Discussing a patient with type 2 Diabetes Mellitus.
Introduction
The author of this essay will be discussing a patient with type 2 Diabetes Mellitus and will also be discussing the nursing care that will be received by the patient following a hypoglycaemic attack.
The patient being described is a fictitious seventy year old lady called Mabel Gordon; she lives in a flat in a city centre with her husband Bert. Mabel has had type 2 diabetes for years which has been poorly controlled by medication and diet. Mabel's diabetes has now progressively worsened; she has been commenced on a self-managed insulin therapy plan. She is cared for by the community nursing team and her GP; she attends the regular diabetic clinic. Mabel has no other medical conditions but is currently suffering a cold. On a trip to the chemists Mabel feels unwell, clammy, trembling and confused; the chemist calls Bert and the district nurse. On her arrival the district nurse treats Mabel for a hypoglycaemic attack, to which Mabel responds, but is concerned about Mabel's high temperature, she arranges for Mabel to be admitted to hospital.
Aetiology and Pathophysiology
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 cells secrete glucagons and Beta cells secrete insulin hormone. 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, (insulin was discovered in 1922 by Banting and Best). 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. This resistance to 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 declines 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 impaired suppression of glucose production, (Porth, 2002).
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 diabetes are; glucosuria, polydipsia (excessive thirst), polyuria (passing excessive urine), infections, weight loss, muscle cramps, lethargy, visual disturbances and ketoacidosis may be present, (Burden, 2003a).
Hypoglycaemic attack's such as Mabel's can occur in type 1 or 2 diabetes. Hypoglycaemia occurs when the blood glucose level falls below 3.5mmol/L however symptoms rarely appear until this level drops below 3mmol/L, the three main causes of hypoglycaemia are; excessive insulin, insufficient food and unusual exercise. Symptoms develop rapidly, usually taking 5-15 minutes, (Alexander, Fawcett and Runciman, 2002). Some of the signs and symptoms 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).
Nursing Process
The nursing process is all about individualising nursing. In previous years nurses were allocated tasks to do 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 is a series of four interactive phases. Roper, Logan and Tierney (1996) state that "the process is neither a model nor a philosophy but simply a method of logical thinking and it needs to be used with an explicit nursing model" (Roper et al, 1996, p51).
The first phase of the process, assessing, is carried out at the start but it is important to remember continued assessment as the treatment or illness progresses. Assessment is done by collecting information from or about the patient, observing and questioning, this is called subjective information. Objective information ...
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The nursing process is a series of four interactive phases. Roper, Logan and Tierney (1996) state that "the process is neither a model nor a philosophy but simply a method of logical thinking and it needs to be used with an explicit nursing model" (Roper et al, 1996, p51).
The first phase of the process, assessing, is carried out at the start but it is important to remember continued assessment as the treatment or illness progresses. Assessment is done by collecting information from or about the patient, observing and questioning, this is called subjective information. Objective information is gained by measuring and testing as appropriate. This is done in order to identify and prioritise patient problems.
The second phase is planning, the objectives are to prevent previously identified problems progressing to actual problems, solving the actual problems, alleviating the problems that cannot be solved and preventing a treated problem from reoccurring. To achieve these objectives goals need to be set in collaboration with the patient and/or their family, the goals should be achievable. These goals should be built into a nursing care plan.
The third phase, implementing, is the stage at which 'the wheels are put in motion' to work towards achieving the agreed goals. 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, evaluating, is carried out similarly to assessing. The idea is to ascertain whether or not the goals have been achieved or are being achieved. This provides the footing for further assessing and planning, for example, if the goal has not been achieved, Why not? (Roper et al, 1996).
Nursing Framework
The Roper, Logan and Tierney model of nursing is called the Activities of Living in which there are twelve activities, (Appendix 1). This model is a hugely diverse model and it is arguably the most commonly used model by British nurses, (Gray, 2002).
Models have been criticised for not accommodating all patient situations and being too rigid. The activities of living model has its own good points just like many others and it could be adapted to suit specific patients. 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, p26-27).
