After reviewing several topics, the population I have chosen to study is the local African-American diabetic population. This population is where I feel the greatest positive impact will occur. Currently employed with a nonprofit hospital, it is evident that many individuals lack health insurance and currently suffer from multiple, uncontrolled chronic medical issues. I have confidence in the fact that through teaching, the cycle of having uncontrolled chronic illnesses can be broken.
Aggregate Details
The aggregate chosen for the Capstone project will focus on the local African American diabetic population. The chosen population, largely located within the city of Ft. Pierce, Florida has an approximate population of 25,000 African Americans. This community presents with many risk factors, and several chronic diseases. One of the most widespread is diabetes. The CDC states, “In 2010, the prevalence of diabetes among African American adults was nearly twice as large as the prevalence among white adults” (CDC, 2015).
Many factors may contribute to the above statistic, and many of them are decisional attributes, which precede type II diabetes in the populace. Body image is one of the first decisional attributes, which comes to mind. Often, weight is not seen as a negative issue within the community. Medical standards may place an individual within the obese category, but the community and the individual may not feel the same way. The African American community has many factors that contribute to the obesity problem, mainly, the cultural foods that are often cooked. This population often serves meals consisting of fried foods, foods that are very high in carbohydrates and starches, as well as lots of sweets and sugars. The feeling of no control over medical conditions is another decisional attribute. This attribute leads an individual to believe they are unable to change their situation. Some studies have shown that many individuals, who have a family history of diabetes, or other chronic illnesses, believe they are destined to suffer from the same afflictions. A lack of education leads them to believe there is nothing they can do to change this. Health fairs and teaching workshops within the community can aide in the reduction of diabetes and other chronic illnesses.
Describing the Aggregate
Diabetic conditions are dreaded. There are two types of diabetic conditions, type 1 and 2. These conditions have been on the rise in the recent times and are socially termed as lifestyle diseases. The reality of the conditions has led to an evolution in the field of medical research, especially among the racial minority population in the United States. There has been an observed trend of increased diabetic conditions among the African-American population, especially at Ft. Pierce, Florida. The trend has been worrying especially due to its observable racial inclination. This has brought the need to objectively research on the relationship thereof. This project investigates the causes of the rising cases of diabetic conditions among the African American population in Florida with particular attention to Ft. Pierce town. It investigates also the medical infrastructural support network available for the patients. The support infrastructure includes the clinical and knowledge repository, technology and personnel together the medical facilities dedicated to helping the patients.
The modern medical practice has been largely based on evidence-based practice, an approach that involves research and experiment-oriented study that give recommendations that are credible and viable in dealing with any emerging condition. Ft. Pierce is a cosmopolitan suburb but having African American population that is slightly higher than the other races. The local medical facilities have recorded increasing rate of type 2 diabetic conditions among the African American (Signorello, Schlundt, Cohen, Steinwandel, Buchowski, McLaughlin, Hargreaves,& Blot, 2007). This forms the subject of this capstone project in order to understand the remedial actions that could be necessary both in the short and long run. It is also important to delineate clearly the extent of the problem and it’s causing factors. This falls right in the domain of Evidence-based practice (EBP).
Results
Among the sampled African American population, 30 were found to be nursing type 2 diabetic conditions while 5 were in the brink of developing the condition. Further, the remaining were fairly aware of the requisite deliberate actions that can avoid the predisposition to the developing the conditions. For those 30 nursing the diabetic conditions, 15 were not aware of the basic lifestyle vigilance that is precautionary in preventing the disease. Further, 8 of the others were obese and others neglected basic physical exercise necessary for healthy living. On the other hand, for the whites sample, 26 were diabetic, some of them drifting to severe conditions. Further, 3 were in the brink of developing the condition. The remaining people part of the sample did not have the infection and indicated no signs of developing the condition. They were evidently fairly informed about the disease.
Of the 26 patients, only a paltry 8 were not aware of the information on diabetes, the precautionary measures needed the management issues and the lifestyle adjustments that reduce the predispositions. 6 of them were obese.
The information above can be tabulated for easy referencing.
