Type (Carrier, 2009). He was subsequently diagnosed

Type 2 Diabetes Mellitus and thePatient JourneyMr Joe Bloggs (The patient willbe referred to as ‘Joe Bloggs’ throughout this essay, this is a pseudonym. Theclinical area will also not be identified in order to respect confidentiality) isa 56-year-old man with poorly controlled type 2 diabetes mellitus.

He presentedto his GP aged 41 with symptoms of excessive thirst, fatigue and polyphagia;which are common presenting features in diabetes mellitus (Carrier, 2009). Hewas subsequently diagnosed with type 2 diabetes through an oral glucosetolerance test and a glycated haemoglobin (HbA1C) test. His treatment began witha combination of diet modification and regular exercise, a plan was made withthe dietician to outline important dietary requirements to ensure goodglycaemic control. He was also advised to begin to self-monitor his bloodglucose levels. Mr Bloggs was then prescribed Metformin to help with thecontrol of his blood glucose.

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He finds glycaemic control difficult and timeconsuming and feels that the symptoms he experiences following diagnosis aredue to this. Diabetic foot ulcers are an issue for the patient currently. MrBloggs has also experienced bilateral proliferative diabetic retinopathy thatwas treated with full pan retinal photocoagulation. A right vitreoushaemorrhage occurred as a result of Mr Bloggs’ diabetes, decreasing visualacuity. He attended the ward for a planned right vitrectomy which was requiredto treat the visual disturbances (floaters in vision) caused by the vitreoushaemorrhage.

One of the presenting featuresexperienced by Mr Bloggs prior to diagnosis was fatigue. Among people with diabetes,fatigue is a prevalent and distressing complaint. It has been noted byclinicians who work with patients affected by diabetes the considerable tollthat fatigue takes on the lives of their patients, yet there is littleempirical research describing the severity of the problem.

There are multiplepossible causes of the symptom. Fatigue in diabetes may be associated withphysiological phenomena, such as hypo- or hyperglycaemia or wide swings betweenthe two, this may be important to consider in patients with poor diabeticcontrol, such as Mr Bloggs. Fatigue may also be related to psychologicalfactors, such as depression or emotional distress, possibly relating to thediagnosis, or relating to the intensity of diabetes self-management.

This was afactor noted by Mr Bloggs as he finds the large self-care aspect of hiscondition difficult to manage. Fatigue may also be related to such lifestyleissues as lack of physical activity or being overweight—especially common inpeople with type 2 diabetes. (Fritschi and Quinn, 2010).

However, the complexinterplay 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 biologicalfactors are likely to influence these relationships and may better explain thehigh levels of fatigue seen in patients with type 2 diabetes mellitus.(Fritschi et al, 2015). This would indicate that it is important to considermultiple contributing factors when considering what nursing care may berequired in order to reduce the impact of fatigue on the patients’ health andlife.

An assessment of the patient’s lifestyle may be useful to rule out someof the possible causes. An important aspect of controlling symptoms is patienteducation and ensuring that the patient is able to control their long-term conditionas best as possible. Confusion over what constitutes a healthy diet shows theimportance of comprehensive, accessible diabetes education, essential toensuring good glycaemic control, and preventing diabetic complications,including diabetic retinopathy (Hall et al, 2016).

It may be possible that MrBloggs would benefit from further patient education in regards to dietmanagement and exercise which could reduce the symptom of fatigue that heexperiences.A major complication of MrBloggs’ condition is that he has developed diabetic retinopathy, althoughtreated with pan retinal photocoagulation, visual acuity has declined as aresult of the changes in the eye due to his diabetes. For nearly four decades,laser photocoagulation has been the effective approach for the treatment ofsight-threatening retinopathy. The strongest evidence came from two landmarktrials in the 1970s and 80s; the Diabetic Retinopathy- and the Early TreatmentDiabetic Retinopathy Studies. These studies showed how pan-retinal laserphotocoagulation can reduce the risk of moderate to severe visual loss at leastby 50%, with timely intervention. A very striking feature of diabeticretinopathy is that it may not cause any complaints until late stages, this maybe the reason that Mr Bloggs lost visual acuity as the retinopathy wasn’ttreated at an early enough stage.

Although this is a significant opportunityfor people who have their recommended fundus examination regularly. Ifsight-threatening retinopathy is diagnosed early it gives the opportunity fortimely treatment, and to preserve vision (Karadeniz, 2017). Regular examinationand screening is extremely important to preserve and prolong vision indiabetes. Diabetes planning and retinopathy screening should be part of acoordinated response which may reduce the chance of presentation of thiscomplication (Karadeniz, 2017).

