Category: Diabetes

Introduction

In this paper I intend to present on the case of Mr. Douglas, admitted to the unit with confusion, and disorientation. History revealed Type 1 diabetes and hypertension. The diabetes was managed with Insulin and Perindopril managed the hypertension. The low blood sugar level was successfully managed with simple carbohydrates and the BSL started resuming normal level (4.7mmol/L). (Sinclair, 2006, p. 231).The client is now fully conscious with a GCS of 15. In this paper, I would like to present on various nursing diagnosis for Mr. Douglas, with the priority ones such as Risk for high blood sugar, Risk for unstable blood glucose and risk for falls, and the related nursing interventions with the rational (Boyle, Zrebiec, & John, 2007).

Nursing Diagnosis

The nursing diagnosis based on the identified and primary problems are, “Risk for injury related to hypoglycemia, ‘Risk for Unstable blood glucose level (hypoglycemia) related to lack of adequate management of hypoglycemia evidenced by decreased blood glucose level’, ‘Risk for injury related to hypoglycemia, impaired mobility and hypotension evidenced by decreased blood glucose level and blood pressure’. “Risk for imbalanced nutrition, less than body requirement related to inadequate intake of nutrient”, impaired mobility and hypertension evidenced by decreased blood glucose level and blood pressure’ ‘Fatigue related to decreased blood glucose level and poor nutritional intake evidenced by complaints of weakness’, ‘Fear and anxiety related to hospitalization and development of complications evidenced by the verbal statements of the client. (Farrell, & Dempsey, 2011).

Nursing Interventions for the Primary Problems

‘Risk for Unstable blood glucose level (hypoglycemia) related to lack of adequate management of hypoglycemia and decreased oral intake, evidenced by decreased blood glucose level’. The goal of the nurse is to maintain normalcy in blood glucose level. To achieve this, nurse should maintain a safe and effective glycemic control, and implement nursing care based on evidence (Sanchez & Cruz, 2011, p. 56-89) to achieve glucose control (Judy et al. 2010, p. 98-106). Be alert to monitor for early signs of hypoglycemia (Mayerson, & Inzucchi, 2002, p. 13-28) that can be both neurogenic and Neuroglycopenic symptoms (Briscoe & Davis, 2006, p. 78-95). Review the hisotry and other data such as medications intake to find for clues that may cause persistent hypoglycemia (Cryer et al, 2009, p. 92-124). Perform continuous monitoring of blood sugar to ensure that the patient does not relapse back into hypoglycemia (Klonoff et al. 2011, p. 45-50 & Sanches & Cruz, 2011, p. 57-90). Administer 10% dextrose if the patient’s blood sugar lowers again and the patient is at a risk of falling back into hypoglycemia (Nehme & Cudini, 2009, p. 114-127). Fruit juice or honey could also be used if the patient develops hypoglycemia as these are simple forms of carbohydrates and can be absorbed easily and raise the blood sugar (Gorecki, 2009, p. 34-37). Plan for meal timings and provide required amount of carbohydrates (Day, Paul & Williams, 2009, p. 25-29). If the next scheduled meal is not ready, provide the patient with a combination of carbohydrates and protein, such as ½ cup milk, 1 ounce of cheese, and three saltine crackers. These will keep the blood sugar raised as the meal is in preparation (Smart, Vliet & Waldron, 2009, p. 44-47). Provide foods containing naturally occurring resistant starch (cornstarch) or foods modified to contain more resistant starch (high amylose cornstarch) that can prevent hypoglycemia. Be alert to monitor for hyperglycemia that result from over treatment of hypoglycemia (Shomali, 2011). The effectiveness of the above interventions implemented can be assessed by checking the patient’s blood sugar level regularly and ensuring that it is maintained at a normal level thus successfully preventing the client from hypoglycemia and by maintaining normal blood glucose level (Martorella, 2011, p. 8).

‘Risk for unstable blood glucose level (hyperglycemia) related to continued use of carbohydrate rich foods and fluids for the management of the hypoglycemia is the second priority nursing diagnoses. The evidence is found after testing the patient’s blood sugar level and finding out he has elevated blood sugar level to above normal levels (Bhasin et al, (2009). his could have been brought about by the carbohydrate intake by the patient that was aimed at eliminating the hypoglycemia since the patient has diabetes type 1, his body did not produce adequate insulin thus he was not able to control the sugar level. The goal of the nurse is to prevent hyperglycemia and to maintain a normal blood glucose level so as to maintain a safe and effective glycemic control (Sanches & Cruz, 2011, p. 38-41). To achieve glucose control the nurse should be alert at all times and monitor early signs of hyperglycemia (Judy, Paige, Barnachea, Dawn, Locke, Christy, Backhaus, Brenda & Shannon, 2010, p. 59-62). The nurse should perform continuous monitoring of blood sugar and administer insulin if the blood sugar rises above normal level (Klonoff et al. 2011, p. 58 & Sanches & Cruz, 2011, p. 77). The patient’s history should be consulted to find out the amount of insulin that had been earlier prescribed. The nurse should inform the patient the signs of hyperglycemia and closely monitor him for early signs (Kedia, 2011, p. 55-70). The patient should be assessed continuously to check on signs of ketoacidosis since the patient has diabetes type 1. In the event that the patients blood sugar raises above normal and insulin is administered, an IV set up should be arranged with fluids to hydrate the patient; high blood sugar may cause thirst. Even after administering insulin, the patient should be closely monitored to ensure that hypoglycemia does not recur due to overcorrection of the hyperglycemia (Cryer et al. 2009, p. 67).

The third priority nursing diagnosis is, ‘Risk for injury related to hypoglycemia, impaired mobility and hypertension evidenced by decreased blood glucose level and blood pressure’. (Allemann et al. 2009, p. 13). he expected outcome is that client’s safety will be maintained and is prevented from falls and other injuries. This diagnosis should be prioritized since Hyperglycemia can increase the risk of impaired cognition, and falls in the elderly (Blair et al., 2010, p. 103 & Schwartz et al., 2008, p. 28-29 & Akhuemokhan et al., 2009, p. 88-92).

The appropriate nursing interventions to be implemented are to appropriately maintain blood glucose levels, to provide continuous blood glucose and blood pressure monitoring, and to provide appropriate assistance while mobilizing the client, such as taking him to the bathroom and other daily activities of living (Gray-Micelli, 2008, p. 59). Put up the side rails when the client is in bed (Day, Paul & Williams, 2009, p. 108-109), to avoid injuries. Use standard environmental checklists for other risk factors and keep evaluating the patient’s safety (Gray-Micelli, 2008, p. 66). The nurse should evaluate the effectiveness of above intervention by inspecting the patient to make sure that he has no injuries. The nurse should stay close to the patient to assist him incase he wants to move about and advice him to ask for help (Beacham et al. 2008, p. 425).

References

Akhuemokhan, Eregie, A., & Edo, A. (2009). Hypocalcaemia unawareness and falls in older adults with type 2 diabetes. African Journal of Diabetes Medicine, 14 (55), 22- 24. Web.

Allemann, S., Houriet, C., Diem, P & Stettler, C. (2009). Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis. Curr Med Res Opin, 25(12), 2903-13. Web.

Beacham et al. (2008). Insulin Management: A Guide for the Home Health Nurse. Home Healthcare Nurse, 26 (7), 421 – 428. Web.

Bhasin, Cryer, E., & Vigersky. (2009). Patient Guide on the Diagnosis and Management of Hypoglycemic Disorders (Low Blood Sugar) in Adults. The Journal of Clinical Endocrinology & Metabolism, 94 (3). Web.

Blair., Angela., Hazelwood & Kristen. (2010). Hypoglycemia, diabetes and increased risk of falls, (focus: Aged care). Australian Nursing Journal, 17 (9). Web.

Boyle., Zrebiec, J & John. (2007). Management of diabetes-related hypoglycemia (Review Article). Southern Medical Journal. Web.

Briscoe, J & Davis, N. (2006). Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management. Clinical Diabetes, 24 (3), 115-121. Web.

Cryer, E., Axelrod, Grossman, B., Heller, R., Montori, M. Seaquist, R & John Service. (2009). Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (3), 709-728.