Discussion
The diabetic condition prevention and management are immensely knowledge intensive. People need to acquaint themselves with a lot of information regarding the condition and hence lead healthy lives. Diabetic conditions can be genetic. However, as had been pointed out earlier, the condition can be developed over time and dependent on the lifestyle among other social dynamics. As can be seen from the graphs, the infection rate is high among the African American population sampled. Further, those unaware about the disease are also higher compared to the ones in the white data sampled.
It is worth noting that large percentages of the Black American population in Florida are engaged in formal employment and leading a middle-class lifestyle. As can be seen above, the information on the management of the condition is seriously wanting. Indicators such obesity and high weights, low physical exercises and or lack thereof, unbalance and unhealthy diet having much sugar among others show a population not much informed on this matter hence having much predisposition to developing the infection(Chow, Foster, Gonzalez, & McIver 2012).
The result of the research on the aggregated population will go a long way in making public health policies that are geared community health awareness. This is the demonstration of the evidence based medicine practice, where research informs decision and policy initiatives.
Analyzing the Aggregate Strengths and Weaknesses
Phase 3: Analyzing the aggregate strengths and weaknesses
Using the MAP-IT framework that stands for Mobilize, Assess, Plan, Implement and Track, to plan and evaluate the extent of diabetes, which is a critical public health issue of concern within the aggregate, has the potential to contribute to a healthy group (Harris & LeDoux, 2012). The aggregate consists of African Americans within Ft. Pierce, Florida. To better understand the factors that may have contributed to the rise of diabetic conditions among the African American population, data consisting of a group of fifty (50) African Americans, mobilized with the help of local clinics, was analyzed by their diabetes status and knowledge. Those included in the group possessed similar lifestyle conditions.
Diabetes can be inherited within a family lineage, but it is predominantly a lifestyle disease (UCLA Center for Health Policy Research, 2014). The weaknesses revealed from the aggregate included poor diet, low levels of physical exercise, and the occurrence of elevated cases of obesity and a notable lack of knowledge on prevention of diabetes. On the contrary, the aggregate also had elements of strength that could help them stay clear of the rising statistics of diabetes. A majority of them had regular jobs and were able to make enough money to afford knowledge acquisition and at the same time provide for healthy living habits. Healthy living may involve healthy foods and increased levels of physical activities,
Risk Assessment
The aggregate described in Phase 3 consisted of fifty-(50) African Americans analyzed side by side with a test group of fifty-(50) Caucasians. The driver of the research was to find out the reason for the prevalent rising cases of diabetes within the African Americans population in Ft. Pierce, Florida. Much of what exposed the aggregate to the increased risks of diabetes was largely preventable. Apart from diabetes that is passed from parents to their children, also referred to as type1, all the other cases of those suffering from diabetes type 2, were preventable, through healthy life choices.
On a regular basis, the boy was used to consuming, at least, three bottles of soda a day. Soda is quite sugary, and all its calories are in liquid form. The liquid form makes it quite easy to absorb and leads to a rapid rise in the level of blood glucose (UCLA Center for Health Policy Research, 2014). The body is not accustomed to high blood glucose levels, especially if it happens repeatedly and, as a result, can be clogged in the liver in the form of fats leading to type 2 diabetes (UCLA Center for Health Policy Research, 2014).
Unfortunately, the availability of information amongst the family members on how to get the situation under control was not sufficient. Continued uninformed lifestyle graced with ignorance, gradually worsened the situation. It was typical for the family members that the boy was husky because this body shape acceptable amongst the African Americans population. Similarly, the boy was addicted to video games, which made him quite static, with extremely reduced levels of physical activities. All these lifestyle choices contributed to the dysfunction of his regular blood glucose system.
Results of the assessment
The major factor that led the boy of the family to develop diabetes was the effect of poor health choices. The poor health choices in his situation resulted from two sources. One was his feeding habits and the second was his low levels of physical activity. He needed to eat right and at the same time, ensure that his body actively utilized the food he ate by being active himself. The other factors that added weight to these key drivers were ignorance from his family members and their uninformed continued support of his unhealthy lifestyle. His situation came about not because of the possible effects of genetics but because of a personal choice, which had the backing of loving, though uneducated, family members.
It would be necessary to take the whole family through training that would shed light on the management of diabetes. This education would help quite a bit because the condition had already effected an immediate family member. The impact of this will be informed food choices, not just for their ailing son, but also for themselves, preventing future development of diabetes in the family. They will also need to engage him in increasing his levels of physical activity and carefully watch his other health needs.
