diabetes case study essay

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Case study: a patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse.

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1  

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11  

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

    • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

    • Limited exercise

    • High carbohydrate intake

    • No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14  

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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Diabetes Management: Case Study Essay

Type 1 and Type 2 diabetes contrast based on their definitions, the causes, and the management of the conditions. Type 1 manifests through the pancreas producing little to no insulin, which is why it is essential to monitor the glucose levels in the blood (DiMeglio et al., 2018). People who are genetically predisposed are the target groups, and the condition can correlate with symptoms such as thirst, weight loss, and feelings of hunger. Type 2 diabetes occurs when the pancreas does not create enough insulin while cells do not have an adequate reaction to the insulin that is being produced (Roden & Shulman, 2019). Research shows that more than 90% of Americans with diabetes are diagnosed with Type 2, while less than 6% have Type 1 (Xu et al., 2018). Thus, lifestyle is the most critical factor in terms of prevention and treatment.

Table 1: Diabetes

Based on the fact that Type 1 diabetes correlates with low insulin production while the second type is linked to inadequate response to insulin, managing this hormone that has the function of facilitating the glucose to enter the cell is essential. Moreover, since the gene that regulates the production of resistin is overactive in people with obesity, it is evident that a diet that can reduce excess weight while addressing other diabetes-specific concerns can reduce risks.

Multiple diets claim to be effective in terms of managing type 2 diabetes, yet multiple factors have to be considered. For example, the Atkins diet mainly consists of products high in fiber and low in saturated fat. Since the CDC promotes the avoidance of saturated fat and the increase of fiber intake for sugar regulation, the Atkins diet may be suited for people with diabetes ( Centers for Disease Control and Prevention, 2021). On the other hand, a reduction in carbs may lead to poor glycemic control (Joshi et al., 2019). Thus, the diet has both pros and cons depending on circumstances.

Marketing claims regarding supplements, powders, and teas also target demographics looking for ways to reduce weight. For example, researchers refer to the commonly used ephedra supplements as potentially beneficial in short-term weight loss but mention side effects such as heart and nervous system (Miao et al., 2020). Garcinia cambogia has shown to be ineffective in weight loss and correlates with reports of liver damage ( US Department of Health and Human Services , 2022). Multiple teas, supplements, and powders that claim to be helpful for weight loss are unethically marketed since FDA often finds unlisted ingredients such as sibutramine, which increases blood pressure ( Center for Drug Evaluation and Research , 2022). Instead of opting for uncertified supplements, effective diabetes control correlates with a lifestyle change, including frequent exercise and a healthy and balanced diet. These measures are not only effective in terms of weight loss through calorie intake reduction but also beneficial for glucose regulation.

The case study presents three options, Savannah’s recommendation of following the Atkins diet, Alan’s claim that exercise and healthy eating can lead to positive results, and grandfather’s option of natural remedies. As a low-carb diet, Atkins may be effective since obesity treatment often relies on a carb reduction (Westman & Yancy, 2020). However, Alan’s recommendation of approaching the condition with a balanced overview on health based on activity and avoidance of certain foods is easier to follow and, possibly, more sustainable in the long run (Rubin & Herreid, 2003). Implementing natural remedies may be harmful since, as mentioned prior, researchers refer to the low efficacy and side effects. Thus, Morgan should maintain a healthy weight through balanced meals and higher activity levels.

Center for Drug Evaluation and Research. (2022). Vy & tea contains hidden drug ingredient . US Food and Drug Administration. Web.

Centers for Disease Control and Prevention. (2021). Manage blood sugar . Centers for Disease Control and Prevention. Web.

DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. The Lancet , 391 (10138), 2449–2462. Web.

Joshi, S., Ostfeld, R. J., & McMacken, M. (2019). The ketogenic diet for obesity and diabetes—enthusiasm outpaces evidence. JAMA Internal Medicine , 179 (9), 1163. Web.

Miao, S. M., Zhang, Q., Bi, X. B., Cui, J. L., & Wang, M. L. (2020). A review of the phytochemistry and pharmacological activities of ephedra herb. Chinese Journal of Natural Medicines , 18 (5), 321–344. Web.

Roden, M., & Shulman, G. I. (2019). The integrative biology of type 2 diabetes. Nature , 576 (7785), 51–60. Web.

Rubin, L., & Herreid, C. F. (2003). Morgan: A Case of Diabetes. National Center for Case Study Teaching in Science .

US Department of Health and Human Services. (2022). Garcinia Cambogia . National Center for Complementary and Integrative Health. Web.

Westman, E. C., & Yancy, W. S. (2020). Using a low-carbohydrate diet to treat obesity and type 2 diabetes mellitus. Current Opinion in Endocrinology, Diabetes & Obesity , 27 (5), 255–260. Web.

Xu, G., Liu, B., Sun, Y., Du, Y., Snetselaar, L. G., Hu, F. B., & Bao, W. (2018). Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: Population Based Study. BMJ . Web.

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“Diabetes as a case study of chronic disease management”: Eight years later. The opportunity learned from the COVID-19 pandemic

COVID-19 pandemic is still affecting the world and Health Care systems are facing very difficult situations as never before [1] . People with diabetes are paying a very high price to COVID-19, in terms of worse prognosis and high possibility to die [1] .

Several recommendations have been published on how to manage several specific aspects when COVID-19 is present in people with diabetes [2] , [3] , [4] or on how to manage the diabetes therapy during the pandemic [4] , [5] . However, it is clear that any recommendation to be followed needs an interaction between the person with diabetes and the health care professionals, which has been the major challenge in the period of lockdown and social distance [6] . Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing in order to continue to treat patients [7] .

Paradoxically, the pandemic has resulted in a major reorganization throughout the world in how diabetes care is delivered to outpatients [8] . Paradoxically, because, once again, diabetes has been confirmed as model for the management of a chronic disease and because the adoption of Telemedicine for diabetes management has moved from theory to daily clinical practice [9] . In 2012 a Group of Experts suggested “Diabetes provides a pertinent case of chronic disease management with a particular focus on patient self-management. This paper suggests using a six-step cycle for personalized diabetes (self-)management and collaborative use of structured blood glucose data ( Fig. 1 ). E-health solutions can be used to improve process efficiencies and allow remote access. Available evidence about the effectiveness of the cycle's constituting elements justifies expectations that the diabetes management cycle as a whole can generate medical and economic benefit” [9] .

A process for personalized diabetes management: details in the text.

We had to wait for the COVID-19 pandemic for these words to be quickly translated into action. The most important evidence is that Telemedicine works and it works in Type 1 diabetes, Type 2 diabetes and, notably, in old people with Type 2 diabetes [10] , [11] , [12] , [13] , [14] , [15] . This last evidence overcomes the idea that Telemedicine is a useful tool only for young persons.