Day, A., Paul & Williams. (2009). Brunnar and Suddarth’s textbook of Canadian medical-surgical nursing (2^nd Edi). Lippincott Williams & Wilkins: Philadelphia. Diabetic hypoglycemia. (2010). Web.

Farrell, M and Dempsey, J., (2011), Smeltzer & Bares Textbook of Medical- Surgical Nursing, 2nd Edition, Lippincott Williams & Wilkins.

Gorecki, 2009. Chapter 12: Hypoglycemia. University of Toronto. Web.

Gray-Micelli, D. (2008). ‘Nursing Standard of Practice Protocol: Fall Prevention’. Hartford Institute for Geriatric Nursing, New York University. Web.

Judy, A., Paige, K., Barnachea, Dawn, F., Locke, Christy, L., Backhaus, Brenda R & Shannon, K. (2010). Cultivating quality: an evidence-based protocol for managing hypoglycemia. American Journal of Nursing, 110(7), 40-45. Web.

Kedia, N. (2011). Treatment of severe diabetic hypoglycemia with glucagon: an underutilized therapeutic approach. Dovepress Journal, Volume 4, 337 – 346.

Klonoff, D C., Buckingham, B., Christiansen, JS., Montori, VM., Tamborlane, WV., Vigersky, RA & Wolpert, H.(2011). Continuous glucose monitoring: an endocrine society clinical practice guideline. Journal of Clinical Endocrinology Metabolism, 96(10), 2968-79. Web.

Martorella, AJ.(2011). Iatrogenic hypoglycemia in patients with type 2 diabetes: comparison of insulin analog premixes and human insulin premixes. PostgradMed, 123(4), 7-16. Web.

Mayerson, A, B. & Inzucchi, S, E., (2002). Type 2 diabetes therapy: A pathophysiologically based approach, Post grad Med 111 (3):83-87.

Nehme & Cudini. (2009). A review of the efficacy of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycemia. Journal of Emergency Primary Health Care, 7 (3).

Sanches, P & Cruz, I. (2011). Management of Hypoglycemia: Systematic Literature Review. Journal of Specialized Nursing Care, 4 (1). Web.

Shomali. (2011). Hypoglycemia in the hospital. Journal of Community Hospital Internal Medicine Perspectives, 1(2), 7217.

Schwartz, et al. (2008). Diabetes-Related Complications, Glycemic Control, and fall in Older Adults. Diabetes Care, 31, 391. Web.

Sinclair, J. (2006). Special Considerations in Older Adults with Diabetes: Meeting the Challenge. Diabetes Spectrum, 19 (4), 229-233.

Smart C., Vliet, E & Waldron, S. (2009). Nutritional management in children and adolescents with diabetes. Pediatric Diabetes, 10 (Suppl. 12), 100–117. Web.

The first day I arrived at my clinical agency I immediately realized that there was a great number of follow-ups with diabetes. There are many children among these patients. According to the Diabetes Statistics of 2011of the American Diabetes Association, 215.000, or 0.26% of American children and adolescents have Type 1 and Type 2 diabetes. The percentage correlation is one in every 400 Americans belonging to the age group under 20 years old. These results were derived from various data systems of the U.S. Renal Data System of the National Institutes of Health, the Centers for Disease Control and Prevention, the U.S. Census Bureau, and various published studies. The number of ill people and the percentage correlation were obtained from the National Health and Nutrition Examination Survey of 2005-2008, the National Health Interview Survey of 2007-2009, and the U.S. population estimates of 2010 (National Diabetes Fact Sheet, 2011). This number increases every year. This disease is the seventh leading cause of death in the USA. It is the main reason for nontraumatic lower-limb amputations, heart diseases, stroke, and kidney failure. It is especially difficult to fight this disease for children because of the lack of special knowledge.

After my analysis, I found out that the main reasons for ill children are the irresponsibility of their parents or poor economical situations in their families where children are vulnerable to many diseases because of malnutrition. I also realized that a lot of revenue was being spent on the treatment of the problems that resulted from the mismanagement of this disease. One of the national objectives of Healthy People 2020 is to increase the proportion of persons with diagnosed diabetes who receive formal diabetes education. If a person has diabetes, all necessary information concerning its treatment should be provided to the adults with diabetes as well as to the ill children.

According to the last statistics, Type 1 diabetes is the most widespread among children in America, but there are a lot of cases of Type 2 diabetes. One of the main reasons for the increase of Type 2 diabetes is obesity among children who like eating fast food and do not like going in for sport. Although parents may control the nutrition of their children, it is impossible to look after them everywhere. Children should fully understand the importance of eutrophy with the help of a special diabetes program. But obesity doesn’t explain the increase in Type 1 diabetes among children. It is caused by the inability of the pancreas to produce insulin. This type of diabetes is described as an autoimmune disease. It means that one of the body’s organs or tissues is attacked by the immune system. In the case of Type 1 diabetes, the insulin-producing cells are attacked. Such diseases as measles, rubella, the mumps, and Epstein-Barr virus also may cause the attack of the insulin-producing cells. Chemicals and drugs containing the chemical alloxan or rodenticide vapor may be an environmental trigger for diabetes. Diabetes among children is usually linked by doctors to hereditary factors. Nevertheless, it should be pointed out, that not all children have a family history with this disease. Scientists explain this factor by the existence of antibodies in our organism which are responsible for telling the body to be allergic to itself. These antibodies may present in children’s organisms a long time before they have Type 1 diabetes. They cause this disease when they are combined with other factors. (Aribisala, Chen, Hollingsworth, Lim and Taylor, 2011).

Some of these causes are avoidable while others cannot be avoided in addition to the fact that the disease has no known cure and all that is there is the control of the disease through insulin injection. Management and control of the disease are therefore the main methods that are applied in dealing with the disease. It is also important to note that if a patient does not follow the advice given by the doctor such as taking an insulin injection at regular time intervals severe complications can result. Proper nutrition has been a known way of controlling the disease. However, it has been found out that most people are not keen on their diet especially children who cannot deny themselves delicious food. This may be due to a lack of information or the people’s poor lifestyle. People who have no information on a proper diet such as young children are the most affected group. Educating people on the importance of proper diet can therefore be an effective method of controlling and managing the disease (Caspersen, Engelgau, Glasgow, Mcculloch, Nicholas and Norris, 2002). Educating the patients on the proper use of medication and the importance of following the doctor’s advice is another method that works in the control of diabetes.

References

Aribisala, B., Chen, M., Hollingsworth, K., Lim, E., & Taylor, R. (2011). Reversal of type 2 diabetes: normalization of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia.

Caspersen, C., Engelgau, M., Glasgow, R., Mcculloch, D., Nicholas, P., Norris, S., & (2002). Increasing Diabetes Self-Management Education in Community Settings. American Journal of Preventive Medicine.

National Diabetes Fact Sheet. (2011). Centers for Disease Control and Prevention. Web.

Evaluation Table

Critical Appraisal

Taking into consideration the results of the research and the information found in the articles, the problem of diabetes among African Americans has to be identified and discussed at different levels. Regardless of the already made attempts to underline the importance of lifestyle improvements and the impact of culture, people are in need of new interventions and recommendations (Lagisetty et al., 2017; Zhang et al., 2020). Chrvala et al. (2016) and Cunningham et al. (2018) introduce one of the best practices for the populations to control the risks of diabetes, known as diabetes self-management education or DSME. This process aims to facilitate the knowledge, skills, and abilities of people to promote and understand self-care aspects. The worth of DSME is to rely on evidence-based standards and consider patients’ needs with the goals of caregivers.

African Americans, as well as the representatives of other ethnic groups, face certain challenges, questions, and concerns when they hear about diabetes diagnosis. In the majority of cases, people are informed about the main steps and changes. DSME is a common practice that includes diet management, physical exercises, stress control, and monitoring of vital diabetes signs (Chrvala et al., 2016). It is recommended to analyze the guidelines offered by the American Diabetes Association and develop treatment plans as per obtained knowledge. Diabetes is never simple, and diabetes among African Americans is always a serious health problem that requires special attention and care. As a regular intervention, DSME results in decreased glycated hemoglobin levels and improved clinical, psychosocial, and behavioral issues (Cunningham et al., 2018). Diabetic patients learn how to manage this disease and focus on their personal factors like age, race, or gender and choose strategies that meet their needs and are developed as per available resources, caregivers, and other internal and external factors.