Priority Nursing Diagnosis
Diabetes mellitus in itself is considered an endocrine issue. When determining the priority diagnoses for an admitted patient, however, it is important to consider taking an all-encompassing perspective with regards to the pathophysiology of each patient and address each issue accordingly. The priorities in the selected aggregate for diabetes mellitus are as follows:
Firstly, there is the situation of unbalanced nutrition often evidenced by increased urinary output (or dilute urine), recent weight loss and a decrease in muscle tone, disinterest in eating, diarrhea and an increase in ketosis. Some of the pathophysiological factors that may have led up to these symptoms include insulin deficiency (due to the decreased uptake and utilization of glucose within tissue and subsequent increase of protein and fat metabolism), a decreased oral intake of food possibly due to gastric fullness or abdominal pain, and a hypermetabolic state due to the release of epinephrine, cortisol and growth hormone. Secondly, the situation of disturbed sensory perception or impaired skin integrity may occur due to an imbalance in endogenous electrolytes or glucose and insulin. Decreased circulation often correlates with decreased levels of activity and mobilization. Thirdly, there will be an overall fluid volume deficit. Often occurring in conjunction with unbalanced nutritional uptake, polyuria occurs due to “glucose-induced osmotic diuresis” (Spira, 1997) especially within patients who suffer from hyperglycemia (again, due to insulin deficiency). Dry mucosal membranes, poor skin turgor and delayed capillary refill times are also indicators of a fluid volume deficit. Finally, a diabetic patient will often exhibit overwhelmingly low levels of energy and noticeably impaired abilities to concentrate and maintain regular daily routines. This occurs due to a lack of metabolic energy production – resulting in a hypermetabolic state or infection.
Strategies to Address Diagnoses
The MAP-IT framework that utilizes the steps of Mobilizing, Assessing, Planning, Implementing and Tracking can be used to form intervention strategies to combat the previously listed diagnoses. During the Assessment step, it is particularly important to take the social determinants of health into account while providing service; although the aggregate is a geographically centered population, the needs of the patients will not be entirely uniform. Additionally, during the Tracking portion, regular evaluations of the listed strategies (checking for data validity and reliability) are advisable in order to continue providing the highest level of service.
Unbalanced Nutrition:
Weigh the patient daily. Measuring a patient’s weight allows for a preliminary assessment of the patient’s nutritional uptake.
Auscultate bowl sounds and make note of abdominal pain, bloating, reports of nausea or vomiting undigested food. Hyperglycemia and electrolyte imbalance can affect gastric function (distention of the ileus). Repeated difficulties with lowered gastric emptying time or poor intestinal motility may indicate autonomic neuropathies that will need to be addressed with sympathetic treatment.
Transitioning from fluid nutrients to solid food as tolerated.
Cultural food preferences and the inclusion of family members in meal planning will increase the likelihood of following dietary requirements after discharge as well as facilitating a sense of involvement for family members
Looking for signs of hypoglycemia through changes in the LOC, headaches, rapid heart rate, lightheadedness or skin temperature. Hypoglycemia can potentially occur once carbohydrate metabolism has resumed, glucose levels are reduced and insulin is being provided.
Perform fingerstick glucose testing; bedside analyses of serum glucose levels are much more accurate than merely monitoring sugar levels within urine. Urine sugar levels do not provide accurate indication of serum levels and can be affected by patient’s urine retention.
Disturbed Sensory Perception / Impaired Skin Integrity
Evaluate visual acuity since retinal edema, temporary paralysis of extraocular muscles, hemorrhaging, or the presence of cataracts can impair vision and will require corrective treatment.
Make note of pain sensation or lack thereof, hyperesthesia or sensory loss in the limbs. The occurrence of peripheral neuropathies and any lack of tactile sensation can impair balance and increase risk of injury.
Monitor lab test values for blood glucose, Hb/Hct, BUN/Cr and serum osmolality since imbalances will have an effect on mentation. Be aware of the chance for water intoxication.
The patient should never walk barefoot as all pressure points on the lower extremities have a high risk for ulceration, trauma and infection. The feet of a patient should be checked daily for erythema or trauma since these are immediate signs that the skin needs preventative care. Gentle moisturizers should be used to soften the skin and prevent cracking.