Prior to the COVID-19 pandemic, the use of Tele-health world-wide was quite limited, while during this pandemic many health care professionals have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement [8] . In the post-COVID-19 era, Telemedicine will likely become an integral part of healthcare delivery, especially for chronic illnesses like diabetes. In fact patients will demand this service as they become comfortable with the technology. Furthermore, e-consults and tele-consults between primary care physicians and specialists will also increase. Similarly, the use of self-reflection, applications and tracking data from glucometers, insulin pumps or sensors can help to enhance the transmission of information between persons with diabetes and their healthcare providers.

This rapid need for Telemedicine visits has generated the demand to effectively educate Health Care Professionals on how to optimize its utilization. Clearly, is it time for a different training of the Health Care Professionals, with Telemedicine use being a mandatory field of their education. However, this will be not enough until Telemedicine will be recognized as tool for the delivery of care and adequately reimbursed. Finally, the development of specific algorithms implemented in the Telemedicine adoption for the management of the disease will surely help.

The “six-step cycle for personalized diabetes management” after twelve years seems never than before very useful for the diabetes management we have in front, whether the COVID-19 emergency will last or not.

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Diabetes, Case Study Example

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Introduction and Background

Diabetes mellitus is a serious and debilitating medical condition that if left untreated, leads to numerous complications and bodily system decline and permanent physical damage in patients. It is important to identify the challenges that patients face with this condition and to determine methods of managing the illness to minimize its symptoms and long-term complications. Diabetes emerges when the body is unable to effectively produce insulin at the pancreatic level, thereby interfering with blood sugar levels. When these levels cannot be controlled, a proper diagnosis and treatment must be identified to reduce possible organ and system damage. If treatment is not successful, progressive damage is likely to occur. Therefore, actions to prevent diabetes are essential, including maintaining a healthy weight, proper nutrition, and a routine exercise plan. The following discussion will present an example case study of a 46 year-old female named TP exhibiting many of the advanced symptoms of uncontrolled diabetes mellitus. Her condition will be explored in greater detail and will emphasize the importance of early diagnosis and proper treatment in the continuous management of this condition.

Uncontrolled diabetes represents a unique challenge to physicians and caregivers in the modern era. This condition leads to a significant burden for hospitals and other healthcare facilities as they treat this patient population (Kim, 2007). In 2004, statistics demonstrated that “609,000 admissions were primarily a result of diabetes. Among these 609,000 admissions, 191,181 (or 32%) were due to uncontrolled diabetes conditions” (Kim, 2007, p. 1281). Therefore, the condition of uncontrolled diabetes must be evaluated more closely in patients who face this concern to improve treatment options and to reduce the necessity for hospitalizations (Kim, 2007). It is necessary to consider the alternatives that are available to prevent hospitalizations for diabetes, particularly when there are no debilitating symptoms (Kim, 2007).

In patients with uncontrolled diabetes, the continued elevation of blood sugar leads to a variety of complications which may cause extensive organ and system damage over time (World Health Organization). Conditions such as diabetic retinopathy, diabetic neuropathy, kidney failure, heart disease, and stroke are common long-term complications of uncontrolled diabetes and must be prevented through a comprehensive treatment plan as best as possible (World Health Organization).It is expected that the economic burden of diabetes will continue to grow; as a result, it is necessary for those at high risk to manage their weight, partake in healthy nutrition, and exercise regularly to minimize these risks (World Health Organization).

It is recommended that patients at risk of diabetes or who have already been diagnosed to be provided with education and training in self-management and prevention strategies (American Association of Diabetes Educators, 2010). In this capacity, diabetes experts must address some of the most common types of self-care behaviors for diabetics, including nutrition, physical activity, medication administration, risk assessment (American Association of Diabetes Educators, 2010). From this perspective, patients face critical challenges in managing the diabetic condition, so education is a helpful tool in providing much-needed knowledge and guidance regarding this condition and its long-term impact on organs and systems (American Association of Diabetes Educators, 2010). These efforts also demonstrate the importance of establishing relationships with patients to increase their comfort level and discussion of diabetes and its impact on their lives (American Association of Diabetes Educators, 2010). This is an important and meaningful tool for patients, and in particular, those who experience uncontrollable diabetes and its complications over a period of time (American Association of Diabetes Educators, 2010).

When diabetes remains in an uncontrollable state, it is often very difficult to overcome the symptoms and to lead a life of normalcy without complications. There are methods of managing diabetes that are likely to provide some relief, including the development of a strategy to manage the condition that is adopted on a daily basis to prevent further complications from taking place. For example, blood sugar levels should be monitored daily and patients should recognize the importance of regular meals with a balance of proper nutrition (Mayo Clinic, 2013). In addition, portion control is one of the key necessities of a healthy diet and requires an effective understanding of recommended portion sizes and other characteristics (Mayo Clinic, 2013). In addition, if a patient is insulin dependent, he or she must coordinate the medication schedule along with food intake in order to accomplish the desired treatment and management objectives (Mayo Clinic, 2013). When administering insulin or other medications, it is necessary to be cautious and observant to ensure that there are no accidental errors in use that could further harm blood sugar levels (Mayo Clinic, 2013). This is an important step towards the creation of a more effective treatment plan for the diabetic condition (Mayo Clinic, 2013). Most importantly, patients should be aware of their blood sugar levels on a regular basis so that if any complications arise, they are treated rapidly and effectively (Mayo Clinic, 2013).

Description of Case History

Patient Profile

The patient in question is a 46 year-old Caucasian female who is married with two high school-aged children. She is 5 feet, 3 inches tall and weighs 225 pounds. Over the past five years, TP has gradually gained weight and is now well above her ideal weight of 130 pounds. She does not partake in a healthy diet and eats many of her meals on the go. She also does not exercise on a regular basis and often experiences fatigue. Both of TP’s pregnancies were difficult and had minor complications during birth. TP also experienced post-partum depression with both of her children and has periods of mood swings. She works outside of the home and volunteers at her children’s high school on the PTA. She is often on the go and finds it difficult to maintain a healthy diet. As a result, her weight has increased dramatically over the past several years.

Patient History and Clinical Course

Laboratory Data

The patient first presented at the emergency room with lethargy, fatigue, excessive thirst, and frequent urination. She had become severely dizzy at home and was unable to regain her balance and stand on her own. Her husband suggested that she should be taken to the emergency department for further evaluation. Upon initial examination, her initial blood sugar level upon testing was 205 mg/dL, which was cause for immediate concern. Upon additional testing at fasting, her blood sugar level was 175, which remained high, with diabetes as the primary suspected cause. During her stay in the emergency department, TP’s dizziness subsided and she began to regain full balance and awareness of her surroundings.

Investigations

Upon physical examination and vital signs, the physician noted that TP was severely overweight. Her blood pressure was 165/100 upon measurement. The physician was concerned that a combination of elevated blood pressure and diabetes-related symptoms was highly problematic for TP and likely contributed to her recent dizzy spell. Therefore, she was diagnosed with diabetes and hypertension at the time of the visit. The physician was required to make decisions regarding the course of her care and treatment plan so that she would be able to better manage her symptoms and related complications. However, the physician was concerned regarding her dizziness and as a precaution, ordered additional testing to ensure that there were no underlying neurological complications. Therefore, she was admitted to the hospital overnight for observation and for further testing.