References

Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Education and Counseling, 99(6), 926-943. Web.

Cunningham, A. T., Crittendon, D. R., White, N., Mills, G. D., Diaz, V., & LaNoue, M. D. (2018). The effect of diabetes self-management education on HbA1c and quality of life in African-Americans: A systematic review and meta-analysis. BMC Health Services Research, 18(1). Web.

Lagisetty, P. A., Priyadarshini, S., Terrell, S., Hamati, M., Landgraf, J., Chopra, V., & Heisler, M. (2017). Culturally targeted strategies for diabetes prevention in minority populations: A systematic review and framework. Diabetes Education, 43(1), 54-77. Web.

Zhang, Y., Pan, X. F., Chen, J., Xia, L., Cao, A., Zhang, Y., Wang, J., Li, H., Yang, K., Guo, K., He, M., & Pan, A. (2020). Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: A systematic review and meta-analysis of prospective cohort studies. Diabetologia, 63(1), 21-33. Web.

Evidence-based practices (EBP)

The promotion of lifestyle and dietary changes among newly diagnosed with type 2 diabetes African Americans is a core idea of this EBP project, and the dissemination of the research results plays a crucial role. The major goal of dissemination is to ensure positive changes in care, which includes:

1. The improvement of care quality by managing the health among minority populations (Hearld et al., 2019);
2. The promotion of evidence impact and explanation of significant terms and statistical data (Zhang et al., 2020);
3. The motivation of people, either patients or stakeholders who could make certain contributions to the healthcare system (Melnyk & Fineout-Overholt, 2018);
4. The exchange of information at different levels by means of cooperation.

Dissemination Strategies

There are many strategies that can be offered to disseminate the results of the EBP capstone project, and some of them are defined as effective (inclined to use) and ineffective (not inclined to use). In this presentation, the involvement of mentors and collaboration with administration and other stakeholders are the preferred steps, and the idea to use social networking and web pages has to be removed. EBP mentors are able to identify the most appropriate methods to share new information and motivate participants. They have to learn an organizational culture and the beliefs of the clinical staff to rely on the chosen values and abilities (Melnyk et al., 2016). Administration and stakeholders disseminate the results due to their abilities to place posters and other materials to educate the locals and share new achievements in the chosen research area. Collaboration means the creation of healthcare alliances to remove the gap between practice and evidence (Hearld et al., 2019). Social networking and webpages are less effective for dissemination because there are no guarantees that information is properly distributed and understood distantly.

Dissemination Strategy Rationale

The main rationale for the chosen dissemination strategy is the presence of a particular person to introduce and guide a change. The identification of the role of EBP mentors is a great opportunity to enhance communication between stakeholders, share information about the chosen health problem, and underline the worth of evidence in care (Melynk & Fineout-Overholt, 2018). In addition, a well-trained mentor serves as a source of motivation and explanation of current achievements and interventions to improve health and predict complications.

Dissemination Barriers

Despite the possibility of developing a strong EBP project, some barriers are hard to predict and overcome due to their unpredictability. In this project, attention has to be paid to organizational culture and its appropriateness for the offered change (Melnyk et al., 2016). If culture and the environment do not support the EBP idea, high-quality care can hardly be promoted, and stakeholders should interpret the results in a clear and understandable way. Melnyk et al. (2016) also identify such barriers as the lack of skills and the inability to see the main facts about the health problem. EBP competencies are developed upon the findings of the studies, and inadequate resources lead to poorly taken steps and a lack of success.

How to Overcome the Barriers

Many strategies are developed to overcome the barriers during the process of dissemination. The first task is to identify the barriers and study each of them; the next step is to investigate the existing models for overcoming the barriers and make a final choice, regarding available resources and the environment (Melnyk & Fineout-Overholt, 2018). As soon as the model is introduced, it is necessary to make sure that every single step is recognized and followed. The choice of a leader is the ability to motivate and guide other stakeholders, either passive or active. Finally, the analysis of the achievements cannot be ignored because it is a chance to observe what is done right and wrong and make the necessary adjustments.

Dissemination Outcomes

Some people do not find dissemination as an integral research process and focus on the development of new strategies and skills. However, there is a list of outcomes that cannot be ignored in the EBP project, and they include:

• Awareness of evidence – when people learn something new and realize that much scientific support exists at the moment;
• Health-related decisions – when patients and the medical staff understand that their shared decision-making and cooperation directly contributes to health;
• Positive changes – when stakeholders observe that evidence helps to change the quality of care and introduce new behavioral strategies;
• Prediction of problems – when evidence is analyzed and used to demonstrate how human actions reduce or increase the current statistics;
• Further discussion – when people are interested in the continuation of research and finding out new approaches to deal with a disease.

References

Hearld, L., Alexander, J.A., Wolf, L.J., & Shi, Y. (2019). Dissemination of quality improvement innovations by multisector health care alliances. Journal of Health Organization and Management, 33(4), 511-528. Web.

Melnyk, B. M. & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.

Melynk, B.M., Fineout-Overholt, E., Giggleman, M., & Choy, K. (2017). A test of the ARCC Model improved implementation of evidence-based practice, healthcare culture, and patient outcomes. Worldviews on Evidence-Based Nursing, 14(1), 5-9.

Zhang, Y., Pan, X. F., Chen, J., Xia, L., Cao, A., Zhang, Y., Wang, J., Li, H., Yang, K., Guo, K., He, M., & Pan, A. (2020). Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: A systematic review and meta-analysis of prospective cohort studies. Diabetologia, 63(1), 21-33. Web.

Introduction

A 52-year-old woman with significant family history of type 2 diabetes came to the office for follow up after discharge from the hospital. She was admitted for 5 days with complications of hyperglycemia. She has no complains except for an ingrown toes nail that bothers her and slight tingling sensation on both feet that is not new and is per the patient is “better with Neurontin”. On examination, she is alert and communicating clearly, funduscopi exam is normal and abdomen is obese. Toenails unkempt and overgrown, skin is warm dry and intact. Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally. Temperature-96.4, Blood Pressure-130/92, Resp- 20, Heartrate-84, weight- 225lbs. height: 5′2″ and BMI- 41.1. Pertinent Lab values indicate a recent fasting blood glucose values of 200 mg/dl, Hemoglobin A1c (A1C) of 8.1%, and slight protein in urine. Patient is on Lipitor 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides) and Amlodipine 10mg daily for blood pressure. According to the patient, she has been attempting to lose weight by exercising but has actually gained 5 lbs within the past one month. She loves to eat bread and pasta and finds pastries irresistible. She has been smoking for the past 30 years and currently smokes 1 pack of cigarettes a day.

The differential diagnoses and the patient findings that leads to the diagnosis

Diabetes type two is the primary differential diagnosis because the patient presented with: A family history of diabetes, complications of hyperglycemia, blood pressure of 130/92, ingrown toenails, tingling sensation on the feet, fasting blood glucose of 200mg/dl, basal metabolic index of 41.1, pulse rate of 84 and proteinuria. Secondly, Nephrotic syndrome is the second differential diagnosis because the patient presented with hypercholesterolemia, slight protein in urine, high blood pressure of 130/92, hemoglobin levels of 8.1%, obese abdomen and weight gain. Finally, rheumatoid arthritis is the third differential diagnosis because the patient presented with ingrown toenails, tingling sensation on the feet, and warm intact skin.

