WRITTEN ASSIGNMENT NJ274
During my clinical placement in a hospital ward I had the opportunity to work as part of a multidisciplinary team participating in the process of nursing. The nursing process is based on human relations and exploration of human potentiality. It is changing all the time in accordance with social, technological and human development but the full meaning of nursing profession is the nature of nurse-patient relationship (Stein-Parbury and McKinley, 2000, p.29). The purpose of this assignment is to focus on a patient (after gaining his consent), in whose care I have participated. With regard to confidentiality and in compliance to legal guidelines the patient name has been changed and the trust or ward will not be named (MMC Code of Conduct 2008).
Mr. John Ireland, 85 years old, has been admitted to hospital after collapsing at home. A check on his blood sugar has confirmed hypoglycemia. Mr. Ireland was diagnosed with Type 2 diabetes mellitus nearly 25 years ago. He was initially controlled on diet and Metformin. Over the last year his diabetic control has worsened and three months previously he was commenced on Mixtard 30/70 to supplement his Merformin 500mg. BD. Mr. Ireland lived alone in a 2 bedroom house and his wife was taking care of his diet and medication. Since his wife died 5 years ago, John had managed on his own but last year he had his left leg amputated below the knee as complication of diabetes. He returned home and had to relay on the help of 3 carers daily and “meals on wheels”.
Mr. Ireland has been admitted after collapsing at home because of hypoglycemia (very small amount of blood glucose). On admission, John’s observations revealed anxiety and fear according to his facial expression, the skin had a pale color and looked dehydrated as well as dry mucous membranes and decreased body weight (loose fitting clothing), and there are unpleasant odors from his mouth and his body indicating a poor hygiene and probably urine incontinence. John is wearing two hearing aids and glasses. The medical history revealed high blood pressure, diabetes, left leg amputation below knee as a result of neuro-ischaemic foot.
The interview took place in one of the male bay using the Roper-Logan-Tierney model of practice as an essential tool for data collection. Listening effectively in a confidential way (pulling the curtains around the bed to give him some privacy), trying to have at least a basic level of empathy helped John to feel safe and open up new area for discussions, explore and clarify stories and feelings, search for action strategy (talking about changing few things in his lifestyle) and moving to a further stage of the helping process (Egan 2007 p.132). The patient is the primary source of information and it is essential that whatever data are obtained to be kept confidential in accordance with Data Protection Act 1988.
After gathering information the nurse should ascertain fact from possible fiction, organize information into groups or categories to identify patterns of health or disease filling in the gaps to see more clearly the situation. Health professionals must focus on the psychological and social aspects of a person’s life and make each learning encounter relevant to his/her needs (Knight et al. 2006).
Diabetes mellitus is a complex, metabolic disease characterized by high blood glucose concentrations. It is associated with impaired insulin production and/or action, resulting in the body’s inability to utilize nutrients properly. The various genetic and environmentally or lifestyle factors influence the cause and the prognosis of the condition. Type 2 diabetes mellitus is the most common form of diabetes affecting 2-5% of the population, and the prevalence of it it’s likely to rise as result of aging, lack of physical exercises, inappropriate diet and increase of obesity (Fox & Kilvert 2007).
People respond to the diagnosis of diabetes depending on their own capacity to adjust physically, psychologically , socially, and the availability of family support. Fitting diabetes into family life can be difficult and changes over time with increasing duration of the disease. Living with diabetes requires knowledge and experience, build up over time. The level and pace of learning vary between individuals. It is important for health care professionals to appreciate the gaps between learning, understanding why such gaps occur. Mr. Ireland described relief that did not had a worse diagnosis such cancer. He did not know much about illness but from his knowledge ‘people do not die from diabetes and it is not supposed to change much just to take some medication’. Experiences of diabetes previously learned from family members or friends may have been inappropriate. John clearly received from other people incorrect and inconsistent information to the diabetes requirements for his age and his lifestyle. The assessment and care planning process will look at each patient as a whole with unique characteristics and strengths also to the distinct, functional areas for the purpose of gaining knowledge about the patient’s status, identify possible problems and access them by looking at causes and risks and considering how these can be managed to provide for the patient the highest possible level of well-being, develop and implement an interdisciplinary care plan that is regularly evaluated, involve the patient in discussion and care planning whenever he choose, re-evaluate and modify the plan as appropriate. The care is planned according to the activity concerned. Evidencing the problem and the goal to be achieved will lead to plan the nursing intervention. Evaluation of the patient’s condition and reflection on the evolution of case is needed for deciding any further interventions and planning care in collaboration with the patient, his family and members of multidisciplinary team. The discharge plan may be initiated, recording the problem identified, the factors affecting health recovery, the action and the referral to agencies required.