The physician in charge of TP’s case was required to make a number of decisions regarding the administration of medications to treat the diabetic condition. TP had been notified of her diagnoses and the risks associated with these conditions. Therefore, the physician prescribed an oral medication to determine if TP would respond to this first line of defense and if it would be effective in regulating her blood sugar levels. TP was prescribed Metformin (Glucophage) 500mg BID and Lisinopril (Zestril) 10 mg BID to determine whether or not the patient would respond favorably to this treatment regimen.

Treatment from Admission to Transfer of Care

Upon the decision to admit TP overnight, it was important to administer the recommended medications to ensure that her diabetes and hypertension began to regulate as quickly as possible. This was an important step towards the discovery of new insights regarding the patient and her ability to tolerate the medication and to determine if it would be effective over the long term. It was important for the patient to begin pharmacological treatment as quickly as possible to prevent further complications from her excessive blood pressure and blood sugar levels. Therefore, she was administered the first dose of each medication in the emergency department while waiting to be transferred to the medsurg unit for overnight observation and long-term management of these conditions. TP recognized the severity of her condition and accepted the physician’s recommendations because she sought to improve her own health and to feel better on a daily basis, which she had not experienced for quite some time.

Care Plan During Admission: Patient Goals and Outcomes

Upon review of TP’s current symptoms and presentation, it was important to identify both a short and long-term treatment strategy so that her symptoms would not only improve, but she would also experience significant benefits from medication administration as well as lifestyle changes. It was important to identify the challenges associated with her condition but to also recognize that they were treatable and manageable. Upon review of TP’s case and the decision to admit her overnight for testing and observation, it was determined that her level of comfort and level of knowledge regarding her health status were of critical importance.

Prior to her visit to the emergency department, TP had recognized that her health was suspect; however, she had chosen to ignore some of the warning signs and did not take any precautions or other steps to improve her health and wellbeing through lifestyle changes. Therefore, in addition to establishing a medication-based treatment plan, the patient would be required to obtain additional education regarding her condition and how to best manage it through a combination of medication administration and lifestyle changes. The latter would serve as the primary focus of the educational component of her treatment plan to lose weight, consume a healthier diet, and exercise regularly.

Assessment of Body Systems Influencing Diabetes

Diabetes has a number of significant impacts on organs and systems if left uncontrolled or undiagnosed for long periods of time. In addition, for those patients who are able to manage their diabetes effectively, organ and system damage may also occur. From a cardiac perspective, diabetes is perhaps one of the most important contributors to the diagnosis of hypertension (Diabetes.co.uk) and is likely the reason behind TP’s own diagnosis. Furthermore, patients with diabetes are more likely to experience a greater risk of cardiovascular disease in different forms (diabetes.co.uk). In this context, patients must be observed regularly to identify any possible cardiovascular complications as a result of the diabetic condition (diabetes.co.uk). In addition, diabetes is a precursor in increasing the risk of stroke (diabetes.co.uk). Over time, diabetes has a significant impact on eye function, including a greater risk of diabetic retinopathy, particularly when diabetes is uncontrolled (diabetes.co.uk). Kidney function may also decline with diabetes and may lead to diabetic nephropathy (diabetes.co.uk). Diabetes has a significant impact on nerve function throughout the body, particularly in the hands and feet, and may lead to numbness and tingling, as well as the development of diabetic neuropathy (diabetes.co.uk). Under these conditions, it is important to identify the challenges associated with managing diabetes effectively as early as possible so that long-term damage is minimized for this patient population to prevent serious complications (diabetes.co.uk).

It is important to diagnose diabetes as early as possible so that treatment may begin and long-term complications and organ/system damage may be reduced (Spollett, 2003). In supporting the educational strategy for TP, it was important to utilize the services of an advanced practice nurse (APN) to support the treatment plan and long-term management program (Spollett, 2003). In this capacity, “At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care” (Spollett, 2003). Therefore, it is important for patients to be provided with a strategy or plan of care that will be most effective in meeting their specific needs associated with diabetes management to promote the desired outcomes (Spollett, 2003). It is important for APNs and other clinical knowledge experts to provide guidance and insight as necessary to ensure that patient outcomes are accomplished and met on a continuous basis (Spollett, 2003). It is not sufficient to provide initial education and then fail to continue to provide guidance on a routine basis; rather, patients such as TP must be evaluated and monitored consistently to determine how to best move forward in the chosen treatment plan (Spollett, 2003).

Key Outcomes

In the example case study involving TP, it was important to identify the challenges associated with her diagnosis and plan of care over the long term. TP’s diabetes had progressed for a period of years and had gone undiagnosed. However, the physician and clinical team believed that she could maintain her health and minimize damage by taking her medication as required and conducting several important lifestyle changes in her personal life. The physician recommended that TP establish a healthy nutrition plan and exercise regimen to reduce her weight on a gradual basis. TP took these recommendations seriously and joined a local Weight Watchers group to assist her with her weight loss goals. She began with small yet gradual changes to her diet, replacing some carbohydrates with vegetables and reducing her meat intake. She quit drinking soda altogether and also reduced her intake of sweets. She also began walking three times per week and gradually increased it to six days per week, four miles per day.

Over a period of nine months, TP lost 65 pounds and was on her way to achieving her weight loss goal of 95 pounds. She had achieved her goals and now had a new lifestyle to show for it. As a result, TP’s diabetes was under control and her blood sugar levels were almost consistently in the proper range. In addition, her blood pressure was under control and her medication levels were reduced. She continued to see her physician every few months to determine if there were any other required changes to her medication schedule. TP was on the right track to successful outcomes and sought to be as successful as possible in her lifestyle regimen to eventually be permitted to manage her diabetes without medication and solely with proper diet and exercise.

What Was Learned

With this example case study, it became evident that diabetes is a very serious and debilitating condition that causes widespread damage to organs and systems if left untreated. Therefore, this condition requires immediate diagnosis, care, and treatment to ensure that it is managed properly and effectively. This is an important step towards the development of new strategies to reduce diabetes-related complications and symptoms and to focus on prevention as best as possible. In this example, TP recognized that her health was in a decline, but was perhaps fearful of the outcomes. Therefore, she did not obtain treatment until she had no other choice. This is not the most ideal means of managing this type of condition, as it should be diagnosed and treated as quickly as possible to prevent further complications and other long-term damage to body organs and systems. It is imperative that individuals recognize that when symptoms arise that are typical of diabetes, immediate guidance and treatment are essential to the long-term care plan for these patients.

