According to the NHS, long-term conditions is defined as the “chronic conditions that cannot, at present, be cured”. Chronic conditions refer to human health disease that is persistent or long-lasting in the effects. The term chronic is used to refer to conditions that last for more than three months. Long-term complications of diabetes can cause serious medical risks and in turn increases the risk of mortality. Type 2 Diabetes Mellitus (DM) is characterized by hyperglycemia, inadequate secretion of insulin, insulin resistance and variations in secretion of glucagon. According to WHO, the prevalence of diabetes at a global scale has increased from 4.7% reported in 1980 to 8.5% in recent times, particularly among the adult population (Who.int 2018). According to Public Health England (PHE), 3.8 million people in the UK have diabetes and approximately 940,000 cases are undiagnosed. According to the NHS, the current costs for tackling diabetes is 8.8 billion pounds per year (Gov.uk 2018; Nhs.uk 2018).
The pathophysiology of type 2 Diabetes Mellitus either involves an inadequate secretion of insulin by the pancreatic beta cells or caused due to development of resistance to peripheral insulin. Insulin resistance is caused as a result of elevation in the levels of proinflammatory cytokines and free fatty acids. This in turn results in increased production of glucose in the liver, decreased transport of glucose to muscle cells and increase in fat breakdown. Moreover, it also results in hyperglucagonemia and hyperglycemia (Ozougwu et al. 2013; Ali 2013). Moreover, Type I diabetes is a type of autoimmune disease that involves the destruction of the insulin secreting beta cells by the immune system. While Type I diabetes is associated with higher levels of ketone, Type II diabetes is associated with high cholesterol and blood pressure. Moreover, Type I diabetes is not associated with excess body weight, while Type II diabetes is associated with excess body weight. Complications associated with diabetes include microvascular and macrovascular complications. Microvascular complications results from damage to small blood vessels, while macrovascular complications results from damage to larger blood vessels. Microvascular complications include retinopathy, neuropathy and nephropathy, while macrovascular complications include stroke, heart attack, insufficient blood flow to the legs, among others (Who.int 2018).
Diabetes is associated with various complications and can eventually result in premature deaths. These complications or problems include cardiovascular diseases, kidney failure, vision loss, nerve damage (Schram et al. 2014). Moreover, diabetes can also cause psychological problems like depression, anxiety, schizophrenia, among others (Roy and Lloyd 2012). It brings about significant economic loss for individuals suffering from diabetes. It is also an economic burden for the families of the patients, the healthcare sectors as well as the nation due to the cost of care associated with it. This essay is a case study of a patient suffering from problems associated with diabetes like diabetic nephropathy and depression. Firstly a brief overview of the patient will be given, followed by descriptions of the problems faced by the patient and the associated nursing care plan.
This is a case study of Mr. John Reed, who is a 70-year-old man. Consent had been taken from him before carrying out this case study. In order to maintain confidentiality of information, a hypothetical name has been used. According to the NMC Professional Standards, nurses are expected to treat personal information of their patients in a confidential and private manner, thereby restricting the use of information for professional purposes (NMC 2015). The patient used to serve in the army. He had 4 children, 3 sons and 1 daughter. The sudden death of his wife, however had a significant impact on him and affected him badly. Even though he led a disciplined life in the army, after the death of his wife, he became unsocial, did not carry out any type of physical activities and this in turn affected both his mental and physical condition. Moreover, there was no one to take care of him as his sons went abroad to work and his daughter got married. Throughout the day, he engrossed himself in watching television and eating packaged high calorie foods as well consumed large volumes of artificially sweetened beverages. However, one day when his daughter visited him, he complained of feeling light headed and subsequently fainted. He was rushed to the hospital and subsequent tests revealed that he suffered from high blood sugar levels.
High levels of blood sugar leads to polyuria, which in turn results in severe dehydration and subsequently causing light headedness. Apart from polyuria, he also suffers from nausea, pain and discomfort. Apart from diabetes, further investigation of his medical history revealed that he suffered from diabetic nephropathy as well as depression. The NICE guidelines refer to evidence-based recommendations that are relevant to health and social care in England. The primary aim of these guidelines is prevention of ill health, improvement of the healthcare service quality and protection of good health. According to the NICE guidelines, individuals suffering from diabetic nephropathy is provided information about renal replacement therapy. These include changes in the frequency and time of the dialysis treatment or carrying out exchanges and pre-emptive transplantation (Wanner et al. 2016). He undergoes dialysis every week in order to eliminate the wastes from his body. Moreover, he also suffers from high blood pressure and is under medication. Diabetic nephropathy can be controlled by regulating the blood sugar levels and blood pressure.
