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Patient Participation in Medical Care - Essay Example

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This essay "Patient Participation in Medical Care" presents interpretations that are also limited by the study sample. Adolescents display poor diabetes control, in part, because of hormonal changes. Different findings may have emerged had we studied a sample that displays tighter diabetes control…
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Running Head: CHRONIC ILLNESS – DIABETES TYPE II CHRONIC ILLNESS – DIABETES TYPE II [Name Of Student] [Name Of Institution] CHRONIC ILLNESS – DIABETES TYPE II INTRODUCTION Diabetes is divided into two major categories: insulin-dependent diabetes mellitus (IDDM), or Type I diabetes; and non-insulin-dependent diabetes (NIDDM), or Type II diabetes. Both are characterized by abnormalities in glucose metabolism caused by deficiencies in insulin production or utilization, or both, which lead to chronically high blood glucose (BG) levels or hyperglycemia (Tsalikian, 2005; Zimmerman, 2005, 211). There are, however, significant differences in etiology, pathology, and nursing treatment. IDDM is caused by a combination of genetic and autoimmunological processes that destroy the pancreatic beta cells that produce insulin, a hormone essential for glucose utilization and storage. The resulting insulin deficiencies lead to the accumulation of glucose in the bloodstream, or hyperglycemia. Compensatory fat metabolism produces ketones, which can lead to ketoacidosis and coma. IDDM can occur at any age but typically is diagnosed during childhood and adolescence. It is the most common childhood metabolic disease. In this paper I will discuss in detail a chronic illness. I have chosen diabetes as my subject for detailed analysis. Through this paper, I will demonstrate my knowledge of the chronic condition, in terms of its prevalence in the community, the reasons for its prevalence, and present a brief overview of its pathophysiology and common signs/symptoms. Moreover , I will discuss the Critical Intervention Points for Care and Support under the National Service Improvement Framework for the selected chronic condition that is Diabetes (Type II). DISCUSSION People with chronic illness actively construct mental representations of their disease and use these representations to guide self-nursing treatment decisions. For example, individuals with diabetes believe certain symptoms indicate that their BG levels are low or high and act on these beliefs to raise or lower BG levels without validating BG through objective glucometer testing procedures. People who are relatively accurate in their BG symptom beliefs display better metabolic control than those who are inaccurate, and interventions that improve symptom perception accuracy tend to improve long-term BG control. Thus, BG symptom beliefs appear to play an important role in ongoing diabetes self-management. People with diabetes vary widely in their ability to detect symptoms and accurately estimate BG excursions. These data suggest that some people with diabetes develop symptom beliefs that can guide appropriate self-nursing treatment decisions, whereas others develop beliefs that may lead to nursing treatment errors.NIDDM has a strong hereditary component and is caused by a combination of beta cell dysfunction and insulin resistance. Approximately 80% of NIDDM patients are obese, which is a major contributor to insulin resistance. For this reason, weight reduction alone can often normalize BG metabolism. Onset of NIDDM usually occurs after age 40 and is often asymptomatic. Ketoacidosis is very rare. Until lately, TYPE II DIABETES has been taken care of in the severe care unit. Changes in health care backing and improved management of patients suffering from diabetes have lead to treating growing numbers of patients with TYPE II DIABETES on universal medical-surgical elements. As patients with TYPE II DIABETES necessitate intensive check and medical interference, medical-surgical nurses should have a wide-ranging accepting of the pathophysiologic means, clinical demonstrations, and handling protocols specified for these patients. The preliminary reply of the nurses was in treaty with the universal character of nursing text that is very affirmative on the subject of the nurse's role in managing chronic diseases. With the precedence accorded to teaching in nurse preparation (United Kingdom Central Council for Nursing, Midwifery and Health Visiting 2003) nurses are said to be exclusively located to review their patients' needs for acquaintance and their keenness to be trained. The all-purpose practice surroundings has been seen as contribution the practice nurse the chance to enlarge her skills in this district as well as giving the tolerant the assistance of stability of care. (Greenhalgh 2000, 62-78). The benefit of knowing patients over a lengthy stage of time is strained as one of the principles for a winning patient treating programme (Brown 1998, 95), a key constituent of first-rate care of patients with chronic diseases. The significance of the interpersonal affiliation has been a decisive standard of nursing hypothesis and is another time being reasserted with an importance on the gentle features of nursing and the indispensable 'being with patients' that leave further than the scientific task. (Doona et al. 2004, Gavin 2004, 36). In short, the stress on nurse training, the fresh growths in the practice nurse's responsibility, and the modern awareness in the character of the nurse-patient bond all