Cases of diabetes are on the rise in the modern society especially among the old people. A survey carried out by Centre for Disease Control (2002) showed that cases of type 2 diabetes in the United States are increasing at an alarming rate. Van der Bijl, van Poelgeest-Eeltink, and Shortridge-Baggett (1999) also echoed these views and observed that type 2 diabetes is the chronic condition with the highest frequency of occurrence in the Western countries. Diabetes occurs among all ages and ethnicities. Type 1 diabetes is majorly prevalent amongst children as well as young adults whereas type 2 diabetes is mostly common among older people (NIH 1999; Baker 2000). It is confirmed that about 20% of people aged above 65 years old experience type 2 diabetes, while it is estimated that a similar number is still not diagnosed (ADA 2002). However, there is evidence of type 1 diabetes diagnosed among adults and type 2 diabetes among children, though at a considerably smaller rates.
This article analyses diabetes in detail and presents a case of diabetes among older people. In the framework of this paper, an older adult is defined as any person who is 65 years old and above. The article explores in depth different kinds of diabetes, symptoms of the various forms, diagnosis, and management of diabetes. It also presents a case of 71-year-old woman who is diabetic, suffering from hypertension, and is at a higher risk of developing microvascular and macrovascular complication due to diabetes. The article also presents a reflection of the case and concludes major findings.
A blood ailment when the level of glucose in the blood increases beyond the usual range is commonly known as hyperglycaemia. It is a metabolic condition that results from the abnormal metabolism of sugars and causes elevated levels of glucose in circulation. Normal levels of blood glucose range from 80-99 mg/dl for fasting blood sugar and 80-139 mg/dl for random blood sugar and two-hour glucose tolerance test (Konzem, Devore, & Bauer 2002). An individual is considered to be diabetic if blood sugar levels are 126 mg/dl and above for fasting blood sugar and 200 mg/dl and above for both random blood sugar and two-hour glucose tolerance test. Diabetes emerges when the body is unable to change glucose to energy, i.e. the cells are unable to absorb glucose from the blood stream as a result of high glucose level in circulation. Glucose levels in the body are mostly determined by the carbohydrate foods. Once ingested, carbohydrates are broken down into glucose in the digestive system. Glucose is then transported via blood throughout the body that is used to generate energy in the cells (Medvei 1993).
For glucose to be absorbed into the cell, it requires a hormone called insulin. The pancreas has the Islets of Langerhans forming the beta cells that produce insulin. Diabetes takes place when insulin is produced in the insufficient amounts or none at all. Moreover, it can also occur when the produced insulin is defective, hence, unable to function properly. Diabetes also occurs upon the body’s failure to react to insulin resulting in insulin resistance. Therefore, diabetes is a metabolic condition resulting in the presence of excessive glucose concentration in the blood system (Konzem, Devore, & Bauer 2002).
A Brief History of Diabetes
Early cases of diabetes were detected over 2000 years ago. The condition was known as a dangerous and a deadly disease and was among the leading killers at that time. The name of the disease is derived from a Greek word ”diabaínein”, which means “to stride”. The term “diabetes” was then derived from the word “diabetes”, specifically meaning to “siphon”. Since the condition manifest with the excessive discharge of urine among other signs, the term “siphon” resulted in the adoption of the term “diabetes”, denoting a condition that involves discharge of large volumes of urine (Poretsky 2009). Aretaeus of Cappadocia coined the term as diabetes.
At the beginning scientists diagnosed the disease by tasting urine. Sweet urine signified presence of diabetes. Normally, urine should be glucose-free. However, high level of glucose in plasma results in the presence of glucose in urine (Konzem, Devore, & Bauer 2002).
Types of Diabetes
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There are several types of diabetes that are currently known. Three usual kinds of diabetes include type1 diabetes, type 2 diabetes, and gestational or pregnancy diabetes.
Type I Diabetes
This is also referred as “juvenile-onset diabetes” because it is commonly diagnosed among children. This form of diabetes is insulin-dependent. It has a genetic component and is an autoimmune condition. An autoimmune condition refers to an ailment resulting in the body’s defence mechanism, i.e. the immune system recognises its own cells as foreign and, therefore, attacks and kills them (Rubin 2011).
It is a cellular-mediated autoimmune condition. The immune mechanism recognizes beta cells of the Islets of Langerhans as foreign, thus, attacks and destroys them. This results in the absence of production of insulin or production of it in the small amounts. Out of the diagnosed reports of diabetes in the U.S., type 1 accounts for 5-10 percent of condition mostly diagnosed among children as well as young adults. However, some cases of type 1 diabetes have been reported among adults. This type of diabetes is managed by daily administration of insulin (Rubin 2011).