Mr. John Ireland’s assessment has been done in a holistic approach because the nursing moves beyond disease management and requires that the nurse and patient collaborate to promote health. Observation of the patient are made not only of the physical condition but also of his psychological and emotional state too. Observations depends not just on sight but also uses the sense of hearing, touch and smelling and will direct the nurse to data collection which includes further observation on specific factors.
Along with effective communication to the patient and his care needs, the community health nurse is able to obtain information about Mr. John’s situation from such subjective data as the nurses need have to be aware in building positive yet social relationship with the patient. From perspective in Newman’s theory the nurse can penetrate deeper dealing with the patient as a whole looking at five interacting aspects: physiological, psychological, socio-cultural, developmental, and spiritual (Meleis 1997 p.302). Looking at Mr. Ireland case it becomes apparent that, despite being educated by health care professionals over time, he does not made the choices recommended. One of the motivation for non-compliance is by his own admission that the health care professionals dictate to him what is to be done or changed and expected him to follow the instructions. Better approach in patient education is cooperation and collaboration which is based on preparing the patient to make informed choices and understand his/her values, wishes, and ability to participate in decision making. All professional nurses have had experiences with uncooperative patients, showing the importance of a better understanding of the factors that influence patient decision making such as: beliefs, attitudes, life stress and previous experience (Rankin, Stallings, London 2005).
Nurses, by giving active information, can speed up recovery and reduce the number o possible complications. Barriers to an interference with communication can occur at any point in the process of education and can be environmental which lead to the distortion of the message and distractions. From the joint Department of Health and Diabetes UK Care Planning Working Group they have set a guide on the care planning process for diabetes services. This care planning process aims to help diabetics achieve optimum health trough a partnership approach with health care professionals in order to learn about diabetes, manage it and related conditions better and cope with it in their everyday lives. The main role of a nurse in a diabetes case is education because she informs and teaches the patient about the right management of care and the proper ways of coping with consequences of diabetes. Diet and nutrition, foot care, physical activity, administration of medication, it is the duty of the nurse, but to care. It is also her role to educate those people who don’t have diabetes so as to prevent the occurrence of the mentioned disease. (Overland, J. and Brooks, B.) Nursing theories encourage the nurses to help the patient regain a sense of control and participate active in their recovery. Sometimes the meaning of help changes and like in my experience simply made by being with the patient will offer whatever comfort the situation allows, bringing hope, confidence and trust. The nurse-patient relationship is central to the healing process but different patients have different needs so the nurse must use a mix of skills, styles and techniques to adjust to each individual. Amiably, it has been estimated that the majority of patients with diabetes receive care from community family physician or nurses (Kerr, 1995 p. 65).The complexityand chronicity of diabetes presents special challenges for nurses whose responsibility is the screening andprevention of diabetes complications. Several researcher argued that effective development and dissemination of guidelines should identify and address barriers to implementation in healthcare settings (O’Connor, Rush, Peterson et al, 1996; Hempel, 1990; Miller and Hirsch, 1994; Williams, Munroe, Hospedales et al, 1989; Koperski, 1992). The failure to have care for patients with diabetes maybe assigned to lack of adherence, failure of nurses’knowledge and skill level into health system and that, factors relevantto diabetes care is achievable through implementation of social related diabetes management framework.
Most people with diabetes receive care from community health nurses and other care providers allowing the provision of integrated, accessible health care services by healthcare team who are accountable for addressing majority of personal health care needs, developing sustained partnership with patients and practicing within the context of family and community and if being realized in practice there is comprehensiveness and coordination as matching the care needs of the diabetic patient. The complexity of diabetes and frequent involvement of professional nurses and institution makes positive coordination a cornerstone of high quality diabetes care. Efforts to improve the care of Mr. John must begin with the fact that majority of diabetic patients receive the bulk of their care in primary care practices and are likely to do so for the foreseeable future. Thus, coordination of care across nurses and healthcare is defining characteristic of primary care and is of critical importance for persons with chronic disease. Diabetes have broad spectrum of severity with patients at the less severe end. Nurses can readily meet the clinical needs of Mr. John and other patients suffering from diabetes. However, patients requires complex regimen may benefit from transfer to specialist care, most adults with diabetes have more than one chronic condition. For example, more than half of patients with type 2 diabetes mellitus have concurrent hypertension and another one third or more have clinically apparent coronary artery disease. Professional nurses of diabetes care organize and coordinate patient care through series of interactions during which they elicit and review data concerning patient perspectives and other critical information about the course and management of the condition or conditions, help patients set goals and solve problems for improved self-management, adjust therapy to optimize disease control and patient well-being, and ensure follow-up. Nurses who are skilled in modern self-management support and adjustment of therapy by protocol may be critical components of effective diabetes care (30–32) and can be trained to perform aspects of clinical case management.
