Diabetes in the elderly population remains a public health challenge in the field of nursing. The global prevalence of the disease is 8.8% for individuals aged below 80 years but above 18 years (International Diabetes Federation [IDF], 2019). The socioeconomic impact of the condition is remarkable, and based on World Health Organization [WHO] (2016), diabetes is responsible for close to 1.5 million deaths worldwide. Whereas the disease is a known epidemic, the efficient management of the resulting complications from the illness proves a daunting challenge because it almost entirely depends on changes in lifestyle, diet, and perception of adherence to certain behaviours which are dependent on the patient. Hence, there is a need harness the opinions and experiences of diabetic patients to lessen the developing negative impact the disease has had on the diabetic patients with regards to their families, society, work and spiritual needs.
Though there are many forms of diabetes, the common type the disease that is frequent on older adults is type 2 diabetes and is marked by the somatic cells being resilient to insulin (IDF, 2019). Regardless of the type, the condition is often characterized by hyperglycaemia (WHO, 2016). According to American Diabetes Association [ADA] (2017), many cases of diabetes remain undetected in the overall population. To demonstrate an understanding concerning clinical judgment and inquiry, patient X’s (fictitious name) case study will be used for this assessment task. The task comprises history of the patient’s health issue, disease aetiology, person’s perspective of the health issue, analysis and impact of the disease, intervention and exploration of a nursing response to address the condition.
History and Current Information of Patient X
During the clinical placement at the community nursing centre, Patient X agreed to participate in the current case study. Based on the Nursing Council of New Zealand’s Code of Conduct for nurses [NCNZ] (2012), patient’s confidentiality requires the use of fictitious names to hide the identity of health consumers, as outlined in principle 5. The result of the assessment follows a biopsychosocial assessment that entails the biological, psychological and social determinants that play a role in the presenting health issue. Patient X is 68 years old, New Zealand European, single retiree woman from office work background and with no children. She lives in own 2-bedroom house, does not smoke or take alcohol and has an educational level of four years in college. During the interview, Patient X presents with an obese body, yet with tidy body structure.
Moreover, Mrs. X uses walking sticks to move around, indicating that she has mobility problems. Her house presentation is tidy with a well-kept bed, underpinning that Mrs. X is independent and is capable of attending to her activities unsupported. However, she is receiving domestic home help fortnightly from a private agency, she is very grateful. Though she is self-determining, she cannot drive due to poorly healing wounds on both feet secondary to diabetic neuropathy. She got her left first toe amputated by the end of last year with the very slow healing progress. Therefore, her presenting health issues include poor healing wound, left toes amputated, and right foot plantar ulcer secondary to diabetic peripheral neuropathy with Charcot foot.
Health consumer X was diagnosed with Diabetes Mellitus (DM) Type 2 in 2009. In the year 2019, Mrs X was diagnosed with peripheral neuropathy and Charcot foot as a complication from DM. She got a diabetic foot ulcer (DFU) on the left leg having been infected with Staphylococcus aureus that resulted in bacteraemia. She was presented in the emergency department with fever; chills, increased heart rate, nausea, vomiting and severed erythema which involved the skin, subcutaneous tissue and deep abscess. During the time, clinical decision proceeded with amputation of the left first toe because of the severity of diabetic foot sepsis in the late stages of the year 2020. Currently, Mrs X is mobilizing with Darco shoes, though weight-bearing is limited. Patient X is receiving care in her home from a community district nurse visiting three times a week. The community nurse helps in cleaning and changing wound dressing because she cannot fully bend down. Moreover, Patient X’s wound has poor healing progress that required regular nursing assessment to minimize further complications or infection. Apart from the above assessments, Mrs X gets a podiatrist visit at least once or twice a week.
