Developing a Management Plan for Type 2 Diabetes

Developing a Management Plan for Type 2 Diabetes A long term condition (LTC) is defined as an incurable syndrome. However, some LTC can be managed through medication (Goodwin et al 2010) whereas for others, it can be managed by healthcare providers facilitating health promotional support to patients in order to self-manage their conditions effectively (examples, maintaining healthy diet and physical activities) (Hutchison Breckon 2011). Additionally, for this assignment I will use a case study to discuss my experience about caring for a patient with type 2 diabetes in the hospital. The discussion will include the identified problems to support patients’ needs, the nurses’ contributions to promote patients’ health and well-being as well as the benefits of working alongside with a multidisciplinary team. According to Goodwin et al (2010) type 2 diabetes is also known as insulin resistance. The syndrome is when an individual body lacks the ability to produce sufficient insulin or the body is incapable of controlling enough blood glucose level. It is categorised as a LTC because it is incurable. Nonetheless, it can be managed depending on the individual’s conditions needs such as healthy food and regular activities, or a combination of medications and a healthy lifestyle (Diabetes UK 2012). According to Nursing and Midwifery Council (NMC 2010) Guidance on Professional Conduct, the patient’s identity will be maintained confidential and an anonymous name (Jane) will be used. Jane 65, who has had type 2 diabetes for about two years, was suffering from kyphosis on her back. As she has not been on pharmaceutics’ therapy since her diagnosis, she was advised to maintain her weight within an ideal range. However, Jane has not been able to gain control over her weight (73 kg). She lives alone and has no close family members but she has a good relationship with her neighbours and friends. I met Jane while on placement on an aging admission ward. She was admitted via Accident and Emergency department (AE) to an elderly ward referred by her General Practice (GP) with elevated blood glucose (11.5mmol) which was making her feel weak and was also giving her severe headaches, tiredness and recent weight gain (73.6kg). While she was admitted to AE, her hyperglycaemia was s tabilised with a dosage of metformin (500mg) (8.0mmols) prior to her transfer from AE to the elderly ward. Bakris (2011) suggested that nurses should carry out a comprehensive assessment on patients with type 2 diabetes as this will support the nurse to identify and address issues that can prevent and reduce problems that may affect the patients with type 2diabetes. Diabetes UKÂ  (2012), also recommended that a patient’s risk can be recognised if healthcare professionals could aid an in-depth assessment. This includes; blood glucose level, Hba1c, blood pressure, cholesterol, Body Mass Index (BMI) and waist circumference. The rationale behind the assessment is to support healthcare professionals to make an appropriate individualised care plan considering the patient’s preference (Diabetes UK 2012). To classify any interrelated problem, the nursing assessment was to look at Jane’s medical history before the admission and to observe what her current condition looked like. The nurse along with the author admitted Jane and prior to carrying out the assessment they introduced themselves to the patient. To obtain Jane’s consent, a full detail of the information about the process was explained to her (Nursing and Midwifery Council 2010). Jane’s vital signs presented a blood pressure of 138/80 mmHg, heart rate 84, respiratory rate 16 and temperature 36 degree centigrade. While examining Jane’s nutritional assessment, her MUST stool height was (1.62cm), weight 73.6kg, and waist circumference 88cm. It was identified that she had a BMI of 27 giving her a score (0). In addition to Jane’s assessment, her fasting glucose level was stable 6-7 mmol/litre her foot showed normal to sensation, no sign of lesions on toenails and skin. From Jane’s screening, the underlying cause for Jane’s hyperglycaemia is an increased BMI 27, this indicates overweight as (British Association for Parenteral and Enteral Nutrition 2010) recognised. Overweight is when an individual has more fat than normal in their body. However, an athlete with muscle mass or someone with swollen legs (oedema) could be overweight due to an increase in BMI (Heath Sturdy 2009). According to Nazarko (2008) an individual with a BMI 25-30 is considered to be overweight. BMI is the most common evidence-based tool used to analyse normal weight, overweight or obese in hospital when patients come for admission. It is calculated by dividing an individual’s body weight kilogram by the square of body height (NICE 2006). Waist circumference is also a reliable tool used to recognise overweight and obesity as it provides information with regards to the distribution of excess body fat in a person’s abdomen (NICE 2006). Nevertheless, BMI has some weakness; it is not suitable for individuals with excess body fat or muscle mass as it does not differentiate between excess