The following paper will reflect on an experience as a trainee assistant practitioner which involved the care and support of a patient with type 1 diabetes. For this reflection I will use Bill as a pseudonym name for my patient as The Nursing and Midwifery Council (2010) states that. “The common law of confidentiality reflects that people have a right to expect that information given to a nurse or midwife is only used for the purpose for which it was given and will not be disclosed without permission. This covers situations where information is disclosed directly to the nurse or midwife and also to information that the nurse or midwife obtains from others”. For this assignment Gibb’s Reflective Cycle (1988) will be utilised as I feel comfortable with this model. Gibbs (1998) refers to the experience as an incident which involves exploring good and bad feelings, however Johns (1995) suggests that the fundamental purpose of reflective practice is to enable the practitioner to interpret an experience in order to learn from it.
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Type 1 diabetes is a lifelong condition in which the body cannot control the amount of glucose in the blood. This is because the body cannot produce the natural hormone insulin. Diabetes is a common, lifelong condition and as Zimmet et al (2001) identify that in developed countries one person in thirty may be affected and it is likely that by 2025 there will be three hundred million people with diabetes worldwide, this is mainly the result of more sedentary lifestyles and increased obesity. In 2006 Diabetes UK estimated that there were more than two million people with diagnosed diabetes and up to one million who are still undiagnosed (Diabetes UK 2006). A holistic approach to this long term condition is essential as it can come with so many complications. Complications may arise from inadequate management and treatment of the condition, which can adversely affect the quality of life and have financial implications for patients and the National Health Service (DH2001). There are two types of diabetes. In type 1 diabetes there is no production of insulin by the beta (ß) cells of the pancreas. In type 2 diabetes, which accounts for over 80 per cent of all cases of diabetes, insulin is produced by the ß cells and is released into the bloodstream, but it subsequently fails to act properly at the sites of glucose uptake, which are skeletal muscle, liver and adipose tissue (Donnelley and Garber 1999, Reginato and Lazar 1999).
As a trainee assistant practitioner I was asked by the district sister to visit Bill to do a blood test which had been requested by the general practitioner as Bill is housebound and unable to attend a blood clinic. The blood test was to check his full blood count and HbA1c which had not been done for almost a year. Bill is seventy four years of age, lives alone and has lived with diabetes for many years. Bills wife passed away a year ago and has one son who lives many miles away so sees him very little; he does however have a neighbour who pops in to check on him now and again. Bill administers his own insulin in the mornings and checks his blood sugar levels daily before giving his insulin.
My first impressions of Bill were that he looked frail and quite pale but having not met him before this may have been the norm for him. Whilst taking the blood sample I began chatting to Bill and he started to tell me that he had several episodes of feeling unwell recently and on that morning he had felt particularly unwell. I asked him to explain why he felt unwell and what symptoms he was experiencing. He explained the symptoms included shaking in his hands, feeling lightheaded and a fuzzy headache. As a trainee assistant practitioner I felt it necessary to explore what was wrong with Bill even further. First of all I began taking some basic clinical observations, his blood pressure was 140/90, pulse 80 and regular which were both within normal limits. He appeared pale and clammy so I checked his blood glucose level which was 3.2mmols; Bill was suffering from hypoglycaemia. Blood glucose levels are normally maintained within relatively narrow limits at about 5-7mmol/l (Williams and Pickup 2004).
My immediate concern was to ensure Bills blood glucose levels did not drop any further and the priority was to take short term action and increase his blood sugar to prevent it becoming any worse. Bill had no glucose tablets or glucogen so with his consent I looked in his fridge and cupboards to find something that would increase his blood sugars quickly. All that was in his fridge was a carton of milk a few slices of bread and some jam, I promptly gave him a drink of milk and made a jam sandwich. I felt it was my responsibility to sit with Bill until his blood glucose returned to acceptable levels and he had recovered from this episode of hypoglycaemia. I took Bills blood glucose levels every ten minutes until it returned to a safe and acceptable level. Bills blood sugar was now 5.2mmols and he was feeling brighter I checked to see if he ever recorded his blood glucose levels or kept a record of administration of his insulin but there was nothing. I asked him about his diet he said he hadn’t been feeling up to eating much, I asked who did his shopping which he informed me his neighbour gets his milk and bread and a few other little bits when he needed them. I was aware that the lack of food in the house was probably the cause of Bill suffering from hypoglycaemic attacks.
Hypoglycaemia occurs when the blood glucose level falls below 4mmol/L and is a common side effect of insulin therapy. Causes of hypoglycaemia include missed or late meals, not eating enough, taking too much insulin, exercise and excessive alcohol. National Health Services Choices (2009) state that hypoglycaemia should be treated with fast-acting carbohydrate, for example, 3-6 glucose tablets, 150ml fizzy drink or 50-100ml Lucozade, and followed up with a longer-acting carbohydrate, for example, biscuits or a sandwich. Glucose gels, for example, GlucoGel are useful to raise blood glucose levels and blood glucose should be recorded five to ten minutes after treatment.
