John, a 50-year old man, visits a convenient care clinic complaining of fatigue, increased hunger, increased thirst, and frequent urination over the last two months. He also reports increased episodes of itching. Clinical examination reveals the presence of dark patches on his skin in the neck and armpit areas. Physical examination reveals a weight loss of 5kg over the last one month. Laboratory test show the following results: A1C= 7.1%, FPG= 127mg/dL and OGTT= 202mg/dL. John is single and currently stays alone. He has one sister whom he last met two years ago. He is also not employed currently.
The symptoms exhibited by the patient presented in the above case study require nursing responses that are consistent with both the advanced nursing practice and nurse practitioner role. The patient experiences the following symptom cluster: increased hunger and thirst, and itching. Another symptom experienced by the patient is fatigue. The blood test results of the patient confirm a diagnosis of diabetes mellitus. All the symptoms are common in people diagnosed with diabetes.
Hunger (polyphagia) is one of the three symptoms commonly experienced by people diagnosed with diabetes. Among diabetics, increased hunger results from the reduction in the ability of the body cells to absorb glucose as a result of insulin resistance, inadequate level of insulin in blood, or lack of insulin. Lack of insulin, inadequate insulin levels in the blood, and insulin resistance result from chronic uncontrolled high blood glucose levels. As a result of reduced absorption of glucose, the body fails to synthesize energy from glucose. This lack of energy then results into an increase in hunger. Excessive thirst (polydipsia) is also common among people diagnosed with diabetes. It is mostly attributed to high blood glucose levels. Indeed, people diagnosed with diabetes experience increased thirst mostly whenever their blood glucose level rises high. An explanation for this phenomenon is that high blood glucose concentration causes the kidney’s ability to reabsorb glucose to reduce. As a result, osmotic pressure builds up in the kidney and leads to the loss of more water through urination. Itching among diabetic patients is mostly attributed to yeast infection, poor blood flow, or dry skin. Fatigue is also mostly experienced by people diagnosed with diabetes. The condition is characterized by general body weakness. The cause of fatigue in diabetic patients is the inadequate metabolism of glucose to produce energy that can help maintain the body activities. In diabetic patients, high glucose concentration in the blood hinders the absorption of glucose into the body cells. As a result, the cells end up with no supply of glucose for energy synthesis. This causes short supply of energy in the body hence leading to fatigue.
All the symptoms observed in the patient in our case study are likely to impact negatively on his quality of life. Indeed, the symptoms are likely to affect his social, psychological, physical, and emotional status. To start with, fatigue lowers his physical functionalities since it prevents him from undertaking heavy physical activities. Secondly, the patient is exposed to risk of injury owing to his limited physical functionalities caused by fatigue. People with reduced physical functionalities are more exposed to harm and injury than their counterparts with normal physical ability. Secondly, polydipsia can also impact negatively on the patient. In this case, the patient is likely to develop anxiety and low self-esteem if the condition continues. This is possible mainly because the symptom is likely to stimulate a feeling in the patient that he is not a normal human being like the rest. Consequently, he is likely to get depressed. These symptoms are also likely to inflict a heavy burden into the patient and his family. For instance, having to drink water every now and then is a heavy burden on the patient. Similarly, having to visit the toilet frequently causes a serious discomfort that might eventually lead to depression in the patient. The family members are also likely to suffer emotionally, psychologically, and financially. In terms of financial suffering, the family can be forced to incur the cost of taking care of the patient while in this state of health. In addition, the patient’s current state of health brings sadness to the family members. As a result, it affects their emotional and psychological status negatively.
Overall, the symptoms identified in the patient can impact in all the aspects of his wellbeing. In this case, a consideration is made that a human wellbeing is defined by social, environmental, physical, emotional, and psychological status. A flaw in any of these aspects of the human wellbeing is likely to impact significant negative consequence on the patient. This fact explains why nursing interventions emphasize the need to take a psychosocial approach in dealing with all kinds of cases in the nursing practice.
The nursing care for the patient in the case study should seek to address the patient’s symptoms as well as the patient’s medical condition. In formulating the goals of the patient care, both long-term and short-term goals should be considered. The goals of nursing care for this patient would be the following:
The patient will be able to recognize his behavior or practices that seem to aggravate the feeling of thirst or hunger within 6 hours
The patient will be able to design a dietary plan that is realistic to promote his efforts to control calorie intake within 24 hours
The patient will be able to suggest how the physical activity can be incorporated into his daily schedule within 48 hours
The patient will have been following a calorie-restricted diet for three weeks in one month time.