body fat and muscle mass (Heath Sturdy 2009). Diabetes UK (2012) argued that using BMI alone to calculate a patient’s height and weight would not identify overweight or obesity. However, the combination of BMI and waist circumference will help classify an overweight or obese person, and for this reason Jane’s waist circumference was measured because it is the best way to measure abdominal fat distributed around her waist as suggested by Diabetes UK (2012). Regardless BMI and waist circumference screening tool was used to classify Janes’ overweight, however, according to Ashwell et al (2012) studies have proved waist to height ratio screening tool a better way of identifying overweight or obesity in adult than BMI and waist circumference. As a result nurses should consider using waist to height ratio as a screening tool to recognize overweight or obese patients with diabetes. This is because the tool measures the ratio of an individual waist to his or her height (Ashwell et al 2012). Jane’s height and weight was measured using stadiometer and clinical scale, nevertheless, the use of stadiometer to measure Jane’s height was comparatively weak (BAPEN 2010). Jane is a 65 year old woman with a small kyphosis on her back and according to Hirani Aresu (2012) the result for an elderly with this condition may impair their actual height resulting to false reading. This is because some people grow older with distort height like kyphosis, this as such will result in the individual to losing his or her real height. Kyphosis is a deformity of an individual’s back which can lead to hunched back due to a deviation of a spinal curvature from its normal shape (Kado et al 2013). Therefore the use of demispan measure tool could be an evidence based practice to consider when a patient’s actual height is distorted. As a result this might have worked for Jane as she has a small kyphosis on her back and the NMC (2010) emphasized that nurses should use their clinical knowledge, skills and judgement to classify factors that could impair individual’s height. Consequently, Jane’s hypoglycaemia is partly dependant on her overweight; therefore the main nursing intervention that needs to be targeted is Jane’s weight loss as it will lead to long term benefit for her. This is because overweight can cause hypoglycaemia, overweight is also associated to inadequate exercise and unhealthy eating behaviours considered to be primary factors contributing in the rising prevalence of type 2 diabetes and if not well managed, it could also lead to other complications such as obesity, heart attack or stroke (Diabetes UK 2012). As a result an effective weight management can improve Jane’s wellbeing using nursing problem solving approach. According to Barrett et al (2010) nursing problem solving approach is about understanding the individual as a whole person. Therefore, using the problem solving approach means nurses have to link the individual’s illness to factors that could affect their disease. These involve psychological, emotional, social environment, spiritual and time and if there’s any of these identified then it should be addressed as they form part of the individual’s well-being (Wade 2009). Knol et al (2006) states depression is common in people suffering from type 2 diabetes. Knol et al (2006) also recognised that thirty seven percent of those people with a medical history of depression are prone to have type 2 diabetes. Evidently, Jane during her initial assessment mentioned that she had little knowledge on dietary due to lack of motivation and her dietary history reveals having unhealthy food such as ready meals and dessert while away with friends. Consequently, this has had an impact on her psychological wellbeing. She also recognised excesses carbohydrate intake and her normal dinner meals consist of pasta whereas during the day she often has rice with homemade sauce as well as walking exercise 10-15 minutes twice in a week. However, the nursing team worked with Jane to determine if Jane’s overweight was caused by her not complying with her dietary advice, as a result she agreed that a referral to a dietician and diabetes specialist nurse was her concern and this was made to deliver meal plan as well as maintain her physical activity. This is the best practice as suggested by NMC (2006) that nurses must work together with their patient to ascertain the patient’s understanding about risk associated with overweight. This is because if Jane’s food pattern is left unattended it may lead to further ill health problems such as obesity, stroke and heart disease (Thomas 2008). The United Kingdom Progressive Diabetes Study (UKPDS 1990) recognised the majority of people with type 2 diabetes have ill health complications associated with their long term condition. In addition to this, the role of the dietician is to identify problems relating to an individual’s nutritional status and once identified the dietician working in partnership with the individual will then formulate meal plan that adapt to the person’s needs and preferences (British Dietetic Association 2012). Department of Health (2005) emphasised that nurses should empower