What Should Readers Learn

Based upon the results of this case study, it is important for readers to recognize the necessity of being proactive rather than reactive in diagnosing, treating, and managing diabetes over the long term. These efforts require a greater understanding of diabetes and its impact on organs and systems, as well as the importance of diabetes-related education and a proper treatment plan. This case study example provides further evidence of the dangers of excess weight and obesity on the body and how poor diet and limited exercise play a role in increasing the risk of diabetes and related complications. Therefore, nurses and other clinical staff members must be prepared to work with diabetes patients and possess the knowledge that is necessary to improve outcomes and to reduce these risks over time. These efforts will demonstrate that diabetes should be taken seriously at all times under all conditions and that there are significant benefits to establishing a treatment plan and lifestyle changes to reduce the long-term impacts of this condition.

Diabetes is a highly challenging and complex condition that requires significant attention and focus in order to reduce its symptoms and long-term complications. In this context, it is necessary for patients to recognize when they might have some of the symptoms of diabetes and to seek guidance and treatment from their physician. These efforts require a greater understanding of diabetes and its impact on organs and systems because these impacts may ultimately reduce the quality of life for these patients. Therefore, it is important to identify methods of reducing the risks of diabetes at the prevention stage so that there are fewer diagnoses of this condition in the general population. With this framework in mind, diabetes-related education is critical to prevention and in enabling population groups to recognize their own risks and how to prevent these risks from leading to a diagnosis of diabetes. It is imperative that clinical professionals work with patients such at TP to recognize these risks and to begin treatment as necessary when a diagnosis is made. This will enable clinicians to be effective in addressing the severity of diabetes and its potential impact on patient care and wellbeing for many patients.

American Association of Diabetes Educators (2010). Diabetes education services:

reimbursement tips for primary care practice. Retrieved from http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf

Kim, S. (2007). Burden of hospitalizations primarily due to uncontrolled diabetes. Diabetes Care, 30(5), 1281-1282.

Mayo Clinic (2013). Diabetes management: how lifestyle, daily routine affect blood sugar. Retrieved from http://www.mayoclinic.com/health/diabetes-management/DA00005

Spollett, G. (2003). Case study: a patient with uncontrolled Type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse. Diabetes Spectrum, 16(1), 32-36.

World Health Organization. Diabetes. Retrieved from http://www.who.int/nmh/publications/fact_sheet_diabetes_en.pdf

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• Diabetes Care for Children & Young People

Vol:05 | No:01

Children and young people’s diabetes care: Case study

• 12 Jul 2016

This case study demonstrates the physical and psychological difficulties faced by many young people with type 1 diabetes. Over the year following her diagnosis, Max had a deterioration in glycaemic control despite reporting that little had changed in her management. Detailed assessment revealed a number of psychosocial factors that were preventing her from achieving good control. However, working with her multidisciplinary team, she was able to address these issues and improve her blood glucose levels. This article outlines these issues and the action plan that Max and her diabetes team drew up to overcome them.

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This case study represents the challenges and issues, both physical and psychological, faced by a young person with type 1 diabetes and the support given by her diabetes multidisciplinary team (MDT). Implications for practice are addressed using current evidence-based research. The names of the child and family have been anonymised to protect their identity.

Case study Max (a pseudonym) is a 17-year-old girl who was diagnosed with type 1 diabetes 4 years ago at the age of 13 years. She and her mother were shocked and upset by the diagnosis, and both felt its management would be too great a task to take on by themselves.

Max is an only child and lives with her mother, a single parent. She attends the local state comprehensive school and is popular with her peer group. Her mother was very involved in her care and diabetes management from the onset. Despite this, her diabetes control deteriorated over time ( Table 1 ). In October 2012, her HbA 1c was 56 mmol/mol (7.3%); however, over the next year, this increased to 84 mmol/mol (9.8%) in July 2013. She found it difficult to count the carbohydrate portions in her food and her injections were hurting much more than when she was first diagnosed. She also expressed a fear of hypoglycaemia and of “looking stupid” in front of her friends.

Max and her MDT discussed treatment options to improve her glycaemic control. She refused insulin pump therapy but agreed to a blood glucose monitor and bolus advisor to assist with her regimen of multiple daily insulin injections (MDI). She is now using the bolus advisor confidently and has had regular one-to-one sessions with a psychologist. She is having fewer hypoglycaemic episodes and her HbA 1c has improved; in January 2016 it was 69 mmol/mol (8.5%) and in April 2016 it was 58 mmol/mol (7.5%).

Discussion Diagnosis Max and her mother were extremely shocked and upset by the diagnosis of type 1 diabetes and the potential severity of the condition and intense management required. Both felt it would be too great a task to take on by themselves.

Kübler-Ross and Kessler (2005) suggested that a diagnosis of diabetes is a life-changing event comparable to the experience of loss, and that children and families will often go through the five stages of grief defined by Kübler-Ross (1970) and outlined in Box 1 . They use this as a coping strategy to enable them to eventually acknowledge the condition. However, many families never reach the fifth stage of acceptance and many will fluctuate between the stages.

Although Max and her mum did accept the diagnosis eventually, at times both of them reverted to the earlier stages of grief. The diabetes MDT supported the family from diagnosis and will continue to support them throughout their time within the paediatric diabetes service, through the transition period with both paediatric and young people’s teams, until discharged to adult diabetes care.

The diabetes MDT was established after the Best Practice Tariff was introduced in 2012. It consists of doctors, nurses, dietitians, a psychologist and a personal assistant. It is well recognised that the MDT needs to work together in close cooperation to achieve good practice, and this can be strengthened by using written protocols, guidelines and targets (Brink, 2010). Logic would suggest that centres with MDTs and the same approaches and treatment regimens would have similar outcomes, yet the Hvidøre Childhood Diabetes Study Group has shown this is not the case (de Beaufort et al, 2013). In terms of glycaemic control, there were notable differences in patient outcomes across 21 diabetes clinics, all of which were committed to MDT-based practice. Although factors such as age, type of insulin regimen and socioeconomic status were shown to have some influence over specific outcomes, they did not explain the apparent differences between these clinics.

Family/social history Max is an only child and lives with her mother, a single parent. East et al (2006) suggested that rapid social change over the past 20 years has seen a marked increase in the number of mother-headed single-parent families. Max attends the local state comprehensive school, where she is generally doing well. She is popular with her peer group. La Greca et al (1995) suggested that peer relationships are important in diabetes management, as children and young people (CYP) may receive considerable emotional support from their friends. However, on occasions, Max’s peer relationships have had a counterproductive effect on her, and she feels she is different from her friends as the only one who has diabetes. This at times affects her self-esteem and impacts her diabetes control.

Max’s mother was very involved in her care and diabetes management from the onset. Anderson and Brackett (2005) suggested that parents typically take on most of the responsibility for management of diabetes when children are young or newly diagnosed.