Pathophysiology of Diabetes Mellitus and Diabetes Foot Ulcer
Diabetes is a life-threatening condition that results in the elevation of blood sugar within the body. The level of blood sugar in a human system is regulated by a hormone made in the pancreases-Insulin. The key role of insulin in the blood is to direct the liver, muscle cells, and fat cells to eliminate sugar from the body system for storage (McGloin et al., 2021). However, in a case where the pancreatic organ does not secrete enough insulin or the body is unable to retort to a low amount of insulin in the blood, a large amount of sugar is deposited in the body fluid. Raised blood sugar can result in impairments of the nerves in such extremities of the human system as the hands and feet causing numbness or tingling (Braadvedt & Baylet, 2010; Farhat & Yezback, 2016). The condition coincides with Patient X’s symptoms when she narrates that she does not feel anything from her lower legs down to both feet.
Unmanaged diabetes and deprived foot care controls can result in such foot complications as DFU and amputations. DFU is caused by peripheral neuropathy or ischemia and subsequent shock of the feet (McGloin et al., 2021; Aalaa et al., 2012; Bryant & Nix., 2016). Based on these, the symptoms of Patient X coincide with the illustrated conditions. For instance, because of the loss of peripheral neuropathy, Mrs X developed Charcot foot, a rare but chronic complication of diabetic patients with peripheral neuropathy. Moreover, as a result of loss of morbidity in Mrs X’s feet because of DFU, the patient was forced to use walking sticks to move around.
The development and aftermath of DFU are deteriorated by the same peripheral neuropathy and ischemia and such complications as impaired immune functions. According to Maggini et al. (2018), elderly people have a reduced immune system; thus, their body does not completely fight against the invading bacterial infections leading to bacteraemia. The symptoms of bacteraemia are such conditions as fever, body ache, chills, erythema, skin abscess, and in some cases elevated heart rate just as the symptoms indicated in Patient X. DFU can be slow to heal because the illness can result in severe deterioration of the blood vessels, restricting the supply of oxygen and nutrients to the site of infection, thus lack of healing properties. According to Polikandrioti et al. (2020), individuals with DFU often feel depressed because of the wounds and the effect the condition brings to their life. Depression and psychological trauma may also reduce the process of healing, making them prone to reinfection.
Person’s Understanding/Perspective of their Health Issue
Patient X’s understanding of the health issue is as per the symptoms of DFU. For instance, when Mrs X is asked about personal understanding or perspective of the health issues, Patient X responded that she felt numbness in her lower extremities. Based on this response, it is evident that Patient X had an understanding of what was transpiring within her body. Not feeling anything on the feet is an indication of peripheral neuropathy, a condition that results in numbness of the feet because of damaged nerves (McGloin et al., 2021). Moreover, Patient X notes that she has a crook foot, which in this case a Charcot foot, a peripheral neuropathy disease emanating from damaged nerves in the lower feet and legs causing loss of sensation on the feet (McGloin et al., 2021). Most patients are often aware of their health conditions and with proper guidance, the conditions can be managed. For instance, Sutariya and Kharadi (2016) described that though the majority of patients know their foot care, 50% often indicated poor foot management. Notably, there is a need for thorough education about foot care practices.
Analysis of the Impact of the Presenting Health Issues
Diabetes has a noticeable emotional impact upon the families, specifically on members of the family who have close ties with diabetic patient. According to Grabowski et al. (2017), diabetes is referred to as family disease because the condition affects many people in the family other than the individual diagnosed. For instance, in the case of Patient X, she notes that she relied on her nephew or close friend to bring her to her appointments, a condition that may be tiresome or difficulty to the family. This can be witnessed when Mrs. X acknowledged that sometimes, the brother or nephew are never around and she had to take a taxi for her doctor’s appointments. In this regard, family members are an important segment in diabetic management. In support, Wiebe et al. (2016) direct that social support from family members can be beneficial in terms of medication, physical exercises, and time management. Therefore, Mrs. X is hopeful that once her wound is operated on and fully healed, she will be able to drive again and not rely on her family for transportation.
Several social factors are impacted by the patient’s inability to adhere to treatment, self-efficacy, and health beliefs. Questionably, diabetes control can be complex and challenging because it requires a life-long commitment and a patient’s lifestyle which can only be associated with the type of social framework a diabetic patient gets. According to Miller and DiMatteo (2013), there is an affirmative correlation between social care and medication adherence among diabetic patients. Patient X is on the positive trend by actively joining pub quiz and playing mahjong with friends at her house; thus, her stresses in life can be reduced, hence allowing faster healing processes of her DFU. Importantly, Patient X is in contact with supportive friends who often checks on her and keep herself busy through the crossword. In this case, interventions that involve the use of friends to provide social support are an important aspect of wound healing and for increasing the awareness about the available exercises that helps in reducing the sugar level for Mrs. X.