The patient will have been checking his blood glucose level regularly for three weeks one month from now
With regard to the first goal, helping the patient to be able to recognize his behavior or practices that aggravate the feeling of thirst and hunger is a significant step towards promoting self-care. In this case, the patient first needs to know rationale behind his status before he can accept to adhere to the care given. The second goal is intended to help formulate nutrition education intervention that would assist in promoting glycemic control. As a result of achieving appropriate glycemic control, management of polydipsia and polyphagia would be possible. The third goal guides physical exercise intervention that is also needed to facilitate care delivery to the patient. Achieving this goal would contribute significantly towards the promotion of self-care. The last two goals are long-term goals. They guide dietary interventions intended for the patient. Overall, all the goals mentioned above seek to promote patient empowerment in order to encourage self-care.
The plan of care for the patient in our case study would involve three main interventions: patient education, glycemic control, nutrition counselling, and physical activity. To start with, patient education is a very important approach to promote patient empowerment to support intervention goals of care. In our case, patient education would involve teaching the patient together with people close to him about all aspects of diabetes mellitus. In this case, the approach would involve teaching the patient about the risk factors of diabetes and how to manage the symptoms of diabetes. This intervention is highly effective in promoting self-care and achieving sustainable positive health outcomes both in the short and long run. The intervention is supported by findings from a study carried out by Sperl-Hillen and colleagues (2011) that sought to establish the effectiveness of comparative patient education on management of diabetes mellitus among patients with sub optimally-controlled diabetes. According to the study, individual education is more effective in the management of diabetes mellitus among patients with established sub-optimally-controlled diabetes (Sperl-Hillen et al., 2011). The intervention is further supported by findings of a study by Lagger, Pataky, and Golay (2010). In the study, patient education was found to improve patient outcome. The study was a systematic review of various studies.
Nutrition counselling would also be given. In this case, the patient would be counselled on the appropriate diet that would help promote glycaemic control. Glycaemic control is indispensable to the management of polydipsia and increased hunger since both symptoms are partly attributed to hyperglycaemia. Therefore, attempts to control polydipsia polyphagia should focus on regulating hyperglycaemia. Consequently, the nursing care in this case will involve approaches aimed at attaining glycaemic control. First, the client’s level of nutritional knowledge would be assessed to determine how many insights he has into the aspects of nutrition that contribute or promote the symptoms he presents with. The client would also be assessed to determine his dietary practices. This step would help plan the priority dietary care to be given to the client. Based on the assessment, all the aspects of nutrition would be addressed with a view of promoting management of the symptoms. Precisely, the client would first be asked to adopt a regular meal pattern. This would help promote glycaemic control. Few studies have been conducted to investigate the association between eating pattern and the level of glycaemic control. However, some studies have been carried out on this area and they suggest that indeed eating pattern has an effect on glycaemic control. Some studies have also been done to investigate the association between eating pattern and the risk of diabetes. For instance, according to the findings of a study carried out by Mekary and colleagues (2012), breakfast omission is associated with an increase in the risk of type 2 diabetes in men.
Nutrition counselling is indeed an integral aspect of management of diabetes. Since diabetic patients have compromised ability to regulate blood glucose level, there is a need to design diet cautiously to prevent large fluctuation of blood glucose level. Blood glucose level usually fluctuates between meals. However, this fluctuation is not controlled among people diagnosed with diabetes. In a diabetic condition, the level of blood sugar cannot be maintained within the normal range as is the case in individuals who are not diabetic. This fact explains why modified diet is necessary to help prevent high fluctuations in blood sugar level. Nutrition counselling should greatly focus on restricting calories in order to prevent high fluctuations in glycaemic levels after meals.
Studies have shown that exercise combined with nutritional interventions can significantly improve patient outcome in efforts aimed at managing diabetes. Indeed, recent studies have shown that people who engage in moderate physical activity tend to report improvement in glycemic control as well as the delay in the onset of diabetes and its complications. American Diabetes Association recommends that approaches aimed at managing diabetes should integrate physical activity in order to help improve the level of glycemic control among patients diagnosed with diabetes mellitus. According to Colberg and colleagues (2010), interventions that combine physical activity with weight loss can lower the risk of type 2 diabetes by 58%.In addition; exercise has been shown to improve insulin sensitivity of the various body cells. It is in this sense that exercise possibly contributes to the improvement of glycemic control among diabetic patients. The care plan for the patient in the case study would combine physical activity with nutrition intervention, and other interventions. Through exercise, it will be possible to manage hyperglycemia. Managing hyperglycemia will in turn promote the management of the symptoms such as polydipsia and polyphagia. Consequently, exercise will play an integral role in giving nursing care for the patient in this case study.
Another intervention will involve the management of fatigue. In the case of the patient in this case study, fatigue is possibly attributed to inadequate energy in the body as a result of poor uptake of glucose into the body cells for energy synthesis. Based on the situation of the patient presented in the case study, fatigue would be managed on both short-term basis and long-term basis. On short term basis, the interventions would involve encouraging bed rest and appropriate diet. However, the long-term approach would involve management of hyperglycemia. The patient would also be counselled on how to administer the drugs prescribed by the doctor.