Pathophysiologic and physical findings that support the differential diagnoses

Diabetes type two is a disease that a person inherits genetically, the diabetic person has low or lacks insulin and as a result, the person has to depend on external sources of insulin (Barry & Eastman, 2010). Insulin is a hypoglycemic hormone and it helps in reducing the amount of glucose in blood. When a diabetic person takes a lot of starch and carbohydrates, the body converts it into simple sugars like glucose and since this person does not have insulin, the blood sugars remain high leading to a condition known as hyperglycemia (Barry & Eastman, 2010). On the other hand, excessive exercise and too much insulin intake results into hypoglycemia, a condition in which the blood sugar levels are low because insulin increases the movement of glucose from the blood to the tissues. Therefore, such a person presents with low fasting blood glucose of 200mg/dl. Additionally, the use of insulin to control diabetes causes an increase in weight resulting in a high basal metabolic index. This is because the body converts the sugars that have moved to the body cells into fats. As the diabetes progresses, it affects other body systems leading to microangiopathy, autonomic neuropathy and damage of blood vessels (Rorsman, 2009). Microangiopathy is the damage to the tiny blood vessels resulting to nephropathy that presents with proteinuria, neuropathy that presents with tingling sensation and diabetic foot that present with ingrown toenail. On the other hand, autoimmune neuropathy is the damage to the nerves that supply the internal body organs leading to problems with the pulse rate. Finally, the damage to the inner part of blood vessels aggravates macroangiopathy leading to an increase in blood pressure (Weinger, 2010).

Nephrotic syndrome involves destructions of the kidneys resulting into increase in the permeability of the walls of glomerular capillary leading to proteinuria, edema and hypercholesterolemia (Selley, 2008). Proteinuria leads to too much loss of protein that can cause anemia. On the other hand, edema is accumulation of fluids in the tissues resulting from a drop of plasma albumin with subsequent drop in oncotic pressure that causes fluids to move from intravascular space to interstitial space (Rorsman, 2009). This results into weight gain. Additionally, the decrease of intravascular amount activates renin- angiotensin -aldosterone system that leads to hypertension. Besides, fluids can accumulate in the peritoneal cavity causing ascites that presents as obese abdomen (Sheeetz & Kings, 2010).

Rheumatoid Arthritis is a disorder of the joint that involves the inflammation of one or two joints (Salmon & Phill, 2010). When it affects the toes, it results into ingrown nails that are painful. Additionally, the toe swells and there is uncomfortable sensation of warmth of the skin. Finally, arthritis affects the bone marrow that aids in red blood cells formation leading to low hemoglobin levels (Salmon & Phill, 2010).

Epidemiology of the differential diagnoses

In the world, approximately one hundred and fifty million people suffer from diabetes and there is anticipation that the number will rise to three hundred million. A study done in Australia reported that 8% of the people between 25 years and above had type 2 diabetes (Selley, 2008). Moreover, the prevalence of diabetes type two increases with age and as a result, 20% of the people between the age of sixty years and above suffer from diabetes. Despite the fact that diabetes type 2 is uncommon in Africa, Asia and India, it makes up 90% of cases of diabetes worldwide. Moreover, the risk of cardiovascular diseases like dyslipidaemia and hypertension worsen as the diabetes progresses (Weinger, 2010). Additionally, the susceptibility to diabetes is determined genetically and people of Aborginal, Chinese and Micronesians are at increased risk (Titler, 2008). Even though there are evidences suggesting that genetics contributes to obesity and diabetes, the rise in diabetes and obesity in both the developed and the developing countries are because of a change in balance between diet and exercise.

Nephrotic syndrome can occur at any age and it is prevalent in boys than girls (Rorsman, 2009). Although it is a rare condition, it is very important because it damages the kidney leading to proteinuria, hypoalbuminemia and hyperlipidemia (Rorsman, 2009). Additionally, the occurrence of this syndrome is approximately three incidences per one hundred thousand every year. Moreover, diabetes is the common second cause of nephrotic syndrome in adults. On the other hand, the annual occurrence of nephrotic syndrome in children is approximately six cases per one hundred thousand children (Sheeetz & Kings, 2010).

The rheumatoid arthritis prevalence is almost constant in many places occurring at around 1%.However, it is high in India at a percentage of 6.8. On the contrary, a recent research reported a low prevalence in china and japan and it supported genetic inheritance as a risk of the disease. Moreover, other studies have demonstrated genetic inheritance in rheumatoid arthritis as minimal compared with autoimmune diseases (Salmon & Phill, 2010). The hormones of the female have a protective mechanism in rheumatoid arthritis; for instance, oral contraceptive use and pregnancy are associated with a reduced risk (Salmon & Phill, 2010). On the contrary, postpartum spell is a risk period for the development of the rheumatoid arthritis. Additionally, the risk of development of rheumatoid arthritis is high smokers than non-smokers.

Diagnostic testing for each differential diagnosis

There are diagnostic tests that physicians use to rule in or rule out diabetes and they include, fasting plasma glucose levels, plasma glucose and causal plasma glucose (Titler, 2008). Therefore, the following findings are suggestive of diabetes: A fasting plasma glucose level that is more than 126mg/dl, plasma blood glucose that is more than 200mg/dl and causal plasma glucose that is more than 200mg/dl (Selley, 2008). On the other hand, diagnostic tests for nephrotic syndrome are urine total protein estimation, Comprehensive metabolic panel, lipid profile, electrolyte, urea and creatinin evaluation. As a result, the following suggests nephrotic syndrome: proteinuria of more than 3.5g per 1.73m² per 24 hours, hypoalbuminaemia with albumin levels of more than 2.5g/dl, hypercholesterolemia and increase in the levels of electrolyte, urea and creatinine (Titler, 2008). Finally, diagnostic tests for rheumatoid arthritis include imaging and blood tests. X-rays of the feet in early stages demonstrate swelling of the soft tissues, articular osteopenia and lack of the joint space while in late stages it demonstrates subluxation and erosion (Salmon & Phill, 2010). Ultimately, the blood tests include testing for rheumatoid factor and in case it is absent the arthritis is referred to as seronegative because in 15% of the patients, rheumatoid factor is usually absent in early stages of the disease (Salmon & Phill, 2010). As a result, the clinicians usually use serological test because it is specific (Salmon & Phill, 2010).Finally, information about the cost of the above testing was inaccessible.

Expected standard of care for the differential diagnosis

Diabetes is an incurable disease therefore, care concentrates on keeping the levels of blood sugars close to the normal and this is via exercise, diet, medications and support (Allbright, 2009).To begin with, the diabetic person should modify his lifestyle in a number of ways. For example, he should take a diet low in carbohydrates, fats and salts while high in vitamins. Additionally, he should learn to balance exercise and diet to avoid hypoglycemia that results when a diabetic person exercises too much after taking a diet with low calories (Selley, 2008). Moreover, the diabetic person should stop smoking because it hastens the harmful effect of diabetes. On the other hand, diabetic medications are significant when diet cannot control diabetes. Finally, the diabetic person requires support like counseling so that they can find it easy to adapt to the new situation of a completely different lifestyle (Selley, 2008).

The care of nephrotic syndrome depends on the cause but in general, the health care professionals direct care towards alleviating the presenting signs and symptoms that are edema and high blood pressure. The patient with nephrotic syndrome require a bed rest with elevated lower limbs so as to decrease the lower limbs edema which is usually common in this patients ( Rorsman, 2009). Besides, the health care professional monitors the amount of fluid intake and output because too much intake of fluid will exacerbate the condition. On the other hand, a decreased output means that the kidneys are not functioning well (Sheeetz & Kings, 2010). Additionally, the modification of diet is imperative because a diet that is low in salt greatly helps in regulating the blood pressure. Finally, the treatment of underlying cause facilitates faster recovery (Rorsman, 2009).

Although the health care professionals usually focus on objective measurement of the rheumatoid arthritis, the impact of the disease on the quality of patient’s life is important. Therefore, efficient biologic therapies can improve the patient’s quality of life by reducing pain (Salmon & Phill, 2010). Recently, the management of rheumatoid arthritis has shifted from a slow approach where administration of treatment was slowly in response to the signs of the disease to an aggressive approach where control of inflammation is in the earliest time possible (Mari, Baldi, & Guarino, 2008). Additionally, primary care physicians are responsible for early treatment because they are the first ones to come in to contact with the patients and their actions determines the patient’s prognosis. Besides, they should refer patients to the rheumatologists if they cannot diagnose the disease because the rheumatologist can help to confirm the disease and commence on the appropriate modifying therapies (Mari, Baldi, & Guarino, 2008).