After ensuring that Bill’s hypoglycaemic attack had subsided and he was feeling better I made him a cup of tea and left him another sandwich that he could have at lunchtime. My initial feelings were of concern for Bills safety in the future and as a trainee assistant practitioner I knew that it was my responsibility to see my mentor immediately to discuss the situation. I was satisfied that I had taken the time to find out what was wrong with Bill and that he had recovered from his hypoglycaemic attack which I may not have taken time to do in my previous role. From the years of working in the community nursing setting experience I was fully aware that other mutli-displinary agencies may need to be involved in the care of Bill. I returned to the office and fed back to my mentor and later that day we returned to Bill and a full assessment was undertaken, it came to light that Bill had been struggling for some time with his diabetes, personal care and shopping and housework. It was decided by my mentor that for the interim period until care and support for Bill could be implemented that the district nursing team would administer his insulin that way his blood glucose levels could be regularly recorded and ensure that he has eaten something. He was also referred to the community diabetic nurse for a review of his insulin regime.
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Dietary management of type 1 and type 2 diabetes Nutritional therapy is an integral part of effective management of diabetes and has a vital role in helping people with diabetes to achieve and maintain optimal glycaemia control (Delahunt 1998, UKPDS 1990).I visited the general practitioner surgery and obtained some patient information on diabetes care and diet and took them to Bill, with the supervision of my mentor I sat with him and read through them. Once a care package was in place the carers would be informed of what foods Bill should and should not have and they would help with meal preparation. The British Diabetic Association (1999) suggest that ideally dietary information should be delivered by a diabetes specialist dietician, however in the case of Bill awaiting an appointment to see the dietician would have taken time and the information was needed on a more urgent basis.
McGough (2003) suggest that structured patient education plays an important role in enabling people with diabetes to manage their diabetes on a day-to-day basis and a greater emphasis should be on the benefits of regular physical activity and weight management. More flexibility in the proportion of monounsaturated fat and carbohydrate in dietary intake and sucrose should no longer be restricted to a specific amount. For Bill initially it was essential that he was provided with regular meals and snacks at least three times daily to prevent any further hypoglycaemic attacks. An urgent referral was sent to members of the multi-disciplinary team and a meeting was arranged the following day with a social services. Referrals were also sent to the community diabetic nurse, dietician and foot health services. On assessment with my mentor she identified that Bill had not been washing properly and had not cut his toe nails for some time, Bill was also experiencing pain in his legs and feet. Bill was likely to be experiencing diabetic peripheral neuropathy, and I completed a pain assessment chart with him. Hill (2009) identifies that painful neuropathy affects the feet, typically causing burning or stabbing pain, which is particularly apparent at night. This was a mirror of what Bill described his pain as and we reassured him that his pain control would be discussed with his general practitioner as at present Bill took no analgesia at all and there was none in the house. The general practitioner prescribed paracetamol 1000mg four times daily initially as he felt that the pain may improve once more control had been gained again with his diabetic control. I returned to assess Bills pain control several days after commencing paracetamol and it had improved, he was still experiencing slight discomfort but felt that he would like to continue on this regime as he did not want anything stronger at the present time. It was agreed with Bill that this would be reviewed again the following week.
A joint visit was done with the diabetic nurse, my mentor and myself and it was identified that Bills technique of giving his own insulin was poor due to poor dexterity in his hands and he was unable to turn his insulin pen properly or read the digits on the pen clearly. It was unclear how long Bill had been trying to manage in this way but Bill would certainly need long term care with his insulin from the district nursing team. The diabetic nurse identified that Bills eyesight was particularly poor and that he had not had his eyes checked for several years. Diabetic retinopathy is a major cause of blindness and many patients do not have any symptoms of the damage occurring in the retina until the complications have become advanced. NICE (2008) recommend annual screening for all patients with diabetes and that a record of the retina is made by digital imaging for year on year comparison to identify the development and progression of retinopathy. The general practitioner was informed that Bill had not had his eyes checked and he agreed that he would refer him for retinopathy screening.
As a trainee assistant practitioner I have learnt valuable knowledge in the management and care of patients with diabetes, from Bill requiring a routine blood test he has become a complex patient with multiple problems related to his diabetes. Due to the word limitations of the essay all areas of complications relating to diabetes could not be covered but through researching and reading around the topic I am aware of other complications such as nephropathy, cardiovascular, cerebrovascular and peripheral vascular disease. I have continued as an assistant trainee practitioner to visit Bill and monitor his progress with my mentor. His blood glucose levels have improved and are maintained controlled between 6-9mmols. Bill has needed some psychological support as he is used to seeing few people and all of a sudden his life has changed and he has several members of the multidisciplinary team visiting and reviewing him regularly. Overall I feel a sense of satisfaction that from a routine blood test and utilising a more advanced role all of this relating to Bill has been identified and his health and care are much more improved.
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