add to ensuring that the job is likely to be compassionate and individual nurses to hold close to the addition of their position in supervising patients with chronic illnesses. The dispute posed by diabetes Diabetes is a set of widespread chronic disorders distressing at least 2% of the populace of Australia, being predominantly widespread in the aged and some racial minorities. Its fitness care costs are towering with a minimum of 4% of the National Health Service (NHS) resources being spent on citizens with diabetes (CSAG 2000 98). The dimension of the trouble and the stress on the NHS are understandable and were echoed in the precedence accorded to diabetes in executive goal setting. Type II diabetics’ calls for firm control of diet, mass and other standard of living behaviors if long-term problems are to be reduced. This is attained by customary evaluations of experimental measurements, way of life and medicine. Nevertheless, as nearly all of the Type II patients are old and few have any immense eagerness for varying life-long habits they can pretense an extensive confrontation for both the principal care group and professional nurses. Both IDDM and NIDDM are associated with long-term complications including heart disease, peripheral vascular disease, neuropathy, retinopathy, and renal disease. Diabetes is the leading cause of blindness, lower extremity amputations, and kidney transplants in the United States. Research strongly suggests that chronic hyperglycemia is a major factor contributing to long-term complications. A 10-year study funded by the National Institutes of Health, the Diabetes Control and Complications Trial (DCCT Research Group, 2003, 11), is now under way to assess the relationship between long-term glycemic control and diabetic complications. Long-term glycemic control in this and numerous other diabetes studies is monitored by measurements of glycosylated hemoglobin (HbA1 ) , a short-lived protein which is structurally altered by the attachment of glucose molecules. Thus, HbA provides a biological marker of hyperglycemia over a 2- to 3-month period. Because of the belief that chronic glycemic control is critical, efforts to manage diabetic hyperglycemia have become more aggressive. Nursing treatment goals for both IDDM and NIDDM are to normalize BG levels (70–180 mg/dl) and prevent long-term complications. The four major components of diabetes management are medication, diet, exercise, and self-monitoring of BG (SMBG). Because diabetes and its nursing treatment are so complex, education is also included in the American Diabetes Association's regimen recommendations. The major difference in nursing treatment regimens is that insulin injections are necessary for the IDDM individual to survive. Insulin regimens vary greatly, however, depending on targeted BG control and patient motivation. Some patients may take only one or two daily injections, whereas others follow more intensive insulin regimens involving several daily injections or insulin pumps for continuous insulin delivery. Frequent SMBG is essential with the intensive insulin regimens, requiring 3 to 5 daily self-tests. With NIDDM, initial nursing treatment often focuses on diet and exercise therapy to reduce weight. In addition, oral medications or insulin injections may be necessary to control BG. SMBG is also recommended, especially for NIDDM patients on BG-lowering medications. Self-Nursing treatment Because the characteristics of the diabetes regimen (e.g., complexity, chronicity, demand, and patient responsibility) typically predict poor adherence, regimen adherence is of special interest in diabetes research. However, there has been a growing realization that the study of adherence in diabetes presents several unique conceptual and methodological problems (Glasgow, Wilson, & McCaul, 2002; Johnson, 2005, 87-110). For example, it is not always possible to assess adherence because patients have not received explicit prescriptions but, rather, general instructions such as “try to exercise more.” This means that the adequacy of diabetes self-care behaviors, and not adherence to it, is often the construct of interest. Diabetes research shares with other illnesses the problem of obtaining valid measures of selfcare behavior and, by necessity, must often rely on self-report data. Patient Characteristics In both children and adults, the presence of psychological disturbance such as depression and anxiety has been associated with poor diabetes management, although some studies have not replicated this relationship (Nagasawa, Smith, Barnes, & Fincham, 2005, 362). Personality characteristics may also influence self-nursing treatment. A recent study found that patients with alienated, opportunistic, and explosive temperaments were in poorer glucose control (Lustman, Frank, & McGill, 2001). Individual coping skills, both in terms of diabetes-specific problem solving and ability to cope with life stress, can also influence self-care and nursing treatment outcome (Delamater, Kurtz, Bubb, White, & Santiago, 2004, 44; Hanson et al., 1999, 41). More interest has recently focused on the role of patients' health beliefs, including beliefs about symptoms, disease severity, vulnerability to negative consequences, nursing treatment benefits and costs, and perceived ability to successfully perform self-care tasks (i.e., perceived self-efficacy; Glasgow, 2001, 95; Grossman, Brink, & Hauser, 2004, 132-8; Kurtz, 2005, 77). Although health beliefs have repeatedly related to self-care in patients with both IDDM and NIDDM, the types of beliefs predicting adherence differ across