First line and second line treatment of the differential diagnoses

In amalgamation with lifestyle modifications, medications play a significant function in controlling hyperglycemia in diabetic patients. As a result, Metformin is an oral anti diabetic first line drug that diabetic patients use when lifestyle modification alone is not sufficient (Allbright, 2009). As the disease progress, metformin may fail to control the levels of glycemia and hence many diabetic patients will require additional oral drugs or insulin as the second line treatment. Examples of second line anti diabetic medication include meglitinides, sulfonylureas, and insulin. When the metformin is not effective, the presented guidelines recommend a variety of options. Nevertheless, the guidelines lack specific information regarding which drugs are second lines and which ones as first line but instead it recommends a stepwise approach in adding drugs from various sources (Allbright, 2009). Moreover, the recommendation concentrates on efficacy and safety but cost effectiveness is not considered. Since there is a large population of patients with diabetes, the sub optimal use of second line drugs is likely to have a detrimental effect on the health outcome and the cost effective use of the medication (Braunwald, 2009). Therefore, there is the need for recommendations that focus on clinical and cost effectiveness of the medication in the patients with insufficiently controlled diabetes.

The first line treatment of nephrotic syndrome depend on the cause of the disease and it can include corticosteroids like prednisolone to reduce the swelling, diuretics to reduce edema and Angiotensin II receptor blocker to reduce the protein loss in urine, blood pressure and the disease progress ( Rorsman, 2009). In case the condition worsens, the health care professional prescribes the second line treatment to avoid the development of chronic kidney disease. This treatment includes hemodialysis, peritoneal dialysis or a kidney transplant (Sheeetz & Kings, 2010).

The two lines of medication that treats rheumatoid arthritis include first line treatment that alleviates pain and acute inflammation and second line treatment that promotes the remission of the disease and prevents the progression of the destructions of the joints. First line medications are available in oral formulations and they include Non Steroidal Anti inflammatory drugs like aspirin and etodolac (Mari, Baldi, & Guarino, 2008). On the other hand, second line treatments are available in both oral and injectable formulation and they include disease-modifying antirheumatic drugs like hydroxychloroquine, and cyclophosphamide (Salmon & Phill, 2010).

Conclusion

In conclusion, diabetes is a complicated disease because it presents with symptoms that are suggestive of other diseases. Therefore, the health care professionals need to be alert while carrying out the investigations so that they do not miss out the proper diagnosis. In the above presented case, the patient has type II diabetes and not nephrotic syndrome or rheumatoid arthritis. This is because most of her presentations are suggestive of diabetes. Additionally, diabetes can progress to nephrotic syndrome and diabetic foot, which usually present like rheumatoid arthritis.

References

Allbright, M. (2009). Diabetes Management: A Challange to Health Care Proffessionals. Journal Of Diabetic Nursing , 10(13), 55-66.

Barry, M., & Eastman, A. (2010). Hyperglycemia enhanses DNA Fragmentation After Trancient Cerebral ischaemia. Journal of Cerebral blood Flow and Metabolism , 125(45), 312-315.

Braunwald, A. (2009). Management of Diabetes with Oral medications and Insulin. Journal of Healthy Life Span in Diabetic Patients , 9(12), 94-105.

Mari, A., Baldi, S., & Guarino, D. (2008). Management of Rheumatoid Arthritis: A Changing Standard of Care. The journal of Clinical Endocrinology and Metabolism , 327(76), 49-72.

Rorsman, P. (2009). Nephrotic Syndrome:Treatment Overview. The British Journal of Diabetes and Vascular Diseases , 108(28), 1183-1192.

Salmon, P., & Phill, G. (2010). Rheumatoid Arthritis and Associated Conditions. Journal of the Royal Society of Medicine , 97(25), 175-184.

Selley, Z. (2008). New Advancement in Diabetic Management. Journal of Diabetic Nursing , 7(367), 193-277.

Sheeetz, M., & Kings, L. (2010). Nephrotic Syndrome: Causes, Presentation and Comprehensive Management. Journal of American Medical association , 47( 21), 9-20.

Titler, W. (2008). A Diabetic Self Management Education Program: Creating one that is sustainable. America Journal of Nursing , 31(5), 248-300.

Weinger, T. (2010). State of the Science of Diabetic Management: Strategies for Nursing. America Journal Of Nursing , 35(7), 330-345.

4-2-2016 a home visit was made to the client who had Ataxia and diabetes mellitus. This patient was deeply depressed due to numerous contributing factors. The therapist used different reasoning strategies in her session. The main purpose of this session was to introduce the new cushion for the client and provide all detailed information, in addition, to reporting any change of the patients need.

At the beginning of the sessions, interactive reasoning was used. The therapist was clearly using the interpersonal skills and strategies to support and motivate the patient to engage in the therapy. For example, the therapist listened carefully to the patient, using non-verbal agreement. It was used to convey a sense of acceptance, trust and hope to the patient and to engage the client in looking at the cushioning product. Furthermore, a sense of humor was used to help a client to interact with the student and to relieve tension

Moreover, the usage of the knowledge about the clients disability and diabetes could be described as adherence to scientific reasoning. The therapist uses the knowledge of the nature of the illness in developing health complications to guide the intervention choices. In this case, such factors as static posture and prolonged position from the immobility due to ataxic paralysis, along with the poor circulation and potential impairment of sensation that is often associated with diabetes will increase the risk of developing severe pressure ulcers and infection. Therefore, the therapist prioritizes using the cushion to the client and persuades the patient to accept the product by discussing the merits of the infinity cushion with a low profile in enabling the customer to transfer easily from and to the wheelchair

Also, the intuitive reasoning was confirmed during the discussion with the therapist at the therapeutic session. It was related to the continual refusal for many therapeutic recommendations. For instance, refusing to tilt in space would help the patient to raise her lower limbs and improve circulation as well as prevent or delay complications. Also, refusing the use of the electric wheelchair instead of the manual one would conserve energy and effort and would help the patient to do shopping without fatigue and being exhausted. The therapist felt that the patient may want to make her condition regress and that it was due to her profound depression. This fact impacted the therapist to make a decision to inform the case manager about the health deteriorations. It is important to emphasise that it was compatible with the client-centred approach, and the competent patient had the complete right to accept or to refuse the treatment. Therefore, the main role of the practitioner was to advocate and educate the patient to make a decision.

The narrative reasoning was another approach used in the case. The therapist talked about some essential activities in the client’s daily life, such as sleeping, toileting, and cooking. It helped to identify some occupational performance hinders appeared due to some technical problems and to make the plan to find the needed solution. For instance, the client mentioned the difficulty related to the transferring to bed because the remote control of the electric device needed to be replaced. It made the therapist create the plan to provide the client with the contact details of the bed manufacturer to organize the repair of some additional service. It is also vital to check the W/C quote if solid layers were added.

Eventually, these different types of reasoning helped to solve the problems and to design and conduct the therapeutic process.

On the 2^nd March, while we were going to trail a wheelchair for one of the clients, the question who should prescribe and assess the wheelchair were raised. Should it be a physical or occupational therapist? Although both of them had the right to do it and this fact initiated the interesting discussion. As my background is physical therapy, I also felt curious to get to know who might be better. This fact made me reconsider the knowledge and skills of PT and OT that could be used. I think both PT and OT have the knowledge in the medical conditions and skills to teach a user how to manage and how to transfer in/out of it. OT has skills to report on a person’s physical and mental state and on the ability to handle chair whereas a physical therapist is more focused on the physical body and biomechanics. OT has skills to report on areas where the chair will be used and adaptations needed for this usage to be successful. OT knows which chairs are available and suggests most suitable one related to given environment and the kinds of activity which clients want to perform with this chair. Moreover, OT has the knowledge of the environmental factors (physical, institutional and social environment) client factors, carer, personal choice, finance and safety issues. Therefore, a wheelchair that is prescribed by an occupational therapist would be more investigated, justified and potentially more suitable (Coolen, A., & Kirby, R. 2002) This discussion provided me with a great insight about the skills in both fields and highlighted the fact that an occupational therapist should take into his/her account the knowledge of the multiple levels and factors for the better evaluation of the case.

Topic -2 – Conducting a semi-structured interview 500

The Canadian occupational performance measure format has been used for a client with a mobile bike accident. The information was gathered by asking questions related to self-care activities, productivity, and leisure. The main occupational performance issues were identified as the difficulty in putting socks on, domestic activities, getting out the house, access the community, and travel safely in the retirement village. Then I asked the client to give a number from 1 to 10. 10 stood for extremely important and satisfactory whereas one meant less important and satisfactory.