The condition manifests itself in different ways such as polydipsia, polyuria, polyphagia, blurred vision, emaciation, and extreme fatigue. If not attended early, type 1 diabetes can develop into a serious life-threatening condition, called diabetic ketoacidosis or diabetic coma (Rubin 2011).
Type II Diabetes
This is the most prevalent kind of diabetes affecting almost 90-95 of all diagnosed diabetes cases. Also called “non-insulin dependent or adult-onset diabetes”, it is a lifestyle as well as a metabolic condition whose predisposing factors include family lineage, i.e. genetic factors, old age, overweight, sedentary lifestyle and ethnicity. In addition, previous case of gestational diabetes in women also increases the risk of getting type 2 diabetes. Statistics shows that almost 80% of people who suffer from type 2 are obese. The condition is also common among certain ethnicities, such as Mexican-Americans and African-Americans (Perez-Stable, Napolex-Spriner, & Miramontes 1997).
It is caused by the failure of the body tissues to react to insulin, i.e. insulin resistance. The pancreas produces insulin in sufficient amount but the cells fail to respond to it resulting in raised level of glucose circulating in the blood. The condition starts with normal production of insulin, although the production decreases over time leading to similar effects as type 1 diabetes. The symptoms develop gradually and in some cases, it is asymptomatic. The symptoms include primarily thirst and hunger, frequent urination, fatigue, gradual body wasting, slow wound healing, blurred vision, and presence of glucose in urine (Genuth et al 2003). If the condition is not attended, it results in the development of cardiovascular diseases, kidney problems, loss of eyesight, as well as other complications.
This type of disease is characterised by an increase of the blood sugar level in late stages of pregnancy among women. However, this condition disappears after birth. Gestation diabetes predisposes an individual to type 2 diabetes later in life. According to statistics, gestational diabetes increases the chances of contracting type 2 diabetes by 40 to 60 percent. Cases of gestational diabetes that develop to type 2 afterwards are mostly associated with overweight and physical inactivity. Pregnancy hormones and/or insulin deficiency cause gestation diabetes, which mostly affects certain ethnicities and is suspected of having a genetic component. This condition is sometimes asymptomatic and often goes unnoticed (Crowther 2005).
Diabetes is diagnosed by establishing the glucose level in blood. This has been the practice for a long period. There are three commonly used methods to establish blood glucose, including fasting blood glucose test, oral glucose tolerance test, and random glucose test. “Fasting blood glucose test” is done after eight hours of fasting preferably early in the morning. It is the preferred method of determining blood glucose level in non-pregnant adults and in children. Under this test, an individual is considered to be diabetic when it is higher than 126 mg/dl. Normal blood glucose ranges from 80-99 mg/dl and, therefore, the range between 100-125 mg/dl is considered as prediabetes (Konzem, Devore, & Bauer 2002).
Oral glucose tolerance test is usually done two hours after administration of a solution of 75 grams of glucose in water. Normal blood glucose for this test ranges between 80-139 mg/dl, whereas prediabetes range is 140- 199 mg/dl, hence, diabetes starts from 200mg/dl and above. This test is the preferred method of testing gestational diabetes. Blood sugar levels are usually lower than normal during pregnancy. Therefore, the determinant ranges are usually lower than normal. Random blood sugar is conducted randomly at any time and diabetes onset range is 200 mg/dl and above (Knowler et al 2002).
Haemoglobin 1c (A1C) is used to monitor glucose levels in blood over a period of 2 to 3 months. The test is used in management of diabetes as it predicts the chance of microvascular and macrovascular complications developing.
Diabetes cannot be cured. However, it can be managed to reduce its effects and extend the patient’s life. Diabetes is managed through a multi-faceted approach, which include healthy diet, physical exercise, lifestyle change, and through medication and insulin injection (Peyrot 1999). Immediate target of the diabetes’ management is to lower blood glucose level to normal. However, since glucose is normally accompanied by other complications, the broader aim of diabetes’ management is to prevent microvascular complications, which include retinopathy, nephropathy, neuropathy, and macrovascular complications, i.e. arterial diseases, stroke, and myocardial infections. Insulin injection raises the blood insulin level, hence, lowering blood glucose level. This intervention is employed to manage diabetes 1 and in some cases diabetes 2. Long-acting insulin is injected once per day whereas short acting insulin is injected multiple times during a day. Insulin is sometimes used together with other drugs. Some of these drugs are injected to increase production of insulin by the pancreas, e.g. sulphonylureas. Others increase activity of insulin and cellular responsiveness to insulin, e.g. thiazolidinediones, whereas some delay glucose absorption from the gut, e.g. metformin. Other drugs suppress the effects of glucagon, an antagonistic hormone to insulin (Knowler et al 2002).
