This paper is going to illustrate a case study, which has been chosen during the two weeks of clinical practicum. It will present the medical history of the patient, focus on current health status and discuss the main responsibilities of community health nurse.
H.S is a 74 years old Emirati, female, married and has 3 daughters and 5 sons. She has been referred to health home care setting on 24/2/2011. The patient’s past medical history included mild intermittent asthma, irritable bowel syndrome, acute gastritis, esophageal reflux, acquired hypothyroidism, generalized anxiety disorder, essential hypertension, diabetes mellitus type-1, chronic diastolic failure, blurred vision and impaired hearing. The patient has allergies from dust and medication like penicillin. Her surgical history was significant for cholecystectomy. Also, she had grafting surgery that done to repair the wound at right forearm which resulted from road traffic accident. Current medications include montelukast (singulair); 10mg orally once daily, steroids 500mg orally once per day, insulin 34 units in the morning and 32 units on evening, and cozaar 50mg once daily. Currently, the patient is suffering from uncontrolled diabetes. The fasting blood glucose ranged from 239-455 mg/dl and the past prandial glucose and bed time glucose ranged from 240-598 mg/dl. This assignment will shed light on one of the chronic disease which the patient has, diabetes, including pathophysiology, sign and symptoms, risk factors, epidemiology, diagnosis and treatment. In addition, it will illustrate the community health nurse roles regarding diabetic patient.
Diabetes mellitus is a worldwide epidemic disease. It is a metabolic disorder manifested by elevation of blood glucose level due to an absolute shortage of insulin production and action (American Diabetes Association, 2004). The two main classification of diabetes are type 1, this type represents insulin dependent diabetes, and type 2, non-insulin dependent diabetes (Meetoo & Allen, 2010). Additional types of diabetes mellitus include gestational diabetes, maturity once diabetes of the young, diabetes resulted from cystic fibrosis, and cushing’s syndrome diabetes (Meetoo & Allen, 2010).
As our patient is suffering from diabetes type-1, the nurse must understand the pathophysiology of this type in order to provide optimal care. Type-1 diabetes is found to be a result of an autoimmune mediated damaging of B-cells, pancreatic cells responsible for insulin production. Destruction of these cells will lead to insulin deficiency, which will result in increase of blood glucose and glycosuria. Mainly it is symptomatic disorder unlike type-2 diabetes (Meetoo & Allen, 2010). Type-2 diabetes is considered silent killer; most people with such disease are unaware because it is asymptomatic in many cases. It is characterized by abnormal insulin production, insulin resistance, and alteration in glucagon synthesis (Casey, 2011). Elevation in blood glucose caused by limitation of insulin in transporting glucose into the cells for energy synthesis. High glucose level enhances insulin production. So that, people with this type of diabetes often characterized by excessive insulin production (Casey, 2010). Diabetes’ symptoms might slightly vary according to the type.
Hyperglycemia manifested by a number of symptoms such as polyuria, polydipsia, weight loss, in some cases associated with polyghagia; feeling hungry as a result of cellular starvation, and blurred vision. Polyuria occurs when the amount of glucose filtration by the kidney overwhelms reabsorption mechanism (American Diabetes Association, 2004). Fatigue may be presented due to metabolic changes (Casey, 2011). These symptoms could not be severe in type-2 diabetes as much as type-1 (Casey, 2011).
Uncontrolled diabetes like in H.S case might lead to unpleasant consequences. These complications include retinopathy with loss of vision, nephropathy; which results in renal failure, peripheral nephropathy with high risk of foot ulcer and cardiovascular symptoms (American Diabetes Association, 2004).
There are many risk factors that lead to hyperglycemia. Some of these factors are non-modifiable such as heredity and race factors. Other modifiable factors include obesity, lack of exercise, impaired glucose tolerance, cardiovascular disorder, and high level of triglycerides (Rodbard et al, 2007).
Diabetes mellitus accounts for high epidemic percentage throughout the world. The total number of people with diabetes was significantly increased from 124 million in 1997 to 221 million in 2010 (Meetoo & Allen, 2010). From a global thought, the highest three countries estimated to have the highest number of people with diabetes in 2000 and 2030 are India, China, and the United State of America. The most affected groups are people between 45-64 years old (Meetoo & Allen, 2010). The risk of death for people with diabetes mellitus is twice that among individuals without diabetes of similar age (Rodbard et al, 2007). If patient diagnosed before age 40 years, the average reduction in life expectancy is 12 years for men and 19 years for women (Rodbard et al, 2007).
There are a number of diagnostic procedures that have been used to determine the blood glucose level. These strategies include observation the symptoms of diabetes such as polyuria, polydipsia, and weight loss (Rodbard et al, 2007). In addition, diabetic patient could be identified with fasting plasma glucose concentration more than or equal 126mg/dl or plasma glucose concentration more than or equal 200 mg/dl in normal status. These measurements taken by using a 75-g oral glucose tolerance test (Rodbard et al, 2007).
