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Diabetes CASE Study LONG TERM Condition 840474

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Module: Nursing Adults with Long Term Conditions

Title: Case Study

Word Count: 1,

This is a case study that gives an overview of a patient with a long-term condition (LTC) and how this condition is being managed. It outlines the underlying causes, pathophysiology and existing management plan of the condition and considers the role nurses play in caring for such patient. Lastly, issues relating to end of life (EOL), palliation and the role of nurses in empowering the patient and his family/carers to be actively involved in a patient-centred approach will be explored; as this promotes quality of life (QOL) even in EOL period.

The patient is a 78-year old man diagnosed with type 2 diabetes mellitus (T2DM) 28 years ago; he attended the in-patient clinic for a check-up during the placement. The National Institute for Health and Care Excellence (NICE) (2017) defined T2DM as a chronic metabolic disorder characterised by insufficient production of pancreatic insulin (a hormone that controls blood glucose) and the body’s inability to utilise insulin effectively (insulin resistance), resulting in high levels of blood glucose (hyperglycaemia). Globally, the disease is on the rise with the number of people with diabetes increasing from 108 million in 1980 to 422 million in 2014, causing 1 million deaths in 2016 (World Health Organisation (WHO), 2018a). In the UK alone, roughly 2 million people are currently diagnosed with diabetes, of which 90% of them have T2DM (National Health Service (NHS), 2016).

The underlying causes of T2DM are a combination of genetic and environmental factors which can lead to impaired insulin secretion and/or insulin resistance (Kaku, 2010; Prasad & Groop, 2015). Several risk factors associated with the development of T2DM include family history, obesity, physical inactivity, ethnicity as well as age. It has been shown that there is approximately 40% lifetime risk of developing T2DM if one parent has the disease (Ali, 2013), and approaches 70% if both parents (Lyssenko & Laakso, 2013). The condition is two to four times more likely to develop in people of Black African origin than white descent (Osei K, & Gaillard, 2017).

Assessing the patient’s history during the visit showed that he was a Black African, had both parents having T2DM and was inactive physically. The patient had body mass index (BMI) of 31 kg/m 2 ; therefore, classified as obese (obesity: BMI >30 kg/m 2 ). T2DM is usually associated with obesity and physical inactivity (NICE, 2017), and excess fat is the strongest risk factor for T2DM (WHO, 2016). Therefore, the causes of the disease in this patient could be multifactorial - the family history, obesity, physical inactivity, ethnicity as well as age.

Insulin resistance and/or reduced insulin secretion contribute to developing this pathophysiological condition (Kaku, 2010). Thus, the disease arises because insulin secretion

of the multidisciplinary team (Cable, 2014), with the patient being at the centre of the self- management plan. They work with specialists including diabetologist, podiatrist, ophthalmologist, and dietitian (Cable, 2014) to provide integrated care and support the patients to have a good QOL. When required, and as observed, the nurses offered advice on decisions about medications, dietary modifications, prevention and treatment of complications associated with the disease to achieve holistic care (Marie Curie, 2019).

The patient had been supported by the team, especially the nurses with which he had regular contacts with, to self-manage his diabetes for over 28 years. The reason for his recent hospital admission was due to a severe hyperglycaemic episode (hyperosmolar hyperglycaemic state) in which his blood sugar surged to over 40 mmol/l (Scott and Claydon, 2012), with associated thirst, polyuria, blurred vision and fatigue. This was found to be related to difficulty in adhering to medication advice and management plan recently. Poor medication adherence can occur in at least 45% of patients with T2DM (Polonsky & Henry, 2016). The nurses assisted in providing more education about T2DM and its management to both the patient and his family and advising the family to encourage the patient to move around in the house. Educating patients about their disease to understand the necessity for, and benefits of, improved glycaemic control has a vital role in empowering them to take active responsibility to manage their condition daily (Nazar et al., 2016; Bartol, 2012). It was observed that the community nurses assisted with the administration of the reviewed medication to minimise the symptoms of hyperglycaemia since his family members were not always around. Therefore, the nurses help patients by providing guidance, answer questions or concerns from the patient and encourage them to “own” their disease. They are also involved in the referral and work with the consultants and patients to produce a comprehensible, cohesive, and safe treatment plan to ensure all-inclusive, efficient, and effective care (Bartol, 2012).

WHO (2018c) defined palliative care as an approach that improves the QOL for patients and their families and relieves suffering and problems associated with a life-threatening illness. This is achieved through the prevention and early identification using the correct assessment to provide physical, psychological and spiritual support to minimise the patient’s pain and other symptoms. During the EOL care, patients are in the final stages of care where the condition does not respond to any active treatment (Palliative Care Alliance, 2014). At this period, the diabetes management changes to focus on avoidance of uncomfortable symptoms of hyperglycaemia rather than the prevention of long-term complications; thus, achieving targeted glycaemic control becomes less of a priority (Munshi et al., 2016).