Besides reducing the amount of glucose in the blood stream, Hemoglobin A1C testing is also used to predict the risk of diabetes occurrence by monitoring blood glucose over a period of time (Edelman et al2004; Pradhan et al2007; Sato et al2009; Geiss et al2006).
Management of diabetes also includes healthy eating, exercising and general lifestyle change. These practices are mostly applied to the management of type 2 diabetes. Diabetics should also refrain from smoking and alcohol consumption.
Nursing Framework and Theory Patterns
This case applies Dorothea Orem's theory of Self-Care while applying Barbara Carper fundamental patterns of knowing. According to Orem (1991), self-care is “learner behaviour composed of deliberate goals that directs action” which are the advantages of possessing knowledge and decision-making ability. It includes practices that are initiated by an individual who performs them to maintain his or her health, life, and well-being. On the other hand, Barbara Carper’s fundamental ideas are conceptions in an investigation that determines the nature of knowledge intended to be developed and the methods of organizing, testing, and applying the gained knowledge. Barbara identifies four patterns of knowing essential for learning and teaching of nursing. These include empirics, personal attributes, aesthetics, and ethics (Carper 1978). Empiric is the science of nursing based on facts that are empirically collected and verified, whereas aesthetics involves the art of nursing. Personal attributes entail the knowledge acquired from understanding of oneself and empathy in practise of nursing. Finally, ethics is the moral understanding of knowledge. They are the professional guidelines that guide how nursing professionals should behave in their line of duty.
Orem’s Self-care Theory
According to the Orem’s self-care theory, people engage in daily actions of caring for oneself in order to meet three requisites described by Orem, i.e. developmental, universal and health deviations. As people mature, they interact socially; thus, attain deliberate actions and capabilities to care for themselves. Experimental knowledge is supported by formal information systems to determine the fundamentals, which should be met, and the means through which they should be met. Generally, self-care aims at enhancing individual monitoring and elevation of the health and well-being of an individual. The three fundamentals described by Orem and personal characteristic, known as conditioning factors determine the ability of people to take care of themselves. Conditioning factors include socio-cultural background, state of development of a person, age, gender, family system, availability, and adequacy of resources as well as health status and systems.
According to Orem, self-care takes place when a person takes deliberate actions to meet all self-care fundamentals. Intellectual and psychomotor abilities as well as knowledge are important in performing a deliberate action (Norris, Engelgau & Narayan 2001). Finally, Orem says that every individual can develop and learn how to take care of him or herself depending on the developmental level of that person.
Nursing Process adaption on Orem Theory for Diabetes
The capacity of a person to manage diabetes by themselves depends on a number of factors. These factors include health information especially that is related to diabetes, age, and personal characteristics. According to American Diabetes Association (2002), knowledge about diabetes is important as it helps a person horn own skills essential for management of diabetes (Young-Hyman 1999). The patient who is an older adult requires a set of knowledge about diabetes to self-manage the condition. This includes knowledge about dietary manipulations, blood glucose testing skills, physical activities, and management of glycaemic level. In addition, the patient needs to have knowledge regarding symptoms related to low and high levels of blood glucose, medication, disease prognosis and when to initiate medical emergency systems.
Knowledge about detection and diagnosis of diabetes is more important to older people (Beeney & Dunn 1990; Brown 1990). This is explained by the fact that diabetes of type 2 as well as “Impaired Glucose Tolerance” are mostly common among older people as opposed to youths and children. As Colagiuri et al. (2002)observed, people aged fifty-five years and above have higher chances of having undiagnosed diabetes of type 2. Type 2 diabetes and “Impaired Glucose Tolerance” conditions are mostly accompanied by high blood pressure and increased blood cholesterol, which increases the chances of developing cardiovascular diseases among older people. Since diabetes is incurable, knowledge about diabetes management is vital, especially among older adults to avoid morbidity and mortality due to complication resulting from diabetes.