All water temperatures for bathing should be double checked due to a decreased sensation and higher risk for burns.
Overall Fluid Volume Deficit
Report for signs of dry mucous membranes, decreased skin turgor, a weak rapid pulse, a sudden weight loss of 2% or more, low blood pressure and elevated levels of Hct or BUN
Control diarrhea through the prescription of antidiarrheal agents and antimicrobial therapy
Maintain intravenous fluid therapy as ordered and take whatever actions are required to reduce nausea and vomiting
Orthostatic blood pressure levels should be monitored since hypovolemia occurs through hypotension and tachycardia.
Recording respiratory patterns and noting the presence of acetone breath. Acetone breath occurs due to the breakdown of acetoacetic acid and is a side product of ketosis. Correcting hyperglycemia and acidosis will incur the normalization of the respiratory rate.
Fatigue:
Pulse, respiratory rate and blood pressure fluctuations before and after activities should be noted in order to determine physiological levels of tolerance.
Discussing the importance of continuing to move and stay active helps to motivate patient to continue despite initial levels of fatigue.
Creating a personalized plan for the patient which alternates period of activity with periods of uninterrupted sleep will prevent excessive levels of fatigue and motivate them to continue moving
Providing adequate ventilation and the administration of oxygen as required will allow for improved breathing and relaxation in the patient.
Disaster Plan and Disaster Pack Approach
The aggregate in question consists of the African American population within Ft. Pierce, Florida. Florida is a coastal state commonly witness to severe tropical storms and flooding, hurricanes and tornadoes. There have also been periodic reports of district fires. Ft. Pierce, specifically, has over 1.3 miles of shore line with a humid subtropical climate. A large aspect of geoenvironmental diabetology (Cook, 2011) has to do with how geophysical phenomena impact a diabetic patient, especially during a classified disaster situation.
In geographical areas prone to disaster situations, it is imperative that there is an emergency strategy in place to prevent fatality or dangerous complications for individuals with medical disorders. For example, diabetic patients or families in which a member is a diabetic patient, specialized diet (with measured amounts of glucose) are required at all times for the affected individual and are integral to their daily lives. A disaster kit should be created in advance with extra instructions for a non-healthcare provider to use if they are the first responder. A basic disaster kit for diabetic patients should include materials for both hyperglycaemic and hypoglycaemic situations. The kit should include supplemental insulin doses, ketone strips, a ketone meter (with instructions), glucose tablets, glucose tubes, fruit juices or other quick-acting glucose products. Extra batteries for detection meters and a flashlight, as well as several bottles of water should be included. Alcohol swabs, extra copies of prescriptions a bottle to dispose of sharp objects such as lancets and syringes are also advisable. General first-aid kit materials such as bandages, adhesives, gauze pads, scissors and tweezers and ice pack would also ideally be included as some diabetic patients may have greater complications. Non-perishable foods such as nuts, granola bars, dry cereals, dried fruits, and electrolyte drink and juice boxes for a period of at least 3 days are excellent additions to disaster packs. Patients should also consider having a medical alert bracelet for situations where the individual can no longer speak for themselves. Identification and extra copies of prescription lists should be placed in wallets or purses. Copies of emergency telephone numbers, local poison control and personal physician contact information should be placed somewhere within the kit.
Implementation of the Care Plan
Within the previously selected aggregate, a sample group was chosen to see short term results of the implemented care plan. This sample group consisted of 10 older patients (aged over 50 years) with an even distribution of 5 males and 5 females. . Since the period of study is within the short time span of two weeks, older diabetic patients were chosen since they are more likely to exhibit clear symptoms. No patients with exceedingly complex complications or secondary infections were chosen to prevent outlier data.
In implementing the care plan, several facets will be utilized. The plan can be further divided into two overarching categories: immediate clinical checks and long term lifestyle adjustments. The former includes daily monitoring of unbalanced nutrition through glycemic levels and electrolyte imbalances, reducing fluid volume deficit by maintaining intravenous fluid therapy as required, monitoring orthostatic blood pressure levels and recognizing the presence of ketone breath as well as ensuring adequate levels of ventilation and oxygen administration. The latter will account for methods such as creating a personalized activity level plan for patients to reduce fatigue, discussing the importance of regular movement, the usage of regular skincare and moisturizing to prevent topical ulceration or trauma and including cultural food preferences to encourage the following of dietary requirements.