patients with long term condition so that the individual is capable to manage and live with their disease effectively. NICE (2008) also suggested this method of approach as the best practice as it helps the individuals to manage their condition. According to Thomas (2008) weight loss through dietary can be defined as a reduction of less food intake to that of the energy used by an individual. Therefore the dietician along with the nursing team main target was how Jane would lose weight through dietary behaviour change and in order to achieve this she was seen a day after her admission. The initial approach considered was the motivational interview based on providing a solution to a suitable diet. Motivational interviewing is a collaborative patient centred approach in a form of supporting a person’s motivation to encourage and empower patients’ behaviour change (Resnicow Mcmaster 2012). This is to maintain the patient’s autonomy based on his or her needs for their condition and that any decision made is eventually up to the patient (Resnicow Mcmaster 2012). Jane agreed having a motivational interview and had the opportunity to discuss her dietary plan with the main focus on the types of food she likes as mentioned above. In order for Jane to have an appropriate balance diet, the dietician and the nursing team worked with Jane by setting a realistic goal. This is because for an individual to lose weight involves time and encouragement to achieve his or her goals effectively and therefore the best practice is setting an appropriate goal that suits Jane (Thomas 2008). It was difficult to set a short term goal for Jane as she was unable to maintain weight loss due to lack of motivation and therefore a long term goal was set with smaller intake of caloric food so that Jane could gradually lose weight and also improve her glycaemic control (Diabetes UK 2012). Jane was offered the importance to a strict diet and she was provided food such as fish, vegetables, low starchy food per day; a reduction of low sugary food was put in place. She was also encouraged to drink two litres of water daily. Her daily food intake was recorded to meet her dietary care plan needs as (Lang Froelicher 2006) recommended. Moreover, Jane during her admission was subjected to weight monitoring and repeating her ‘MUST’ screening progress for any changes in her BMI (BAPEN 2010). Jane following a regular monitoring, on her fifth day on admission was still considered overweight; however, evidence shows a minimal improvement of 900gms weight loss. A risk of any physical complications of diabetes was low and no episode of hyperglycaemia. Her symptom of severe headaches and tiredness was now resolved and she was more excited to go home. Following Jane’s outcome of her dietary care plan, if Jane can be convinced to increase her physical activity her need for hypoglycaemic drug will be minimised. This is because the combination of dietary and an increase in physical activity on a regular basis is recommended to be more effective for an individual to achieve weight loss in a long term goal (NICE 2006). As such Jane’s care plan was reviewed with the nursing team prior to discharge and from her assessment it was recognised that she does not need a psychological referral but to improve her knowledge with regard to her type 2 diabetes so that she can self-manage her diabetes successfully. Even though Jane was suffering from kyphosis, physically she was fit to increase her physical activity and following the discussion how significantly an increase in exercise can have positive effect on glucose management, Jane agreed to walk each day in the mornings 20 – 25 minutes. After reviewing Jane’s dietary and physical options, a discussion about the need to continue metformin helped to improve her glycaemic control; therefore she was prescribed 500 mg twice a day. Metformin is an oral drug to lower glucose level in the blood. Jane will benefit from taking metformin as it is associated to weight loss this will prevent her from gaining more weight (NICE 2009). Other oral anti-diabetic agent such as thiazolidinedious and sulphonyureas were not recommended due to an increase of body weight caused by these agents. Prior to discharge Jane was informed about the importance of community nurse. The nursing team liaised with the community nurse for a regular monitoring of Jane’s glucose level as well as her weight. NMC (2010) highlighted that consent must be given to Jane before involving a community nurse thus it is the right of an individual to confidentiality and consequently is a must for a nurse to respect this. To sum up, Jane’s dietary plan did not make much significant changes in her weight, however, on discharge she was educated to continue recording her daily food and drinks intake, regular exercise, to closely monitor glucose level for symptoms of hyperglycaemic or hypoglycaemia. Further information about getting support from educational programme such as DESMOND was discussed with Jane. She was also given information leaflets which were easy to read as supporting interventions to help increase her knowledge about how to self-manage her diet.