Proper diabetes care plan for Mr. John plays a vital role in his illness care, social support and improvements is critical to the success of diabetes management. The future of Mr. Johns care needs will depend on the nurses and other care providers ability to manage his social and medical needs. Recognition of diabetes as one of the most challenging chronic illnesses to manage has led to a dramatic increase in diabetes research focused on behavioral and psychosocial issues and that social support plays significant role in explaining certain self-care behaviors and outcomes The impact of diabetes was expressed in
both physical and psychological terms. Many reported feeling physically tired and
sometimes physically sick, feeling physically sick was often associated with having other chronic conditions. The psychological impact of diabetes was
stronger and emerged as feeling nervous, tired and worries about diabetes
complications, and feelings of dietary deprivation. The nurse role is to describe the feeling of responsibility for providing emotional and/or tangible aid to extended family members and friends. Care should be provided to Mr. John as appropriate management behaviors particularly lifestyle behaviors and the
increased level of responsibility. Diabetes is deteriorating chronic disorder and
no matter how well nurses delivers prevention, patients will require expert help from specialist centers. If seamless care is to be provided for Mr. John then some practices should share patient management protocol with other health care colleagues.7 However, existence of care protocol does not mean that nurses agrees with it or uses it. If there is no protocol then it is impossible for patients
to have consistent care across the needed interface. Nurses will try to optimize patient outcomes through series of interactions during which they elicit and review data concerning the patient perspectives and some critical information
about diabetes, its management of condition as well as help the patient to set goals and solve problems for improved care management and applies to clinical and behavioral interventions that prevent complications and optimize diabetes control, Mr. John’s well-being and ensuring of continuous follow-up.
Social theory is placed on how the patient interacts to what others think or believe about his condition as these interactions are likely to be productive if Mr. John is active, informed patient in the nursing care. He must have ideal information, skills, confidence to make best use of his involvement with the nursing team and the latter must have the necessary expertise, resources to act, rather than just react, to ensure effective care management.
Previous investigations indicate differences in knowledge about Diabetes and the body in people from different parts of the world (Hjelm et al. 1998 and 1999). Nurses should learn about the implications for health promotion activities of differing knowledge bases in different populations. Discussions of the influence of socio-economic and cultural beliefs are important for understanding the influence of individual beliefs about health and illness. The impact can be on individual and societal level, reduced by appropriate treatment (DCCT 1993, Turner 1998). Nursing profession needs to include sound knowledge base about diabetes and its management, as well as measures for secondary prevention aimed at promoting health and preventing the development of complications related to the
Disease, a health problem demanding physiological, social and psychological adaptation (William-Olsson 1986, Ternulf Nyhlin 1990, Wikblad and Montin
1992), nurses should learn holistic approach to the disease in all its dimensions, so as to diminish its effects as recommended and described in guidelines for diabetes care (Socialstyrelsen 1999). Nurses should also learn how to develop a diabetes care organization that is patient centered, high quality and cost effective.
Examples are multidisciplinary teams, evaluations from the patient perspective and studies of cost-effectiveness (Ragnarson Tennvall & Apelqvist 1997, Apelqvist & Larsson 2000, Hjelm et al. 2002). Nurses will have pathways
for rapid expert assessment and intervention aimed at teaching patients to live with the problem and to react early to signs of ill-health. The main underlying causes of Mr. John’s diabetes did showed to be genetic factors and relatively rapid changes of lifestyle (Zimmet 2000). Energy dense food rich in fat and carbohydrates is often less expensive than healthy food. The global market has developed and habits have spread from industrialized countries (Philips and Verhasselt 1994) concerns not only economic change, but also changes to diet (Zimmet 2000). Furthermore, it is important that nurses become aware of and active in international and regional agencies involved in global social, health, nutrition and welfare like, WHO, United Nations Development Program, nurses should be involved in the development of policies for education and intervention and legislative changes to reduce the adverse effects of nutritional transition (Zimmet 2000).
