Template for Action plan for Case Study – MM

What is the goal/aspect of diabetes care/management patient would like you to help them with?

MM does not want to go onto to Insulin therapy as she’s heard bad stories of insulin and losing limbs. She is willing to try anything else to see if it controls her diabetes. She feels a lot of her negative aspects in her life have been addressed she is working through them and she wants to lose weight and try to get her diabetes under control

What action (s) will the patient take and when?

The patient will currently try and relook at her eating habits in relation to her diet. She is considering batch cooking, portion meals and freezing them. She saw a leaflet in the waiting room about healthy helpings and asked if I knew anything about it. Advise her it was a group session meeting over 8 weeks looking at healthy eating, lifestyle and ways to put it into practice. It was also occurred no cost so she indicated she would look into this and let me know the next time we met. She will look at ways to increase exercise. We discussed this in more detail activities like swimming would take pressure off feet – she never learnt to swim. I gave her a leaflet for her to make contact with technogym in the area. A form of exercise with different equipment whilst body is mostly sitting on a machine similar to exercise club called Curves.

She also indicated she was happy to consider more medication to control her diabetes and so to reduce her HbA1c and hopefully her weight.

When will the action take place?

The pt was away to go on holiday so not appropriate to implement any new medication change until she returns. She advised me she would keep an eye on what she ate while away and try to keep as active as possible till she returned to see me.

On a confidence rating of 0-10 how confident is the patient of achieving their goal?

(0=not confident 10 =very confident)

7 – she does want to change and move on with her life. She wants to be able to play more with her grandchildren.

W


ho/what will help them achieve this goal?

If MM can see and feel the changes she is about to undertake this will her motivated to keep going. Her Grandchildren are at the active phase and want her to join in with them – she also wants to join them and have fun. Support from her family as they want her to be more an active role member for the grandchildren.

Who /what may stop them achieving this goal?

Patient falls back to her old ways. If the family due to their busy lives overlook her and she feels she hasn’t got the support, if she doesn’t have weight loss this will deflate her confidence in achieving the goals. If she is not able to exercise because the planter fasciitis reoccurs this will disengage her motivation and could affect her diabetic control.

As their healthcare professional what is your role?

To provide ongoing support so to help the patient loose weight and try and bring her HbA1c back in line. Continue to be up to date with the information I give her in relation to external support to the diabetic clinic for example healthy helpings. Be able to discuss this with the patient so she is able to make an informed choice. Work along with the patient in the treatment options available to her. Be able to explain how the medication works to try and improve glycaemic control address the medication side effects and any other requirements she may have to perform with appropriate medication choices. I will work along with the patient so to enhance good rapport in order to alleviate any fears together try and achieve the required goals.

Review Date 3 weeks

Rationale for intervention(s)

Nice (2009) guidelines when to consider medication options for diabetic control.

Diet measures/ exercise education reinforced each time, essential part in the diabetic management.

Triple therapy GLP1agonist receptor improves gylcaemic control. Works well with metformin and SU. MM’s BMI was greater than 35Kg. Its action to stimulate insulin secretion and delay gastric emptying therefore appetite reduction and weight loss.

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Brief outline the intervention(s) considered with the patient and the evidence base supporting this intervention(s) provide references when appropriate

Waddington (2011) like others comments on the weight battle in relation to diabetes suggesting to improve patients confidence in weight loss patients have to play a active role in the decision making process. Importance of getting this right is huge the current cost of obesity alone to the NHS estimated at 1 billion/ year Diley (2008)

The ever growing problem which was made a priority by the DOH in 2004 is now a serious concern of the UK. That was 10 years ago how true was there prediction. It’s reckoned to surpass smoking as biggest cause of premature loss of life Diley (2008).

Our aim to try and achieve weight loss Haslam (2005) goes onto to highlight this as a mainstream treatment. If there is a 10% reduction it improves diabetes control all round.

Waddington (2013) compares the commercial weight industry organisations, similarly examining energy input versus output combined with exercise the aim – weight loss. Not a quick fix nor easy and can be very misleading. MM hereby commencing a free healthy dietary course similar to this via the NHS non biased.

MM’s exercise limited but aware of the government’s recommendation of 30 minutes of exercise a day. Robertson (2009) and Mayor (2012) comment 70% of the population don’t do enough exercise yet a cornerstone of diabetes management. It in- expensive method use a pedometer to achieved 10,000 steps a day provides a visual encouragement tool Waddington (2009).

