Introduction
According to Burns, Richardson, and Brady (2010), type-2 diabetes is classified as one of the common lifestyle diseases known to be more prevalent among the elderly. This does not necessarily mean that children cannot fall victim to the disease. Type 2 diabetes is becoming increasingly common not only in the United Kingdom but also in many other countries around the world. Once diagnosed with this disease, one may be forced to completely transform his lifestyle. The kind of food taken, the amount of exercise and medication are some of the issues that one may be forced to embrace when managing the disease. The research by the Department of Health (2010) reveals that many people who follow the prescribed lifestyle can live without being affected by health complications and pains associated with diabetes. They lead a near-normal lifestyle. However, many people are unable to change their lifestyle as advised by the practitioner. Diabetes management is about discipline. As Cavan (2013) puts it, the only person who can ensure that there is success in the management of diabetes in any setting is the patient. This is a lifestyle disease and managing it may demand change in some of the common practices. In this paper, the researcher will focus on how a patient, JT, can be helped to manage his type 2 diabetes.
Past Medical History of the Client
Managing diabetes may not be a simple process as many people may want to believe. Cavan (2013) says that the process may not only be physically demanding but also mentally torturing. It is not easy for an individual to suddenly change a lifestyle that he was used to his entire life. That is why before starting a diabetes management program one should try and understand the history of the patient to determine the most suitable way that will help the patient. JT, a 55-year-old Caucasian man, was diagnosed with type 2 diabetes 2 years ago when he had an NHS health check. It is reported that at the time of the diagnosis, he was obese, weighing 118 kilograms with a body mass index of 39.9. At the time of diagnosis, JT was not a smoker, having quit the habit when he was 45 years. He also reported that he consumed alcohol on special occasions only.
After the diagnosis, he was introduced to a strict diet, daily exercise, and started metformin that was titrated up to 100 mg two times a day. This helped him lose 20 pounds. The report indicates that the level of his blood glucose improved, and within only four months, his A1c had declined to 6.2% from 7.2%. After some time, it was noticed that his A1c had risen to 7.3 without any clear explanation. To manage this deterioration, he was added Amaryl at a dose of 2 mg daily to stabilize his condition. After three months, JT had gained 11 pounds and his A1c rose to an alarming 8.1%. The patient’s condition was deteriorating despite the efforts put in place by the primary caregivers. It is important to note that more focus was put on monitoring the patient that empowering him to take care of himself.
Present State of the Client
JT’s condition has worsened over the past two years and this has created a need for him to be under close monitoring of primary caregivers. When the patient was first diagnosed with this complication, he noted that he felt the urge to fight the disease through any means possible. However, he gave up along the way after a few months when he noticed that he had made some little progress. JT has stopped the strict physical exercise he maintained two years ago. What is more worrying is that he has stopped taking his medication regularly. He admits that he is currently taking medicine when he feels physical discomfort, not as routinely directed by the physician. He reported that he is planning to stop taking his medication completely, claiming that he is tired of taking medicine even when he is feeling unwell. The positivity with which he had approached his medical condition two years ago when he first tested positive with diabetes seems to have been lost along the way. The counseling given to him seems to be having no serious impact on his current trends. As of now, his condition is worse than it was six months after being diagnosed with the disease. He is adding more weight, a trend that is not only aggravating his condition but also puts him at risk of contracting other serious medical problems such as cardiovascular diseases. The A1c is currently well above 8.1% and if measures are not taken, it could worsen very soon. The practitioner is not very sure how to deal with the current condition of the patient, especially his negative attitude towards medication that developed in the recent past.
Issues Identified from the Case Study
After understanding the past and present medical history of the patient, it is necessary to identify specific issues from the case that can help in developing a working formula for managing the patient’s condition. A critical analysis of the case reveals that the medical program started well when JT was first introduced to it. However, some fundamental principles were ignored which might have led to the relapse. The first principle was the patient’s need to take control of his program. As stated above, managing diabetes requires discipline and dedication. This can only be achieved if the patient is empowered. Before starting the program itself, the patient must undergo a series of counseling to address all the fears he might have about his new condition and its implications. Through this progress, a patient should be encouraged to ask any question they might have about the disease and ways of managing it. In this case, the patient was introduced to a series of medications and lifestyle management programs before he was able to comprehend the issues at hand. His initial positive response may be associated with fear.