studies (Brownlee-Duffeck et al., 2004; Cerkoney & Hart, 2005, 56; Hampson, Glasgow, & Toobert, 2005, 22; Wilson et al., 2003). Harris, Skyler, Linn, Pollack, and Tewksbury (2001, 62) have suggested that different health beliefs influence adherence to specific regimen tasks. Social and Familial Factors It is not surprising that family relationships and interactions can either enhance or interfere with diabetes management. In children, family conflict and dysfunction is predictive of adherence difficulty, whereas increased levels of family support, cohesion, and organization are associated with better adherence and metabolic control (Anderson, 2005; Hanson, Henggeler, & Burghen, 2004; Hauser et al., 2005, 301-8). The Family Behavior Checklist, which measures both supportive and nonsupportive familial behaviors, has been found to predict adherence in adolescents and adults (Glasgow & Toobert, 1998; Hansen et al., 2004; Schafer, Glasgow, McCaul, & Dreher, 2000; Schafer, McCaul, & Glasgow, 2003, 145-7). Glasgow and Toobert (1998) have also demonstrated that this diabetes-specific measure is a better predictor than global measures of support. Support from non-family members of the social network has not yet been investigated. Another important but empirically neglected social influence is the patient–physician relationship. We do know that patients with both IDDM and NIDDM who discontinue follow-up or infrequently attend clinics tend to be in poorer health and worse glycemic control than patients with regular follow-up (Hammersley, Holland, Walford, & Thorn, 2002, 109-23; Jacobson, Adler, Derby, Anderson, & Wolfsdorf, 2001, 32). Although there may be many reasons for failure to attend clinics, Jacobson et al. (2001) found that infrequent attendance was not associated with health insurance coverage or traveling distance. Rather, patients who attended infrequently had no interest in discussing their nursing treatment with or receiving advice from their physician. Environmental Factors and Behavioral Contingencies Some of the most interesting work in this area has examined environmental “barriers to adherence” from the patient's perspective, such as cost, time, resource availability, and competing demands, all of which predict self-care in both IDDM and NIDDM patients (Glasgow et al., 1999; Irvine, Saunders, Blank, & Carter, 2005, 55). Natural contingencies associated with diabetes and its nursing treatment are another important factor. For example, adherence can have negative consequences, such as the increased risk of hypoglycemia or weight gain associated with more intensive insulin regimens. Self-monitoring of BG levels can also act as a form of punishment because patients often obtain measurements indicating their BG is too low or high (Jones, 2005). Consequently, patients are more likely to self-test on days when they have followed the prescribed regimen. Moreover, better adherence does not necessarily lead to better diabetes control. From a behavioral perspective, improvements in self-care followed by failure to improve control should reduce future efforts. As of yet, research has not addressed these potentially significant effects on patient behavior. A critical issue facing researchers is the identification of patients at high risk for self-care problems and development of effective interventions to achieve optimal diabetes management. A major obstacle to such intervention is the difficulty of developing programs that are pragmatic, feasible, and cost-effective for wide-scale application (Glasgow, Toobert, & Hampson, 2001, 34). However, the possibility of pragmatic intervention is suggested by creative solutions such as integrating problem-solving training into routine clinic visits (Anderson et al., 1999, 58) and cost-effective methods such as supportive telephone followup (Estey et al., 2005, 11-8). Another future challenge is developing methods to maintain self-care improvements over time. Rubin et al. (2005), for example, found that improvements in insulin adjustment and SMBG were maintained after intervention, but changes in diet and exercise were not. Psychosocial Impact The impact of and adjustment to diabetes begins with diagnosis. Most research investigating the effects of diagnosis has concentrated on children and adolescents, with recent studies following patients and their families across the first year after diagnosis (Jacobson et al., 2004; Kovacs, Iyengar, Goldston, Stewart, Obrosky, & Marsh, 2005, 67). Many patients experience psychosocial disturbance following diagnosis, including depression, anxiety, and social withdrawal. However, significant levels of distress are seen in only approximately one third of patients and, by the end of the first year, almost all children recover (Jacobson et al., 2003; Kovacs, Brent, Steinberg, Paulauskas, & Reid, 2003, 66-78). Parents' psychological response to the diagnosis is an important predictor of the child's adjustment. In NIDDM adults, psychological distress is also observed following diagnosis (Cassileth et al., 2000), but patients typically return to premorbid levels of functioning after adjustment (Jones, 2005, 26-8). As diabetes progresses, psychosocial problems often occur secondary to the onset of complications. For example, patients who experience loss of vision exhibit symptoms of emotional distress, primarily depression and decreased self-esteem (Wulsin, Jacobson, & Rand, 2004, 19-41). However, patients with stabilized vision loss show less disturbance in mental health than patients with fluctuating vision (Bernbaum, Albert, & Duckro, 1998, 62). In this study, rehabilitative