excessive urine), infections, weight loss, muscle cramps, lethargy, visual disturbances and ketoacidosis may be present, (Burden, 2003a).
Hypoglycaemic attacks such as Megans can occur in both type 1 and type 2 diabetes. Hypoglycaemia occurs when the blood glucose levels fall below 3.5mmol/L however symptoms rarely appear until levels drop below 3mmol/L. The three main causes of hypoglycaemia are; excessive insulin, insufficient food and unusual exercise. Symptoms rapidly develop usually taking between 5-15 minutes, (Alexander, Fawcett and Runciman, 2002). Signs and symptoms which accompany hypoglycaemia are sweating, confusion, headache, nausea, rapid pulse and trembling. These are described as being neuroglycopenic, characterised by an impaired cognitive function, unusual or aggressive behaviour, or they can be adrenergic involving the sympathetic and parasympathetic systems, (Burden, 2003b).
The nursing process is based upon individual nursing. In previous years nurses were allocated tasks, rather than patients to care for. The importance of patient centred care is now recognised and nurses are allocated patients rather than jobs (Roper, Logan and Tierney, 1996). The nursing process has a series of 4 interactive phases . The first phase is accessing which is carried out at the start of treatment but important to remember continued assessment as the treatment or illness may progress. The second phase is planning, the aims are to prevent previously identified problems progressing to actual problems. This improves the problems that cannot be solved and prevents a treated problem from reoccurring. To achieve these objectives goals need to be set in collaboration with the patient and their family. In the case of the patient being incapacitated the family or next of kin would usually make these decisions. These goals should be built into a nursing care plan. The third phase is implementing the care aims. Nursing interventions are carried out as part of this; it is helpful and necessary for nurses to make clear the reasons and decisions that lay behind these interventions. The fourth phase is evaluation, which is similar to assessment. The idea is to ascertain whether or not the goals have been achieved or are being achieved. This provides footing for further assessment and planning, for example, if the goal has not been achieved the reason why is explored (Roper et al, 1996).
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The Roper, Logan and Tierney model of nursing is called the Activities of Living in which there are 12 activities, (Appendix 1). The Activities of living model is very diverse and it is debated it is the most common used by british nurses, (Gray, 2002). Models have been criticised for not accommodating all patient situations and being too rigid. Walsh (1998) states that "Models are not set in tablets of stone, but rather are loose frameworks of ideas whose aim is to facilitate care, not to get in the way", (Walsh, 1998). Walsh (1998) emphasises that readers should question any lack of psychological and social dimensions of the Roper, Logan and Tierney model and suggests that is a simplistic approach to assessment (Walsh, 1998). However Roper, Logan and Tierney break down the factors influencing the activities of living into five categories: biological, psychological, sociocultural, environmental and politicoeconomic, (Roper et al, 1996).
Maintaining a Safe Environment
Megan is an independent lady and should be aware of all the factors influencing her external environment, however due to her aging Megan has found she is becoming more dependent on others to assist her in keeping a safe environment. One factor which could affect Megan's safety could be diplopia, this is a symptom caused by her diabetes which may make her vision blurred. When Megan suffers from a hypoglycaemic attack and becomes confused she is at her most vulnerable stage, which means the need for others to be aware of her situation is essential. In this instance Megan remains conscious throughout the attack, however unconsciousness is a major risk factor, as this would make Megan completely dependent. Once admitted to hospital Megan would need to be assessed on her absolity to maintain a safe environment, and safety problems that arise should be addressed (Roper et al, 1996).
Megan has no day to day difficulties with effective communication, however there are several factors which have affected her communication during her hypoglycaemic attack and during her hospital stay. Hypoglycaemic attacks can cause ineffective communication due to the neuroglycopenic symptoms of slurred speech and tingling around the lips (Alexander, et al 2002). Megan also confined that she was embarrassed due to her confusion after the attack and explained it left her feeling self-conscious. Megan therefore felt vulnerable, worried and confused. Roper (1996) believes this could lead to unwillingness to communicate to staff and other patients, (Roper et al, 1996).
Megan is usually independent with her breathing, however when she suffered from her hypoglycaemic attack her breathing was disturbed. This lead to the district nurse monitoring Megan's respirations, pulse, temperature and blood pressure. If Megan had not received immediate treatment from the district nurse she may have become unconscious and her breathing would have become shallow. Once Megan was admitted to hospital her respirations were monitored and her position was suited to her comfort and she was sat upright with ensured her breathing was not an issue.