Deterioration in diabetes control Max’s diabetes control had deteriorated since her diagnosis ( Table 1 ). In October 2012, her HbA 1c was 56 mmol/mol (7.3%), which indicated a good level of diabetes control and a reduced risk of diabetes complications, as suggested by the DCCT (Diabetes Control and Complications Trial; DCCT Research Group, 1994). At her subsequent diabetes clinic appointments up to July 2013, she reported that “nothing had really changed,” except she “didn’t have time to think about her diabetes,” although she felt guilty because she knew she could make herself ill and her mum would get upset. She stated that it was hard counting the carbohydrate portions in her food and her injections were hurting much more than when she was first diagnosed. Her height and weight remained static.

Diabetes care is greatly influenced by psychosocial factors when they obstruct people’s ability to manage their diabetes and achieve good metabolic control. A team-based approach to addressing an individual’s ability to cope is critical (Kent et al, 2010). It is important for healthcare professionals to be aware of how CYP think at the different stages of their development, as their understanding of illness and chronic health conditions is often greater than that of their peers. Jean Piaget (1896–1980) investigated cognitive processes in children, calling them “schemas”. By the time children reach around 12 years of age, they can describe illness in terms of non-functioning or malfunctioning of an internal organ or process. Later in development they can appreciate that a person’s thoughts or feelings can affect the way the body functions, which demonstrates an awareness of psychological factors (Taylor et al, 1999).

Spear (2013) proposed that we can begin to understand how young people with type 1 diabetes think, feel and behave if we consider the cognitive and biological changes that occur during adolescence. Glasper and Richardson (2005) suggested there is now a growing awareness that CYP are able to make their own decisions if given information in an age-appropriate manner. Gillick competence identifies children aged under 16 years as having the capacity to consent to their own treatment if they understand the consequences (NSPCC, 2016).

Butler et al (2007) suggest that adolescence is a time of upheaval when young people have to deal with the influence of peers, school life and developing their own identity, as well as all the physiological changes that occur. Young people with type 1 diabetes have the added responsibility of developing autonomy regarding the self-management of their condition. Hanas (2006) suggests that parents should continue to take part in their child’s diabetes care into adolescence and not hand the responsibility to the young person too early. Snoek and Skinner (2002) suggest that intensive self-management of diabetes is complex and time-consuming, and creates a significant psychosocial burden on children and their families.

There are significant challenges for CYP to engage in effective diabetes self-management. Several of these were identified with Max and her mother:

• Deterioration in diabetes control.
• Difficulty with carbohydrate counting.
• Insulin omission.
• Fear of hypoglycaemia.
• Painful injections.

Action plan An action plan was discussed between Max and the MDT. As she was on an MDI regimen (a long-acting insulin at bedtime and rapid-acting insulin with meals), a bolus advisor/blood glucose monitor was demonstrated and discussed with her and her mum. Max felt she would be able to use this to help eliminate the calculations which, although she was capable of doing them, she often lacked time to do so. With further discussion, Max said she was “scared of getting it wrong and having a hypo”. Insulin pump therapy was discussed but she did not want to “have a device attached to my body because it would remind me all the time that I have diabetes”. Insulin pump therapy is recommended as a treatment option for adults and children over 12 years of age with type 1 diabetes whose HbA 1c levels remain above 69 mmol/mol (8.5%) on MDI therapy despite a high level of care (NICE, 2015a).

The National Service Framework standard 3 (Department of Health, 2001) recommends empowering people with diabetes and encourages them and their carers to gain the knowledge and skills to be partners in decision-making, and giving them more personal control over the day-to-day management of their diabetes, ensuring the best possible quality of life. However, if a diabetes management plan is discussed in partnership with a (Gillick-competent) young person but they elect not to comply with the plan despite full awareness of the implications of their actions, then the diabetes team should support them whilst trying to encourage them to maintain the treatment plan. This can be very difficult and frustrating at times, as a healthcare professional is an advocate for the patient, and promotion of the best interests of the patient is paramount.

Psychology involvement Max was reviewed by the psychologist to assess her psychological health and wellbeing. The psychologist used the Wellbeing in Diabetes questionnaire (available from the Yorkshire and Humber Paediatric Diabetes Network) to assess her and identify an optimal plan of care.

The psychology sessions were focussed on her issues around the following:

• Worry about deterioration in control.
• The consequences of insulin omission.

Max had a series of one-to-one appointments and some joint sessions with the paediatric diabetes specialist nurse and/or dietitian, so this linked into other team members’ specialities.

Carbohydrate counting and use of a bolus advisor The dietitian assessed Max and her mother’s ability to carbohydrate count using a calculator, food diagrams and portion sizes, and both of them were able to demonstrate competency in this task. Garg et al (2008) have shown that the use of automated bolus advisors is safe and effective in reducing postprandial glucose excursions and improving overall glycaemic control. However, this can only be true if the bolus advisor is being used correctly and is confirmed as such by comparing blood glucose and HbA 1c results before and after initiation of the bolus advisor, and observing the patient using the device to ensure it is being used safely and correctly.

Barnard and Parkin (2012) propose that, as long as safety and lifestyle are taken into consideration, advanced technology will benefit CYP, as inaccurate bolus calculation can lead to persistent poor diabetes control. These tools can help with removing the burden of such complex maths and have the potential to significantly improve glycaemic control.

Insulin omission and fear of hypoglycaemia Max also expressed her fear of hypoglycaemia and of “looking stupid” in front of her friends. She admitted to missing some of her injections, especially at school. Wild et al (2007) suggest that a debilitating fear of hypoglycaemia can result in poor adherence to insulin regimens and subsequent poor metabolic control. Crow et al (1998) describe the deliberate omission or reduced administration of insulin, which results in hyperglycaemia and subsequent rapid reduction in body weight. Type 1 diabetes predisposes a person to a high BMI. Adolescent girls and adult women with type 1 diabetes generally have higher BMI values than their peers without the condition (Domargård et al, 1999). Affenito et al (1998) observed that insulin misuse was the most common method of weight control used by young women with type 1 diabetes. However, Max’s weight remained stable and there was no clinical indication that she was missing insulin to lose weight; rather, it was her fear of hypoglycaemia that drove her to omitting insulin at school. With the use of the bolus calculator, she was reassured about her calculations for insulin-to-carbohydrate ratios, but it was reinforced with her that the device would only work efficiently if she used it correctly with each meal.

Painful injections Max also highlighted that her injections were now more painful than when she was first diagnosed, and this was causing her distress each time she had to inject. Injection technique was discussed with her and demonstrated using an injection model, and her injection technique was observed and appeared satisfactory. She was using 5-mm insulin needles and so was switched to 4-mm needles, as recommended by Forum for Injection Technique (2015) guidelines.

Appropriate technique when giving injections is key to optimal blood glucose control; however, evidence suggests that injection technique is often imperfect. Studies by Strauss et al (2002) and Frid et al (2010) revealed disturbing practices in relation to injection technique, with little improvement over the years. Current diabetes guidelines do not include detailed advice on injection technique, and only the guidance on type 2 diabetes in adults (NICE, 2015b) makes any reference to providing education about injectable devices for people with diabetes. However, the older Quality Standard for diabetes in adults (NICE, 2011) recommends a structured programme of education, including injection site selection and care (Diggle, 2014).

