Case Profile : Alice (People living with DM and chronic kidney disease (stage 3)
Alice is a 50 years old female living with a Type 2 DM with insulin treatment. She also has a diagnosis of chronic kidney disease (stage 3) and has a difficult time in sustaining glycaemia control “Brittle Diabetes”
Reason(s) for seeking care:
Recent severe hypoglycaemic episode, found unconscious by husband, ambulance called and glucagon IM used (2x 2mg) with responding GCS 10/15, BIBA and admitted to medical ward.
Past medical history:
? Rheumatoid arthritis
? Type 2 DM
? Chronic Kidney Disease stage 3
Social and Patient Narrative:
? Lives with husband and has 2 adult children within 5 minutes driving distance
? Family concerns over recent hypoglycaemic episodes – do not understand why Alice’s blood glucose levels are high one minute and low the next
? Family have had to call the ambulance twice in the past six months – husband “ surely there is something we can do at home”
? Is seeing a rheumatologist, and was recently started on steroid treatment for rheumatoid arthritis (per specialist) with no insulin adjustments
Medications:
NovoMix 30/70 mix; 20 units in the morning and 20 units at night
Prednisolone 2.5mg (titrated down from 20mg over w
2 weeks)
Diagnostic reports:
HbA1C 8%
Creatinie 111
eGFR 38
ACR 6
Part 1: Holistic Assessment – Alice
Alice has "Brittle" diabetes (DM) with fluctuations in her blood glucose level despite medical management. "Brittle" DM is difficult to manage and requires a holistic approach. A holistic approach for Alice includes assessing the physical, emotional, social, spiritual and environmental domains (Dunning 2009). The Living With Diabetes Study (LWDS) is a holistic tool using standardised scales and questions to measure domains. It includes how DM affects quality of life, such as mental health and well being, patient satisfaction of health services, patient management of DM, and DM natural progression over time. Findings from this tool can provide a more comprehensive view of the everyday lived experiences of people living with DM to improve health service delivery (Donald et al. 2012). Alice’s quality of life is affected poorly by DM and her and her family have concerns and believe her DM is not being managed satisfactorily.
Continuous communication about treatment goals, impact on well being and progression of condition is important for DM management. It is critical to have effective communication between the patient and their health care team throughout the cause of the disease (Wait 2011). The LWDS tool can ensure continuous care within a well organised system, where every health care professional involved in care is aware of the patients needs and how their position corresponds to the patient’s overall care pathway (Donald 2011). This is important in Alice’s case as she has a complicated case with a Nephrologist, Rheumatologist and a General Practitioner with a risk of communication breakdown.
DM is demanding and can have a daily impact psychologically and socially which may result in poor control of blood glucose levels (Donald et al. 2012). Blood glucose monitoring is another holistic, individualised assessment, providing insight into the effectiveness of the DM management plan, especially in unstable or "brittle" DM (Dunning 2009). It is a self management tool to maintain patients quality of life, allows direct feedback and provides them with confidence, control and responsibility over their disease (Diabetes Australia 2008). Regular readings and pattern changes are an educational tool utilised to inform the patient and health care professionals about the effects of lifestyle, behavioural and medication changes, determining the best management strategy. It also detects hypoglycaemia and hyperglycaemia which can improve safety and help motivate people living with DM to make appropriate treatment changes (Colagiuri et al. 2009).
Assessment Statement:
70 y.o female who lives with Type 2 Diabetes Mellitus and Rheumatoid arthritis. Microvascular complication: recent diagnosis of Chronic Kidney Disease stage 3. Pertinent issue: brittle diabetes with severe hypoglycaemic episodes requiring hospital admission. Social: Lives with husband and has good family support from children. Concern: DM management and ineffective communication between all health care professionals.
References:
Colagiuri S, Dickinson S, Girgis S & Colagiuri R, 2009, ‘National evidence based guideline for blood glucose control in type 2 diabetes, Diabetes Australia and the National Health and Medical Research Council (NHMRC), Canberra 2009, viewed 15 September 2013,
<https://diabetesaustralia.com.au/PageFiles/763/Final%20Blood%20Glucose%20Control%20Guideline%20August%202009%20(2).pdf>.
Diabetes Australia, 2008, ‘Blood glucose monitoring’, Diabetes Australia, Canberra 2013, viewed 15 September 2013,
<https://www.diabetesaustralia.com.au/en/Living-with-Diabetes/Type-1-Diabetes/Managing-Type-1-Diabetes/Blood-Glucose-Monitoring/>.
Donald, M, Dower, J, Ware, R, Mukandi, B, Parekh, S & Bain, C 2012, ‘Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study’, BioMed Central Public Health, vol. 12, no. 8, pp. 1-10, viewed 15 September 2013, PubMed Database.
Dunning, T 2009, Care of People with Diabetes: a Manual of Nursing Practice, 3rd edition, Wiley-Blackwell, West Sussex, UK.
Wait, S 2011, ‘Applying a holistic view to diabetes: management and care in Europe’, European Coalition for Diabetes, October 2011, viewed 15 September 2013,
<https://www.ecdiabetes.eu/documents/Holistic-view-to-diabetes-Nov-2011.pdf>.
Part II (500 words)
Based on the “assessment statement” from part I, highlight how potential nursing practice strategy(s)/ intervention may best meet and addresses the pertinent needs and issue of the case profile. Refer to credible research resources to substantiate your choice of approach/es.
Would you please use the references provided if possible. Thank you.
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