Children vs. Authority: Rebellious Attitudes

Children vs. Authority: Rebellious Attitudes to Avoid Societal Expectations Children's literature has an extremely influential way of shaping a child's outlook on life. When children read stories, they often relate to the characters on a very personal level, whether the character is polite and kind or rude and bratty. The plots of children's stories can influence generations of children in negative and positive ways. For over one hundred years, one of these influential texts is still J. M. Barrie's Peter and Wendy, which originated as a play.The main character, Peter Pan, is a boy ho lives in Neverland and refuses to grow up. He lives by his own rules, with no parental guidance to help him learn right from wrong. The same concept is depicted in Harriet the Spy by Louise Fitzhugh. Harriet, an eleven year old aspiring writer, creates her own rules for being a child rather than conforming to societal expectations. In a book written by Colin Heywood, the historical expectations of childr en are explored with the conclusion that the expectations of children will continue to change over time, and Heywood is in hopes of this becoming a positive change.During the transition period from child to adult, many children rebel against authority figures, including parents or institutions. In Peter and Wendy and Harriet the Spy, the main characters rebel against authority in such a way as to defy social order. Living in Neverland, Peter refuses to mature and wishes to remain a boy forever, while Harriet could careless about conforming to the typical social requirements of her gender. Heywood discusses the gradual societal changes inflicted upon children from before the writings of J. M. Barrie to current novelists today.Both Peter and Wendy are strong examples of children who oppose parental authority fgures in order to resist the social normalities which proceed adolescence. Barrie's character of Peter Pan opposes all authority in Peter and Wendy, however, the parental fgure o f Neverland -Captain Hook- is the one authoritarian fgure in Peter's fantasy which he cannot escape. The plot seems to thicken as the story continues, and their is major friction between the two characters: Peter avoids authority while Hook demands it. Peter interacts with parental authority throughout the novel, beginning with the Darlings.He frequently listens to the stories Mrs. Darling tells in the nursery, yet will not commit to the idea of parents and the rules that come along with them. He instead encourages Wendy, Michael and John to fly to Neverland with him, enticing them with â€Å"mermaids† and â€Å"pirates† (Barrie 97-100). This enticement is a depiction of Peter avoiding authority; he is encouraging the children to rebel and leave their parents for a fantasy island with no rules. A second example of Peter resisting authority is his interaction with Captain Hook in Neverland.Hook represents the dominant adult authority in a fantasy land with no ules, ther efore, Peter and Captain Hook are polar opposites in the story. Peters constant opposition to boyhood leads to Hooks death to the infamous crocodile. Through Peters defile of authority to both parental fgures in the novel, he is avoiding the social structure which occurs in ones growth from child to adult. Besides blatantly stating â€Å"l always want to be a little boy and to nave tun,† Peter Pan continuously suppresses the idea of parental guidance or any type of authority (Barrie 92).Peter does not want to participate in the normal milestones of life, nstead, he wishes to stay a boy forever. He is constantly avoiding rules, adults, and any concept of responsibility expected from him. Although Peter demonstrates many qualities of a young man, especially with his leadership of the lost boys, he continuously defies the social normalities which follow adolescence. In an article written about J. M. Barrie, it states that Peter and Wendy stand out from other works for its use of â€Å"childhood innocence, the island as a retreat from society, separation, the fantastic, and the need for social order† (Schoenberg and Trudeau 2).Social order s a reoccuring theme in Barrie's novel; the evident lack of social order emphasizes the evident need for it. When Wendy travels to Neverland with Peter she begins feeling romantically inclined towards him, however, Peter does not return the same emotion. He is incapable of romance, as he is not a man nor wishes to be one. He demonstrates authority himself, yet will not accept it from others. With the control of his own fantasy in Neverland, Peter eliminates any possibility of having a father and instead takes on the role as he sees fit.

