The Nursing Management of Type 2 Diabetes Mellitus Essay

The Nursing Management of Type 2 Diabetes Mellitus Essay

This report was written to highlight the main aspects of nursing management for patients with Type 2 diabetes. It is primarily aimed at nurses working in primary care, although may also be useful for nurses working in other areas.

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Summary
Type 2 diabetes is increasing in prevalence, and the nurse is often the main health care professional providing care for these patients. This report discusses some of the aspects of care for patients with Type 2 diabetes, including providing advice on diet, and exercise, self-monitoring of blood glucose levels, drug therapy, and the psychosocial impact. The importance of promoting self-management, and joint decision making, is highlighted throughout, and recommendations for practice, in each section, are made.The Nursing Management of Type 2 Diabetes Mellitus Essay

Introduction
Type 2 diabetes mellitus is a chronic metabolic condition, characterised by hyperglycaemia, caused by defects in insulin secretion, insulin action, or both (National Institute of Health and Care Excellence (NICE) 2015; Aslan 2015). There are an estimated 3.3 million people with Type 2 diabetes in the United Kingdom, with a further 500,000 as yet undiagnosed. It is increasing in prevalence, and by 2030 is expected to be the third leading cause of death worldwide (Bannister 2016). Type 2 diabetes is associated with long term macrovascular and microvascular complications, which increase mortality, and reduce quality of life. Obesity, a sedentary lifestyle, and genetic factors, are major risk factors for Type 2 diabetes (NICE 2015).The Nursing Management of Type 2 Diabetes Mellitus Essay

Pathophysiology
Glucose is the main energy source for the cells of the body, and levels in the blood are usually kept stable by the regulatory actions of hormones, primarily insulin, which triggers the movement of glucose from the blood stream into the cells, thus lowering blood glucose levels, while another hormone, glucagon, stimulates the release of glucose from the liver in order to raise blood glucose levels (Bannister 2016). A major cause of Type 2 diabetes is insulin resistance; a reduced response of tissues to the action of insulin, which is further exacerbated by obesity, and a lack of physical activity. When insulin resistance first develops, the body compensates by producing extra insulin. However, as the disease progresses, the pancreas is unable to maintain this, and insulin secretion also becomes impaired, leading to a further deterioration in blood glucose levels. There may also be an increased level of glucagon in patients with Type 2 diabetes, resulting in excess glucose being produced by the liver, and resistant hyperglycaemia (Lippincot Williams & Wilkins 2010; Brashers, Jones & Heuther 2015).

Signs and symptoms
The signs, and symptoms, of Type 2 diabetes are directly related to hyperglycaemia. Increased thirst, and polyuria, occur when the kidneys are unable to reabsorb the excess glucose, altering the osmotic pressure in the tubules, and leading to excess urine production. To counter dehydration, the body stimulates thirst (Ashalatha & Deepa 2011; Bannister 2016). The altered metabolism of glucose, fats, and protein, leads to poor use of ingested food, which results in lethargy, and fatigue. Symptoms such as poor wound healing, and recurrent infections, occur due to the high glucose levels in the body stimulating the growth of microorganisms, and impairing blood supply. Genital itching, and thrush, are caused by glucose being present in the urine, which encourages fungal growth (Brashers, Jones & Heuther 2015).The Nursing Management of Type 2 Diabetes Mellitus Essay

The nurse’s role in the management of Type 2 diabetes
Type 2 diabetes is a complex condition, for which most of the management is done by the patient themselves (Yu, et al. 2014). Self-management behaviours, such as eating a healthy diet, taking regular exercise, self-monitoring blood glucose levels, and taking prescribed medications, are all associated with good glycaemic control, and so should be encouraged (Houle, et al. 2015). Traditionally diabetes care has been prescriptive, and check-list driven, but promoting self-management requires a more co-operative, shared approach, where the patient has an active role in their care, and their autonomy and personal preferences are recognised (den Ouden 2015). This is also in line with the Nursing and Midwifery Council (2015), who state that the nurse should act in partnership with the patient, and encourage, and empower people to share decisions about their care, and treatment. However, this approach works best when both the nurse, and the patient, wish to embrace empowerment, and it may require a change in practice from the nurse, towards a more communicative approach, where the entire focus is on the patient’s needs. The nurse should take a holistic approach, recognising the barriers the patient may have to self-management, and seek to address these (Bostrom 2014).The Nursing Management of Type 2 Diabetes Mellitus Essay

Dietary advice
NICE (2015) advise that providing dietary advice for patients with Type 2 diabetes should be an integral part of their care, and that each patient should receive individual, ongoing, support with their nutritional needs. Although, ideally, every patient should see a dietician, services are often limited, and so the main responsibility for providing dietary advice usually falls on the nurse, particularly practice nurses (Parry Strong 2013).