Clinical reasoning is a common skill that all clinicians are expected to possess and utilize, and all students are expected to develop. The initiative session started when we entered the clients house I had the opportunity to ask the client about his/her mood and feelings, and he answered: “Well but not good”. Then I asked him about the reason for it ( the strap on his cheek ). He told me the story about cancer and it helped to initiate the chatting. It was really good for me, helped to build rapport, and I felt more comfortable as it went naturally and spontaneous. When I started to interview him, I felt uncomfortable for many reasons. First, I felt that asking questions as an interviewer was not natural at the first contact. It made me think that the interviewee might feel the same. I also thought that the presentation of the questions in the narrative form could be more appropriate. I felt that such skills as the attendant behavior in terms of the eye contact and active listening could also help. Additionally, because of my soft voice, I had to speak louder for a client to be able to hear me better. Also, I asked some open and closed questions. Sometimes I also asked the client for more clarification and paraphrasing. I focused on his strength which was his writing as editor. However, it would be better to summarise what the client said after each section. I believe this skill can be learned and will be improved in time and due to the practice. The occupational issues were chosen resting on the patients identification.

The main difficulty is connected with my question about the rating scale and the importance of the performance and satisfaction. The English grammar was another challenging issue as it is my second langue, but I believe that the concept is not easy. I felt that the client got the meaning of the first two issues, but then I realized that he start to confuse the performance and satisfaction. It might happen because normal people do not think in this way, and I felt I needed to repeat what these numbers meant. However, I felt I could not do it because the constant reminding of the things he did not understand was not compatible with the concept of respect for older people. It this regards, I think that the preparation with the supervisor was really helpful, and her guidance was really effective. Especially useful were her tips to simplify the language with a client and avoid all technical and academic language which was the main concern for me. I have already mentioned that English is my second language, and I use it mainly for various academic purposes, not in the everyday life. I think it should be suggested in the manual to make some concepts easier..

The client is 81 years old lady who lives with her son. She had hypertension, osteoarthritis of the right and left knee in 2001, lumbar radiculopathy in 2004, left hip osteoarthritis in 2005, left hip dislocation in 2008, total left hip replacement in 2008, and left hip prosthesis dislocation in 2012. The son is the primary carer. She discharges from Mornington centre at 14/1/16 following right hip replacement. She had the previous history of falling before hip replacement due to the problems with balance. She had difficulty getting out of screen door with 4WF. Also, difficulty in lower herself into the toilet at night. She has to use the bed pan at night to ease toileting and to empty the contents into the bucket. These issues have improved since surgery, and she is linked to physiotherapy and occupational therapy for ongoing therapy. Now, she is independent in self-care activities and receives home help for domestic activities and shopping. Eventually, wheelchair has been recommended to enable her to access community without risk of falls or having fatigue.

Introduction

Diabetes mellitus (DM) is one of the most common chronic diseases in the world. The rapid spread of the incidence of diabetes mellitus (DM) has become a non-infectious epidemic. Recently, this disease has begun to be studied as a social problem that is becoming increasingly more urgent. Moreover, six of the ten countries with the highest prevalence of diabetes are located in the Middle East (Icon Group International, 2017). This determines the exceptional relevance of research on the current situation and prospects for treating diabetes in the Gulf countries. One such study is the systematic review on the quality of type 2 diabetes management in the countries of the cooperation council for the Arab states of the Gulf, prepared by Alhyas, McKay, Balasanthiran, and Majeed back in 2011, published in PlosOne.

The Philosophical Underpinnings of the Paper

Medicine, like no other discipline, needs an understanding of processes and phenomena in their integrity. This most important task can be solved only on the basis of the interpretation of medical science data from the standpoint of a systems approach. A medical specialist needs, first of all, to see the connection between various processes and phenomena during the development of the disease, that is, the true essence of the pathological process, as well as to understand the principles of choosing therapy and indicators for assessing its effectiveness. The systematic review is a well-established and widely accepted tool in the medical community for applying a systemic approach to health problems.

The Theory Used to Support the Research

Systematic reviews synthesize the results of original studies using approaches that reduce the possibility of bias and random errors. The authors of systematic reviews use the theory of evidence-based medicine and prevention, which is a policy and practice of applying the best external evidence acceptable to healthcare professionals and related industries, patients, and society as a whole. In particular, the aim of the review under consideration was to “examine the current quality of management of type 2 diabetes in the member states of the GCC” (Alhyas et al., 2011, p. 2). It is an important technology for maintaining and improving health.

The evidence-based approach as a technology for achieving high-quality medical care and management in health care is recognized and has been introduced over the past decades. The prerequisites for this were primarily economic: against the background of limited sectoral resources in the world, the costs of medical services and research increased significantly, which, among other reasons, was due to the predominance of chronic noncommunicable diseases in the morbidity and mortality patterns. A significant problem was also the quality of information support for management decisions in medicine and its transparency for patients and society as a whole. Accordingly, information support of medicine regarding such chronic non-communicable diseases as diabetes, especially in the regional context, is an important theoretical implication of research.

At the same time, the methodological basis of the evidence-based approach in health care – clinical epidemiology – provided it with the methods of medical statistics, reliability criteria, and methods of data generalization. The authors suggest clear criteria for inclusion and exclusion of publications for reviews and identified 27 published studies to include in the review. The selection of the main parameters of SD type 2 management provided the formation of a data array for further use by medical professionals and public health regulators. This data is used in medicine as a source of information for clinical decision making, planning of future research, and health policy development, thereby strengthening the link between the best research results and optimal care.

The Appropriateness of the Methodology Used

The evident proof of the appropriateness of the methodology applied by the authors is their conclusion that the quality of type 2 diabetes management in the GCC region can be characterized as “poor.” Based on the available data sets, the authors modeled heterogeneous groupings in accordance with the requirements of systems analysis, within the framework of the systems approach. At the same time, it should be noted that the authors do not pay enough attention to the quality of the general sample of studies for analysis – they claim that there are “no limitations on publication type, publication status, study design” (Alhyas et al., 2011, p. 1). Dividing the sample into subsections according to research design criteria, patient samples potentially could significantly improve the quality of the results obtained.

Alternative Theory and Alternative Research Methodology That Could Have Been Used

It is known that the most general and unifying theory of the origin of diseases is the theory of diseases of civilization and social adaptation. The term “adaptation” as a process of overcoming inadequate conditions by the body that does not correspond to the properties of the body is no less popular than “stress” (Topol, 2019). Disadaptation is considered as the basis of the disease; in this regard, a determination theory of medicine was developed, the main goal of which is to unite all the basic modern knowledge accumulated in the field of biomedical research into a single system (Topol, 2019). The doctrine of adaptive response is that the determination factor is always specifically refracted through internal systems. Investigating the regional features of the incidence of type 2 diabetes, the authors should consider, in particular, some social and cultural determinants of the current situation. The determinative theory of medicine is an attempt at an integrative methodological concept that generalizes the patterns of the emergence and development of pathological conditions, processes, and patterns of the formation and maintenance of health. Its functions are the following (Topol, 2019):

• Informative (obtaining information about the adaptive nature of reactions);
• Systematizing (generalization of the facts of clinical and experimental medicine into a single system of adaptive response);
• Predictive (anticipation of new facts, phenomena, and patterns of adaptive response);
• Explaining (phenomena, facts, adaptive response).

In view of the approach to the formation of the sample presented in the considered systematic review, as well as the tasks of publication of the study set by the authors, the application of the determinative theory seems to be the most appropriate. In addition, when speaking of alternative research methodology, the application of grounded theory should be proposed. It enables in-depth analyses of empirical facts and allows the emergence of new themes, issues, and opportunities in the process of research, as well as revealing of latent interrelationships and dependencies, not evident in a standard systematic review.