Graphic Novel Deconstruction Essay

This essay will deconstruct Neil Gaiman’s graphic novel The Sandman Volume#1 Preludes and Nocturnes (1991), in order to gain an understanding of narrative is presented through the use of image. It will also comment on the codes and conventions within the chosen text. Preludes and Nocturnes is the collection of eight comics in the Sandman series, with Neil Gaiman writing for a regular series for the first time. As such Preludes and Nocturnes is somewhat a work in progress, as the creative team honed their work. If read from cover to cover you will see a marked improvement in the writing over the course of the volume culminating in a much more tightly wound climax than at the beginning. The first chapter Sleep of the Just is a good place to start looking at the panel construction of the narrative. On the page (Tab. 1) we see the first three panels over-laying the fourth panel. The first two panels are narrow and rectangular and the third is square. The gutters are very narrow and not a lot is happening in the panels. This indicates that panel-to-panel, not a lot of time has passed between transitions. However rather than use moment-to-moment transition the creators have used subject-to-subject as a method of keeping a moderate pace for the reader to become interested in what they are seeing on the page. This is continued throughout the eight panel page. Alternatively, the creators could have shown the first two panels as one, allowing the dialogue to take place straight away as the car pulls up to the mansion. The panel could then be expanded showing the mansion in more detail and allowing for the removal of panel three completely. We already know the man is here for a reason, therefore we make an assumption he will leave the car and knock on the door. ) This would potentially allow for the removal of Panel Four, going straight to the man knocking on the door and the door being answered. This would then clear up what is a relatively cluttered page and make the narrative much more direct. Dialogue and pacing are used to high degree throughout this chapter sometimes appearing cluttered and confused, and sometimes this is compound by the unusual panel shapes employed. However this has been used to great effect (Tab. 2) The thin oddly constructed/shaped panel’s one and two, are almost seen as though they are slices of Burgess’s insanity and obsession. Subject-to-Subject transitions are used to aid pacing in what otherwise would be a lengthy a page due to the amount of dialogue. Although the majority of the spoken word is short, there is a lot of it to read. A six panel page is probably right for this instance however more conventional panel shapes would probably aid the reader more. The caption box in the first panel is used in parallel to what is in the picture; the reader doesn’t actually see the words of the spell tolling in his head, but they are given a sense of the psychological effect it takes on Burgess. On the very next page closure is used perfectly. Burgess demands for the being to come forward and with each chant, that being becomes more corporeal with the end result, the creature arriving in the room. The dialogue used is interdependent to the imagery. Without one or the other the reader wouldn’t be able to pick up the full picture of what is happening. To speed this page up you could probably remove the panels with Burgess and just have the three panels of the creature appearing with the dialogue situated around him, as if surrounded by people. In (Tab. 3) we can see a classic example of moment-to-moment transitions, twelve panels depicting and old man dreaming of becoming young again as he walks along a dark corridor before realising he is in a nightmare of his own making. Twelve panels on a fifteen panel page seems like a lot, however it serves to really ramp up the tension in the terms of the narrative as this is a turning point for the whole story. Interestingly the transitions used serve as the opposite to what is actually happening; the de-aging process of decades in just a few seconds or minutes intensifies the dream/nightmare feel. For the sake of quicker pacing you could perhaps take a few panels out here and there, showing a larger passage of time between the transitions and the de-aging process, however you would then run the risk of losing the tension build up. An interesting point to note is the dialogue for Morpheus, his speech bubbles are jagged black items with white text, that serve the purpose of defining his character as not of this earth and more important than any other speaker. (Tab. 4) poses some interesting issues. Panel 1 bleeds in from the top of the page to the half-way