The nurse must ensure a patient-centred approach is taken, and that consideration is given to the patient’s age, social situation, culture, beliefs, eating patterns, and any comorbidities that may have an impact on their diet. However, it has been noted that nurses may be less confident in providing dietary advice for patients whose culture differs to their own. This can be overcome by assessing the patient’s current diet, and determining their individual eating habits, to avoid stereotyping, and making assumptions about diet based on culture (Parry Strong 2013; NMC 2015). The patient’s willingness to change should also be considered, and the nurse should identify the challenges, and barriers to change, that the patient may have, and assist them with techniques to overcome these (Robertson 2012; NICE 2015).The Nursing Management of Type 2 Diabetes Mellitus Essay

As obesity is a major risk factor for Type 2 diabetes, the focus of much of the dietary advice will be weight loss, which can lead to improved glycaemic control, and reduce cardiovascular risk factors. A low-fat diet, such as is recommended by NICE (2015) is usually advised, however, emerging research shows that a low carbohydrate diet may be more effective (Gulbrand, et al. 2012; Jonasson 2014). Although more research is needed to confirm these findings, and the guidelines have not yet changed, it is important that the nurse keeps up to date with new research, and recommendations, so that they can ensure that the advice given is in line with the best evidence available (NMC 2015). The nurse should also be aware that many patients have difficulty adhering to weight loss programmes, and that they are often unsuccessful. Identifying reasons for this, tailoring interventions for each patient, and using goal setting techniques, may improve success rates, and encourage the patient to make long term changes to their dietary habits (Ciampolini, et al. 2010; Parry Strong 2013; Ortner Hadziabdic, et al. 2015).

Exercise
Along with dietary changes, exercise interventions should be a main part of the treatment of Type 2 diabetes, and this is often part of the nurse’s role. Physical inactivity is one of the major risk factors for Type 2 diabetes, and is responsible for an estimated 7% of the disease worldwide. Increasing activity levels can reduce obesity, but also has a direct impact on glycaemic control, independently of weight loss, and can improve blood glucose levels, reduce risk of complications, increase exercise capacity, reduce adipose tissue, increase lean tissue, improve blood lipid profile, reduce blood pressure, and improve quality of life. It may also increase beta cell function, in those with some residual insulin secreting capacity (Hansen, et al. 2013; Matthews, et al. 2017).The Nursing Management of Type 2 Diabetes Mellitus Essay

NICE (2013) gives recommendations for identifying people who are less active, and advising them on increasing activity levels. It is suggested that information is given about local opportunities for exercising, there should be a written outline of the discussion, and the goals set, and that initial discussions are followed up, to review progress. Care must also be taken to advise on safety precautions, specifically for those with Type 2 diabetes, and the nurse should be aware of how to safely manage exercise with regards to the circumstances of each patient, such as the type of medication they take, and any comorbidities, or diabetes related complications (Hansen, et al. 2013). Despite these guidelines, exercise advice is rarely discussed during consultations, due to lack of time, lack of knowledge, or lack of training. Information, and training, should be provided for the nurse, as well as the patient. Changing sedentary behaviour can be challenging, and the nurse must be aware of the patient’s health beliefs, so that interventions, and advice, can be tailored to the patient’s own goals, current activity levels, preferences, and barriers (NICE 2013; Matthews, et al. 2017).The Nursing Management of Type 2 Diabetes Mellitus Essay

Blood glucose monitoring
According to NICE (2015), self-monitoring of blood glucose levels should be offered to patients with Type 2 diabetes only if they are on insulin therapy, take oral medications that increase the risk of hypoglycaemia while driving, or operating machinery, if there is evidence of hypoglycaemia, or during pregnancy, or pregnancy planning. Blood glucose monitoring is a useful tool, which can help to achieve good glycaemic control, by allowing the patient to understand the effect of diet, and exercise, on their blood glucose levels, make decisions about diet, activity levels, and medications, identify hypoglycaemia, and enhance feelings of being in control (Hortensius, et al. 2012; Malanda, et al. 2015). However, many patients do not test as often as recommended, or do not make use of the results. This may be due to feeling distressed when blood glucose levels are out of target boundaries, avoiding thinking about their diabetes, not seeing the value in checking blood glucose levels, not understanding how to interpret the results, a lack of education, or a lack of communication with health care professionals. Therefore, the nurse must ensure that they fully discuss blood glucose monitoring with the patient, assessing any barriers they may have, and ensuring that they understand what to do with the results. By providing patient centred care, and determining the patient’s needs and goals, mutual targets can be set, which are realistic and achievable (Hortensius, et al. 2012; Polonsky, et al. 2014).The Nursing Management of Type 2 Diabetes Mellitus Essay

