Nursing management of a chronic illness - diabtetes type II

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The impact of diabetes mellitus is manifold and adapting to and managing diabetes has been described as a fine balancing act (Lubkin & Curtin, 1990). It involves balancing the demands of diabetes management with the desire to live a ‘normal’ life. This is an intricate process, requiring compromises between self-control and professional expertise. It is arguably the role of the nurse to strive to understand the complexity of this balance and to offer realistic advice, support and education that pertains to the individual and not just prescriptively to the illness. Person-centred care is currently one such approach and is certainly the buzzword of current literature (Paterson, 2001).

From a professional perspective it is imperative to examine the impact of diabetes mellitus, a condition that affects not only the individual but also their respective families. Diabetes is an all-encompassing condition and is one of the biggest health challenges of the twenty first century (Diabetes UK, 2011). Experts agree that the UK’s diabetes prevalence is on the increase and the impact of the condition is manifold (WHO, 2004). Despite recent strides in the self-management of diabetes, many sufferers do not achieve optimal outcomes and suffer devastating complications of macrovascular and microvascular disease (Kumar & Clark, 2002). Indeed, the list of complications is endless; sufferers are at risk of retinopathy, nephropathy, cardiovascular disease, erectile dysfunction and strokes. The consequences of such an illness therefore dictate a professional obligation to pursue further examination.

The motivation to scrutinize this subject from a personal perspective stems from a desire to understand the mismanagement of this condition. A gap currently exists between the promise and reality of diabetes care (Funnell, 2003). Current literature suggests that practice is the key to successful self management (Taylor & Bury, 2007). However, the reality is that many nurses fail to recognise this and subsequently fail to understand the sheer magnitude of the diabetes regime (Paterson, 2001). A lack of empathy with regards to the impracticalities of total adherence leads to goals that are prescriptive in nature. Consequently, a vast literature in non-compliance exists (Albright, 1994). It is therefore arguably the responsibility of the nurse to strive to understand and assist the patient to overcome the barriers faced by this chronic and debilitating condition.

A 76 year old gentleman with a 2 year history of diabetes mellitus type II presented to the emergency care centre (ECC) with a fractured right wrist. Mr Jones had fallen due to a suspected hypoglycaemic attack brought about by the mismanagement of his diabetes. On admittance to ECC, Mr Jones’ vital observations were taken and it was documented that he was tachycardic at 110bpm, had a raised blood pressure of 220/93 and was noticeably anxious. Conversations with his daughter ascertained that he managed his diabetes by administering insulin usually prior to meals. He took no oral medication for his diabetes such was the severity of hi diagnosis. She intimated that her father was very ‘hit and miss’ with his injection regime and with his glucose monitoring and that his ‘sweet tooth’ often ‘won the day’. She also stated that her father enjoyed his nightly brandies. Essentially, she felt he was uncomprehending of the serious nature of his condition.

Mr Jones was transferred to our rehabilitation ward after surgery on his wrist with the hope that re-enablement back into the community would eventually be feasible. We understood that Mr Jones currently lived in sheltered accommodation with a package that included twice daily carers and daily meals on wheels. His daughter visited him when she could but we were informed she was increasingly finding her father unable to cope at home. His co-morbidities included osteoporosis, rheumatoid arthritis and suspected retinopathy. His previous past medical history included four coronary artery bypass graphs, a bilateral orchiectomy, two myocardial infarctions and more recently a pacemaker had been put in-situ. He was taking over ten different types of medication as well as attempting to adhere to his daily insulin regime. The goal was to help Mr Jones self-manage his diabetes whilst recognising the demands of his co-morbidities. We also wanted to work with his daughter, recognising her needs and the pressures she was facing looking after an increasingly dependent relative. It was felt that fulfilling his needs would require the assistance from occupational therapy, physiotherapy as well as social services. He would also need to maintain contact with a wide range of professionals to meet his diabetes needs.

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The first stage of managing Mr Jones’ care would involve a complete, holistic nursing assessment of the patient’s needs, regardless of the reason for admission (Prigmore, 2006). This assessment is a multidisciplinary activity. It would include a full nursing history of the patient, followed by a psychological examination and then a physical examination. The latter examination would include the use of a range of assessment tools including the Barthel index, the index of independence (activities of daily living) and the Glasgow Coma Scale. Information gathered could then be used to form the basis of the care plan which would ...

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