training for patients with fluctuating vision loss improved psychological status, suggesting the need for early intervention. Diabetes can also have a negative impact on marital and sexual satisfaction (Schreiner-Engel, Schiavi, Vietorisz, & Smith, 2004,44). In many cases, this is secondary to problems in sexual functioning, which are prevalent among diabetic men (see Cox, Gonder-Frederick, & Saunders, 2001, 200). Although diabetic impotence is more likely to be organic in etiology than in other groups, the problem may be exacerbated by psychological and behavioral factors. Several studies have found a higher incidence of depression and anxiety disorders in both IDDM and NIDDM patients, independent of such factors as diabetic complications and loss of function (Geringer, Perlmuter, Stern, & Nathan, 1998; Lustman, Griffith, Clouse, & Cryer, 2003; Popkin, Callies, Lentz, Colon, & Sutherland, 1998, 165). Lustman et al. (2003), for example, reported a twofold increase in psychiatric disorders in diabetic patients, a higher rate than either the general population or other groups with chronic illnesses show. In addition, patients with a history of depression have shown a fivefold increase of recurrence risk, leading to the conclusion that the course of depression is more severe in diabetic populations (Lustman, Griffith, & Clouse, 1998). Another study recently found an increased prevalence of depression and anxiety disorders in 113 young adults with IDDM (Mayou et al., 2001, 21). Some researchers believe there is a unique relationship between depression and diabetes and speculate that a similar biological abnormality may contribute to both, such as elevated cortisol, decreased norepinephrine and serotonin, or cerebrovascular disease (Geringer, 2005; Popkin et al., 1998, 32). However, this conclusion remains tentative. A survey of more than 3,000 individuals in the Los Angeles area found that diabetic subjects had a higher rate of affective and anxiety disorders than those with no chronic illnesses, but not a higher rate than subjects with other chronic illnesses such as arthritis and heart disease (Wells, Golding, & Burnam, 1999, 47). Behavioral Weight Loss Interventions Obesity is uniquely relevant to NIDDM. A 10-pound weight loss has been associated with improved metabolic control, whereas correlations of retrospective data suggest a 3- to 4-month increase in life expectancy for every 2.2 pounds lost (Lean, Powrie, Anderson, & Garthwaite, 2005, 58-61, 72). Experimental studies have investigated a variety of different nursing treatment parameters. Heitzmann et al. (2004) reported that behavior modification was superior to control, cognitive, or cognitive plus behavior modification therapy in terms of weight loss and that men responded better to behavior modification. Regardless of nursing treatment group, men showed greater improvement in HbA1 at the 18-month follow-up. Wing, Epstein, Paternostro-Bayles et al. (1998) reported two studies comparing behavioral weight loss programs with and without exercise: one compared stretching versus walking 3 miles three times a week, and the other compared no exercise with walking 3 miles four times a week. Only the latter comparison showed a specific nursing treatment effect for both weight loss and HbA1 . In the context of a behavioral weight loss program, Wing (1999) evaluated the relative role of teaching patients how to make self-care decisions (e.g. reduce calories, increase exercise, and adjust medications) on the basis of SMBG results, compared with simply providing BG measurements. They found no beneficial effects in teaching self-care decision making. Cognitive-Motor Deficits The brain can neither effectively store glucose nor utilize metabolic fuels other than glucose. Reduced BG to the brain can result in transient dysfunctions, whereas prolonged and severe hypoglycemia may lead to permanent brain damage. In addition to hypoglycemia, prolonged and extreme hyperglycemia may lead to permanent dysfunctions. Although there has been a literal explosion of diabetic neurobehavioral research, we address the more recent and striking findings. CONCLUSION Interpretations are also limited by the study sample. Adolescents often display poor diabetes control, in part, because of hormonal changes. Different findings may have emerged had we studied a sample that displays tighter diabetes control and thus experiences more hypoglycemia. One of the purposes of the study was to determine how one psychological variable—negative affectivity (NA)—influences these self-regulatory aspects of diabetes management. It should be noted, however, that the BG threshold at which symptoms occur varies greatly across patients, moderate levels of hypoglycemia are often symptomatic, and the magnitude of change in physiological functioning as opposed to only the absolute level of physiological functioning contributes to subjective symptomatology. Yet, we do acknowledge that associations among trait anxiety, actual low BG symptoms, and the accuracy of low BG symptom beliefs could have been affected by the low frequency of extreme hypoglycemia. Replication of these findings with different patient samples may thus clarify their interpretation. Despite these limitations, this study supported a symptom-perception explanation of the association between NA and BG symptom reports and suggested that NA-related constructs play a role in diabetes management. Specifically, the combination of high trait anxiety with high internal focus may not bode well for tight diabetes control. 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