Type a pseudonym. The clinical area will also not

Type 2 Diabetes Mellitus and the
Patient Journey

Mr Joe Bloggs (The patient will
be referred to as ‘Joe Bloggs’ throughout this essay, this is a pseudonym. The
clinical area will also not be identified in order to respect confidentiality) is
a 56-year-old man with poorly controlled type 2 diabetes mellitus. He presented
to his GP aged 41 with symptoms of excessive thirst, fatigue and polyphagia;
which are common presenting features in diabetes mellitus (Carrier, 2009). He
was subsequently diagnosed with type 2 diabetes through an oral glucose
tolerance test and a glycated haemoglobin (HbA1C) test. His treatment began with
a combination of diet modification and regular exercise, a plan was made with
the dietician to outline important dietary requirements to ensure good
glycaemic control. He was also advised to begin to self-monitor his blood
glucose levels. Mr Bloggs was then prescribed Metformin to help with the
control of his blood glucose. He finds glycaemic control difficult and time
consuming and feels that the symptoms he experiences following diagnosis are
due to this. Diabetic foot ulcers are an issue for the patient currently. Mr
Bloggs has also experienced bilateral proliferative diabetic retinopathy that
was treated with full pan retinal photocoagulation. A right vitreous
haemorrhage occurred as a result of Mr Bloggs’ diabetes, decreasing visual
acuity. He attended the ward for a planned right vitrectomy which was required
to treat the visual disturbances (floaters in vision) caused by the vitreous
haemorrhage.

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One of the presenting features
experienced by Mr Bloggs prior to diagnosis was fatigue. Among people with diabetes,
fatigue is a prevalent and distressing complaint. It has been noted by
clinicians who work with patients affected by diabetes the considerable toll
that fatigue takes on the lives of their patients, yet there is little
empirical research describing the severity of the problem. There are multiple
possible causes of the symptom. Fatigue in diabetes may be associated with
physiological phenomena, such as hypo- or hyperglycaemia or wide swings between
the two, this may be important to consider in patients with poor diabetic
control, such as Mr Bloggs. Fatigue may also be related to psychological
factors, such as depression or emotional distress, possibly relating to the
diagnosis, or relating to the intensity of diabetes self-management. This was a
factor noted by Mr Bloggs as he finds the large self-care aspect of his
condition difficult to manage. Fatigue may also be related to such lifestyle
issues as lack of physical activity or being overweight—especially common in
people with type 2 diabetes. (Fritschi and Quinn, 2010). However, the complex
interplay between blood glucose control, diabetes symptoms, diabetes distress
(burdens of diabetes and its treatment, worries about adverse consequences),
depression and fatigue is not well understood. Other individual and biological
factors are likely to influence these relationships and may better explain the
high levels of fatigue seen in patients with type 2 diabetes mellitus.
(Fritschi et al, 2015). This would indicate that it is important to consider
multiple contributing factors when considering what nursing care may be
required in order to reduce the impact of fatigue on the patients’ health and
life. An assessment of the patient’s lifestyle may be useful to rule out some
of the possible causes. An important aspect of controlling symptoms is patient
education and ensuring that the patient is able to control their long-term condition
as best as possible. Confusion over what constitutes a healthy diet shows the
importance of comprehensive, accessible diabetes education, essential to
ensuring good glycaemic control, and preventing diabetic complications,
including diabetic retinopathy (Hall et al, 2016). It may be possible that Mr
Bloggs would benefit from further patient education in regards to diet
management and exercise which could reduce the symptom of fatigue that he
experiences.

A major complication of Mr
Bloggs’ condition is that he has developed diabetic retinopathy, although
treated with pan retinal photocoagulation, visual acuity has declined as a
result of the changes in the eye due to his diabetes. For nearly four decades,
laser photocoagulation has been the effective approach for the treatment of
sight-threatening retinopathy. The strongest evidence came from two landmark
trials in the 1970s and 80s; the Diabetic Retinopathy- and the Early Treatment
Diabetic Retinopathy Studies. These studies showed how pan-retinal laser
photocoagulation can reduce the risk of moderate to severe visual loss at least
by 50%, with timely intervention. A very striking feature of diabetic
retinopathy is that it may not cause any complaints until late stages, this may
be the reason that Mr Bloggs lost visual acuity as the retinopathy wasn’t
treated at an early enough stage. Although this is a significant opportunity
for people who have their recommended fundus examination regularly. If
sight-threatening retinopathy is diagnosed early it gives the opportunity for
timely treatment, and to preserve vision (Karadeniz, 2017). Regular examination
and screening is extremely important to preserve and prolong vision in
diabetes. Diabetes planning and retinopathy screening should be part of a
coordinated response which may reduce the chance of presentation of this
complication (Karadeniz, 2017). Another important consideration in diabetic
retinopathy is the psychosocial impact that it may have on the patient. It has
been demonstrated that working- age adults with a visual impairment are
significantly more likely to report lower levels of mental health, quality of
life and social functioning (Nyman et al, 2010). Because of the combined stress
of diabetes and the actual or threatened visual impairment experienced, the
impact is likely to be considerable. By increasing our understanding of the
social implications of diabetic retinopathy, improved services such as family
counselling, work and financial support and social networking advice can be
offered to those most in need (Fenwick et al, 2012). In conjunction with the
ongoing behavioural demands of the condition (medication dosing, frequency, and
titration; monitoring blood glucose, food intake and eating patterns, and
physical activity) and the possible complications, living with diabetes can be
increasingly distressing and difficult, which indicates why diabetes care
services and psychosocial support is so important (Young-Hyman et al, 2016)