Ethical Issues

In accordance with the concept of evidence-based medicine, the results of only those clinical studies that are conducted on the basis of the principles of clinical epidemiology are recognized as scientifically grounded. It makes possible minimization of both systematic and random errors (using the correct statistical analysis of the data obtained in the study). Thus, this fact determines the need for a high level of the ethical responsibility of the researcher. The authors themselves claim about the heterogeneity of studies included in the sample as a major limitation on the strength of conclusions formulated (Alhyas et al., 2011). No proper statistical analysis has been performed, but the authors argue that the level of treatment for type 2 diabetes in the Gulf countries is not satisfactory. The validity of the systematic review under consideration cannot be verified, which is somewhat of a violation of research ethics.

Conclusion

The critical analysis of the article under consideration allows concluding that systematic review represents a kind of first step in outlining the problem of type 2 diabetes management in the countries of the cooperation council for the Arab states of the Gulf. Although the overall philosophy and methodology of systematic reviews is observed, the sample is not representative, and the quality of the publications included in the review is ambiguous. However, the review has scientific and practical value in terms of evidence-based medicine in treatment of type 2 diabetes in the Gulf countries and other regions, especially for developing countries.

Reference List

Alhyas, L. et al. (2011) ‘Quality of type 2 diabetes management in the states of the cooperation council for the Arab states of the Gulf’, PlosOne, 6(8), pp. 1–6. Web.

Icon Group International (2017) The 2018-2023 world outlook for type 2 diabetes mellitus treatments. Author.

Topol, E. (2019) Deep medicine: How artificial intelligence can make healthcare human again. New York: Basic Books.

Introduction

The online peer discussion has enhanced my internalization on the implications of Gestational Diabetes Mellitus (GDM), specifically in the context of NSW Australia. The online posts and peer discussion enabled me to gain insight as we were engaged in exchange of significant ideas on the topic under discussion. The contributions from each group member summed up to the development of the briefing document.

Gestational Diabetes Mellitus

The contributions from group members gave me a clear picture of GDM as a chronic disease, and the issues surrounding it. I gained the understanding that GDM is the disorder of carbohydrate intolerance mostly diagnosed in women who are expectant. During pregnancy, the body’s glucose metabolism is affected by the progesterone that is produced by cortisol, prolactin and the placenta. This interference is the main contributor to GDM. The demand of insulin in the body during pregnancy often increases starting from the second trimester. Given that most of the expectant women experience inadequate production of insulin, they often get hyperglycaemia as the growth and development of the foetus relies on the blood glucose. Conversely, high perinatal morbidity is associated with GDM. The condition is noted as a common complication that stems from GDM and its development corresponds to the development of pregnancy.

Gestational Diabetes Mellitus in the Context of NSW Australia

The group members’ contributions expanded my understanding of GDM in the context of Australia. GDM is prevalent in NSW Australia and its figures hit 4.7% in 2005. The group of women who are at a higher risk of infection are the indigenous women of which NSW makes about 8% of the total population.

The Implications of Gestational Diabetes Mellitus

With regard to this topic, the critical aspect is the fatal nature of GDM. It can possibly result in diabetes, which is a chronic disease. This leads to the risk of people developing multi-organ diseases. We had a deeper evaluation of the implications of GDM and we cited the inadequacy of resources and technology as the contributors of GDM. We all agreed that the nature of GDM calls for specialised care, which has not been realised much in the case of NSW Australia. Geographical isolation has contributed to the complexity of GDM, given that regional centres are far away from the remote communities. Expertise and medical equipment and supplies are among the inadequacies.

Prevention and Management of Chronic Disease Course

The online posts and peer discussion intensified our concern for the disorder, and we explored the current measures being employed in NSW Australia. Glucose monitoring through screening and management of the disease through patient education has been employed in NSW. Given that these initiatives have expanded the women’s understanding of GDM, we resorted to expound on patient education as it is the most successful approach. We decided to raise the awareness of GDM amongst midwifes, GPs, partners, patients and the public at large. This is a step seeking to reduce the chances of people developing type 2 diabetes and neonatal morbidity in WNSWLHD. I personally took the task of exploring the best prevention and management measures of GDM. I identified that universal screening should be done at intervals of 26-28 weeks with a 50g glucose load. In cases where the outcome turns out as positive, a glucose load of 75g OGTT should be administered. More so, women living in isolated areas should have better access to antenatal care. This should be the responsibility of telehealth consultants. The antenatal care team has to be supplied with additional aboriginal health workers to enhance support for the indigenous women during pregnancy. Furthermore, it is significant to have a better control of glycaemia so as to prevent neonatal morbidity. This implies that telehealth should monitor BGLs/ adequacy of diet regularly. Women who develop GDM should be subjected to OGTT within 6-8 weeks of post delivery. Additionally, they should be issued with letters informing them of the implications of GDM with regard to type 2 diabetes, and the significance of having OGTT. Reminder letters should be sent to patients in a bid to reinforce the significance of further testing. Distribution of brochures about GDM should also be included in obstetric practices, antenatal clinics and GP practices within WNSWLHD via the Division of General Practice.

Hormonal Alterations of the Endocrine Pancreas in the Case of Diabetes Mellitus

Diabetes mellitus (DM) may be regarded as a severe chronic illness that affects millions of people across the globe. It is a particular group of serious physiological dysfunctions “characterized by hyper-glycemia that results directly from inadequate insulin secretion, insulin resistance, and excessive glucagon secretion” (Blair, 2016). The pancreas is responsible for the secretion of insulin and glucagon for the regulation of blood glucose levels. The main function of insulin produced by β cells within the pancreas in response to food intake is to lower blood sugar levels by the facilitation of glucose uptake in the cells of the liver, fat, and muscle from the bloodstream (“Diabetes Mellitus,” n.d.).

Thus, being a metabolic disease characterized by the high levels of sugar in the blood over a long period of time, DM is defined as one of the global major health issues with life-threatening symptoms including renal failure, possible blindness, amputation of lower limbs due to poor blood circulation, heart attack, and stroke (Okur, Karantas, & Siafaka, 2017). As a matter of fact, all forms of DM are characterized by the pancreatic β cells’ inability to meet the demand of insulin secretion due to the functional β cells’ deficit in the peripheral insulin resistance’s setting or the cells’ almost complete loss (Saleh & Butler, 2019). In general, the deficit in β cell mass occurs due to the cell’s death, their degranulation that implies the depletion of insulin granules due to stresses, or their dedifferentiation or transdifferentiation – the alteration or loss of functional mature β cell identity (Saleh & Butler, 2019).

Type 1 Diabetes

This type, also known as insulin-dependent, childhood-onset or juvenile diabetes, is a result of β cell destruction that leads to deficient insulin production and complete insulin insufficiency n the body (Okur et al., 2017). Type 1 diabetes may be also defined as a particular autoimmune reaction characterized by the invasion of the immune system against functional mature β cell that produce insulin. Patients with this type of DM require the administration of insulin on a daily basis to control the blood sugar level, and non-administration is life-threatening. In general, the reasons for Type 1 diabetes are currently not identified and not preventable (Okur et al., 2017). However, such factors as viral infections and environmental risks may contribute to the occurrence of this disease.

Type 2 Diabetes

This most typical non-insulin-dependent or adult-onset type of diabetes is a result of a “continuous insulin secretory defect on the basis of insulin resistance in relation to the body’s inefficient use of insulin” (Okur et al., 2017). In the case of Type 2 diabetes, the body may produce insulin, however, it becomes so resistant that the hormone is inefficient (Okur et al., 2017). As a result, the pancreas produces more insulin in order to compensate its function’s reduction. Similar to Type 1 diabetes, the exact reason for non-insulin-dependent diabetes mellitus is unknown as well. However, the most significant factors that may contribute to its occurrence include poor nutrition, physical inactivity, and obesity.

Conclusion

It goes without saying that pathophysiology plays a highly significant role in advanced nursing practice as knowledge related to the mechanisms of the disease’s occurrence inevitably contributes to the understanding of its treatment. From a personal perspective, this research dedicated to the pathophysiology of diabetes mellitus is beneficial for me as a health care provider. I have extended my knowledge in the functionality of insulin and the differences between the two main types of diabetes mellitus.

References

Blair, M. (2016). Diabetes mellitus review. Urologic Nursing, 36(1), 27-36.

Diabetes Mellitus. (n.d.). 2021, Web.

