Diabetic

REFLECTIVE ESSAY ON TYPE 1 DIABETES MELLITUS Diabetes is a global problem in increasing propotions.there are an estimated 2.35 million people with diabetes in England and 100,000 more people are diagnosed with diabetes every year (Dpt of Health,2001).this is predicted to grow more than 2.5 million by 2010.the total cost of diabetes in the UK in 1998 was estimated at 1.83 billion, or 3.4 % of health care expenditure (DOH,2001).however 40% of this cost is used in the management of preventable diabetes complications (CALMAN,1998).The main aim for maintaining normal blood glucose is to prevent development of ketoacidosis,to prevent electrolyte abnormalities, to prevent impairment of leukocyte functions and to prevent impairment of wound healing (Diabetusuk,2002).Structured education can improve knowledge, blood glucose control, weight and dietary management, physical activity and psychological well being (DOH,NSF FOR DIABETES,2010).here I have chosen one of my patient who is having type 1 diabetes and recurrent admission with diabetic ketoacidosis.to fulfil the requirement of her problem I have followed schons (1983)model of reflection .I had an opportunity to look after her while she was admitted in my ward. Diabetes mellitus comes in many forms-types1, which is insulin dependent, type 2 and gestational diabetes. All theses are inability to self-regulate the levels of blood glucose or cellular fuel in the body. National Diabetics audit and diabetes Quality Outcome Framework (QOF) are providing data that will support effective measurement of improvement in diagnosis and care. I have learned that reflection is a psychological construct that is related to cognitive processes such as thinking, reasoning, Considering and purposeful (Gregory, 1987).I think it is most important that we should be followed reflective practice in our day to day life to bring success in every action. However, we reflect many things in our daily life, Donald Schon (1983, 1987) who differentiated between reflection in action and reflection on action. Based on his study, I understand about reflection on action, and reflection in action. Reflection in action will occur during our practice. This can be identified while doing our work; we can adjust or correct our actions to make the work in a better way. However, reflection on action will occur after finishing our work or action. It would be recollection of our memory based on our actions. So that we can analyze and reconstruct our work and we can perform the same action in a best way in future. Also I understand about technical reflection will be based on scientific method and rational (Quinn, 1998).this deductive thinking allows us to validate our knowledge base practical reflection leads to understanding and this guides us to transform our knowledge, ideas and skills on our action to perform in a good manner (Taylor J,2000). In reflective practice, I have realized that cognitive skills are required for critical thinking. It includes decision-making and problem solving methods. Problem solving involves assessing, planning, implementing and evaluation (Wilkinson 1996).I recognised that reflection is a way in which professionals can bridge the theory-practice gap (Schon 1983).I became conscious about the reflection is not simple process and practitioners need coaching and reflective diaries as tools for dealing with problems. I understood about planned approach that helps to learn is a key element for clinical supervision and it supports practices promoting the standard of care. From the above clarification, I have chosen schon model of reflection to meet my patient’s problem. my patient is a 42 years old lady admitted elective from home with generally unwell for 2 weeks,nausea,back pain, constant and dull in nature, similar to the pain when she had urinary tract infection in the past. The general practitioner saw her prior to this admission to the hospital and urine culture was analysed coliform bacillus, she was treated with cefelaxin, later she developed dental pain one week ago and was seen by the dentist who diagnosed as dental abscess due to her wisdom tooth .she was treated with amoxicillin for this. Upon admission to the hospital, she had severe toothache and her nausea being worsened. She has history of type 1 diabetes and she is on five time’s daily insulin. She takes actrapid u500 25 unit 4 times a day and humulin m3 22 units at bedtime. Type1 diabetes come from its association with the genes for the DR3 and DR4 molecules in the HLA immune response gene region on chromosome 6,the presence of islet cell antibodies in serum before and at the time of diagnosis. the finding of an aggressive round cell infiltrate in the islet of patients dying diagnosis, and association with other conditions more clearly recognised