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Lee is only the first step in the process of building a team that is able to cover all aspects of Mrs. Lee's care. The team approach involving a social worker, nurse, physician, pharmacist, and physical therapist affords Mrs. Lee a full range of professionals attending to her various needs.
Although Mrs. Lee has a number of problems that need to be addressed the one problem that must be addressed immediately is her elevated blood pressure. Hypertension is an important risk factor for the development and worsening of many complications of diabetes and an elevated blood pressure is like walking around with a detonated bomb. Within moments, and with little warning, a diabetic patient can suffer a stroke or heart attack as a result of an elevated blood pressure. Well over fifty percent of diabetics suffer from hypertension and proper treatment of hypertension can minimize most of the tangential problems such as kidney and heart disease that occur in diabetic patients (Epstein, 1997). As any blood pressure reading above 130/80 is a cause for concern, the fact that Mrs. Lee's blood pressure reading is 160/90 is strong evidence that her condition is out of control and that action must be taken to decrease her blood pressure. The medications that Mrs. Lee is presently taking are appropriate choices but there is a strong possibility that her medications may need adjusting or that some alternative medications may have to be considered. From a nursing point-of-view, adjustments in medication are the responsibility of Mrs. Lee's treating physician but other health care professionals should be aware of this potential problem.
Hyperglycemia (high blood sugar) has been identified as a major factor in the development of problems related to diabetes. In the past several years a new testing method has emerged that has proven to be good barometer for determining how well an individual diabetic patient is responding to treatment. The test, known as HbA1c, measures glucose levels over a period of a three-month period affording the diagnostician with a clearer idea of the patient's condition (Deichmann, 1999). The fact that Mrs. Lee's HbA1c level was so elevated might indicate a need for more frequent testing. It should be the goal of Mrs. Lee's treatment team that every effort is made to decrease her HbA1c scores to a more stable state. A 9% reading is not acceptable and is a strong indication that Mrs. Lee's present treatment program is inadequate.
Even if all of Mrs. Lee's other health indicators were in the normal range, the fact that she presents herself with an open and ulcerated foot is indicative of problems throughout her systems. Off all the problems that Mrs. Lee has her ulcerated foot is the one most likely to cause her to be hospitalized. As such, it is imperative that Mrs. Lee's foot be treated in accordance with strict protocol (Kruse, 2006). This protocol would include debridement which would mean the removal of necrotic tissue and foreign bodies down to the presence of viable tissue. Performing this action will decrease the risk of infection and the chance that more aggressive methods will have to be used in the future. Providing Mrs. Lee with some form of offloading is also important. Whether through the use of a wheelchair or crutches, relieving some of the pressure on the foot will enhance the possibility that the foot will heal properly. Finally, every effort must be made to avoid an infection developing in the area. The use of the antibiotic Ciproflexecin is appropriate but the foot must be carefully monitored. If the foot fails to respond a stronger antibiotic should be prescribed.
Assuming that Mrs. Lee's foot responds to treatment, a comprehensive program that advises her how to care for her foot in the future should be initiated (Ward, 1999). This program should provide her with information regarding proper footwear and nail care including possible visits to a podiatrist. She must be advised to carefully examine her feet for any sign of active lesions or any other deformities such as callus, skin cracks, or discoloration. Damage to the periphery nerves can occur rapidly in diabetic patients and early intervention can minimize the potential for a serious condition developing (Calle-Pascual, 2002).
Examining each of Mrs. Lee's problems in isolation makes the process seem simplistic but, in reality, the treatment program is far more complex and that is why a team approach is advisable. As a disease, diabetes is difficult to treat because in order to treat it properly it is necessary to change many of the basic behaviors of the patient. Many diabetic patients live a sedentary lifestyle, maintain poor dietary habits, and suffer from obesity. Changing these behaviors is extremely difficult but crucial to any major success in treatment. What generally occurs is that health care providers find themselves putting out one fire just in time to address a new one. Mrs. Lee's situation is typical of the problems faced by health care professionals. She exhibits a broad range of problems which makes it difficult to determine where to begin in providing her treatment.
Treating diabetes is also difficult because proper treatment requires active participation by the diabetic patient. Much of the information that health care professionals must rely upon is generated through the efforts of the patient. It is the patient that must perform the tests necessary to monitor glucose levels. It is the patient that must maintain his or her diet and it is the patient that must participate in an exercise program. The result, more often than not, is that treatment plans are based on information that is inaccurate. That is the beauty of the HbA1c test. It allows the health care professional to have a long-range, objective evaluation as to whether or not a treatment program is accomplishing its goals. Its results are not based on self-reporting by the patient.
Designing a treatment plan for Mrs. Lee demands that it be done based on the team approach. The evidence is overwhelming that intensive diabetic management involving careful follow-up with the patient and intense support is the most successful form of treatment for type I diabetic patients. This form of treatment is beyond the ability of sole practitioners or any one individual to maintain. Intensive diabetes management requires a core group of skilled professionals with diverse roles, skills, and functions. Membership on this management team should include physicians, nurses, dietitians, and behavioral scientists. In essence, the team should reflect the basic requirements of diabetes treatment: nutrition, medication, self-monitoring, and self-management. The team should be able to address the regular and recurring needs of most diabetic patients.
For the team approach to succeed the care must be patient centered and goal oriented. Each aspect of the treatment program should be afforded equal importance and specific goals should be established. Key elements of the program should be shared leadership between the members, shared respect between team members, and a collaborative, rather than a consultative, relationship between team members.
In the traditional diabetic treatment program the roles of each participant are defined by the physician. In the team approach there is a shift toward shared leadership which theoretically promotes mutual problem-solving and open communication between all team members. In practice, most teams will still find that a physician is identified as team leader but such physician will find his or her role greatly diminished. The physician is no longer the all-knowing, all-powerful demi-god, but rather, an enlightened coordinator of services relying upon the education and skills of other team members. The team approach increases the responsibilities of nurses. Although physicians will remain responsible for the overall medical management of patients and the primary providers of acute care, nurses will become responsible for the day-to-day management of the diabetes regimen.
For too long, nurses, dietitians, podiatrists, social workers and other health care professionals have been omitted from the decision making process in regard to the treatment of diabetic patients (Vinicor, 1995). Patients were forced to rely on the expertise of their primary care physician and the limited time that such individual had to spend on the patient's case. The result was that the full breadth of the patient's medical care may have been overlooked. A change to a team approach will allow nurses and other team members to enjoy more authority in the treatment of the diabetic patient. Responsibilities of team members may include providing diabetes education, assisting in the choice of insulin regimen and adjusting insulin dosages, and helping patients through the plethora of other problems that diabetes brings. In the process, the patient is provided with improved access to those on his treatment plan and his specific problems are afforded greater attention.
In the specific case of Mrs. Lee the advantages that a team approach can provide her should be obvious. She presented herself for her annual review with a number of serious problems. If a team approach had been initiated for Mrs. Lee prior to her annual review…[continue]
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