When he was told for the first time that he was suffering from diabetes, he must have panicked and embraced the program out of fear of imminent death. The positivity in the program and all the effort to follow instructions given by the physician was, therefore, an attempt to stay alive. With time, he came to accept the fact that he was suffering from the disease. However, instead of becoming empowered with this knowledge, he developed a sense of resentment towards the program and everyone involved with it. This explains why he rejected the counseling program that was offered by a medical practitioner. He has learned that his body can feel well even without medication. This is why he admitted that he would avoid medication when he is not feeling sick. This irresponsible statement demonstrates that JT was not empowered in the first case to understand his unique medical condition. No one told him that the body may feel when even in cases where there is a serious medical condition that should be addressed. He was not informed that lack of discomfort and pain are not necessarily signs of good health. It may also be possible that during the initial program, the practitioner who was assigned to him failed to develop a close personal relationship with him. The refusal to take any counseling may be a result of this poor relationship that makes it difficult for the patient to trust any other practitioner.
Managing the Patient’s Condition
Analysis of the past and present medical history of the patient has made it possible to identify critical issues that have made JT relapse after making impressive progress at the initial stages of his medication. At this stage, the researcher will develop a program for managing the patient’s condition taking into account issues that have been identified in the section above. The proposed program will be simple and it will start with a concerted effort to empower the patient. Then it will move to wellness issues before culminating into a serious medication program. It is important to note that the decision to start with an empowerment program has been informed by the revelation that the patient has rejected medication and any form of counseling. As Cavan (2013) says, he is lost in a state of denial and lack of trust for the medical processes he has been subjected to over the past two years. It is only after achieving a complete change in the current attitude towards his medication and medical staff that the patient will be able to start participating in other subsequent stages of this program.
Personal empowerment
This program will start by reviewing the current knowledge that the patient has about diabetes. To do this successfully, it may be necessary to assign a new practitioner to his case other than those who were responsible for his health management on the previous occasion. This strategy will help in winning back his lost confidence and trust in the program. It may be necessary to involve members of his family or even close friends in the program at this early stage to make the patient more comfortable. After winning back the confidence and trust, the practitioner will then need to start a detailed education about diabetes. The patient will have to understand every little piece of information about diabetes, from possible ways through which he may have developed the condition to ways of managing it ad possible consequences of mismanaging the condition. First, the patient must understand that being diagnosed with type-2 diabetes is not equivalent to receiving a death sentence. There is a possibility that JT had despaired, believing that he would die soon due to his condition. Such issues must be addressed at this stage. The practitioner must make an effort to understand all the fears and concerns of the patient. Knowing the exact reasons why he stopped the medication, neglected the physical exercise, and even counseling will be of critical importance at this stage to help address the issues mentioned above. Cavan (2013) says that providing the patient with reading materials about diabetes or even relevant movies may help empower the patient and eliminate wrong perceptions that may otherwise make it difficult to address medical problems affecting the patient. Finally, the practitioner will inform the patient about his specific role in the entire program.
Understanding diabetes ABCs
This stage may still be considered as the patient’s empowerment program. However, this stage delves deeply into specific issues that a patient must understand and embrace for the rest of his life as a way of managing the disease. In this formula, A stands for A1c. This refers to a blood test done after every three months to determine the patient’s blood sugar level. The goal is always to make an effort to ensure that the level is maintained below 7. High sugar levels in the blood may pose a danger to the heart, kidneys, blood vessels, eyes, and feet (Department of Health 2001). Its regulation helps in ensuring that these systems and organs are protected. B is for blood pressure management. It is important to monitor the force that blood exerts against the wall of blood vessels. High pressure on these vessels will always overwork the heart. This may expose the patient to a series of medical problems which include stroke, heart attack, and serious damage to the eyes, kidney, or blood vessels themselves. Maintaining a regular practice of checking blood pressure is an important practice for the patient. The goal should be to have a blood pressure level which is below 140/90. C in this formula stands for cholesterol levels in the blood. According to the Department of Health (2003), the blood has two types of cholesterol which are HDL and LDL. LDL is a dangerous type that easily clogs blood vessels lowering their function. It is the leading reason for heart attack. HDL is a beneficial type of cholesterol that helps in cleaning the blood vessels by eliminating LDL. The level of HDL can be improved in the blood system by maintaining a strict nutritional practice.