Individuals with diabetic disease and its complication often face discrimination at work due to their condition and may be forced to early retirement. This is because persons with diabetic condition and their related complications are often associated with low productivity (Pedron et al., 2018). According to New Zealand Government (2020), an individual can continue to work after turning 65 years because there is no basic retirement age in the country for employees, apart from some few exceptions. In this case, a person can apply for superannuation at 65 years, thus continue to work as a fully employed individual. In this regard, despite Patient X being at 68 years, her retirement must have been due to her DFU condition, rendering her unsustainable for work. Rodriguez-Sanchez et al. (2018) indicate that diabetes reduces the health-sensitive type of work by nearly 11% and volunteer-related work by 2.7%. Therefore, as a result of early retirement, Patient X has to depend on her pension scheme, which she notes is not “big enough” to sustain herself in terms of providing healthy foods. Consequently, the junky foods have negative impact on her wound healing process because they raise her blood glucose level.
Cultural Needs or Beliefs
Diabetes and diabetic self-management can impact both positively and negatively on the cultural values and beliefs of an individual. Diabetes is associated with changes in a person’s traditional norms, thus affecting cultural beliefs (Song & Lipman, 2008). Since diabetes result from high blood glucose levels, certain cultures believe that by using herbal remedies, the glucose levels in the blood can be controlled (Abdulrehman et al., 2016). However, since Patient X does not believe in any such traditions as taking a natural herbal supplement to lower her glucose level in the blood. Moreover, Patient X notes that through such methods, her monthly budget will be raised. Diabetes and diabetes management affect all cultures, races, and diverse ethnicities (Rebolledo & Arellano, 2016). However, certain cultures have a dominant meal plan, which can provide difficultly in diabetes control (Cervoni, 2021). Through this analysis, is imperative to state that through diabetes, Patient X has been influenced culturally into believing in the dominant meal plan; by stating that though not tagged into any tradition, she loves eating good food. However, the “good meal” quoted are the one responsible for the delayed wound healing as illustrated earlier.
Patient X has severe stress because she seeks various approaches to cope with life with amputated toe and delayed wound healing because of DFU. According to Choi and Hastings (2012), damages to both the somatic and mental aspects of life may cause spiritual health to be at serious risk. This way, an individual may experience such emotional challenges as loneliness, depression, and loss of meaning in life (Stuckey et al., 2014). For example, Patient X reports that she grew up a Presbyterian but has not been active in church lately. However, according to Choi and Hastings (2019), religion can cultivate a positive attitude towards the meaning of life. In this regard, Patient X shows hope and purpose in life when she says that she is optimistic in her viewing of life and disregarding all negative events through moving on. She also feels a sense of belonging when she joins the rest of her friends in the pub to have fun. Furthermore, Patient X has a sense of strength and hope by reporting that she is confident her feet will be better and she would be able to move around freely.
Hydrofera Blue Wound Dressing as Intervention
Patient X uses the Hydrofera Blue wound dressing intervention to manage her DFU. Hydrofera Blue dressing is a form of the bacteriostatic method of wound dressing that is different from other types of dressings because it requires to be hydrated to work efficiently, at the same time absorbing moderate –the to-excess amount of drainage. In this case, a layer which is made of Hydrofera polyvinyl alcohol sponge, methylene blue, and crystal violet, performs the absorptive role, thus promoting wound healing (Edwards, 2016). Since Patient X has DFU on her left foot infected with Staphylococcus aureus that resulted in bacteraemia, the use of Hydrofera Blue dressing is the best method for use. Specifically, the wound dressing method is indicated to inhibit the growth of such bacteria like methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci (Woo & Heil., 2017). Moreover, the presence of normal saline in Hydrofera Blue is favoured for wound dressing because the solution does not interfere with the normal healing process or alter the normal bacterial flora of the skin (Singh et al., 2019). The intervention supports optimum wellness for Patient X because, apart from allowing quick wound healing, it does not induce tissue damage or cause adverse reactions such as skin allergies.
