Managing Diabetes in a Patient with Enduring Mental Health

DIABETES A CONTEMPORARY APPROACH 2486 WORDS CONTENTS CONTENTSPAGE1 INTRODUCTIONPAGE2 DISCUSSIONPAGE2 CONCLUSIONPAGE8 REFERENCESPAGE9 ARTICLES ACCESSED ONLINEPAGE12 appurtenance 1SCENARIOPAGE13 APPENDIX 2 EATWELL PLATEPAGE14 Introduction Lavinia had suffered a retrograde in her moral health and had been exploitation illicit drugs and alcohol to combat the disturbing positive symptoms of her illness and had stopped taking any of her irrefutable musics.The nursing assessment indicated that the first egression to deal with was her disorganised demeanor and once that was under get a line a series of therapeutic interventions could be put in place to aid her recovery. Initially her disorganised presentation and challenging behaviours (Beer et al, 2005 Xeniditis et al, 2001) made it difficult to engage with her with in a therapeutic way and she resisted staves attempts to help her. The decision was made to manage her using intramuscular injections (IM) of an anxiolytic that neces sitated using animal(prenominal) restraint in order to administer the IM.The first few days were non pleasant for Lavinia collect to staff take aiming to restrain and inject her in order to manage her challenging behaviours but her chaotic behaviour did resolve over time and she became more accepting of staff interventions. Lavinias named nurse engaged with her and worn-out(a) time counselling her and a series of therapeutic interventions were agreed. cordial health nurses argon specialists in condole with for pot with mental health problems and it has been identified that they defend deficits in their association of diabetes (Nash, 2009).This was the case in sympathize with for Lavinia at the time. Little emphasis was placed on the importance of managing her diabetes because staff were not aw be of the implications of unfortunate diabetes management. Discussion In the United Kingdom mental illness is by far the largest single writer of burden of disease. there is no o ther illness or disease in the combined fulfilment of persistence, preponderance and breadth that impacts on the somebody more (Friedli and Parsonage, 2007).There is an inextricable link amidst poor mental health and an dislodge magnitude assay of physical illness, increase health risk behaviour, deprivation, poor educational achievement, kernel misuse (National Institute for health and clinical Excellence, ( skillful) 2009). Managing mental illness carries the single largest cost to the National health Service (NHS) coming in at ? 10. 4 billion (Department of Health, 2012). Schizophrenia is a psychotic upset that can pretend a debilitating violence on many aspects of a persons brio including perceptions, thinking, language, emotions, social, behaviour.The positive symptoms of schizophrenia can include hallucinations of any senses, delusions, disorganized thought processes, causing the person to lose contact with reality. Diabetes is a serious terminus that can possess a debilitating effect on the person. It can cause kidney failure, blindness, heart disease, stroke, psychosocial problems, if left untreated (NICE, 2008). The United Kingdom is facing a significant increase in the be of large number diagnosed with diabetes. In the noncurrent 16 years the number of people diagnosed with diabetes has increased from 1. million to 2. 9 million cases and it is estimated that this figure depart continue to increase as the number of older people and overweight/ weighty people increase (Diabetes in the UK, April 2012). Diabetes mellitus is a condition whereby the body is unable to properly use the glucose it produces because of either lack of or resistance to the hormone insulin. There are two main parts of diabetes symbol 1 & type 2. Insulin is needed to enable the glucose to pass from the breed and enter the cells of the body where it is stored. figure 1 diabetes occurs when the body (pancreas) is unable to produce its own insulin (an autoimmune d isease) and the person unavoidably to pick up regular daily injections of insulin to counter this. Type 1 diabetes accounts for approximately 10% of all people with diabetes (Diabetes in the UK, April 2012). Type 2 diabetes mellitus is a condition whereby the body either does not produce able insulin or that the person is insulin resistant. It can be treated with medication alone or medication and insulin.Type 2 diabetes accounts for approximately 90% of all people with diabetes (Diabetes in the UK, April 2012). It is known that type 2 diabetes mellitus has an increased prevalence in people with schizophrenia compared to the the general population (Schoepf et al, 2011). Further, the treatment for schizophrenia is typically with antipsychotic medication and it is now clear that some antipsychotics elevate the risk of developing diabetes and weight gain (iatrogenic effect) though unsloped why this happens is not fully understood (Dixon et al. 000). Lavinia suffers from schizophren ia, is grievous, takes antipsychotics, and suffers from type 2 diabetes. Diabetes is potential differencely a life impenetrable condition. Blood glucose levels below 3. 