Eating and Drinking
Until recently Megan's diabetes had been controlled by diet and medication, however as this was no longer giving sufficient control Megan was commenced on insulin. Megan explained that her dietary intake has been poor due to skipped meals, this was concluded as the cause of her hypoglycaemic attack. Staff nurses carried out a blood sugar analysis and recognised a low blood sugar level and then administered a quick acting carbohydrate. In situations where medical staff are not available things such as sugary sweets or drinks can be used as a hypostop. On admission to hospital Megan's eating and drinking habits were assessed by a dietician. Help and support is needed from all nurses and doctors to achieve a balance between diet, exercise, blood sugar monitoring and insulin administration. Patients need to be educated so it is possible for them to lead a normal life, (Roper et al, 1996).
Megan usually has no problems eliminating however her diabetes has caused polyuria due to the concentration of glucose in the glomerular filtrate, (Walsh, 2002). There is a possibility of incontinence during a hypoglycaemic attack which is why a urinalysis should be carried out on admission to hospital. It is essential patients know the location of the toilets. It was necessary to offer Megan a commode as she felt unable to walk to the toilet during some points, (Roper et al, 1996).
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Personal Cleansing and Dressing
Megan currently has no problems with her cleansing and dressing but her increasing age and frailty may make some aspects of this difficult. In hospital Megan felt it was important that she continued with her normal routine and that she looks and feels as good as she usually does. The nurses on the ward therefore encouraged this and made the available privacy she needed.
Controlling Body Temperature
Megan was found suffering from pyrexia after her attack, possible due to the cold she was suffering from. Megan was therefore encouraged to cool down by shedding outer layers and using a fan. It was important to Megan that she felt comfortable and not too hot or cold. During her hospital stay Megan's temperature was monitored.
During Megan's hypoglycaemic attack she was unable to mobilise due to the neuroglycopenic symptoms she experienced (dizziness and unsteadiness). Occasionally muscle twitching and seizures may occur (Alexander et al, 2002). Megan's safety should be a priority during these attacks. Megan was able to gain her mobility independently during her hospital stay.
Working and Social Life
Megan is retired however she still lives independently with her husband in their home. Megan also has two adult children and four grandchildren. Megan feels her diabetes adversely affects her ability to have an active social life. A diabetes specialist has therefore been assigned to Megan which will enable her to explore different ways to enjoy social activities such as eating out. The British Diabetic Association therefore emphasises patient education is essential (British Diabetic Association).
During her stay in hospital, Megan has found she is a sufferer from polyuria which could lead to a problem with nocturia; this could affect the amount and quality of sleep she gets. Megan was informed about sleep promotion during her stay in hospital as it influences an individual's physical and psychological well-being. Megan reported that the hospital environment affected her sleep due to the change in lighting, ventilation, noises and bedding. Patients should be encouraged to go to bed and wake up at their normal times, however this may not be possible due to ward routine, (Humm, 2001).
Reoccurring hypoglycaemic attacks may result in death although this is rare it is still important that Megan's diabetes is managed appropriately. (Scottish Executive, 2002). The most common cause of death in diabetes is coronary heart disease, the mortality being doubled for individuals with diabetes, (Burden 2003). Megan wished to discuss her fears about death which meant nurses were prepared to discuss this with her and her family.
Epidemiology, Policies and Health Promotion
The World Health Organisation (WHO) found that in 2009 over a million people in the UK suffered from diabetes (World health organisation 2011). As previously discussed 80% of type 2 diabetes sufferers are overweight. The initial control of diabetes through diet and exercise is paramount. Health professionals can give advice on this and there are many health initiatives run throughout the country to help. Two local initiatives are the Food co-op Network North-east and the Walk to Health. The food co-op network provides fresh fruit, vegetables and other healthy foods. The aim is to supply these foods to people at reasonable prices to promote and encourage healthy eating. The Walk to Health initiative is run from many hospitals and health centres. Patients are given packs containing maps of pre-planned routes between 1-8 miles long, the walks are safe and many can accommodate prams and pushchairs. They also give advice on safety and levels of fitness and have a diary for people to record their progress, (Health Promotions, 2003). All health professionals should be aware of such initiatives run in their area so they can help and encourage their patients to participate and improve their health.