point with the next two panels over laid. However here is where it can get confusing for a reader who reads from left to right on a single page. Panels 4-6 do not follow the traditional design of a comic book. Rather than continuing the dialogue under panels 1-3 they extend onto the next page and initially this is confusing as the readers first thought is to go down the page. It is almost as if the writer wants you to stop and think for a moment. This layout is continued through panels 7-13 and in panels 10-12 the structure becomes jagged indicating Cain’s fractured mind finally snapping and lashing out at his brother Abel, the word â€Å"IRVING † capitalised and coloured in red accents this. This section uses several different types of panelling ranging from aspect-to-aspect (panels 1-4 7-8) subject-to-subject (5-6 9-13. ) This unusual layout has been created because of the opening dialogue, Lucien the Librarian stating that â€Å"It has been a strange century. † The creators probably felt that they could accentuate this by creating this page layout. It would have worked much better if it had been done over a single A2 sheet but restrictions prevent this so readers would have to be careful to make sure they read the page right. It would flow better if the panels with Cain and Abel had been left out entirely or at least placed on a separate sheet. Again closure is shown on the final panel with blood spatter getting that message across loud and clear. (Tab. 5) brings good examples of word specific text in subject-to-subject panels, also note the colour change to black and white, given in context with each panel it conveys the message that all is well and the world is resting. The use of Morpheus’s coat as a panel enveloping Arkham Asylum is used to indicate that he is back in control of the dream realm and is repairing the damage done by his captivity. Throughout the Preludes and Nocturnes there has been a constant improvement in the way it is presented and written. In particular as the narrative continues, there are subtle changes in colours, from really quite dark to eventually ending up with a white background as Morpheus goes about his quest to right the wrongs done to him. The writers also moved to more traditional conventions of comic books in respect to panelling moving away from the sometimes claustrophobic and cluttered panels in the early chapters to the more familiar boxy panels that most sequential art uses, however that is not to say the gothic inspired artwork doesn’t have its place, in the early stages of the story, entrapment and imprisonment were key themes. As the creative team honed their skills the works became more coherent and easier to understand. It is easy to see why this series is so popular.

Privacy in the Workplace Essay - 2057 Words

Privacy. There seems to be no legal issue today that cuts so wide a swath through conflicts confronting American society: from AIDS tests to wiretaps, polygraph test to computerized data bases, the common denominator has been whether the right to privacy outweighs other concerns of society†¦ This quote from Robert Ellis Smith explains, in one sentence, the absolute need to ensure privacy in the workplace. One of the most interesting, yet controversial, areas concerning public personnel is employee privacy. What limits are there to employers’ intrusions into, and control over, employees’ behaviors and personal properties? There are five major areas which trigger privacy matters in the area of public sector employment: background†¦show more content†¦Privacy also hinges on a respect for a persons inherent dignity. An employee can claim a protection of his reputation and sense of self-worth against defamation, discrimination, or personal abuse. A person also has the right to maintain his personal beliefs and convictions against coercion and manipulation. Applied to the environment of public employment, this conception would prohibit any employer from harassing individuals on the basis of their class or status, or their personal characteristics. It would prohibit employers from shaming employees and causing emotional distress in the process. It would prohibit an employer from breaching the confidentiality of an employees record or publicizing closed hearings concerning the employee. This is one area where an employees privacy interests may be violated in a technological environment by fellow emp loyees who may use bulletin boards to post embarrassing information or defamatory messages to be read by others. This conception of privacy can also be extended to a claim against pervasive intrusion by employers into employees work activities. 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