as being of autoimmune origin (Diabetes and endocrinology,1991). She has recurrent admission to the hospital with diabetic ketoacidosis and urinary tract infection. The progression of ketoacidosis will generally be announced by a complaint of feeling unwell, followed by loss of appetite, and then vomiting. Abdominal pain may accompany ketoacidosis and mimic an acute abdomen.acidotic breathing, severe dehydration and loos of consciousness are severe events of grave prognosis if medical help is not sorted immediately, or if diagnosed delayed (Diabetes and endocrinology, 1991) She self catheterizes due to neuropathy. Bladder dysfunction usually takes the form of loss of tone with a large increase in volume. It is therefore usually asymptomatic. Urinary tract infection and retention are recurrent in my patient’s case. Her blood glucose level was ranging from 2-30mmol, checked urine for ketons and was 4+ .not eaten anything for 1 day, but she had her regular insulin dose. Blood glucose upon admission was 17.3mmol.routine bloods were sent including ABG to the lab for further investigation. Meanwhile she was reviewed by the team doctors and advised to start glucose potassium infusion. She always had poor venous accesses she had Hickman line inserted 2 months ago ,so I have changed her Hickman line dressing under aseptic technique and flushed with heparin ,the line was patent and commenced on glucose potassium infusion as per the protocol, checked her blood glucose every 2 hours and titrated the infusion as per protocol. Her early warning scores were two but she looked very lethargic, so doctor prescribed additional intravenous fluid to hydrate her. She also has intravenous antibiotics for her urine infection. Her apatite was very poor, therefore the following day I have arranged to get to see the dietician.reviewd by the dietician and started on supplement to boost her up. She was still nauseated and antiemitics prescribed eight hourly, which given with desired effect. The following day she looks much better, her blood glucose levels were greatly improved. Glucose potassium infusion continued. Her apatite was improved, but she felt nausea occasionally, intravenous cyclizine 50 mg helped her. I have also observed her elimination needs, she did complained of loose stools after starting amoxicillin, but she has not had any further episode. There is no doubt that diabetics have negative impact on quality of life. People with diabetes report lower psychological well being than those without disease (Speigh, 2002).Depression is three times as common as individuals who have diabetes compared with general population. I was thinking how to give my best support towards her feelings. She is on regular diazepam 2 mg tds and fluexetine 60 mg daily. National Service Framework data for diabetes empowers patient to take personal control of day-to-day management of their diabetes. She has good support from her family. However, she was very upset as her mother passed away recently. Therefore, she needs constant reassuring which I did. On the fifth day of her admission, she improved tremendously. Consultant reviewed her on the ward and decided to stop her glucose potassium infusion, and she managed to eat and drink well. We have started her regular insulin, five times daily. Her glucose level has come down gradually to normal range in time. Intravenous antibiotics changed to oral form. Urine for ketons became negative. All her routine blood tests improved greatly. I have mentioned her that exercise play key role in the management of diabetes. During activities, glucose will be utilized, so that requirement of insulin will be reduced. In addition, regular exercise help to increase cardiovascular efficency, decreased preassure, reduce stress, aid in weight reduction and apatite control. It also promote wellbeing and aid in blood glucose control (Dunning, 1994). I have demonstrated the right way of administering insulin to her and the right site for administration. I have explained that lipohypertrophy is a local response to injected insulin. It is found to be common, when actively sought. Even in patients without evident subcutaneous fat hypertrophy, ultrasonography of injection sites will often reveal increased thickness, with areas of fat interleaved between disorganised fascial planes and scar tissue. The phenomenon is of clinical significance since insulin absorption is significantly disturbed from these sites when compared to a standard subcutaneous injection. At present, however, it remains unclear action, or whether, as is likely, erratic and unpredictable absorption occurs, possibly with loss of bioavailability. Does foot care education prevent podiatric complication' Yes. Effective foot care includes a variety of behaviours, such as appropriate foot washing, nail