Applying appropriate intervention for patient with chronic disease like diabetes is an essential strategy to prevent any complications that might result from unstable condition (Pimouguet, Goff, Thiebaut, Dartigues & Halmer, 2011). The aims of diabetes treatment are to control blood glucose level to reduce the risk of long term complications and to help the patient with diabetes to live normal healthy life (Meetoo & Allen, 2010). The choice of treatment depends on the type of diabetes. For instance, patient with type 1 and some cases with type 2, insulin is an appropriate treatment in maintaining nearly normal level of blood glucose (Meetoo & Allen, 2010). Unlike type-2 diabetes, in which management processes are based mainly on life style modifications. For example, regular food intake, regular exercise, weight management and limited alcohol intake. Also, oral anti-diabetic agents are used to maintain normal level of blood glucose and to enhance the action of pancreatic cells (Meetoo & Allen, 2010). Furthermore, one of the most effective methods which are essential for patients with type-2 diabetes or for people who are at high risk is regular monitoring of blood glucose level .This method helps to prevent acquiring diabetes for people who are at increased risk of hyperglycemia or for those who have poor glycemic control (Grant, 2010).
The role of the nurse in delivering community health care is considered an essential part in managing patient’s condition at home sitting. As nurses working in community care, a number of responsibilities are involved in care of patient with diabetes including assessment and providing optimal intervention (Carey & Courtenay, 2008). The nurse is considered the only professional who has a complete knowledge about patient’s medical status (O’Reilly, 2005). Effective assessment will enable the nurse to create appropriate plan regarding patient’s condition and provide best care (World Health Organization, 2001). For optimal care, the community nurse should has enough knowledge regarding patient’s health disorder include functional limitations, patient’s medical history, prognosis, physical assessment for all body systems and behavioral status (O’Reilly, 2005). In addition, it is important to assess other factors that could affect patient’s health such as safety of living environment, types of daily living activities, medication awareness and compliance, equipment availability such as oxygen, intravenous therapy, and parenteral nutrition (Smeltzer, Bare, Hinkle & Cheever, 2008). For diabetic patient, the nurse is responsible to assess specific factors that might interfere with glycemic control. One of these factors is age- related changes such as physiological functions. For instance, loss of taste and olfactory functions may lead to malnutrition intake. So, that will lead to abnormal metabolism and blood glucose maintenance (O’Reilly, 2005). Dehydration is also one of the complication that might occur due to loss of thirst perception which affected by age factor. The nurse must evaluate the condition carefully in order to meet the needs (O’Reilly, 2005). Also, the nurse must assess for the presence of neuropathies, because it increase the risk of fall and infection (Smeltzer, Bare, Hinkle & Cheever, 2008). Furthermore, visual deficits and retinopathy must be assessed because the patient may be at risk of taking medication inaccurately and become unable to perform regular blood glucose test (O’Reilly, 2005). The nurse should ensure that the patient is aware about all medications and being compliance with. Also, identification and investigation of any complications are very crucial to protect the patient from life threatening condition (Diabetes Specialist Nurses, 2007). If the patient has diabetic foot, the nurse should assess the wound, regular dressing must be done and monitor for any further complications (Smeltzer, Bare, Hinkle & Cheever, 2008). Moreover, accurate documentation is necessary to ensure patients need correctly (O’Reilly, 2005).
Diabetes mellitus requires regular self care behaviors
. Nurse is responsible to teach the patient about appropriate self management (Smeltzer, Bare, Hinkle & Cheever, 2008). Physical and emotional stress could affect glycemic control negatively, so patients must learn how to balance among such factors. They should learn daily self care skills to prevent instability of blood glucose. In addition, patients must be aware about good nutrition by following a calorie- controlled diet (Smeltzer, Bare, Hinkle & Cheever, 2008). They should know that they might need additional meals and snacks during various exercises or at bedtime to prevent hypoglycemia. Also, patients must have knowledge regarding medications side effects and disease progression. Patients and family members should be taught about the symptoms of both hyperglycemia and hypoglycemia in order to be able to provide a required care (Smeltzer, Bare, Hinkle & Cheever, 2008).
In conclusion, this essay has discussed a case study that has been chosen during the clinical practicum time. Mainly, it focused on one of current health problem in which the patient is suffering from, diabetes mellitus. It discussed the pathophysiology of the two types of diabetes, type-1 and type-2. Diabetes is characterized by a number of symptoms such as polyuria, polydipsia, weight loss, and polyghagia. There are many risk factors might cause diabetes such as obesity and sedentary life style. This paper has also presented statistical information regarding diabetes disorder throughout the world, it found that India is the highest country that account for the highest number of people with diabetes. Moreover, there are various diagnostic methods that are used to identify and investigate patients with diabetes or who are at high risk. Treatment strategies are varying with different types of diabetes. Type-1 is insulin dependent diabetes while type-2 is non-insulin dependent. Diabetes mellitus is considered a chronic disease that required regular appropriate care at home sitting. Community health nurse has a number of responsibilities regarding diabetic patients care include effective assessment and providing teaching plan that help the patient to maintain controlled blood sugar level. Finally, diabetic patients should be aware about daily self care.