Type 2 Diabetes Mellitus And The Patient Journey: Case Analysis
Mr Joe Bloggs (The patient will be referred to as ‘Joe Bloggs’ throughout this essay, this is a pseudonym. The clinical area will also not be identified in order to respect confidentiality) is a 56-year-old man with poorly controlled type 2 diabetes mellitus. He presented to his GP aged 41 with symptoms of excessive thirst, fatigue and polyphagia; which are common presenting features in diabetes mellitus. He was subsequently diagnosed with type 2 diabetes through an oral glucose tolerance test and a glycated haemoglobin (HbA1C) test. His treatment began with a combination of diet modification and regular exercise, a plan was made with the dietician to outline important dietary requirements to ensure good glycaemic control. He was also advised to begin to self-monitor his blood glucose levels. Mr Bloggs was then prescribed Metformin to help with the control of his blood glucose. He finds glycaemic control difficult and time consuming and feels that the symptoms he experiences following diagnosis are due to this. Diabetic foot ulcers are an issue for the patient currently. Mr Bloggs has also experienced bilateral proliferative diabetic retinopathy that was treated with full pan retinal photocoagulation. A right vitreous haemorrhage occurred as a result of Mr Bloggs’ diabetes, decreasing visual acuity. He attended the ward for a planned right vitrectomy which was required to treat the visual disturbances (floaters in vision) caused by the vitreous haemorrhage.
One of the presenting features experienced by Mr Bloggs prior to diagnosis was fatigue. Among people with diabetes, fatigue is a prevalent and distressing complaint. It has been noted by clinicians who work with patients affected by diabetes the considerable toll that fatigue takes on the lives of their patients, yet there is little empirical research describing the severity of the problem. There are multiple possible causes of the symptom. Fatigue in diabetes may be associated with physiological phenomena, such as hypo- or hyperglycaemia or wide swings between the two, this may be important to consider in patients with poor diabetic control, such as Mr Bloggs. Fatigue may also be related to psychological factors, such as depression or emotional distress, possibly relating to the diagnosis, or relating to the intensity of diabetes self-management. This was a factor noted by Mr Bloggs as he finds the large self-care aspect of his condition difficult to manage. Fatigue may also be related to such lifestyle issues as lack of physical activity or being overweight — especially common in people with type 2 diabetes. . However, the complex interplay between blood glucose control, diabetes symptoms, diabetes distress (burdens of diabetes and its treatment, worries about adverse consequences), depression and fatigue is not well understood. Other individual and biological factors are likely to influence these relationships and may better explain the high levels of fatigue seen in patients with type 2 diabetes mellitus. This would indicate that it is important to consider multiple contributing factors when considering what nursing care may be required in order to reduce the impact of fatigue on the patients’ health and life. An assessment of the patient’s lifestyle may be useful to rule out some of the possible causes. An important aspect of controlling symptoms is patient education and ensuring that the patient is able to control their long-term condition as best as possible. Confusion over what constitutes a healthy diet shows the importance of comprehensive, accessible diabetes education, essential to ensuring good glycaemic control, and preventing diabetic complications, including diabetic retinopathy. It may be possible that Mr Bloggs would benefit from further patient education in regards to diet management and exercise which could reduce the symptom of fatigue that he experiences.
A major complication of Mr Bloggs’ condition is that he has developed diabetic retinopathy, although treated with pan retinal photocoagulation, visual acuity has declined as a result of the changes in the eye due to his diabetes. For nearly four decades, laser photocoagulation has been the effective approach for the treatment of sight-threatening retinopathy. The strongest evidence came from two landmark trials in the 1970s and 80s; the Diabetic Retinopathy- and the Early Treatment Diabetic Retinopathy Studies. These studies showed how pan-retinal laser photocoagulation can reduce the risk of moderate to severe visual loss at least by 50%, with timely intervention. A very striking feature of diabetic retinopathy is that it may not cause any complaints until late stages, this may be the reason that Mr Bloggs lost visual acuity as the retinopathy wasn’t treated at an early enough stage. Although this is a significant opportunity for people who have their recommended fundus examination regularly. If sight-threatening retinopathy is diagnosed early it gives the opportunity for timely treatment, and to preserve vision. Regular examination and screening is extremely important to preserve and prolong vision in diabetes. Diabetes planning and retinopathy screening should be part of a coordinated response which may reduce the chance of presentation of this complication. Another important consideration in diabetic retinopathy is the psychosocial impact that it may have on the patient. It has been demonstrated that working- age adults with a visual impairment are significantly more likely to report lower levels of mental health, quality of life and social functioning (Nyman et al, 2010). Because of the combined stress of diabetes and the actual or threatened visual impairment experienced, the impact is likely to be considerable. By increasing our understanding of the social implications of diabetic retinopathy, improved services such as family counselling, work and financial support and social networking advice can be offered to those most in need. In conjunction with the ongoing behavioural demands of the condition (medication dosing, frequency, and titration; monitoring blood glucose, food intake and eating patterns, and physical activity) and the possible complications, living with diabetes can be increasingly distressing and difficult, which indicates why diabetes care services and psychosocial support is so important.