trimming, footwear, and, perhaps most importantly, vigilance for the signs and symptoms of abrasions, scapes, sores that can develop into infections that ‘‘threaten life and limb’’.observational studies suggest that the absence of foot care education may contribute to a greater risk of foot problems. in a survey of patients who had developed foot ulcer, only 29% previously considered themselves at risk of foot problems, while 59% of a comparison group had not had their feet examined in the prior 10 years. Only 30% reported that they had received information about foot care from their health care providers (Evidence based diabetic care 2001). Therefore, I have emphasised to my patient that it is very important to attend her podiatry appointment although she has no skin problems to her feet I also arranged an outpatient follow up appointment to see the diabetic specialist nurse chiropodist and dietician upon discharge. My short-term objectives were to reassure and allay fear of everything about diabetes and to establish trust between my patient and the diabetic team as well as concentrate on gradual reduction of blood glucose. My long term objectives were make the patient accept diabetes as part of life and recognise her part in the successful management of the diabetes, maintain acceptable range of blood glucose, regular medical appointment, ongoing support and encouragement through the diabetic clinic would say successful patient monitoring has been achieved for her by continuous monitoring of blood glucose, weight ,blood pressure, diet foot care and nutrition. The white paper (2005) focuses largely on take apart in the internal market and the development of primary care. the provision of specialist services which investigate and treat the bulk of serious ill health despite their accounting form about £2.14 billion of NHS expenditure annually (national diabetes, 2006). The recommendation generally came under three categories raising awareness, prevention, and supports for people have diabetes. For raising awareness, it needs a campaign to promote awareness the issue of diabetes with particular communities. The primary care trust local branch, schools and relevant community and voluntary groups should work together to develop raising awareness. Second category is prevention, which requires PCT, and GP’s (general practitioners) should target to those high risks and screening should be done in simple and low cost through urine or blood testing. The NHS screening committee is currently carrying out research on the feasibility of introducing a national screening programme for diabetes. third category is to give complete health education and support people who have diabetes. the labour government proposed banning of foods includes burgers,crisps,and fizzy drinks sweets to promote personal wellbeing. In conclusion, based on reflective practice, I have given effective care to my patient to manage her diabetes. She has been improved by day-to-day care delivery, monitoring blood sugar levels to prevent complication. Her blood glucose levels has been improved and I could able to maintain her blood glucose level between 7-10mmol/ltr.and also I have arranged annual screening to check her eye, kidney, nerves and foot to prevent further complications. I have analysed her problem based on Schon (1983) model of reflection and achieved problem solving by proper assessment interventions and evaluations. I gave health education to her and the family. through various research studies regarding diabetes and as well as reflective practices I came to know about how effectively I can manage the diabetes patient and how can I give my full support to them to lead quality life in society without Complications. I also came to know about how to give nutritional support for type 1 insulin dependent diabetes clients with balancing between their blood sugar and nutrition. I have been satisfied about her health improvement and have brought good progress on her condition. Word count: 2115 References 1) Calman .T, (1998) Nursing times (April,2005), ‘how to diagnose diabetes’ volume 101 no16 page no 28-29. 2) Department of health (2001)www.dh.gov.uk 3 )Diabetesuk (2002) www.diabetes.org.uk 4) Turnbridge,W.M.G (1991) Diabetes and endocrinology in clinical practise. 5) Dunning.T (1994) Care of people with diabetes, ‘‘A manual of Nursing Practise’’, page no 72-74. 6) B C Decker 2001-Evidence based diabetic care. 7) Gournay.N (2000)- Mental health, evidence based Approach. 8)National diabetes (2006)- www.jmir.org 9)Speight.B, (2002)- Nursing times(july,2005), ‘‘Use of insulin in Diabetes’’,volume 101 no 28 10)Quinn.M,(1998) Continuing professional development in Nursing, ‘A Guide for Practitionors and Educators’’. 11)Taylor.J(2000) Reflective practise,A guide for nurses and Midwives.