The aim of diabetes’ self-management is to lower the blood glucose to normal level and to minimise or eliminate chances of development of microvascular and macovascular complications. Microvascular complications associated with diabetes, especially of the type 2 diabetes include retinopathy, nephropathy and neuropathy, whereas macrovascular complications are arterial diseases, stroke and myocardial infections. This is achieved through injection of insulin, which is important in management of diabetes of type 1 as well as some cases of diabetes of type 2.
History of the Patient/Client
The patient is a 71-year old woman who lives alone in a terrace house with steps. She has a supportive nurse who lives in the nearby neighbourhood. She is retired and has a moderately active social life, whereby she meets with her friends three to four times in a week.
Physical and laboratory examinations revealed that the patient is overweight and suffers from high blood pressure and coronary artery disease. About a year and a half ago, the patient was diagnosed with myocardial infarction of the inferior arterial wall. Upon further investigation, it was revealed that the right coronary artery is partially blocked and there is some degree of narrowing of blood vessels in the heart. In addition, she was found to have a mild elevation of triglycelidemia and a slightly low level of High Density Lipoproteins. The patient did not report any chest pain. Her breathing was normal. She was placed on medication of aspirin and beta-blockers. She was also taught about the importance of behavioural and lifestyle change.
Fasting blood sugar level, blood pressure and pulse rate were examined. Creatinine blood urea nitrogen, A1C concentration, lipid analysis and microalbumin assay was also conducted. She has diabetes II.
Assessment of Patient’s Health Needs
The patient requires stabilising of her blood sugar and her body weight. She also needs to control her blood pressure, coronary artery disease and myocardial infarction. Due to blockage and narrowing of some blood vessels and high levels of triglycelidemia, the patient should control her fat intake.
Identification of the patient/clients problems/nursing diagnosis
The patient was diagnosed with diabetes II, hypertension, obesity, and coronary heart disease. The patient also had partial occlusion of right coronary artery and partial blockage of heart blood vessels. She also had myocardial infarction and high level of triglycelidemia and a slightly low level of High Density Lipoproteins. She also had some degree of retinopathy and nephropathy.
Nursing care plan
Increased thirst and frequent urination.
Blood pressure and heart rate test,
Body Mass Index,
Dilated eye examination
Fasting blood glucose,
Haemoglobin A1c test,
Blood Urea Nitrogen Test,
Microalbumin and creatinine test.
Fasting blood glucose at 173 mg/dl;
blood pressure and pulse rate of 147/89 mmHg and 81 respectively;
Creatinine level of0.8 mg/dl, 12 mg/dl of blood urea nitrogen, 9.6% concentration of A1C and 1,993 microgram/dl of microalbumin.
LDL cholesterol 120mg/dl;
Occlusion of right coronary artery and narrowing of heart blood vessels;
Elevation of triglycelidemia and a slightly low level of High Density Lipoproteins.
Risk of developing cardio-vascular diseases, and
To reduce blood sugar levels;
To reduce the body weight;
To contain high blood pressure;
To reduce progression of microvascular complications and reduce risks of development f macrovascular complications
Tighter glycaemic control while avoiding treatment-induced hypoglycaemia;
Drug intervention i.e. aspirin and beta-blockers (Parchman et al2002; Paterson et al2001);
Use inhibitors of angiotension-converting enzyme or angiotensin receptors;
Controlled diet (ADANIDDKD 2002);
Health education (Baltes, Smith, and Staudinger 1992; Baker et al2000);
Physical body exercise;
Counselling to avoid stress.
If desired glucose level and A1c concentration is not achieved, she will be placed on oral agents metformin and thiazolidinedione
After 3 months the patient had demonstrated reduced levels of cholesterol in blood vessels, reduced blood sugar levels, reduced blood pressure and reduced chances of developing microvascular and macrovascular complications.
The disease management plan described for the patient is sufficient for her situation. The plan takes into account current condition and future risks associated with the plan. The immediate aim of the plan is to lower blood glucose level. However, the plan takes note of the risks of hypoglycaemia resulting from glucose-lowering strategies. The plan also takes into consideration future risks, such as development of cardiovascular condition. Therefore, the plan proposes appropriate mitigation measures.
In addition, the plan suggests proper medication for the patient. Finally, the plan proposes a very good health education and a plan for physical exercises that reduce the risk of complications.
Treatment for the diagnosed Conditions
For high blood pressure, the patient’s treatment includes angiotensin converting enzyme as well as angiotensin II receptor blockers. These are useful medications, and they prevent kidney illnesses in diabetic individuals therefore most appropriate for the patient (Web Medicine 2012).