Walsh (1998) urges his readers to question any lack of psychological and social dimensions of the Roper, Logan and Tierney model and suggests that it is a rather 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
Mabel is an independent adult and should be aware of all the factors influencing her external environment, however, her ageing may mean she is becoming dependant on others to assist her to keep a safe environment. Her diabetes being a biological factor could give her blurred vision (diplopia) which could be a safety hazard. When Mabel suffers a hypoglycaemic attack and becomes confused she is at her most vulnerable stage, the need for others to be aware of this and assist Mabel is paramount. Although in this instance Mabel remains conscious throughout the attack unconsciousness is a risk, in the event of unconsciousness Mabel would slide from being independent to total dependency. Once admitted to hospital Mabel would need to be assessed on her ability to maintain a safe environment, and safety problems that arise should be addressed, (Roper et al, 1996).
Communicating
While Mabel has no day to day difficulties with effective communication there are several factors that may affect her communication during her hypoglycaemic attack and during her stay in hospital.
During Mabel's hypoglycaemic attack she may not have effective communication due to the neuroglycopenic symptoms of slurred speech and tingling around the lips, (Alexander et al, 2002). Also her confusion and her environment may lead her to have feelings of embarrassment and a loss of self confidence. During her admission to and stay in hospital Mabel may feel vulnerable, worried and confused; this could lead to unwillingness to communicate with staff and other patients, (Roper et al, 1996).
Breathing
The majority of people are independent in breathing from birth to death, (Roper et al, 1996). Mabel would usually be independent with her breathing however when she has the hypoglycaemic attack her breathing may be disturbed. The district nurse would monitor Mabel's respirations, pulse, temperature and blood pressure. If Mabel had not received immediate treatment from the district nurse she may have become unconscious and her breathing would have become shallow. Once in hospital Mabel's respirations should be monitored, her position in bed should be suited to her comfort and if sat upright her breathing should not trouble her.
Eating and Drinking
Until recently Mabel's diabetes had been controlled by diet and medication however this was no longer giving sufficient control and she was commenced on insulin. Recently Mabel has been unwell and her dietary intake has been poor with skipped meals, this was the main cause of her hypoglycaemic attack. The district nurse would carry out a blood sugar analysis and would recognise a low blood sugar level; the district nurse would then need to administer a quick acting carbohydrate. Things such as sugary sweets or drinks can be used as well as hypostop. On admission to hospital Mabel's eating and drinking habits would need to be assessed, this could be done by a dietician or a diabetes specialist nurse. 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).
Eliminating
Mabel normally has no problems eliminating however her diabetes may cause polyuria due to the concentration of glucose in the glomerular filtrate, (Walsh, 2002). There is a possibility of incontinence during a hypoglycaemic attack. Once admitted to hospital a urinalysis should be carried out. It is essential patients know the location of the toilets. It may be necessary to offer Mabel a commode if she feels unable to walk to the toilet, (Roper et al, 1996).
Personal Cleansing and Dressing
Mabel currently has no problems with her cleansing and dressing but increasing age and frailty may make some aspects of this more difficult for her. In hospital it will be important for Mabel to feel that she can continue her normal routine and that she looks and feels as good as normal. The nurses should encourage this and make available the privacy she needs, (Roper et al, 1996).
Controlling Body Temperature
During Mabel's hypoglycaemic attack the district nurse takes her temperature. Mabel has a high temperature (pyrexia), possibly due to her cold; she should be helped to cool down. This could be done by shedding outer layers of clothing, opening windows or using a fan. It is important that Mabel should feel comfortable, not too hot or too cold. In hospital Mabel's temperature should continue to be monitored and the reason behind it should be investigated, it may be necessary to administer antipyretic medication, (Roper et al, 1996).
Mobilizing
During Mabel's hypoglycaemic attack she may be unable to mobilize normally due to the neuroglycopenic symptoms she may experience; these could be dizziness and an unsteady gait. Occasionally muscle twitching and seizures may occur, (Alexander et al, 2002). Mabel's safety should be a priority during this. Once her hypoglycaemia is under control and she is admitted to hospital Mabel should be able to regain her independence in mobilizing.
Working and Playing
Mabel is retired although she still lives independently with her husband in their home. Mabel also has two grown-up children, and three grandchildren. Mabel may feel that her diabetes adversely affects her ability to have an active social life. A diabetes specialist could help Mabel to see that it is possible to enjoy social activities like eating out, this is why patient education is important, (British Diabetic Association).