5mmol/l are too low for the brain to function this is hypoglycaemia. The signs of hypoglycaemia are similar to a person experiencing psychoses, e. g. aggression, disorientation, changed behaviour. It would have been imperative that nursing staff should have made it a priority that Lavinias broth glucose levels were monitored.Lavinia could have been experiencing a hypoglycaemic state when in fact nurses efficiency have mistaken this for challenging behaviour. Lavinias blood glucose levels might have been above the exhorted guidelines (8mmol/l) which is hyperglycaemia and the nurses would need to have an understanding of the potential elevated blood glucose levels can have, e. g. damage to the micro and macro vascular system leading to blindness, increased risk of heart attack, increased risk of stroke, diabetic ketoacidosis.Not having sufficient cognition of diabetes while at the same time caring for someone with diabetes and not acting compromises the nurses professional obligations ( treat and Midwifery Council, NMC, 2002) and the NMC or the courts would have no reluctance in pursuing this should it become an issue (Kane Gorny, 2009). Any nurse who likes for a person needs to be competent. Roach (1992) defines competence as, the state of having the knowledge, judgment, skills, energy, flummox and motivation required to respond dequately to the demands of ones professional responsibilities. The nurses caring for Lavinia would therefore be affair bound to refer her to a diabetes nurse/Dr. According to the NICE (2008) recommendations it is vital that people with diabetes receive an one-year check up including blood pressure feet check smoking status urinary albumin psychometric streak (or protein test to measure kidney function) serum creatinine test retinopathy screen cholesterol le vels weight and BMI measurements HbA1c blood glucose levels.Lavinia may have had these checks carried out within the last 12 months but due to her chaotic modus vivendi over the past few months her results might differ significantly thus during this admission it would be an opportune time to have these checks carried out. Hypertension can have devastating effect on the person whether they have diabetes or not, e. g. increased risk of stroke, cardiac disease, renal failure. Research by Diabetes UK (2012) found that little more than 50% of people with diabetes were meeting their blood pressure targets which they recommend should be 130/80.The importance of close foot care in diabetes cannot be overstated. Poor foot care can lead to ulceration and ill health, necrose and even amputation. Diabetes UK state that up to 80% of amputations annually in England are avoidable. The risks that smoking presents are soundly documented, e. g. heart disease, stroke, vascular complications, amput ation. A person with diabetes is pre disposed to certain illnesses and should he/she decide to smoke thusly their health risk profile increases considerably by multiplying the potential deleterious effects.Blood tests can identify potential or actual renal failure. Diabetes causes harm to the micro vascular system which includes the very tiny vessels in the retina of the eye. If this is not addressed it can lead to blindness and Diabetes UK recommend an annual eye screen. High cholesterol levels are serious whether the person has diabetes or not and can lead to heart disease, circulatory complications, stroke, fertile liver. Abnormal levels of cholesterol can cause insulin resistance.Type 2 diabetes is one of the most serious consequences associated with being obese or overweight. Over the past 25 years the number of people in England who are classed as obese has doubled and it is anticipated by the year 2050 obesity go away affect 60% of large men, 50% of adult women, and 25% o f children (Foresight, 2007). The blood glucose levels HbA1c is an indicator for risk of damage to blood vessels. NICE (2008) recommend an HBA1c level of between 6. 5% and 7. 5% would be the goal for people with diabetes.For people with type 2 diabetes, effective blood glucose run into can reduce the risk of diabetic eye disease by 25% and kidney damage by 33% (UK prospective Diabetes Study (UKPDS). It is clear that management of diabetes can be a challenging role and a multidisciplinary approach is needed to manage it as effectively as it can be managed. Multidisciplinary teamwork is outstanding in any care giving role (Liberman et al, 2001). The most important person in the multidisciplinary team is Lavinia. She is the person who has the most control and needs to manage her diabetes on a daily basis.For Lavinia there are two issues managing schizophrenia and managing diabetes. Using a depot antipsychotic in preference to oral medication would help Lavinia because a nurse would administer it weekly thus reduce the risk of relapse. NICE guidelines (2009) advise that people with schizophrenia should be offered access to psychological therapies including cognitive behavioral therapy (CBT) and/or family therapy. If Lavinia did gain from psychological interventions it might reduce her reliance on medication thus cut down side effects.In order to manage her diabetes Lavinia should have access to a team of professionals including diabetic nurses podiatry Drs ophthalmology dietician pharmacist physiotherapist counsellor. An assessment for management of diabetes should be holistic (Dunning, 2009 pgs. 36 49) and appropriate to a persons lifestyle. For Lavinia this means sitting down with a specialist diabetic nurse and having a complete assessment of her lifestyle and her understanding of how it interacts with her diabetes. She needs to fully understand the importance of good glucose control and the consequences of poor control.She might already have experienc ed hypoglycaemic attacks but been unaware of what they were/are, i. e. could be disconnected with positive effects of schizophrenia. As a starting point it would be appropriate to ensure she knows how to test her blood glucose levels, which is one of the NICE (2008) guidelines, and how to interpret the result. She needs to be aware of the relationship between solid food intake, physical activity