Another important consideration in diabeticretinopathy is the psychosocial impact that it may have on the patient. It hasbeen demonstrated that working- age adults with a visual impairment aresignificantly more likely to report lower levels of mental health, quality oflife and social functioning (Nyman et al, 2010). Because of the combined stressof diabetes and the actual or threatened visual impairment experienced, theimpact is likely to be considerable. By increasing our understanding of thesocial implications of diabetic retinopathy, improved services such as familycounselling, work and financial support and social networking advice can beoffered to those most in need (Fenwick et al, 2012). In conjunction with theongoing behavioural demands of the condition (medication dosing, frequency, andtitration; monitoring blood glucose, food intake and eating patterns, andphysical activity) and the possible complications, living with diabetes can beincreasingly distressing and difficult, which indicates why diabetes careservices and psychosocial support is so important (Young-Hyman et al, 2016)Pathways to diabetic footulceration are similar in most diabetic patients.

Lesions generally result whena patient has two or more risk factors, with diabetic peripheral neuropathyplaying a central role. Decrease in sensation, foot deformities and limitedjoint mobility can result in abnormal biomechanical loading of the foot. Thisproduces high pressure in certain areas, to which the body responds withthickened skin. This leads to a further increase of the abnormal loading, oftenwith subcutaneous haemorrhage and eventually ulceration (Schaper et al, 2016).Precautions can be taken to reduce the risk of diabetic foot ulcers. Generalmeasures include interventions that Mr Bloggs should have been undertaking aspart of his diabetic control i.

e. eating a healthy balanced diet and trying tokeep 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’srole is important in this aspect as regular inspection and examination of the at-riskfoot, education for the patient and family and prompt treatment ofpre-ulcerative signs are all key elements which underpin prevention of footproblems. All people with diabetes should have their feet examined at leastonce a year to identify those at risk of foot ulceration.

Patients with a high-riskfactor should be seen more often based on their risk category (Schaper et al, 2016). Education for the patient is ofparamount importance. The aim is to improve patients’ foot care knowledge,awareness and self-protective behaviour, and to enhance motivation and skillsin order to encourage adherence to this behaviour. People with diabetes shouldlearn how to recognize potential problems in their feet and be aware of thesteps they need to follow if these problems arise. The educator must demonstratethe skills, such as how to cut nails appropriately, how to examine the sole ofthe foot and how to check between toes. Education should be provided in severalsessions 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 alecture method has a significantly better effect on healing of the diabeticfoot ulcer especially in terms of surface area of the ulcer (Hajbaghery andAlinaqipoor, 2012). It is essential to evaluate whether the person withdiabetes (and, favourably, any close family member or carer) has understood theinformation, is motivated to act and adhere to the advice and has sufficientself-care skills. Furthermore, healthcare professionals providing theseinstructions should receive periodic education to improve their skills in carefor patients at high-risk of foot ulceration, and to improve their ability toteach the skills required (Schaper et al, 2016). Having a family member orcarer who understands the information and importance of foot care may be usefulin Mr Bloggs’ case as he has poor visual acuity which may mean he isn’t able toadequately complete his self-foot inspections.

Also, he finds his long-termcondition difficult to manage which may result in less motivation forself-protective behaviours so having a friend or family member to encourage andhelp him may be useful.Mr Bloggs may have multiplepotential future care needs if his diabetes continues to be poorly controlled.Chronic hyperglycaemia is associated with many serious complications such asheart disease, stroke, end-stage renal disease, neuropathy, dental disease,amputations and premature mortality. Various pathways have been recognizedthrough which elevated blood sugar is thought to mediate cellular dysfunctionand damage. If these complications were to arise, Mr Bloggs’ lifestyle and careneeds would be likely to change significantly (Vora et al, 2012).

The Diabetes Action Plan 2010 highlightsactions that have been taken in order to improve care for those with diabetesin Scotland. These include implementation of research-based high quality clinicalpractice, supported by NHS boards, NHS Quality Improvement and Diabetes UKScotland. One of the aims of the action plan was to promote self-management ofthe condition through effective education, better access to psychologicalsupport and the use of information technology. Also, minimising the impact ofpotentially serious complications associated with diabetes (ScottishGovernment, 2010). The Diabetes Improvement Plan also set out goals to beachieved 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 toself-manage their condition by accessing high quality, consistent education andcreating care plans individualised to the patient (Scottish Government, 2014).It would be important toconsider many aspects of nursing care for patients with type 2 diabetesmellitus.

Not only are there multiple presenting symptoms that need to bemanaged in order to ensure a good quality of life. There are also many possiblecomplications that can develop due to poor glycaemic control or delayeddiagnosis (Brooker et al, 2011). Patient education and sufficient self-careskills are an essential aspect in minimising the likelihood of complicationsdeveloping and having good symptom control (Hall et al, 2016). However, havinga heavy focus on education and self-care can mean that self-management ofdiabetes can seem very overwhelming and difficult to the patient which mayreduce the patient’s motivation for positive behaviours (Fritschi and Quinn,2010).

Changing behaviour and adhering to self-protective behaviours can bedifficult 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 (socialsupport) and how any obstacles or difficulties will be overcome. Sustainablechanges should be the aim so that the patient can live a healthy and enjoyablelifestyle (Greaves, 2012).


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