Management of the symptoms that the patient is presenting with requires a multidisciplinary approach. Members of the multidisciplinary team who will be of great help include a nurse practitioner, physician, dietitian, psychologist, and physical fitness specialist. Each member of the multidisciplinary team would play different roles depending on their areas of specialization in coordination with one another. The role of the physician, in this case, is to perform medical examinations and to prescribe treatments and medications for the patient. The dietician’s role involve conducting nutrition education and helping the patient design an appropriate diet depending on the patient’s preferences. In this case, the dietician plays a facilitating role. The phycologist’s role in managing the patient is also very important considering the psychosocial status of the patient. The patient is at risk of psychological problem considering that he stays alone and he is not employed. The situation is likely to expose him to the risk of psychological problem. Consequently, a psychologist’ input is highly needed in this case. The physical fitness specialist would also take part in managing the patient. In this case, his role would involve training the patients on some of the workouts that would improve his level of fitness as well as improve his glycemic control ability.
The bulk of the management of the patient is conducted by the nurse. In this case, the nurse carries out almost all the tasks carried out by other members of the multidisciplinary team. The nurse plays part of the role performed by the physician. For instance, the nurse conducts an assessment. However, the assessment conducted by the nurse only focuses on the patient’s response to the current medical condition. The nurse also plays part of the role played by the dietician in the sense that the nurse gives the patient nutrition counseling in which the nurse counsels the patient on the appropriate nutritional practices. The nurse is also tasked with providing counselling to the patient. Overall, the nurse is at the center of care process aimed at managing the symptoms presented by the patient in this case study.
The implementation of the best practice in the case of the patient whose situation is presented in this case study might not be easy due to several reasons. First, some of the possible best practices might not be part of the procedure contained in the protocol guiding the ward in which the patient has ben admitted. Indeed, one of the main factors inhibiting the implementation of best practices in several departments is the fact that sometimes the existing protocols at the departments may be contradicting the recommendations of the best practice. In the case study discussed here, the presence of department protocol that recommends a different practice from that recommended in the best practice is one of the most possible factors that can affect efforts being made to implement the best practice.
Implementation of best practices also requires resources. However, in cases where resources are not adequate, it might be difficult to implement best practices appropriately. Similarly, the situation of the patient in the case study requires resources in order to be solved using best practices. Another possible impediment to the implementation of best practices in solving the patient’s situation is the presence of an organizational culture that embraces a different practice. Introducing new best practices becomes challenging in such cases since key stake holders have to endorse the new best practice.
Factors promoting the implementation of best practices that are likely to found in the various healthcare settings are the supportive healthcare staff, presence of policies that encourage the implementation of evidence-based practices if done in the best interest of the patient, and the availability of adequate resources to aid in promoting the implementation. Any of these factors might be present in the case study presented in this paper. The presences of policies that support implementation of best practices create a conducive environment for any evidence-based and approved practices to be implemented in order to promote nursing care. Supportive staff also helps encourage the implementation of the practices. Furthermore, the role played by the patient in determining the intervention given and how the intervention can be given is also plays a major role in either facilitating the implementation of the best practice or impeding its application. For the implementation of the best practice to be executed, the patient must make an informed choice with regard to it.
Once of the possible means through which nurses can deal with the barriers of the implementation of clinical best practices is through influencing key decisions made in various healthcare systems. One of the possible means through which this would be possible is through taking part in meetings where the key decisions are often made. Besides, adequate data can also be gathered to support the suggestions for particular policies that seek to recommend certain practices as sound and appropriate in various situations. This approach is applicable in the context of this case study. Furthermore, advanced practice nurses can use their persuasion skills to help patients make the right informed decisions with regard to whether best practices can be implemented while care is being provided to them or not.
References
Colberg, S. R., Sigal, R. J., Fernhall, B., Regensteiner, J. G., Blissmer, B. J., Rubin, R. R., & Braun, B. (2010). Exercise and type 2 diabetes the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes care, 33(12), e147-e167.
Lagger, G., Pataky, Z., & Golay, A. (2010). Efficacy of therapeutic patient education in chronic diseases and obesity. Patient education and counseling, 79(3), 283-286.
Mekary, R. A., Giovannucci, E., Willett, W. C., van Dam, R. M., & Hu, F. B. (2012). Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. The American journal of clinical nutrition, 95(5), 1182-1189.
Sperl-Hillen, J., Beaton, S., Fernandez, O., Von Worley, A., Vazquez-Benitez, G., Parker, E., & Spain, C. V. (2011). Comparative effectiveness of patient education methods for type 2 diabetes: a randomized controlled trial. Archives of internal medicine, 171(22), 2001-2010.
