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Chronic illness today is sometimes referred to as a pandemic due to the increasing prevalence of such illnesses (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014). Some examples of illnesses that can become chronic are heart failure, kidney disease, cancer and diabetes (Lewis et al., 2014). This paper will focus on type II diabetes (DMII). DMII manifests as a result of insulin resistance, inadequate insulin synthesis due to morphological changes in pancreatic beta cells, changes in adipokine production and increased glucose synthesis by the liver in fasting and post ingestion periods (Lewis et al., 2014). DMII accounts for 90% of diabetes patients and typically has a gradual onset (years) with very little or no symptoms (Lewis et al., 2014). Risk factors of DMII can be divided in to modifiable and non-modifiable. Modifiable risk factors include obesity, sedentary lifestyle and poor diet while non-modifiable include heredity, age, and ethnicity (Lewis et al., 2014). Other risk factors such as history of impaired glucose tolerance or fasting glucose can also lead to DMII (Lewis et al., 2014). Many people are diagnosed with DMII during routine blood tests. Treatment of DMII often includes insulin, oral antihyperglycemics, exercise and nutritional therapy (Lewis et al., 2014). Adjunct medications such as ace inhibitors, angiotensin II receptor antagonists, lipid lowering agents, antiplatelets are also used in preventing diabetes complications (Lewis et al., 2014). Treatment also typically involves patient education on diabetes management strategies such as controlling blood pressure and blood sugar.
Barriers to Self-Management
Barrier 1: Patient Lifestyle
Patient lifestyle is not only a risk factor of developing DMII but can also be a major barrier to self-management. For therapeutic outcomes to be accomplished, patients have to be willing to make some lifestyle changes especially in regard to diet and exercise. Prevalence of DMII development is more common in adults age 35 and older; furthermore, approximately 80 to 90% of those with diabetes have an increased body max index during the diagnostic period (Lewis et al., 2014). Patients who dont adhere to treatment goals and medications also increase their chances of developing acute and chronic complications of DMII. In some cases, patients who adhere to treatment goals including a combination of diet, exercise, and self-monitoring strategies (blood sugar control, blood pressure monitoring), are able to return to normal body weight and even normalize their blood sugar (Lewis et al., 2014).
Barrier 2: Social Economic factors
Social economic factors play a major role when it comes to the management of patient conditions as clearly noted in (Sav et al., 2013) and (Lewis et al., 2014). In Sav et al. (2013), several interviewees attributed their lack of medication adherence to high medication costs. According to Lewis et al. (2014), low income Canadians are three times less likely to fill their prescriptions, and 60% less likely to seek out necessary medical tests and treatment due to cost compared to their mid to high income counterparts. Social economic factors may influence whether an individual is able to get access to the appropriate care they need (Sav et al., 2013). Factors such as transportation, medications, health insurance and even geographical location can all affect an individuals ability to access healthcare (Sav et al., 2013).
Barrier 3: Lack of Cultural Competence in Healthcare
A lack of cultural knowledge in healthcare can be a barrier to communication, proper self-management and a cause to eventual adverse health outcomes (Lewis et al., 2014). There are numerous people from varying cultures accessing healthcare and all these people come with varying beliefs and outlooks about disease and health (Lewis et al., 2014). According to Sav et al. (2013), most knowledge today in regard to chronic disease is relevant but unfortunately only focuses on the disease aspect of the individual and not as a whole. Furthermore, the information is mostly from people of similar or the same culture (mostly older Caucasian adults) and therefore may be blind to the experiences of minority cultures with chronic diseases (Sav et al., 2013).
Nursing Interventions
Educate Patients on Diabetes Management
Patient education on DMII management is key to ensuring optimal patient health outcomes. As aforementioned, DMII patients who are well educated and aware of the disease process management strategies and adhere to treatment goals are more likely to improve their condition significantly (Lewis et al., 2014). Patients should be educated on the DMII disease process first by analyzing what they know the filling in the gaps. Knowledge of the disease process may aid in increasing adherence to treatment as patient will better understand the reasons for their prescription (Lewis et al., 2014). Teaching should also involve the importance of nutritional therapy and exercise as maintaining adequate body weight and controlling blood sugar. Following recommendations by the Canadian Diabetes Association (CDA), the patient should be educated on limiting fatty foods, sugar and sweets, increasing fiber in diet, eating 3 meals a day about 6 hours apart and increasing fluid intake to prevent dehydration (Lewis et al., 2014). Patients should also be educated on exercise and rest regimens as exercise has been shown to have a sensitizing effect on insulin thus resulting in a lowering of blood glucose in the body (Lewis et al., 2014). Exercise also helps in reducing body fat and weight which in turn helps to reduce insulin resistance which may further aid in the normalization of blood sugar and even blood pressure (Lewis et al., 2014). Although exercise is good, diabetic patients should also be taught about rest periods, eating before and after exercise, carrying diabetic approved snacks or glucose tablets in order to prevent the occurrence of hypoglycemia (Lewis et al., 2014). The CDA also reccomends that diabetics should be started on exercise regimen after the approval and assessment by a doctor (Lewis et al., 2014). Diabetic patients should also educated on the importance of medication and or treatment adherence if necessary, as they are at risk of developing acute and or chronic complications that can affect the whole body system and even lead to death (Lewis et al., 2014). Acute complications typically manifest as a result of mild, moderate and extreme blood glucose flactuations(Lewis et al., 2014). Some acute complications of DMII include hypo/hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state(Lewis et al., 2014). All the afformentioned acute complications can also lead to additive adverse effects on the body resulting in kidney failure, fluid shifts, hypovolumea, electrolyte imbalances Etc(Lewis et al., 2014). Chronic complications often result from vascular problems such as damage or accumulation of plaques in small, medium and large vessels(Lewis et al., 2014). Chronic complications can increase a patients risk for heart disease, stroke, hypertension, neuropathy, nephropathy, retinopathy, altered immune system, and skin breakdown (Lewis et al., 2014). Patients should be educated on recognizing symptoms especially for the acute symptoms as these happen fast and can lead to seriouse harm or death.