Based on the case study, Patient X has poor self-management skills about diet and a healthy lifestyle. The nurse should work alongside Patient X in identifying and developing her self-management goal plan. The nurse should apply the use of the S.M.A.R.T. goal, which is specific, measurable, attainable, realistic, and time-bound. The objective of the S.M.A.R.T. goal is to ensure that Patient X has changes in her poor lifestyle skills that encompass poor diet and lack of physical exercise that play a key role in the control of blood glucose level. For Patient X who has had a long-term illness with diabetes, it is imperative to educate on the diverse lifestyle alterations that are vital to remain healthy and control their blood glucose levels. Patient X and her family should appreciate that diabetes entails self-management to preserve their glucose levels efficiently.
Therefore, the specific goal for Patient X is the attainment of self-management skills. Evaluation of the achievement on self-management, in this case, is an outcome of the X’s ability to sustain their blood sugar levels within their conventional target range (Rebar et al., 2017). In this regard, some of the self-management objectives are as follows: plans for ensuring a diabetic diet, knowing which starch sources are used to manage hyperglycaemia, and what dietary variations are desirable during the diabetic condition (Ministry of Health, 2021). Other goals may include comprehending the effect physical activity and weight plays in the management of glucose levels and deliberate on the processes of observing blood sugar levels (Rebar et al., 2017). In high blood sugar, the circulation of blood around the site of DFU is reduced because of narrowed blood vessels, thus impairing wound healing process in diabetic patients because of limited oxygen and nutrients, thus lowered wound healing (Davis et al., 2018). Hence, the primary outcome for these goals is to achieve optimal blood glucose control and enhance wound healing in Patient X.
Other positive outcomes are to circumvent the development of other chronic complications of diabetes. For instance, the patient should have reduced episodes of hyperglycaemia, uphold the optimal vision, and mental functioning (Rebar et al., 2017). Education begins upon a diagnosis; the primary care nurse should discuss the basics of the disease pathology and the actions and effects of the prescribed medication (Koetsenruijter et al., 2014). Education continues by explaining hyperglycaemia symptoms, how to avoid these symptoms, and how to counteract the symptoms (Egan, 2017). The nurse should also discuss proper diet and exercise, other contributing lifestyle factors, and the importance of knowing how and when to adjust medication or diet (Sinclair et al., 2008). For educating that includes demonstrating skills, the nurse should request the client to “teach-back” to ensure the steps are understood (Braadvedt & Bayley, 2010; Powers et al., 2020). Nurses should provide information about the resources available to the client. Learning about and controlling diabetes and DFU requires an interdisciplinary approach.
The nurse should also assist patient X in working out or setting out a plan that fits her expectation and needs. Using psychometric measurements, the health-related quality of life is evaluated using the SF-12, after every 3 months to justify the workability of the specified goal (Lyrakos et al., 2013). Imran notes that psychological intervention indicates positive wound healing and enhances the quality of life and well-being of an individual with DFU after 3 months (as cited in McGloin et al., 2021). Hence, the nursing goal is certainly achievable, realistic, and time-framed.
Efficient self-management skills in type 2 diabetes are a concern to many diabetic patients. The current study delivers a deeper comprehension of the experiences faced by Patient X, diabetic type 2 patients, with the findings signifying that there is a serious need for psychosocial and culturally appropriate patient education on the role of high blood glucose on wound healing. Based on the illustrations, ultimate healing of DFU involves a well-orchestrated incorporation of self-management skills that emphasizes on such lifestyle behavioural changes as diet supervision and physical exercise, which play a role in optimal blood glucose control. As demonstrated, hyperglycaemia has been linked with delayed healing of DFU. Interventions that target improvements in glycaemic control are thus of potential benefit. Because of poor self-management skills in Patient X, the use of education that targets diet and lifestyle has been proposed for her glycaemic control. Therefore, any dietary or nutritional mediation that has the primary goal of cultivating positive glycaemic control in persons with diabetes, are correlated with positive changes in active DFU result.
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