and medication understanding how managing these can help her maintain appropriate blood glucose levels. sustenance is known as the cornerstone of management in type 2 diabetes.An appropriate diet will help control blood glucose levels, maintain an appropriate weight/body mass index, and prevention of complications. Lavinia is obese which is possibly due to the combination of antipsychotic medications she takes for schizophrenia and her lifestyle. An assessment by a dietician or specialist diabetic nurse into her eating habits would help to identify any areas she would benefit from by qual ification changes to her diet. The Eatwell Plate (Department of Health, 2011) offers a model for healthy eating in the United Kingdom (see appendix 2).It gives good visual, easy to understand, guidance on the balance/proportion and types of food that contribute to a healthy diet. Lavinia would benefit from an assessment with the physiotherapists to determine her level of physical fitness and areas that could be worked on in order to improve her fitness with a view to losing weight. Exercise can reduce the risk of major illnesses e. g. heart disease, stroke, diabetes and cancer by up to 50% (National Health Service, 2012). However, the benefits of exercise on glycaemic control and body mass in type 2 diabetes is not clear (Boule et al, 2001).The potentially damaging effects that diabetes can have on a person are well known and documented (e. g. UK prospective Diabetes Study, 1977 thru 1997 (UKPDS). The damaging effects of poor blood glucose control are not always immediately observa ble and consequently people with diabetes do not always fully appreciate the importance of controlling their blood glucose levels (see Mail Online, 2010). The reality of diabetes care is ego management and effective self management delays the onset of complications. Lavinia needs to understand how the lifestyle choices she makes, e. . level and relative frequency of physical activity, what and when she eats, managing her mental health, are all major factors in controlling her diabetes. Because the damaging consequences of not managing diabetes are not immediately obvious the impetus to manage it is not always paramount (Diabetes UK, 2012). It might be enough that Lavinia understands these factors and therefore takes action to manage her condition. If not, she would need support to help her change her behaviour/lifestyle in order to manage her diabetes. There are several models of behavioural change, e. g. ealth belief model (Becker, 1974) hypothesis of reasoned action (Fishbein a nd Atzen, 1975) social learning theory (Bandura, 1977). Motivational interviewing (MI) (Rollnick and Miller, 1995) is a model that is used to arrive about behavioural change and has been shown to be effective in bringing about change in a range of healthcare settings including diabetes care, e. g. VanWormer et al (2004) Clark and Hampson (2001) Kim et al (2004). The aim of MI is to bring about dissonance in the persons beliefs and thoughts by bringing about a state of cognitive dissonance, i. e. he difference between where the person is currently and where they want to be in future and setting small goals to achieve. Thus, Lavinia has full knowledge of the damaging effects diabetes can have and in future she would like to get married and have children. To have children she needs to be as healthy as she can be and therefore she will be self motivated to resolve the dissonance she experiences. Used in combination with Prochaska and DiClementes model, stages of change (1983) and Egan s (1998) skilled helper model of problem management could work to good effect for Lavinia in bringing about a change.Conclusion The link between poor mental health and poorer outcomes for physical illness, increased health risk behaviour, deprivation, educational achievement, substance misuse is well known (NICE, 2009). Diabetes is potentially a life threatening condition Lavinia has schizophrenia and diabetes. Her poor mental health could be supporting the deleterious effects of her diabetes. Not having sufficient knowledge of diabetes while at the same time caring for someone with diabetes and not addressing it compromises the nurses professional obligations (NMC, 2002).Lavinia needs support from both the mental health and diabetes services. She needs to have a good understanding of the interplay between the diabetes and mental health. She needs to have insight into potential relapse signatures to her mental health so that she can get help as early as possible. A diabetes counsell or could help Lavinia make lifestyle changes by engaging her in a course of motivational interviews (Rollnick and Miller, 1995) in combination with Prochaska and DiClementes model, stages of change (1984) and Egans (1998) skilled helper model of problem management. ReferencesBandura, A. 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Available and accessed in July 2012 at http//www. dailymail. co. uk/health/article-1309609/The-cruel-cost-ignoring-diabetes-Jane-lost-arm-legs-disease-like-didnt-seriously. html NHS Choices.Accessed online in July 2012 and available at http//www. nhs. uk/Livewell/fitness/Pages/Whybeactive. aspx UK prospective Diabetes Study (1977-1997). Available and accessed online in July 2012 at http//www. dtu. ox. ac. uk/ukpds_trial/index. php Appendix 1 Scenario Lavinia (pseudonym) is a 25 year old female with a history of schizophrenia stretching back to her late teens. She has been placed on a section of the Mental Health Act (MHA, 1983) and detained on a psychiatric intensive care unit (PICU) due to her presenting with chaotic behaviour posing a threat to