Many patients are passive, and the origins of this passivity do not lie only within the patients, but also in the way they are spoken to and dealt with by the healthcare professionals. Different situations demand different responses from the professionals. Telling patients what to do might be a relatively straightforward procedure, but it may not be the most effective or the most rewarding approach to take with patients (Rollnick and Mason 2001). Treatment plans should involve the person and the family and have to incorporate each individual’s own chosen goals. Interventions must aim to promote and maintain self-care behavior and maximize freedom and flexibility in individual’s life. People can have motivational problems because they do not feel that change is important or they are concerned about their ability to achieve it. The basic routine of psychological care is to check what people know about their situation, then to amplify or correct this information if necessary. The interaction between mental health and diabetes can lead to a vicious cycle of worsening diabetes management and mental illness. From diagnosis, health care professionals and carers can play an important role in the mental health of diabetics by promoting psychological support to enable patients to come to terms with their diabetes and to take increasing control of their disease. Diabetes can cause psychological distress, separate from mental illness. Inability to perform activities of daily living and depending on other people increases the poor compliance with medication regiment and dietary guidelines. John’s way to cope with diabetes is regressive behavior indicated by stubborn refusal to respond to new conditions. The person with diabetes makes choice that affect his/her health care, is in control of what he/she learns and the self care practices he/she adopts. The consequences of this choices affect the persons diabetes outcomes which give him/her the empowerment over the illness. Some studies argued that man are better able to adjust post-bereavement, others, however have contradicted this viewpoint because more men then women are inapt at looking after themselves, becoming more depressed following bereavement (Hamilton 2006). From the social level, the loss of spouses and friends, retirement, cause all the people to disengage from contact with others. The disengagement theory was by Cumming and Henry and attracted immediate controversy. The theory has been criticized by Barnes et al.(2004) which found that such behavior was present before old age. Disengagement can be indicative of illness and withdrawal may in some instance be an early sign of serious health problems. The theory itself is no longer supported but the discussion and the research continue (Meiner and Lueckenotte 2006). Many people would probably like to combine aspects of disengagement and activity lifestyles and shown preference for family relationships. Older people prefer to live independently but also to have their children living near by to give the opportunity for activity interacting with family members with disengagement trough the privacy of their own homes (Stuart-Hamilton 2006). The geographical distance between Mr. Ireland and his soon means no younger generation to interact with resulting in psychological stress. The stress became greater when his wife died implementing a higher level of loneliness. It is important to note that for an individual affected by a chronic illness the psychological, social and familial factors are somehow interconnected. The emotional closeness between family members is in accordance with psychological and social wellbeing and can be a great support or disappointment according with circumstances (Gubrium and Holstein 2000).
The case study do imply to the real situation that, the majority of the people surrounding Mr. John intends to sympathize with him who have diabetes because of the fact that they think people with diabetes can’t eat sweet which is very unfortunate place in, being that sweets are very much fun to eat and often a misnomer that people with diabetes can’t eat anything sweet but its not practically true but the society don’t know about that that they have been misguided since when you tend to ask the majority they don’t easily point directly what diabetes is all about. It is not really nurses in the hospital but, it is the community health nurses duty to dissipate information to the residents, to the patients about certain medical conditions relating to diabetes which denotes a type of chronic illness. Indeed, people think when they hear about diabetes the victim can no longer eat sweets and believed that diabetes is caused by eating too much sweets in short, they always relate diabetes to sweets The differences between patients and professionals in their understanding often result in conflicting expectations about treatment, priorities and outcomes of care. There demonstrate that patients’ personal understanding of illness is an important complement to the traditional professional view of diabetes. They could serve as a foundation for development of health history interviewing, as well as development of systems of documentation. Patients’ personal understandings of diabetes in their daily lives are considered to be an important shared source of information for planning meaningful care. Furthermore, upon adopting constructive diabetes representations, Mr. John needs a supportive care and family groups whose lifestyle does not radicallyconflict with the demands of diabetes for social care and his well being will be optimal (Glasgow, Hiss, Anderson et al., 2001).
Nurses’ perceptions in caring for persons with diabetes have been little studied and addressing to this gap, certain research process incurs sample of nurses from Western health care system on nurses’ perceptions of problems encountered in the care of patients with diabetes as well as problems encountered by patients in diabetes management also nurses’ suggested solutions. The nurses perceived that they as nurses, needed more education to improve their care of diabetes patients; few nurses believed it was within the scope of their practice to change treatment regimens. The one perception was that acceptance of diabetes, knowledge deficits and non-compliance assumes to primary patient problems in the management of diabetes., reinforcement of importance of follow up in diabetes care to achieve patient needs. Other studies provide evidence for positive relationship of social support and chronicillness self-management for diabetes for instance, dietary behaviorappears to be particularly susceptible to social influences In addition, there is need to elucidatethe underlying mechanisms by which support influences self-managementand to examine whether social impact varies by diabetes,type of care/support as well as patient behavior. There must be understanding as tohow the social environment may influence diabetes care in nursing care ways along with social support. Patients and professionals agreedthat information given to patients, interaction between professionalsand patients, patient autonomy, access were important forgood diabetes care.Nurses will put emphasized empathy and aspects of goodcommunication and patients the desire to know enough to live a normal and happy life as related to changes in patients’ needs at specificpoints in the development of their diabetes, in their orientationsto care. Patients should be involvedin setting priorities for care. Since these priorities are dynamicfurther work is needed to explore the nature of patient satisfactionwith diabetes care.
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