Conclusion The issues and concerns this young girl had were identified and addressed by the diabetes MDT. She was assessed by several members of the team, and a credible, evidence-based action plan was put into place to assist her and her mother to manage her diabetes at this difficult time. Max is now using the bolus advisor confidently and having fewer hypoglycaemic episodes, and her HbA 1c has improved. She prefers using the 4-mm injection pen needles, although she remains hesitant when giving injections; she will still not consider insulin pump therapy. Her one-to-one sessions with the psychologist have now ceased, but she is aware she can access a psychologist at clinic on request, or if the MDT assesses that her psychological health has deteriorated.

When a child in a family develops a chronic condition such as type 1 diabetes, effective communication is vitally important to address issues with the family at the earliest stage so that problems can be discussed and, hopefully, resolved before they escalate out of control. Upon reflection, the team could have become more intensely involved at an earlier stage to prevent Max’s diabetes management issues and stop her HbA 1c from reaching such a high level. Furthermore, the new NICE (2015a) guideline has set the target HbA 1c at ≤48 mmol/mol (6.5%), so there is still some work to be done. However, the outcome of this case appears to be favourable at present.

Affenito SG, Rodriguez NR, Backstrand JR et al (1998) Insulin misuse by women with type 1 diabetes mellitus complicated by eating disorders does not favorably change body weight, body composition, or body fat distribution. J Am Diet Assoc 98 : 686–8 Anderson BJ, Brackett J (2005) Diabetes in children. In: Snoek FJ, Skinner TC (eds). Psychology in Diabetes Care (2nd edition). John Wiley & Sons, Chichester Barnard K, Parkin C (2012) Can automated bolus advisors help alleviate the burden of complex maths and lead to optimised diabetes health outcomes? Diabetes Care for Children & Young People 1 : 6–9 Brink SJ (2010) Pediatric and adolescent multidisciplinary diabetes team care. Pediatr Diabetes 11 : 289–91 Butler JM, Skinner M, Gelfand D et al (2007) Maternal parenting style and adjustment in adolescents with type I diabetes. J Pediatr Psychol 32 : 1227–37 Crow SJ, Keel PK, Kendall D (1998) Eating disorders and insulin-dependent diabetes mellitus. Psychosomatics 39 : 233–43 de Beaufort CE, Lange K, Swift PG et al (2013) Metabolic outcomes in young children with type 1 diabetes differ between treatment centers: the Hvidoere Study in Young Children 2009. Pediatr Diabetes 14 : 422–8 Department of Health (2001) National Service Framework: Diabetes . DH, London. Available at: http://bit.ly/18OpAzL (accessed 24.02.16) Diabetes Control and Complications Trial Research Group (1994) Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 125 : 177–88 Diggle J (2014) Are you FIT for purpose? The importance of getting injection technique right . Journal of Diabetes Nursing 18 : 50–7 Domargård A, Särnblad S, Kroon M et al (1999) Increased prevalence of overweight in adolescent girls with type 1 diabetes mellitus. Acta Paediatr 88 : 1223–8 East L, Jackson D, O’Brien L (2006) Father absence and adolescent development: a review of the literature. J Child Health Care 10 : 283–95 Forum for Injection Technique (2015) The UK Injection Technique Recommendations (3rd edition). Available at: http://bit.ly/1QeZU2E (accessed 24.02.16) Frid A, Hirsch L, Gaspar R et al (2010) The Third Injection Technique Workshop in Athens (TITAN). Diabetes Metab 36 (Suppl 2): 19–29 Garg SK, Bookout TR, McFann KK et al (2008) Improved glycemic control in intensively treated adult subjects with type 1 diabetes using insulin guidance software. Diabetes Technol Ther 10 : 369–75 Glasper EA, Richardson J (2005) A Textbook of Children’s and Young People’s Nursing . Churchill Livingston, London Hanas R (2006) Type 1 Diabetes in Children, Adolescents and Young Adults (3rd edition). Class Publishing, London: 329, 349–50 Kent D, Haas L, Randal D et al (2010) Healthy coping: issues and implications in diabetes education and care. Popul Health Manag 13 : 227–33 Kübler-Ross E (1970) On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families . Tavistock Publications, London Kübler-Ross E, Kessler D (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss . Simon & Schuster UK, London La Greca AM, Auslander WF, Greco P et al (1995) I get by with a little help from my family and friends: adolescents’ support for diabetes care. J Pediatr Psychol 20 : 449–76 NICE (2011) Diabetes in adults (QS6). NICE, London. Available at: www.nice.org.uk/guidance/qs6 (accessed 24.02.16) NICE (2015a) Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18). NICE, London. Available at: www.nice.org.uk/guidance/ng18 (accessed 24.02.16) NICE (2015b) Type 2 diabetes in adults: management (NG28). NICE, London. Available at: www.nice.org.uk/guidance/ng28 (accessed 24.02.16) NSPCC (2016) A Child’s Legal Rights: Gillick Competency and Fraser Guidelines . NSPCC, London. Available at: http://bit.ly/1Tj6DcF (accessed 24.02.16) Snoek FJ, Skinner TC (2002) Psychological counselling in problematic diabetes: does it help? Diabet Med 19 : 265–73 Spear LP (2013) Adolescent neurodevelopment. J Adolesc Health 52 (Suppl 2): 7–13 Strauss K, De Gols H, Hannat I et al (2002) A pan-European epidemiologic study of insulin injection technique in patients with diabetes. Practical Diabetes International 19 : 71–76 Taylor J, Müller D, Wattley L, Harris P (1999) The development of children’s understanding. In: Nursing Children: Psychology, Research and Practice . Stanley Thornes, Cheltenham Wild D, von Maltzahn R, Brohan E et al (2007) A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns 68 : 10–5

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Home Essay Examples Health Type 2 Diabetes

Diabetes Type 2: Case Study

• Category Health
• Subcategory Disease
• Topic Type 2 Diabetes

This assignment will provide and outline a patient case study. It will critically analyse the health issue of the patient, explore and take account of the culture, socioeconomic factors, discrimination, and ethnicity. Additionally, it will also outline critically the patient’s service provision and individualised policy, practice delivery care and services the patient received. It will conclude by outlining the main issues and the challenges that arises in the discussion of the case study about the health and social practice and policy. Finally, recommendations will be made to the policies, governmental guidelines and future practice that meet the needs in this case study.

• SH6053: Type 2 Diabetes
• Name: Mrs. B
• Gender: Female
• Date of Birth: 02/03/1945
• Sexual Orient: Heterosexual
• Marital Status: widow
• Nationality:
• Cultural Background: Irish
• Religion: Christian

Overview of Health History

Mrs B reports having a fairly unremarkable medical past, until her retirement age; when she needed a hip operation after a fall. She recalls her health started to struggle when she was diagnosed with type 2 diabetes and hypertension at the age of 61. She had a stroke in 2005 and it was recently identified by her GP that after the stroke she developed a slight cognitive impairment, with the GP identifying this as the reason for her memory problem. Mrs B used to be a heavy smoker before she had the stroke. She drinks occasionally and described her diet as being usually healthy with one or two heavy meals during the week.