Pathways to diabetic foot
ulceration are similar in most diabetic patients. Lesions generally result when
a patient has two or more risk factors, with diabetic peripheral neuropathy
playing a central role. Decrease in sensation, foot deformities and limited
joint mobility can result in abnormal biomechanical loading of the foot. This
produces high pressure in certain areas, to which the body responds with
thickened skin. This leads to a further increase of the abnormal loading, often
with subcutaneous haemorrhage and eventually ulceration (Schaper et al, 2016).
Precautions can be taken to reduce the risk of diabetic foot ulcers. General
measures include interventions that Mr Bloggs should have been undertaking as
part of his diabetic control i.e. eating a healthy balanced diet and trying to
keep active; which can improve circulation. Footwear is also very important,
correctly fitting shoes should be worn at all times (Brooker et al, 2011). The nurse’s
role is important in this aspect as regular inspection and examination of the at-risk
foot, education for the patient and family and prompt treatment of
pre-ulcerative signs are all key elements which underpin prevention of foot
problems. All people with diabetes should have their feet examined at least
once a year to identify those at risk of foot ulceration. Patients with a high-risk
factor should be seen more often based on their risk category (Schaper et al, 2016). Education for the patient is of
paramount importance. The aim is to improve patients’ foot care knowledge,
awareness and self-protective behaviour, and to enhance motivation and skills
in order to encourage adherence to this behaviour. People with diabetes should
learn how to recognize potential problems in their feet and be aware of the
steps they need to follow if these problems arise. The educator must demonstrate
the skills, such as how to cut nails appropriately, how to examine the sole of
the foot and how to check between toes. Education should be provided in several
sessions over time, and preferably using a mixture of methods (Schaper et al,
2016). It has been shown that a combined method of education when compared to a
lecture method has a significantly better effect on healing of the diabetic
foot ulcer especially in terms of surface area of the ulcer (Hajbaghery and
Alinaqipoor, 2012). It is essential to evaluate whether the person with
diabetes (and, favourably, any close family member or carer) has understood the
information, is motivated to act and adhere to the advice and has sufficient
self-care skills. Furthermore, healthcare professionals providing these
instructions should receive periodic education to improve their skills in care
for patients at high-risk of foot ulceration, and to improve their ability to
teach the skills required (Schaper et al, 2016). Having a family member or
carer who understands the information and importance of foot care may be useful
in Mr Bloggs’ case as he has poor visual acuity which may mean he isn’t able to
adequately complete his self-foot inspections. Also, he finds his long-term
condition difficult to manage which may result in less motivation for
self-protective behaviours so having a friend or family member to encourage and
help him may be useful.

Mr Bloggs may have multiple
potential future care needs if his diabetes continues to be poorly controlled.
Chronic hyperglycaemia is associated with many serious complications such as
heart disease, stroke, end-stage renal disease, neuropathy, dental disease,
amputations and premature mortality. Various pathways have been recognized
through which elevated blood sugar is thought to mediate cellular dysfunction
and damage. If these complications were to arise, Mr Bloggs’ lifestyle and care
needs would be likely to change significantly (Vora et al, 2012).

The Diabetes Action Plan 2010 highlights
actions that have been taken in order to improve care for those with diabetes
in Scotland. These include implementation of research-based high quality clinical
practice, supported by NHS boards, NHS Quality Improvement and Diabetes UK
Scotland. One of the aims of the action plan was to promote self-management of
the condition through effective education, better access to psychological
support and the use of information technology. Also, minimising the impact of
potentially serious complications associated with diabetes (Scottish
Government, 2010). The Diabetes Improvement Plan also set out goals to be
achieved for diabetes care in Scotland where person centred care is a focus,
the aim is to ensure people living with diabetes are empowered and enabled to
self-manage their condition by accessing high quality, consistent education and
creating care plans individualised to the patient (Scottish Government, 2014).

It would be important to
consider many aspects of nursing care for patients with type 2 diabetes
mellitus. Not only are there multiple presenting symptoms that need to be
managed in order to ensure a good quality of life. There are also many possible
complications that can develop due to poor glycaemic control or delayed
diagnosis (Brooker et al, 2011). Patient education and sufficient self-care
skills are an essential aspect in minimising the likelihood of complications
developing and having good symptom control (Hall et al, 2016). However, having
a heavy focus on education and self-care can mean that self-management of
diabetes can seem very overwhelming and difficult to the patient which may
reduce the patient’s motivation for positive behaviours (Fritschi and Quinn,
2010). Changing behaviour and adhering to self-protective behaviours can be
difficult so it’s important to ensure a clear, specific plan is in place,
including what is going to be done, who is going to help the patient (social
support) and how any obstacles or difficulties will be overcome. Sustainable
changes should be the aim so that the patient can live a healthy and enjoyable
lifestyle (Greaves, 2012).

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