Expressing Sexuality
Mabel is married to 69 year old Bert, it is common for sexuality to be passed over in regards to older people. However although sexual activity may decrease with age older people are still sexual beings. It is imperative for nurses to remember this and be prepared to discuss any sexual problems or worries Mabel may have. Administering injections to herself may make Mabel feel self conscious about her body and she may feel less attractive, (Roper et al, 1996).
Sleeping
People spend an average of 1/4 - ? of their lives asleep, (Roper et al, 1996). Mabel may suffer from polyuria which could also mean that she may have a problem with nocturia; this could affect the amount and quality of sleep she gets. Once in hospital it is vital to promote good sleep as this influences individuals physical and psychological well-being. The hospital environment may affect Mabel's sleep due to the change in lighting, ventilation and bedding. She should be encouraged to go to bed and wake up at her normal times although this may not be possible due to ward routine, (Humm, 2001).
Dying
This is the final activity of living; the only certain thing in life is eventual death.
Continual reoccurring hypoglycaemic attacks may result in death, although rare, hence the need for good diabetes management, (Scottish Executive, 2002). The most common cause of death in diabetes is coronary heart disease, the mortality rate being twice that for people without diabetes, (Burden, 2003c). Mabel may wish to discuss any fears and wishes she has about dying. Nurses would need to be prepared to discuss this with her and possibly her family, (Roper et al, 1996).
Epidemiology, Policies and Health Promotion
The World Health Organisation (WHO) found that in 2000 some 1804943 people in the UK suffered from diabetes, while the Grampian Health Board find that currently there are 11000 sufferers in Grampian, (World Health Organisation, 2003) and (Grampian Health Board, 2002).
The Scottish Executive working with NHS Scotland bought together a Scottish Diabetes Framework. This is designed as a starting point for addressing the increasing problem of diabetes in Scotland over the next ten years. It has specific targets for the first two - three years to work towards developing integrated, patient-centred diabetes services. The framework is recommended to be read and used in conjunction with the 'Management of Diabetes' guideline produced by SIGN, and with the Clinical Standards for Diabetes produced by the Clinical Standards Board for Scotland. Both these documents were published in November 2001. A model of diabetes care, consisting of twenty-two building blocks was developed by the Working Group. The framework identifies seven of these as first stage priorities, (Appendix 2), (Scottish Executive, 2002).
There is also a policy written on behalf of the Grampian Diabetes Integrated Care Steering Group called the Grampian Guidelines for the Management of Diabetes Mellitus. These were bought out in June 2000 with the aim of assisting health professionals involved in diabetes care to plan and implement local care plans. They were written by local healthcare professionals, the aim is to support local practice within Grampian. They set out guidelines for, the management of new diabetic patients, suggest education topics for patients, give targets for glycaemic control, give regular review schedules, management of diabetes emergences in the community and give guidance on eye screening, foot care, renal disease, cardiovascular disease and gestational diabetes. These will facilitate and ensure a common standard of care and provide guidance to the various support services available, (Grampian Diabetes Integrated Care Steering Group, 2000).
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.
Appendix
Appendix 1:
Roper, Logan and Tierney Activities of Living Model
: Maintaining a Safe Environment
2: Communicating
3: Breathing
4: Eating and Drinking
5: Eliminating
6: Personal Cleansing and Dressing
7: Controlling Body Temperature
8: Mobilizing
9: Working and Playing
0: Expressing Sexuality
1: Sleeping
2: Dying
(Roper, Logan, and Tierney, 1996, p35)
Appendix 2:
Seven first stage priorities:
• Patient information, Education and Empowerment.
• Heart Disease.
• Eye Care.
• Strategy, Leadership and team working.
• Education and Training for Professionals.
• IM & T and Diabetes Registers.
• Implementation and Monitoring.
(Scottish Executive, 2002, p6)
References
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Burden, M. (2003a). Diabetes: signs, symptoms and making a diagnosis. Nursing Times. Vol.99, No.01, p30
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Burden, M. (2003c). Diabetes: new treatments and guidance. Nursing Times. Vol.99, No.03, p30
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