The patient in this case study suffers from both diabetic nephropathy and depression, both of which are co-morbidities in association with diabetes mellitus. Diabetic nephropathy is associated with loss of kidney function and is one of the co-morbidities of diabetes mellitus. It slowly progresses over time and is associated with individuals suffering from long standing diabetes (Zhuo et al. 2013). Diabetic nephropathy is characterized by decreased glomerular filtration rate, persistent albuminuria and elevated levels of blood pressure. Diabetic nephropathy is the leading cause of development of chronic kidney disease worldwide. Early treatment can prevent the development of diabetic nephropathy, but in the case study, the individual has a long standing condition of diabetes mellitus and in the absence of routine screening and urinalysis, his condition of diabetic nephropathy became highly severe. Major changes in the histology of the glomeruli occur in individuals suffering from diabetic nephropathy. The increased blood sugar levels or hyperglycemia induces mesangial expansion by ether increasing the matrix production or by increased glycation of matrix proteins. Apart from this, it results in thickening of the glomerular basement membrane and glomerular sclerosis (Grove et al. 2014).
Hypertension in association with diabetes plays an important role in progression of diabetic nephropathy. Diabetic nephropathy along with hypertension and hyperglycemia results in acceleration of kidney failure. Hyperglycemia increases the production of the transforming growth factor β and vascular endothelial growth factor, which in turn results in cellular hypertrophy and also increased synthesis of collagen, subsequently inducing changes in the glomeruli and matrix proteins. Hyperglycemia also activates the enzyme protein kinase C, which may further contribute to the development of kidney disease (Garud and Kulkarni 2014). Apart from diabetic nephropathy, the patient also suffers from depression. Depression and major depressive disorder (MDD) are more prevalent among individuals suffering from long standing diabetes mellitus than those without such medical conditions. The patient described in this case study suffers from various depressive symptoms and these symptoms have further deteriorated his quality of life. Most of the day he remains sad and feels hopeless. The memories of his wife further aggravate his depressive symptoms and sometimes it is associated with angry outbursts on his family members and his care-givers. A number of times he has attempted to commit suicide, moreover, he also suffers from poor sleep, lack of appetite, cognitive impairment, among others. He is currently on anti-depressants in order to control the symptoms associated with depression. The NMC Professional Standards state that nurses are responsible for promoting and preserving the privilege and trust that is inherent in the relationship, between them and their clients (NMC 2015). According to NICE, people diagnosed with diabetes mellitus are at an increased risk of developing depression (NICE Evidence Search 2018). Consequences of diabetes mellitus like increased risks of development of medical complications, poor control of diabetes, high rate of mortality and increased cost of healthcare often results in the development of depression. In this case, also, the patient is highly overwhelmed by his wife’s death and he also considers himself a burden for his children due to the high treatment costs.
The poor lifestyle of the patient has also significantly contributed to the development of diabetes and subsequently depression. It results in a vicious cycle, where diabetes gives rise to depression and this in turn may prevent the individual to properly manage his blood glucose levels, which further aggravates his condition of high blood glucose levels (Sweileh et al. 2014). The autonomy and dignity of the elderly patient were preserved, while taking essential decisions related to diagnostic assessments and medication administration. However, his daughter was also informed in the shared decision making process and her informed consent was taken before any decisions were made on therapeutic interventions. Involving the family members in shared decision making, provides a clear insight on the preferences and demands of the patient (Barry and Edgman-Levitan 2012). This showed congruency with the NMC Professional Standards, where the nurses are involved in informing the person who requires care and their nominated family members or partners about the purpose and nature of the recommended care plan (NMC 2015).
Management of diabetes is the first step in prevention of diabetic nephropathy. In the later stages of the disease, the kidneys fail to function effectively and daily nursing care is highly essential. The nursing care plan for diabetic nephropathy includes management of high blood pressure by monitoring of blood pressure before, during and following dialysis, along with the administration of anti-hypertensives. Monitoring of blood glucose levels to ensure that the level is not above 180mg/dL, insulin administration, education about nutritional changes and providing low protein diets. Dialysis results in loss of iron and vitamin C, which is supplemented by providing with diet rich in iron and vitamin C. This helps to prevent anaemia. It is also necessary to monitor the output of urine and its colour. Urinalysis and urine gravity tests are carried out (Eboh and Chowdhury 2015; Otoda, Kanasaki and Koya 2014). The NICE guidelines for management of diabetic nephropathy include the testing of the albumin-creatinine ratio, estimation of the glomerular filtration rate, diagnosis of microalbuminuria, maintenance of blood pressure and referrals to renal specialists or nephrologists.