For coronary artery disease, the treatment includes medications for lowering cholesterol, agents to reduce blood pressure, antiplatelet medications, such as acetylsalicylic acid, and medications to treat angina, such as beta-blockers and calcium channel blockers that reduce heart load (C-Health 2012).
ACE inhibitors are pharmacological medications that can treat the heart issues in the diabetic patient (Konzem, Devore, & Bauer 2002).
This is the use of art to treat patients living with different health conditions (Codario 2010). The use of art is guided by professional ethics within nursing discipline. Art therapy creates a conducive and relaxing environment as well as reduces stress which increases the recovery process of the patient, which is favourable for our aged diabetic patient. When combined with the science of nursing, art therapy becomes very effective in relieving suffering from a patient. Therapeutic art takes different forms e.g. communication, connection between the nurse and the patient, possession of proper skills, determining the course of action and application of ethics in practice of nursing (Codario 2010).
Therapeutic communication is centred towards the patient and it is non-judgemental. Nurses should interact with the diabetic patient at the right time and place. This helps create a bond between the nurse and the patient. The nurse should set the stage before communicating with the patient. The nurse should introduce himself/herself and explain the purpose of interaction and the amount of time he/she intends to stay with the patient. The nurse should listen to the patient actively and show empathy to the patient (Codario 2010).
Proper connection between the nurse and the patient improves the well-being of the patient. The patient fell appreciated and well taken care of. The patient therefore follows the instructions of the nurse properly. This also makes the working environment better for the nurse as the patient becomes more responsive when he/she is properly connected to the nurse.
Skills are important in the field of nursing. Proper skills enable the nurse to attend the patient properly and give the appropriate care to the patient. Possession of adequate skills builds confidence in the nurse which increases performance.
Nurses are the care-givers to patients. Therefore, they determine the course of action in a particular condition. The nurses understand what should be done to better the condition of the patient. Therefore, the nurse determines the course of action that should be followed in treatment of patients (Codario 2010).
Finally, nurses should employ the code of conduct during their practice. Ethics are the guiding principles that ensure nurses discharge their duties in the most professional manner.
Application of Orem’s Theory in the patient’s Case
Orem’s Nursing Process
Nursing is needed for this patient with diabetes II to raise the agency of self care in order to meet the demands for therapeutic self-care that are related to genetic as well as constitutional defects, human measures and their outcomes.
Designing a nursing system as well as planning for delivery of care
Step 1-collecting data on:-
- The diabetic II status
- The views of the physician concerning the above status
- Patient’s view on her health
- The goals of health as presented in the care plan
- Patient’s needs for self care
- Her capability to undertake self care
In general, diabetes is a serious condition affecting many people around the world, especially the elderly. Diabetes of type 2 appears to be the chronic condition with the highest frequency of occurrence in the Western countries. It is both a lifestyle as well as a metabolic disease. Modern way of life puts an individual at a high risk of getting diabetes.
There are different types of diabetes. The three major types include diabetes of type 1, diabetes of type 2, and gestational diabetes. These types affect different groups of people and have different predisposing factors, though the classification is not absolute. For example, type 1 is common in children, whereas type 2 is common in adults and gestational diabetes affects women at later stages of pregnancy.
The critical analysis has classified the condition into different types, explored diagnostic criteria, as well as discussing the management of the disease. In this discussion, healthy education appeared to be a key component in the prevention and management of diabetes. Different groups of people need to understand their risk of contracting diabetes and hence take the necessary precautions. In addition, diabetic patients require good understanding of the diagnostic methods and management practices tailored to fit their condition. With the help of a qualified medical professional, diabetic patients are put on the right medical regiment. In addition, diabetics need to adjust their lifestyle to reduce the detrimental effects of diabetes.
Finally, the article presents a case study of an elderly diabetes patient with other conditions such as hypertension, high lipid levels, and partially blocked heart blood vessels. The patient has also developed mild microvascular complications, such as retinopathy and nephropathy because of diabetes and she is at a higher risk of developing macrovascular complications such as heart diseases. The article analyses this case using Orem’s theory of self-care while applying Barbara Carper fundamental patterns of knowing. The model is well suited for the patient as it places majority of management responsibilities on herself. The pattern of knowing is also effective as knowledge about diabetes is paramount in management of diabetes. The article also reflects the care plan proposed for the patient and finds it to be appropriate.
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