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The Overview of Social History

Mrs B was born in the East Midland to an English mother and Irish father, she is the only surviving child of five siblings. Mrs B left school at the age of 15 and went on to work in a holiday Inn as kitchen porter. She left the job after few years to be married and raise her family. Mrs B never went back to work again. She had financial support from the government and also obtained a small amount of pension from her late husband’s place of work.

Family background

Mrs B is a 74-year-old woman, who currently lives alone in a council property in the East Midlands. She was married in the mid 1960s and she has three children. They all live locally. Her husband used to work in a manufacturing factory until he retired due to health issues and unfortunately passed away in the mid-90s. Since then she has been living alone but moved from her family house to a smaller council flat in 2000. Mrs B is a Christian and attend church locally every Sunday church locally. She relies on her son to take her to church and shopping, whenever her son is not available to take her, she would not able to attend due to her health issue.

Main Health and Social Challenges

Mrs B did not have a good start in life. she stopped going to school at the age of 15 and went on to work at an early age, start family life by getting married and having children. Her biggest challenge was when she lost her husband and moved from her family home to a smaller apartment. Mrs B’s another major challenge was when she was diagnosed with type 2 Diabetes, hypertension and stroke in the year 2005. She is now in her 70’s and since after the stroke, she was unable to manage her medication. In this issue, she risks more complications, mainly because the medication helps her in reducing hypertension (high blood pressure) also reduced the persistent of high level of blood glucose circulating due to a significantly reduce response to insulin or the lack of insulin in the body

History of Her Health Interventions (Effectiveness/Ineffectiveness)

Following her visit to the GP, her GP conducted an assessment on mental capacity to see if she could able to make her own decision regarding her health care, the GP also identified that although Mrs B had a stroke as well as cognitive problems, and notwithstanding, she still have the mental ability to make decisions concerning her treatment and care. However, it is also important to note that whenever she visits the GP, her presentation might be altered. For instance, she sometime become confused and forgetful. Which make it important for her mental capacity to be assessed once again, before obtaining her consent in other for the care and procedures to be delivered.

The History of Social Interventions (Effectiveness/infectiveness)

Mrs B believes she has the ability to make decisions by herself regarding her treatment and care. During the GP earlier assessment, she clearly stated she did not need any support, that she could manage independently without any help. While, her children told her to accept some support in the case of them not able or available to help. Although, she still felt that she could manage without any help. Mrs b also stated that she did not want ‘people’ (social services) ‘snooping and interfering’ because she does not trust them as they might probably decide to put her in a nursing home’.

Diabetes is said to be a serious and chronic disease that happened when the body does not produce sufficient insulin or when the body cannot respond effectively using the insulin it produces. While Insulin is hormone that controls blood glucose due to non-existence of insulin in the body or a notably weaken the function or the response of insulin in the blood (Diabetes UK, 2010). Also, diabetes has great impact on the health and wellbeing of individuals, families, people and society. It is as well suggested that 9.6 % of all adults affected with diabetes in UK are men while, 7.6 per cent are women (Public Health England, 2016).

Diabetes affect more than 1.4 million people in the UK (Diabetes UK, 2010) diabetes has two types, type 1 and type 2, both having one thing in common by persistent of high level of blood glucose circulating; due to a significantly reduce response to insulin or the lack of insulin in the body or to both factor combination. Type 1 diabetes is when the glucose in the body is too high and cannot produce enough hormone called insulin. Insulin administration is required daily to regulate the glucose amount in the blood, because the body immune has destroyed the insulin. Type 2 diabetes on the other hand, is when the insulin in the pancreas (Beta cells) makes in the body that cannot work properly, and the amount of insulin produce in the cell is reduced in the body by the level of insulin resistance inside the body. In most case insulin resistance is connected with being overweight and lifestyle factors where patient’s metabolic reaction toward insulin stop reacting.

Mrs B has type 2 diabetes, she identified herself as a Christian living in a small community of older people and her children lives close by, she had a quite a number of social supports from friends in her church and her children. Being around her children and church member seem to keep her occupied. In terms of ethnicity, diabetes type 2 is more common among Black people, South Asians, of African-Caribbean origin and African (Diabetes UK, 2014). In addition, the South Asians people living in UK are 6 times more likely to develop the disease than the white population. And African-Caribbean and African population in UK are three times more likely to have the disease than white people (Public Health England, 2018). On the other hand, (Diabetes UK, 2014) also stated that Obesity is 80-85% another risk factor of developing type 2 diabetes.

According to Diabetes UK, (2017) noted, it was estimated that there are nearly 1 million people living with diabetes in UK, that are undiagnosed having type 2 diabetes. Furthermore, globally the prevalence of diabetes in adults is between the age of 20 and 79 and it was also estimated that globally in 2012, the disease affected 382 million people. In the UK, the number of growing elderly population mostly affected are aged 65 and current the figures of (Office for National Statistics, 2010) suggested that over the last 25 years 15 per cent increased in 1984 to 2009 as well as, 16 per cent rise of 1.7 million people. While Diabetes UK (2010) stated that the national trend was reflected on evidence of people over the age of 65 on local level in East Midlands where Mrs B lives suffer diabetes.

Type 2 diabetes has one of the greatest links with obesity. Although, nearly two in every three individuals in UK are obese or overweight with 65.7% of men and 61.9% of women. Also, in 2006, about one in four kids in England that were measured in reception year are obese or overweight. While, in year six the rate is almost one in three. Furthermore, in UK, high levels of men meet the recommended levels of physical activity than women (Diabetes UK, 2010); however, moderate 30 minutes physical intensive activity a day for five day a week was recommended for everyone by the department of health. Additionally, deprivation is strongly linked with greater levels of obesity, physical inactivity, unhealthy diet and lower level of blood pressure control. However, each of these factors are for the people already diagnosed with the risk of developing serious complications of the health issues; such as type 2 diabetes (Diabetes UK ,2010). While at any given age, most individual in the UK are two times more likely than the average to have diabetes. Also, women who live in a home with low income are four times likely to be diagnosed with diabetes; than the individual’s who lives in the homes with highest income, (Diabetes UK. 2010) In Mrs B” s case, as noted above, she is been living alone in a council house with the effect of financial limitation to buy healthy food and to attend healthcare appointments.