Okur, M. E., Karantas, I. D., & Siafaka, P. I. (2017). Diabetes mellitus: A review on pathophysiology, current status of oral medications and future perspectives. Acta Pharmaceutica Siencia, 55(1), 61-82.

Saleh, A., & Butler, A. E. (2019). Alterations in beta cell identity in Type 1 and Type 2 diabetes. Current Diabetes Reports, 19(83), 1-12.

Necrotizing Fasciitis is associated with different kinds of bacteria that cause damage to deeper skin and subcutaneous tissues (Cain, 2010). Actual destruction is done by toxic substances such as streptococcal pyogenic exotoxins produced by bacteria. These superantigen exotoxins can activate T-cells non-specifically, leading to excess production of cytokines. Excess cytokines cause excess immune response activities and inflammation, leading to severe systemic illnesses such as Necrotizing Fasciitis (Cain, 2010).

Role of Diabetes in Necrotizing Fasciitis

Necrotizing Fasciitis is common in people with a compromised immune system (Cain, 2010). Therefore, any infection that destabilization the immune system exposes a patient to Necrotizing Fasciitis. A poor immune system exposes one to bacterial infection. In the event of such an infection, the body becomes desperate to get rid of the intruders. This causes high defense activities at the point of infection, causing serious inflammation (Cain, 2010). According to Cain (2010), poor glycemic control in diabetic patients compromises the immune system by killing some defense cells such as neutrophils. In addition, tissue hypoxia that results from arteriosclerosis exposes diabetic patients to necrotizing fasciitis. Cain (2010) also observes that excess sugar provides food for bacteria making it difficult for wounds to heal.

Cause of Abdominal Pain

Fournier Gangrene is an infection that spreads so fast (Schroeder & Steinke 2005). Abdominal pain could mean that the infection has spread to the abdomen. In addition, testes originate from the abdomen right below the kidneys (Schroeder & Steinke 2005). Infection of the scrotum which extends to the testes can cause referred pain in the abdomen due to anatomical connections.

Pathophysiology of Fever

Body temperatures are controlled in the Hypothalamus (Schroeder & Steinke 2005). Exposure of vascular bed that surrounds hypothalamus to pyrogens initiates the production of prostaglandin E2 (Schroeder & Steinke 2005). When prostaglandin E2 crosses into the area of the hypothalamus that regulates temperatures, activities that lead to the rising of the setpoint are triggered. Raising the setpoint initiates chills and raised muscle tones in the body. The hypothalamus then responds by initiating activities such as vasoconstriction that lead to an increase in body temperature. Muscle shivers help in generating heat until temperatures match the new set point. For C.S, fever was caused by superantigens released by the bacteria. Although the use of fever in the infected body remains unclear, it is believed that the chemicals that trigger fever also stimulate production of body defence cells (Schroeder & Steinke 2005).

Analysis of Laboratory Results

Elevation of WBC signals infection. Reduction in Hemoglobin can impair oxygen transportation (McGee, 2005). Hematocrit which is a measure of red blood ratio in blood is low at 35% from the expected 37%-48% (McGee, 2005). This causes poor oxygen transportation. Elevation of neutrophils which fight bacteria indicates bacterial infection. Lymphocyte count of 3 is normal. Elevated glucose indicates that the patient is diabetic. Presence of diabetes and poor oxygen supply to tissues exposed this patient to NF (McGee, 2005).

A test score called Laboratory Risk Indicator for Necrotizing Fasciitis is used to determine presence of NF (McGee, 2005). For C-reactive proteins, score 4 is given if the count is equal to or more than 150mg/L and zero is given if the count is below 150. C.S having a count of 8 scores zero. For WBC, zero is given if the count is below 15cells/mm³, one is given if the count lies between 15 and 25 and 2 is given if the count is above 25. C.S scores 1. For hemoglobin, zero is given if the count is above 13.5g/dL, one is given if the count lies between 11 and 13.5 and 2 is given if the count is below 11. C.S having a count of 11.7 scores 1. Score 2 is given for a sodium count below 135mmol/L. C.S scores 2. Score 2 is given for a creatinine count below 1.6mg/dL. C.S scores 2. Score one is given if glucose count is more than 10mmol/L. C.S scores 1. The total score is 0+1+1+2+2+1=7. A total score above 6 indicates very high chances of NF (McGee, 2005). It should be noted that lab results cannot confirm NF. Confirmation can only be done by surgery through biopsy. However, due to NF’s ability to progress so fast, treatment should start immediately after seeing signs.

Other Complications to Monitor

Following the lab results, C.S is exposed to anaemia due to a reduction in Hematocrit. The blood sugar should also be monitored for diabetes (McGee, 2005). Kidney impairment should also be investigated considering the increase in creatinine level.

Standard Treatment

Treatment for necrotizing fasciitis is surgical debridement (Jain et al. 2009). This is a process through which damaged tissues are removed to prevent spreading and speed up healing process. Debridement is combined with antibiotics such as piperacillin and vancomycin which control bacterial activities by interfering with their cell wall formation (Jain et al. 2009). Jain et al. (2009) noted that culture should be done to determine appropriate drugs. Because necrotizing fasciitis is associated with hypoxia, oxygenation of affected tissues is done to stop spreading of the infection (Jain et al. 2009).

Rationale for using Hyperbaric Therapy

In hyperbaric therapy, pure oxygen is availed as treatment (Salcido, 2007). According to Salcido (2007), atmospheric pressure is raised in a well-controlled room containing pure oxygen. This allows the patient to inhale 100% oxygen. Hyperbaric therapy is administered in conditions characterised by shortage of oxygen in tissues such decompression sickness (Salcido, 2007). The therapy is also used to treat wounds that resist healing in diabetic patients. In this case, availing high pressured pure oxygen ensures that the lungs take up more than three times the normal oxygen intake. The oxygen is then distributed throughout the body. Presence of high oxygen stimulates production of growth factors and stem cells which facilitate healing (Salcido, 2007).

Wound Care Orders for Home Care

Since it is difficult for wounds to heal in diabetic patients, C. S. should not fail to take insulin to control blood sugar (Magel, 2008). The patient should also take a right diet including enough proteins and calories which promote healing. Fluids should be taken for hydration. The patient should also observe cleanliness and stay in a room with sufficient air supply for maximum oxygenation (Magel, 2008). Wound dressing should be done properly without imposing too much pressure to allow cell proliferation and faster healing.

Discharge Instructions

NF patients need a lot of monitoring. However, once the situation is under control, patients should be given instructions that would maximise healing outcomes and prevent readmission. Instructions regarding sugar level management should be given (Magel, 2008). Patients should be instructed to ensure their glycated haemoglobin level does not go beyond seven percent. All needles have to remain capped unless they have to be used immediately and should not be recycled (Magel, 2008). Magel (2008) asserts that before any injection is done to either administer insulin or test blood sugar, the point of injection must be thoroughly cleaned. After injection, the area should again be wiped with alcohol pad to avoid infection. The patient should be given instructions with regard to home care wound management. Since NF can completely change the patient’s life, Magel (2008) says that nurses should help in arranging for social services that would improve coping. Physical therapies should also be advised to help the patient regain maximum physical functioning (Magel, 2008).

References

Cain, S. (2010). Necrotizing fasciitis: recognition and care. Practice Nursing Journal. 21(6):297-302.

Jain, A., Varma A., Mangalanandan K. & Bal A. (2009). Surgical outcome of necrotizing fasciitis in diabetic lower limbs. Journal of Diabetic Foot Complications, 1 (4): 80–84

McGee, E.J. (2005). Necrotizing Fasciitis: Review of pathophysiology, diagnosis, and treatment. Critical Care Nursing Quarterly, 28(1), 80-84.

Magel, D. C. (2008). The nurse’s role in managing necrotizing fasciitis. AORN Journal. 88(6):977-982.

Salcido, R. (2007). Necrotizing Fasciitis: Reviewing the causes and treatment strategies. Journal of Advances in Skin & Wound Care, 20: 288-293.

Schroeder, J.L & Steinke, E.E. (2005). Necrotizing Fasciitis: The importance of early diagnosis and debridement. Association of Operating Room Nurses Journal, 82(6), 1031-1040