Drug therapy
It is beyond the scope of this report to discuss, in detail, each of the medications used for the treatment of Type 2 diabetes. NICE (2015) provide an algorithm for drug therapy, which recommends Metformin as the initial drug of choice, if tolerated, along with how to intensify treatment, if targets for glycaemic control are not met. The nurse must have good knowledge of each of these medications, so that they are able to explain their mode of action, benefits, and side effects, to the patient, and support them to make decisions about drug therapy (Bailey, et al. 2016).

Psychosocial impact
As a complex, long-term condition, Type 2 diabetes can have major psychosocial impacts on the patient. Two of the most common are anxiety and depression. Patients with diabetes are more than twice as likely as the general population to develop anxiety and depression, and it may affect around 25% for anxiety, and 11 to 71% for depression (Trento, et al. 2012; Weaver & Madhu 2015). Anxiety, and depression, contribute greatly to morbidity and mortality in Type 2 diabetes, and result in poorer self-management behaviours, poor adherence to medications, and lifestyle changes, increased complications, poorer glycaemic control, and reduced quality of life (Trento, et al. 2015). To tackle this, it is vital that effective screening is in place, to identify those most at risk, and the nurse is ideally placed to undertake this, as they have ongoing, direct contact with patients. However, there is no standardised screening tool currently in use, and current tools may not take in to consideration the fact that many symptoms for both diabetes, and anxiety or depression, are similar, and they may not meet the needs of ethnic minorities (Roy, et al. 2012).The Nursing Management of Type 2 Diabetes Mellitus Essay Under-recognition of anxiety and depression, is a major barrier to effective treatment, and many patients may be undiagnosed. Therefore, it is important that the nurse sees screening for anxiety and depression, as a major part of their role, and that they are aware of the risk factors, such as lower socioeconomic group, ethnic minority groups, living in an area of material deprivation, and a high household burden of child care, or other dependents. This allows the nurse to identify those at risk, at an early stage, and provide appropriate interventions (Gariepy, et al. 2015; Weaver & Madhu 2015).

Conclusion
Type 2 diabetes is a complex, long-term, condition, that requires a great deal of self-management. The nurse has an important role to play in providing information, educating the patient, supporting self-management, and promoting patient autonomy in areas such as diet, exercise, blood glucose monitoring, and drug therapy. This can be done by ensuring patient centred care is used, to determine the patient’s needs, and preferences, and by recognising the challenges, and barriers, such as anxiety, and depression, that the patient may face. This allows appropriate interventions to be implemented, and high quality care provided.The Nursing Management of Type 2 Diabetes Mellitus Essay

Type 2 diabetes is the most common form of the disease. Diabetes mellitus is where the body cells cannot use glucose properly for lack of or resistance to the hormone insulin, which is produced by the pancreas. Diabetes can lead to serious complications over time if left untreated. The high blood sugar levels from uncontrolled diabetes can cause serious long-term diabetic complications. Eventually, they damage the insulin-producing beta cells of the pancreas, reducing insulin output.The Nursing Management of Type 2 Diabetes Mellitus Essay

Type 2 diabetes is also known as the non-insulin dependent diabetes and is the most commonly found type of diabetes in the world. Type 2 diabetes is a lifelong chronic disease in which there are high levels of sugar in the blood. Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar into cells, where it is stored and later used for energy. Patients suffering from type 2 diabetes tend not to respond effectively to insulin and their fat, liver, and muscle cells do not respond correctly to insulin either, which is called insulin resistance. As a result, blood sugar is not able to get into these cells to be stored for energy. And when sugar cannot enter the cells, high levels of sugar build up in the blood. This is called hyperglycemia. Hyperglycemia is the technical term for high blood glucose (sugar). High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly.The Nursing Management of Type 2 Diabetes Mellitus Essay

Type 2 diabetes usually occurs slowly over time and most people with type 2 diabetes have no symptoms at first or it may even take years. Some early symptoms of diabetes may include; bladder, kidney, skin, or other infections those that are more frequent or heal slowly. You may experience some fatigue, hunger, and increased of thirst. Other important symptoms like increased urination, blurred vision, erectile dysfunction, and pain or numbness in the feet or hands. A hormone produced by the pancreas called insulin helps sugar in our blood get into the cells of our bodies.The Nursing Management of Type 2 Diabetes Mellitus Essay

There are several tests that can be done in order to confirm the diagnosis of type 2 diabetes. The doctor can order a fasting plasma glucose test or casual plasma glucose. The fasting plasma glucose test (FPG) is the preferred method for diagnosing diabetes, because it is easy to do, convenient, and less expensive than other tests, according to the American Diabetes Association. Before taking the blood glucose test, you will not be allowed to eat anything for at least eight hours. They can also use the oral glucose tolerance test, for this test you have to fast overnight, and the fasting blood sugar level is measured. Then you have to drink a sugary liquid, and blood sugar levels are tested periodically for the next several hours.