Physical exercise
Following the ABCs of diabetes as defined above should be accompanied by other practices to achieve maximum results. One such practice is maintaining regular exercise. At 55, JT may find it difficult to develop a positive exercise culture at this late stage of life. However, the truth is that he can still manage moderate fieldwork every morning or in the evening. Alternatively, he can visit a local gym where he can spend about 30 minutes daily doing light exercises. However, the Department of Health (2003) warns that people with medical problems must ensure that they conduct their physical exercises under the supervision of experts. This is to avoid cases where they overwork their already weak heart. They can start with slight exercises and progress slowly as their cardiac muscles strengthen. Physical exercise will improve the myogenic mechanism, reducing the risks of problems related to high blood pressure. It also helps in burning out the undesirable LDL cholesterol from the blood. Regular physical exercise also increases general body strength. At 55 years, JT may find some of the routines expected of him as a patient physically and emotionally demanding. By maintaining regular exercise, he will increase his physical and emotional strength, making it easy for him to deal with the challenges that this new condition may bring.
Stress management
The research by the Department of Health (2003) reveals that stress hurts individuals suffering from type 2 diabetes. When one is stressed, the body produces hormones in response, especially if it is prolonged stress. The hormones may cause the blood sugar level to rise to unprecedented rates. Any diabetic patient aims to maintain sugar levels in the blood as low as possible. Stress makes it difficult to achieve this very important goal. Cavan (2013) also notes that stress hinders the ability of an individual to maintain some of the routines required of a diabetic patient. This condition strains the mind and this brings general body weakness and disillusionment. These negative factors make it necessary to find ways of managing stress before it can hurt the patient. Stress management starts with the patient. JT will have to start by identifying stressors in his immediate and external environment. Once these stressors are identified, it will be necessary for him to share the information with the practitioner in charge of managing his condition. The two must discuss and find a way of eliminating these stressors. In case they cannot be eliminated, then they will find a way of reducing their magnitude on the patient. The program may also involve JT’s family and close friends. They may need to be involved in coming up with a solution to issues raised by the client. This teamwork will increase the chances of achieving the desired goal.
Glycemic control
Recent studies have associated glycemic control with the successful management of type-2 diabetes (Department of Health 2010). These studies indicate that glycemic control helps in achieving a sustained decrease in rates of neuropathy, retinopathy, and nephropathy. This means that such a patient’s eye may not be adversely affected by the disease. His kidneys will also be relatively safer compared to an individual who lacks this control. It is important to note that the control lowers these risks considerably, but it does not eliminate them. In his report, Cavan (2013) says that it is not yet clear how this treatment can be administered to patients who are below 13 years and those who are over 65 years. It means that JT falls in the bracket of those who can benefit from it. However, the practitioner must inform him that in the next ten years, an alternative must be found because this form of medication may no longer be appropriate at that stage. Both the patient and the health practitioner will need to take an active role when using this treatment method. For the patient, self-monitoring of glucose will be necessary. As mentioned in the previous section, A1c is conducted once after every three months. However, for a patient who wants to succeed with the idea of glycemic control, the test can be done more frequently in between the three months. This can be after every one month or once after every two weeks. Testing blood sugar can be done by the patient at home or within the hospital without necessarily being assisted by anyone. Some kits can be used to conduct this test.
Glycemic control also involves screening and treatment of nephropathy. The kidney is one of the organs that are easily affected when a patient is suffering from type 2 diabetes. For this reason, measures should be taken to find a way of boosting its performance as much as possible. The kidney nephrons must function optimally. However, they may be prone to damage given the level of sugar in the blood. Glycemic control also involves screening and treatment of diabetic retinopathy. Researchers have confirmed that type 2 diabetes hurts the eye’s retina. If blood sugar levels continue to rise without control, then there can be serious damage to the retina. When diabetic retinopathy is detected and treated early, the impact on the functionality of the eye can be less serious. However, the diseases can be damaging to the eye if measures are not taken early enough to control them.