On the other hand, in terms of socioeconomic factors, Mrs B inability to further her education and where she lives, might have influenced her health condition, while education is a vital means for improving one’s health and well-being, as with people with more education are probable more likely to learn about healthy behaviours. However, patients who had education might be more likely to understand their health needs, follow guidelines, able to communicate effectively with health care providers also able to advocate with their family and others. While, on the other hand, fewer resources and lower income means that individual with fewer education are more likely to live in communities that lack good health resources. Although, these communities are usually economically disregarded and might face more risk of poor health issues, due to, availability fewer means to supermarkets or further causes of healthy food and overflow of fast food outlets and restaurants promoting unhealthy foods. Additionally, socioeconomic factors like educational accomplishment, income and occupation is one of the major factors that influence health.

According to Salway et al., (2007) individuals on low-income might find it difficult to keep a stable healthy diet and the key cause of ill health is linked with economic factors, while poverty sometime results in disadvantaged and lack of nutrition. Furthermore, poverty might also lead to discrimination (both present and past) in addition to failure in national policy and corruption which is directly associated with shorter life expectancy and ill health, (Scambler G, 2019). Furthermore, (Scambler G), stated that having poor health is mostly linked with poverty and low income. However, it can be argued that such condition might affect the living condition of the individual such as housing, food as well as medical care. Although, with more effective approach in mind, promoting of health is intended at targeting groups who are at high risk on developing health issue such as type 2 diabetes. (Salway et al., 2007). Referring this to Mrs B case, moving from her family home to a smaller apartment and being lonely might also have contributed to her health issues.

In relation to service provision for Mrs B, as noted above, Mrs B clearly stated that she did not require any assistance and believes she could cope without any help. Also, during her GP earlier assessment, she clearly stated that she did not need any support, that she could manage independently. Meanwhile, her children told her to accept some support in the case of them not able or available to help. Though, she still felt that she could manage without any help. She also stated that she did not want ‘people’ (social services) ‘snooping and interfering’ because she does not trust them as they might probably decide to put her in a nursing home’. Although, evidence clearly shown that after she had been diagnosed with type 2 diabetes, she was unable to manage taking her medication and also relies on her children to take her to church and shopping, whenever her son is not available to take her, she would not attend.

She is also unable to go out to do shopping or have social activities on a daily basis. With these, no proper evidence of socialising, eating healthy meal and her poor compliance of medication was mention in her case which might suggest; that she might require some care as well as social support. The Mental Capacity Act (MCA) (2005) stated, that there is a well-defined reference mentioned on decision-making process of individuals and on how individuals make ‘unwise decisions. In considering the circumstance surrounding Mrs B case, it seems she is making unwise-decision by not accepting help, although with her GP assessed Mrs B seems to have the ability and capacity of making her own choice based on her own informed value and belief.

While Mrs B declined to be assessed by social service on the view of receiving support care at home, potentially there would be many other support venues, that might be available and may also be a beneficial in improving her health condition and quality of life. With regard to the issue of compliance with her medication, there could be other possible ways to prompt her taking her medication, such as to explore some medication resources like medication alarms that remind individual to take their medication which can be purchase in the chemist or suggest to family to ring her. Additionally, by not taking her medication could put her in further risk of health complications, as mainly because the medication helps her in reducing hypertension (high blood pressure) also reduced the persistent of high level of blood glucose circulating due to a significantly reduce response to insulin or the lack of insulin in the body (Department of Health, 2001).

While it is important for her to continue maintaining her social life link as being elderly, Mrs B meet her religious need by attending church service where she socialises church other member before being taken home. According to (Valtorta, 2012) noted, social isolation is one factor that contribute to other health issue such as loneliness and depression, tackling these problems would consequently has the effect to reduced health inequalities along with improving individual quality of life. However, Mrs B could not able to walk to shop sometime or attend church due to her feeling physically unwell, although, the only way to addressed the issue of loneliness and depression is to see if there is any other way to help and improve her social life through voluntary drivers in the church or any other scheme the council have in their area like ‘ring and ride’ car that she could take when her children are not able to take her. However, in Mrs B case, it might be good ideal to get her shopping delivered by voluntary agencies such as Age UK and many others that may also assist her or offer her support like ordering reading meals food from some large supermarket and company that are specifically arranged to deliver food to elderly.

According to (Singh, 2009) confirmed, that Age UK, also offer different kind of service such as ensuring that Mrs B needs, and entitlement are met by helping her in reviewing her benefits and offer her befriender that might also help her to reduce further risk of social isolated mainly when her children are away.

As previously identified in the case study confidentiality plays a significantly part in the relationship between patient and doctor and the responsibility of confidence arises when individual discloses information to another person in situations that is expect for the information will be held in confidence (Department of Health 2003). However, patient relationship is built successfully, this sequentially encourage the patient to release useful information about their health without hesitation. While not trusting might prompts an impersonal and self-justification attitude to medication by the patient and clinician, which could lead to the deterioration of the quality of profession life and patient care (Guttman, 2017).

Although, during Mrs B visit to GP for assessment, one can assume that the GP conduct medical assessment, like taking her blood and doing her blood pressure; the GP could have asked her prior on carrying out both procedure which she approved on both cases NCM, (2015). However, obtaining consent is a process and important part of health care practitioners’ duties by ensuring that a consent is obtained from the patient before any care procedure can be carried out, also regards and respect must be given to individual who decline treatment. According to (NCM, 2015) stated, that code of professional practice clearly outlines guidance with regard on how to obtain consent and when fail, could be seen as the act of a breach of conduct. One of the issues identified in Mrs B case study, is the issue of code of conduct which highlight individuals that lack capacity and the issues of consent. Furthermore, the (Mental Act, 2005) is intended to protect individual who can’t make decisions for themselves or lack the mental capacity to do so. However, this could be due to a mental health condition, a severe learning difficulty, a brain injury, a stroke or unconsciousness due to an anaesthetic or sudden accident (NHS Choices, 2018). The purpose of the act is to ensure individuals are able to make as many choices for themselves as they can and as a measure of protection for individuals who may not be able to make decisions for themselves due to the reasons listed above.

In conclusion, this assignment has discussed a case study that mainly focused on a health issue in which the patient in the case study was suffering from type 2 diabetes and the assignment also explore the intervention individualised care the patient received. However, there are many issue that can present when a patient been diagnosed with type 2 diabetes, the assessment also show that the main key issue in the case study is on how to control Mrs B diabetes, although, in other to control her diabetes, she needs to accept social service assessment for her to received home care support, maintain effective contact and family involvement and also for her to compline with her medication and furthermore, by encouraging her to accept services that is available.

Taking into account of the issue of type 2 diabetes, which have already increased over the last 25 years, it is obvious that more has to be done in safeguarding and protect the future occurrences of type 2 diabetes in UK. It will be suggested to add to the general nursing approach to individualised care by providing effective regular and appropriate home care sitting, providing effective assessment, teaching plan to help patient to maintain and control their blood sugar level.

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• Nursing & Midwifery Council. (2015) The code: Professional standards of practice and behaviour for nurses and midwives. London: NMC. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf (Accessed May 11 2019)
• ‘NHS Choices – Your health, your choices’. www.nhs.uk. 15 August 2018. (Accessed May 19, 2019)
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