Routine screening for type 2 diabetes is normally recommended at the age 45, especially if you are overweight. If the results are normal then you should repeat the test every three years. If the results are borderline, your physician will tell you when you should come back to retest. Screening is also recommended for people under 45 and overweight especially if you have heart disease or a family history of type 2 diabetes, or blood pressure above 135/80.The Nursing Management of Type 2 Diabetes Mellitus Essay

There is no cure for diabetes but it can be controlled, but it does require a lifelong commitment to blood sugar monitoring, healthy eating, regular exercise, possibly, diabetes medication or insulin therapy. The main goal of treatment is to first lower high blood glucose levels and the long-term goal of treatment is to prevent problems from diabetes. The main treatment for type 2 diabetes is to exercise and diet. Type 2 diabetes can basically be controlled by following a few steps; As long as you test and record your blood glucose, know when to eat and when to eat, how to take your medications if any are needed, and how to recognize and treat low and high blood sugar. It can take several months to get the hang of these basic skills but as everything else it will become second nature.The Nursing Management of Type 2 Diabetes Mellitus Essay

There are several types of medication that can be prescribed by your doctor if diet and exercise does not keep your blood sugar at normal or near normal levels. Some of the drugs prescribed help lower your blood sugar levels in different ways, so therefore your doctor may have you take more than one drug. Some of the most common types of medication are as follows: Alpha-glucose inhibitors (such as acarbose), Biguanides (Metformin), Injectable medicines (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin) Meglitinides (including repaglinide and nateglinide), sulfonylureas (like glimepiride, glyburide, and tolazamide), and Thiazolidinediones (such as rosiglitazone and pioglitazone). Rosiglitazone may increase the risk of heart problems, so before you take this particular medication make sure to discuss any possibilities of heart problems with your physician. These drugs may be given with insulin, or may be used alone. You may need insulin if you continue to have poor blood glucose control. It must be injected under the skin using a syringe or insulin pen device. Insulin cannot be taken by mouth. Women who have type 2 diabetes and become pregnant may be switched to insulin during their pregnancy and while breast-feeding because it is not known whether hyperglycemia medications taken by mouth are safe for use of pregnancy.The Nursing Management of Type 2 Diabetes Mellitus Essay

Although long-term complications of diabetes develop gradually, they can eventually be disabling or even life-threatening. Diabetes can lead to more serious problems after many years. You can develop eye problems, including trouble seeing especially at night, and light sensitivity, and you can even become blind. Your feet and skin can develop sores and infections. After a long time your foot or leg may need to be removed. Diabetes also makes it harder to control your blood pressure and cholesterol. This can lead to a heart attack, stroke, and other problems. It makes it harder for the blood to flow to your legs and feet. The nerves in your body can get damaged and cause pain, tingling, and loss of feeling. And because of nerve damage you could have problems digesting the food you eat. You could feel weakness or have trouble going to the bathroom. Nerve damage can also make it harder for men to have an erection. High blood sugar and other problems can lead to kidney damage. Your kidneys may not work as well and they may even stop working. In order to prevent problems from diabetes, you should visit your health care provider or diabetes educator at least four times a year and discuss any problems you are having.The Nursing Management of Type 2 Diabetes Mellitus Essay

You should always pay close attention to the symptoms of Type-2. If you have a dry mouth, increased hunger, blurred vision, headaches, fatigue, and unexplained weight loss, then you have the most common symptoms. Do not ignore any of these symptoms and get medical attention as soon as possible. Type 2 diabetes can be easy to ignore, especially in the early stages when you’re feeling fine. But diabetes affects many major organs, including your heart, blood vessels, nerves, eyes and kidneys. Controlling your blood sugar levels can help prevent these complications. Good management of your type 2 diabetes includes using your medicines exactly as your doctor prescribes them, making smart food choices, and being physically active. Always remember one thing “your body is your temple” and we must learn how to take care of it and treat the body right so the body can be good to us in return. The Nursing Management of Type 2 Diabetes Mellitus Essay