The goal is more than just helping the patient have comfort in dying but to enable people to live through the effects of their condition. Communication plays an important role in establishing a professional relationship with patients and their family as well as working with other professionals (Scherer & Holly 2015). The discussion of palliative care and EOL care with patients can be very difficult, especially considering the delicate nature of the issues relating to life and death (Dunning & Martin, 2018). Therefore, the information should be discussed in a clear, concise and effective manner allowing the patient and their family to digest the details and ask questions relating to the issues and provide answers as necessary.

Nurses possess a worth of physical and clinical skills that allows them to deliver personalised care tailored to each patient (RCN, 2019). As highlighted, delivering EOL and palliative care is patient-centred and therefore their observational and intuitive ability allows them to recognise deteriorating signs of the patients and recommend appropriate courses of action to the doctors as necessary (WHO, 2018c). Nurses also advocate for patients, as they are at the point of their worse vulnerability at this period especially when some patients may find their condition debilitating and would prefer to end their lives rather than living the painful experiences through EOL. At this stage, nurses can suggest the withdrawal or addition of some medications to enhance patient comfort. Though the patient in question was responding to most treatment, he may need the EOL care when the T2DM condition reaches such a stage.

In conclusion, the case study has highlighted the role of nurses in the treatment and management of LTC and for this patient, T2DM. It showed how nurses work with other health professionals support patients and their family to design a personalised care plan to suit the patient’s needs to promote the QOL. Furthermore, the role of nurses in palliative and EOL care was discussed providing vital details about the use of clinical skills, judgement and effective communication skills to ensure the physical, psychological and spiritual needs of the patient are met while putting their comfort at the forefront of decision making.

References Ali, O. (2013). Genetics of type 2 diabetes. World Journal of Diabetes, 4(4), 114–123.

NHS (2016). Diabetes. Available from: nhs/conditions/diabetes/. [Accessed 01 May 2019].

NICE (2017). Type 2 diabetes in adults: management. Available from: nice.org/guidance/ng28/resources/type-2-diabetes-in-adults-management- pdf-1837338615493. [Accessed 01 April 2019].

Nickerson, H. D., & Dutta, S. (2012). Diabetic complications: current challenges and opportunities. Journal of Cardiovascular Translational Research, 5(4), 375–379.

Osei K, & Gaillard T (2017). Disparities in Cardiovascular Disease and Type 2 Diabetes Risk Factors in Blacks and Whites: Dissecting Racial Paradox of Metabolic Syndrome. Front Endocrinol (Lausanne), 31;8:204.

Palliative Care Alliance (2014). A benefit for hospitals and their patients. Available from: palliativeca/benefit-for-hospitals-and-patients.php. [Accessed 12 April 2019].

Polonsky, W. H., & Henry, R. R. (2016). Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Preference and Adherence, 10, 1299–1307.

Prasad, R., & Groop, L. (2015). Genetics of Type 2 Diabetes—Pitfalls and Possibilities. Genes, 6(1), 87–123.

Robertson, C. (2012). The role of the nurse practitioner in the diagnosis and early management of type 2 diabetes. Journal of the American Academy of Nurse Practitioners, 24, 225–233.

Royal College of Nursing (2016). What person-centred care means. Available from: rcni/hosted-content/rcn/first-steps/what-person-centred-care-means. [Accessed 01 June 2019].

Scherer J, & Holley J. (2015.) Improving advance care planning and bereavement outcomes. American Journal Kidney Diseases, 66 (5):735-737.

Scott, A. & Claydon, A. (2012). Joint British Diabetes Societies Inpatient Care Group: The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes. [Online] Available from: diabetologistsabcd.org/JBDS/JBDS_IP_HHS_Adults.pdf. [Accessed: 04 June 2019].

Walker, R. (2014). Care planning for long-term conditions: part one. Nursing in Practice [Online]. Available from: nursinginpractice/article/care-planning-long- term-conditions-part-one. [Accessed 01 May 2019].

WHO (2016). Global report on diabetes. Available from: doi/10.1128/AAC.03728- 14. [Accessed 02 April 2019].

WHO (2018a). Diabetes. Available from: who/news-room/fact- sheets/detail/diabetes. [Accessed 04 April 2019].

WHO (2018b). Noncommunicable diseases country profiles 2018. Available from: doi/16/j.jad.2010.09.007. [Accessed 10 May 2019].

WHO (2018c). Palliative Care. Available from: who/news-room/fact- sheets/detail/palliative-care. [Accessed 01 June 2019].

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Module : Care of Clients with Acute and Long-term Conditions

University : bournemouth university.