Pathways to diabetic foot ulceration are similar in most diabetic patients. Lesions generally result when a patient has two or more risk factors, with diabetic peripheral neuropathy playing a central role. Decrease in sensation, foot deformities and limited joint mobility can result in abnormal biomechanical loading of the foot. This produces high pressure in certain areas, to which the body responds with thickened skin. This leads to a further increase of the abnormal loading, often with subcutaneous haemorrhage and eventually ulceration (Schaper et al, 2016). Precautions can be taken to reduce the risk of diabetic foot ulcers. General measures include interventions that Mr Bloggs should have been undertaking as part of his diabetic control i. e. eating a healthy balanced diet and trying to keep active; which can improve circulation. Footwear is also very important, correctly fitting shoes should be worn at all times. The nurse’s role is important in this aspect as regular inspection and examination of the at-risk foot, education for the patient and family and prompt treatment of pre-ulcerative signs are all key elements which underpin prevention of foot problems. All people with diabetes should have their feet examined at least once a year to identify those at risk of foot ulceration. Patients with a high-risk factor should be seen more often based on their risk category (Schaper et al, 2016). Education for the patient is of paramount importance. The aim is to improve patients' foot care knowledge, awareness and self-protective behaviour, and to enhance motivation and skills in order to encourage adherence to this behaviour. People with diabetes should learn how to recognize potential problems in their feet and be aware of the steps they need to follow if these problems arise. The educator must demonstrate the skills, such as how to cut nails appropriately, how to examine the sole of the foot and how to check between toes. Education should be provided in several sessions over time, and preferably using a mixture of methods. It has been shown that a combined method of education when compared to a lecture method has a significantly better effect on healing of the diabetic foot ulcer especially in terms of surface area of the ulcer. It is essential to evaluate whether the person with diabetes (and, favourably, any close family member or carer) has understood the information, is motivated to act and adhere to the advice and has sufficient self-care skills. Furthermore, healthcare professionals providing these instructions should receive periodic education to improve their skills in care for patients at high-risk of foot ulceration, and to improve their ability to teach the skills required (Schaper et al, 2016). Having a family member or carer who understands the information and importance of foot care may be useful in Mr Bloggs’ case as he has poor visual acuity which may mean he isn’t able to adequately complete his self-foot inspections. Also, he finds his long-term condition difficult to manage which may result in less motivation for self-protective behaviours so having a friend or family member to encourage and help him may be useful.
Mr Bloggs may have multiple potential future care needs if his diabetes continues to be poorly controlled. Chronic hyperglycaemia is associated with many serious complications such as heart disease, stroke, end-stage renal disease, neuropathy, dental disease, amputations and premature mortality. Various pathways have been recognized through which elevated blood sugar is thought to mediate cellular dysfunction and damage. If these complications were to arise, Mr Bloggs’ lifestyle and care needs would be likely to change significantly (Vora et al, 2012).
The Diabetes Action Plan 2010 highlights actions that have been taken in order to improve care for those with diabetes in Scotland. These include implementation of research-based high quality clinical practice, supported by NHS boards, NHS Quality Improvement and Diabetes UK Scotland. One of the aims of the action plan was to promote self-management of the condition through effective education, better access to psychological support and the use of information technology. Also, minimising the impact of potentially serious complications associated with diabetes. The Diabetes Improvement Plan also set out goals to be achieved for diabetes care in Scotland where person centred care is a focus, the aim is to ensure people living with diabetes are empowered and enabled to self-manage their condition by accessing high quality, consistent education and creating care plans individualised to the patient.
It would be important to consider many aspects of nursing care for patients with type 2 diabetes mellitus. Not only are there multiple presenting symptoms that need to be managed in order to ensure a good quality of life. There are also many possible complications that can develop due to poor glycaemic control or delayed diagnosis (Brooker et al, 2011). Patient education and sufficient self-care skills are an essential aspect in minimising the likelihood of complications developing and having good symptom control. However, having a heavy focus on education and self-care can mean that self-management of diabetes can seem very overwhelming and difficult to the patient which may reduce the patient’s motivation for positive behaviours. Changing behaviour and adhering to self-protective behaviours can be difficult so it’s important to ensure a clear, specific plan is in place, including what is going to be done, who is going to help the patient (social support) and how any obstacles or difficulties will be overcome. Sustainable changes should be the aim so that the patient can live a healthy and enjoyable lifestyle.