Advocate for Policy Change to Improve Patient Outcomes
According to the Canadian Nurses Association (CNA) as noted in Lewis et al. (2014), being an advocate is part of a nurses role. Nurses play a key role in healthcare and as a result are positioned well to help in the shaping of care standards, policy and education (Lewis et al., 2014). Using Evidence Informed Practice (EIP), nurses can gather information based the topic of interest (DMII), gather relevant data related to the topic, assess collected data and relevance to profession, (nursing), patient population and beliefs; this data can then be used in the making of necessary changes to practice and subsequent evaluation (Lewis et al., 2014). Nurses can use EIP to assist in creating new care standards that would aid in reducing barriers and improving management strategies for patients with DMII. An example of a new management strategy can be seen in Steinman et al., (2020) where new care approaches are examined such as mobile health to help keep track and link those with DMII with their healthcare providers, pharmacies, educators and community groups with similar conditions. Using the mobile health strategy in the management of diabetes and hypertension may increase adherence to treatment and allow for those suffering with diabetes to be educators and community builders for those in similar situations (Steinman et al., 2020). According to Steinman et al., (2020), mobile health may also be used to remind patients to take medications, keep medical appointment and other necessary care services. Mobile health seems to have some promise in low to middle income countries and may just work for those in low to middle income status elsewhere including Canada. If implemented, mobile health may help in building more communities and may even lead to an increase in healthcare resource allocation and treatment goal adherence to those suffering with DMII as a result of this peer support model. As noted in Steinman et al., (2020), physician assistive personnel such as nurses, pharmacists and Etc. may be better positioned to educate patients on self-management strategies due to a lack of time by physicians.
Practice Culturally Competent Care
Due to the diverse range of cultures and people who frequent healthcare centers, it is important for healthcare providers to be culturally aware and be ready to provide care that is congruent with the patients beliefs as this would encourage adherence to treatment goals and lead to better outcomes (Sav et al., 2013). An analysis of high-risk populations for the development of DMII reveals that visible minorities in the Asian, Aboriginal, African, and Hispanic populations are at greater risk and thus further drives the point of the importance of cultural awareness and competence (Lewis et al., 2014). The afforementioned highrisk populations all come from varying cultures and as a result will have varying beliefs on issues relating to their health (Sav et al., 2013). For example, when it comes to diet modifications for diabetic patients, adherence to diets may be increased if the educator is aware of some food preferences within a certain culture that may be favorable to the patient and his or her condition (Lewis et al., 2014). As noted in Lewis et al. (2014), The CDA provides dietary information based on specific cultural preferences that may help healthcare providers and patients when meal planning for diabetic patients. New immigrants and people from different parts of the world may also lack the knowledge to navigate the healthcare system and are also more likely to have language barriers which may present challenges in communication (Sav et al., 2013). In order to foster understanding in a patient with a language barrier, Lewis et al. (2014) recccomends that having an interepretor present who is known to the nurse and the patient. The interpretor should be assesed for their values and ability to translate information accurately, furthermore the translator should meet with the nurse and patient prior to the meeting to build rapport. Nurses can also make sure to schedule more time, be proffesional, patient, and speak with clear simple words and sentences avoiding medical jargon (Lewis et al., 2014). Approximately 60% of Canadians have deficiencies in health related knowledge such as how to access necessary care services and information related to increasing skills necessary for self health management(Lewis et al., 2014). As potrayed in the following examples, it is clear that being culturally aware and practicing cultural competence can be a great way for nurses and other care providers to assisst in ensuring that patients are getting the utmost care that alligns with their beliefes and preferences.
Conclusion
To conclude, Chronic disease is rampant globally and many care strategies have been deployed to aid in the management of these diseases. This paper mainly focused on barriers to self-management, nursing interventions and the role nurses play in the management of chronic diseases, specifically DMII. Although some strategies currently exist to aid patients in management of DMII, more research is needed in order to improve and ensure the utmost care for this patient population.
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