According to the Department of Health (2003), diabetic neuropathy is one of the most undesirable conditions that a diabetic patient may develop. This condition may lead to foot ulceration and amputation if it gets worse. This entire program depends on the active participation of the patient in achieving the desired success. The patient will be playing the leading role in most of the activities discussed above. However, diabetic neuropathy may cause immobility among the patient. After amputation, the patient will be incapable of going for the physical exercises as expected in this program. This will worsen his condition and the success rates of all other programs will be affected. According to research by the Department of Health (2010), the risk of amputation for patients suffering from diabetic neuropathy is increased if they males who have had diabetes for more than ten years. The risk is increased further if the patient has poor glucose control, retinal or renal problems, or cardiovascular complications (Department of Health 2001). It is a relief that JT has only been suffering from this condition for two years. However, his recent withdrawal from medication and other support programs means that he may have any of the risk factors mentioned above. The idea of foot ulceration may have devastating mental consequences on the patient. He may despair completely knowing that he will have a slow painful and shameful death. Such a patient may easily be suicidal if they are not offered proper mental therapy. Screening and treating diabetic neuropathy will be considered one of the most important medical programs that JT will have to undergo regularly.
This program is the most comprehensive and very specialized process that JT will have to undergo. As Burns, Richardson, and Brady (2010) say glycemic control may be stressful to a patient because it not only involves monitoring blood sugar levels but also other specific organs within the body that in one way or the other may be affected by the diabetic condition of the patient. It may require a series of tests done regularly on a patient to help in ensuring that these complications are detected early and relevant measures are taken to ensure that risks are eliminated before they occur. The current status of JT as presented in the case is worrying. As of now, he cannot be subjected to this process because of his attitude. He is in denial and is already rejecting some of the medications which are simpler than glycemic control. This program will, therefore, be put on hold until JT’s mentality about the relevant medications is changed.
Group therapy
O’kane, Bunting, and Copeland (2008) say that diabetes is a life-changing disease that knows no social status and whose effect, if not properly managed, may lead to one of the most humbling and very painful deaths. The risk of amputation among diabetic patients is real, and it gets worse as one gets older. This is the direction that JT is taking, and therefore, his condition must be monitored and managed very closely. Given that there is a need to make him participate in this program, it will be necessary to introduce him to group therapy. Having rejected counseling in the past, there is a possibility that he may reject future therapies administered by the practitioner at this primary care facility. There is a need to ensure that this risk is eliminated or reduced as much as possible. This can be achieved when JT is introduced to individuals who are suffering from a similar condition.
The practitioner responsible for managing this patient must ensure he can identify with the team members easily in terms of age and other important demographical factors. The group will offer him the greatest motivation he needs at this critical stage. Whenever he feels weak the team will offer him much-needed support. In case he finds any of the medical staff boring or too demanding, the group will be his source of inspiration and solace. In this group, it will be easy to explain to JT why it is necessary to observe all the medications and lifestyles discussed above. Some of the group members will also help him overcome any form of fear that he may have towards the management of type 2 diabetes. Their success stories may particularly be very important in making this patient not be resigned to his condition. They will motivate him to be a fighter, for the ultimate aim of being a winner in the management of this dangerous disease.
Conclusion
Diabetes mellitus, also known as type-2 diabetes, is increasingly becoming common in our society. In this project, the researcher was presented with a delicate case of JT, a 55-year-old diabetic patient who was diagnosed two years ago. He started medication immediately and for the first few months, he was responding well. However, he gave up his medication after some time, and the case reveals that his condition is worsening. One of the most important revelations from the analysis of his case is that his knowledge about diabetes is limited, especially when he said that he stopped taking medication after feeling well. This disease may affect important organs such as the heart, eye, kidney, or limbs if not taken seriously. That is why in this report the researcher has suggested that the patient should first be taken through programs that will empower him by letting him know about these dangers and how to change his lifestyle. After this, the patient will go through a series of medications, described as glycemic control. This medication will not only help in checking blood sugar levels but also in screening and treating various diseases related to diabetes. To help the patient at this critical moment, he will be introduced to group therapy.
List of References
Burns, C, Richardson, B & Brady, M 2010, Pediatric primary care case studies, Jones and Bartlett Publishers, Sudbury.
Cavan, D 2013, Reverse your diabetes: The step-by-step plan to take control of type 2 diabetes, Vermilion, London.
Department of Health 2001, National Service Framework for Diabetes: Standards, Department of Health, London.
Department of Health 2003, Diabetes Information Strategy, Department of Health, London.
Department of Health 2010, Equality and Excellence: Liberating the NHS, Department of Health, London.
O’kane, M, Bunting, B & Copeland, M 2008, ‘Efficacy of self-monitoring of blood glucose in patients with newly diagnosed type 2 diabetes, British Medical Journal, vol. 12, no. 4, pp. 37-91.