Evaluation of the Plan’s Effectiveness
Diabetes mellitus is a disorder that is treatable and can easily be accommodated within daily life. However, certain population groups within the United States have a greater risk of not receiving appropriate care for their condition. For a rather long period of time, many healthcare institutions have used only top-down approaches with a primary focus on in-hospital care. However, when health practitioners combine immediate clinical care with long-term preventative models, a bottom-up community-based approach becomes much more successful. As per the careful analysis of the aggregate communicated earlier in this report, nursing priorities were identified and a specialized care plan was established. However, using the MAP-IT framework, the final required step for implementing any public health activity is tracking and evaluation. Within this step, one must first account for certain levels of data quality: data collection should be standardized within the sample population, as well as methods of analysis and questioning.
One of the simplest methods of evaluation (set within the parameters of standardized data collection) is checking for visible signs of success. Although these signs of success and their relative visibility would vary depending on the individual, they would more or less include maintaining a balanced weight in patients, reporting general feelings of wellbeing, steady levels of energy and psychological motivation to maintain healthy lifestyle choices. A reduction in complicating factors of disease and secondary infections is also likely. At the end of the two week period, it is also necessary to check for the validity and reliability of the data by revising questions and patient evaluation criteria or even forming completely new collection systems as required.
The implementation of this disease-management plan should not encounter any major barriers unless there is a shortage of medical resources or appropriately educated medical personnel on hand. Long term continuation of successful results within both the sample group and the aggregate is dependent on the permeation of knowledge within the community. As an example, increased awareness and positive reinforcement may result in patients having their feet regularly checked by a doctor, reducing the incidence of relevant trauma. Health practitioners must also be aware of the fact that the aggregate is a minority population and may have various socioeconomic situations that are preventing the continuation of health lifestyle habits. Factors that affect the successful implementation of the plan include things like making sure a focus on patient-needs is a primary concern, the use of a simple but effective design, being able to collect data easily (as well as analyze it effectively) and a fair deal of transparency. Sending the raw data collected over the course of this study to a third-party organization for independent analysis and then following through with the publication of those results will help contribute to the continuing integrity of the care plan. Publishing results is always greatly helpful and quite necessary, as it paves the way for future researchers and practitioners but also encourages the formation of a positive feedback loop within the aggregate.
The projected effectiveness of this care plan is of a high level given the usage of well-established clinical strategies and the broad-spectrum approach used in analyzing the pathophysiological state of each patient. Well planned disease management programs will always enhance the quality of patient care while minimizing the costs associated with providing it, setting the precedent for future efforts to combat the diseases within our countries.
References
CDC. (2015, February 12). Retrieved January 7, 2016, from http://www.cdc.gov/minorityhealth/populations/REMP/black.html
Signorello, Schlundt, Cohen, Steinwandel, Buchowski, McLaughlin, Hargreaves,& Blot, 2007. Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status. American Journal of Public Health. 97(12), 2260-7.
Chow, E. A., Foster, H., Gonzalez, V., & Mciver, L. (2012). The Disparate Impact of Diabetes on Racial/Ethnic Minority Populations. Clinical Diabetes, 30(3), 130-133.
Harris, E. L., & LeDoux, C. J. (2012). Community Health Needs Assessment Reference Toolkit Arkansas Assessment Initiative Hometown Health Improvement. Arkansas Department of Health, Center for Local Public Health & Center for Public Health Practice. Arkansas Department of Health.
UCLA Center for Health Policy Research. (2014). 1 in 3 Diabetes Tied to a Third of California Hospital Stays, Driving Health Care Costs Higher. University of California, Center for Health Policy Research. Los Angeles: Brown Miller Communications.
Spira, A., Gowrishankar, M., & Halperin, M.L. (1997). Factors contributing to the degree of polyuria in a patient with poorly controlled diabetes mellitus. American Journal of Kidney Diseases 30(6), 829-835. Retrieved February 8, 2016.
Cook, C. B., Wellik, K. E., & Fowke, M. (2011). Geoenvironmental Diabetology. Journal of Diabetes Science and Technology, 5(4), 834-842. Retrieved February 8, 2016.