This albumin-creatinine ratio is evaluated because a low amount of urine albumin acts as an early indicator of kidney disease. Most commonly, the albumin test is done in conjunction with an additional creatinine test that helps in calculating the ratio (Chae et al. 2012). Albumin and creatinine are assessed in random samples of urine. The ACR ratio is further calculated. This helps in determining the amount of albumin that escapes from the kidneys into urine (Naresh et al. 2013). The test was carried out in this patient as well. The value for albumin was found to be 300 mg/Dl, and that of creatinine was around 150 mg/dL. On calculating the ACR ratio for the patient, it was found to be approximately 226 mg/mmol, which confirmed the presence of severe diabetic nephropathy. Further confirmation helped in formulating strategies for immediate treatement. Treatments generally involve the use of acetylcholine esterase (ACE) inhibitors like lisinopril (Prinivil or Zestril) (Min et al. 2012). The patient was administered an initial dosage of 20mg Prinivil tablets, once daily for treating his hypertension problems. Lisinopril helps to reduce the blood pressure in patients suffering from diabetes and diabetic nephropathy. Lisinopril normally blocks the effects of ACE, thereby decreasing angiotensin II and preventing constriction of blood vessels. Some of the common side effects of this drug includes light headedness, headaches, cough, vomiting, diarrhoea, chest pain, among others. Furthermore, the patient was also administered with 2.5mg of ramipril drugs once a day for lowering the amount of protein that was lost from urine. It acted as an ACE inhibitor and decresed angiotensin II, in addition to increasing the levels of renal medullary lipids.
The nursing care plan for depression involves providing a safe environment for the patient and assessment of the patient’s suicidal tendencies in order to prevent suicide attempts. As he was in the army, he can be taken to an army veteran’s club, where he can socialize with other individuals of his age and carry out various exercises. Moreover, he can also join a laughing club, as it will help him to reduce his stress levels, reduce pain and will help to strengthen his immune system (Weinberg, M., Hammond, T. and Cummins 2014). His children, who stays away from him should be advised to spend more time with him and engage him in various activities that would in turn encourage him to lead a healthy and happy life. Moreover, cognitive behavioural therapy can be employed to overcome the cognitive impairments. Additionally, educational programs and physical activity classes can be organized to enable the client to interact and socialize with others so that they can express their emotions. Such nursing interventions helps to prevent feelings of loneliness, hopelessness, among others (O’Brien et al. 2014). The NICE guidelines for management of Depression involve assessment, psychoeducation, active monitoring, psychosocial and psychological interventions, electroconvulsive therapy, medications such as antidepressants, among others (Nice.org.uk 2018).
Selective serotonin reuptake inhibitors like fluoxetine and tricyclic antidepressants such as, doxepin or desipramine are normally used to treat symptoms of depressive disorders. Fluoxetine functions by increasing the levels of serotonin in the brain, which in turn helps to prevent symptoms of depression. The patient was administered with 20mg of fluoxetine and 100mg of desipramine, once daily. The doses were initially kept at lower levels and were gradually increased according to the tolerance and response of the patient. The common side effects of Fluoxetine involves nausea, sore throat, diarrhea, indigestion, dry mouth, decreased appetite, among others (Leung et al. 2012). Additionally, the side effects of desipramine administration include, blurred vision, sudden numbness, hallucinations, chest pain and pounding heartbeats (Bet et al. 2013). Metformine (Glucophage) was also orally administered twice a day, in the form of 500mg tablets. This medication was followed to keep a control on his blood glucose levels. This was given in combination with 22 units of daily insulin administration. The British National Fomulary (BNF) pharmaceutical reference book was consulted before prescribing the pharmacological interventions on the patient (Kendall and Enright 2012).
This essay is a case study of an individual suffering from long standing diabetes, which resulted in his developing diabetic nephropathy and depression. These complications greatly affected his way of life. The nursing interventions were provided in order to improve his quality of life by carrying out regular assessments of his blood pressure and blood glucose levels. Moreover, he was also kept on dialysis due to his poor renal function. Apart from this medications were also provided to him in order to reduce the high blood pressure, which can further aggravate his renal problems. The nursing interventions also addressed his depression as he had suicidal tendencies and regular monitoring was done along with administration of medications and therapies to prevent the enhancement of his depressive symptoms.
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