Nice (2009) looked at randomised controlled studies and found that GLP-1 had a greater effect in reducing glycaemic control and weight loss over DPP4 or insulin.

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Reflection of the consultation

What? Description of the event

Recent review with MM increased HbA1c readings – a number of reasons. MM wants help to control her diabetes better and loose weight. Diet and Exercise discussed which treatment options. Liaglutide chosen as once daily injection. Prescription given to patient and return. Self home monitoring of blood sugars Reinforced due to increased risk of hypo with this additional treatment.

So What? Analysis of the event

Outside agencies discussed to assist with diet and exercise measures. Open discussion of treatment options MM decided to go with GLP-1 receptor agonist, Liraglutide was decided as good HbA1c reduction and weight loss and more suited for MM. Reiterated to patient the recommendation on the use of GLP1 for diabetic treatment. A requirement of HbA1c reduction by 1%, weight reduction by 3% in 6 months if not met then to remove treatment choice is advised by Nice (2009)

Now What?

Proposed action following the event

Teach MM administration of liraglutide injection, site rotation, disposal of products, and storage of medication. Guidance liraglutides initial dose 0.6mgs to max 1.2 mgs. Greater risk of hypo’s due to additional therapy additional Blood sugar readings required monitor to be check set properly working.

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References


HARVARD

DILEY A. (2008). HELPING PATIENTS TO LOSE WEIGHT: BEST PRACTICE FOR PRIMARY CARE. primary care nursing. 5 (1), 31-34

HASLAM D. (2005). THE IMPORTANCE OF MANAGING INSULIN RESISTANCE AND WEIGHT. Independent Nurse. 16-17

NICE GUIDELINES (2009)The Management of Type 2 Diabetes



www.nice.org

MAYOR S. (2012).PHYSICAL ACTIVITY : GETTING PEOPLE MOVING TO PREVENT CVD. primary care nursing. 9 (2), 59 – 61

ROBERTSON C. (2009). WALKING YOUR WAY TO GOOD HEALTH. primary care nursing. 6 (1), 33-35

WADDINGHAM F. (2013). WEIGHT LOSS: WHICH METHODS REALLY WORK FOR PATIENTS?. primary care nursing. 10 (2), 59-62

WADDINGHAM S. (2009). HELPING PATIENTS WITH DIABETES TO WIN THE BATTLE TO CONTROL THEIR WEIGHT. primary care nursing. 6 (3), 115-117

WADDINGHAM S. (2011). NINE PROCESSES OF CARE FOR DIABETES. primary care nursing. 8 (4), 170- 173

Detailed case study 2

Consultation Review 1

MM

Review Date

30/09/2013 Patient seen 08/09/2013 (3 weeks ago)

What was the intervention

Commencement of Liraglutide injections 0.6mgs for the next week and increased home blood sugar readings

Patients assessment of intervention

MM felt it was daunting at 1

^st

at the thought of giving herself an injection. She was pleased that she managed to self administer her injections and thought it was that bad after all. We discussed aspects that we previously discussed before starting the treatment. She found she forgot to rotate injection sites, but remembered by the end of the week. She undertook regular blood sugar readings and they were starting to show 5 mmol/lit before bed and on waken 10mmol/lit. No side effects noted and patient dose of liraglutide was increased to 1.2mgs.

Reflection of the consultation

What? Description of the event

A review on how the patient felt with her new choice of treatment and to assess if there were any problems experienced either the injection site, or increase in hypoglycaemia

So What? Analysis of event

On assessment MM was coping well with injecting liraglutide, no side effects were experienced. Increase dose of liraglutide to 1.2 mgs and reassess how effective treatment was in relation to the measurements of home blood monitoring. Reminded her to be aware of possible increase in hypoglycaemia to continue performing measurements as she had done previously.

What now?Propsed action following the event

Next review appointment was made for 1month asked her to bring in her blood sugar readings to assess effectiveness of treatment and no signs of hypoglycaemia. Also advised if there were any problems for her to telephone and ensured she had a note of the number.

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Consultation Review 2

Detailed Case Study 2

MM

Review Date

30/10/2013 Patient seen 30/09/2013 (4 weeks ago)

What was the intervention

Increased dose of liraglutide to 1.2mgs daily

Patient’s assessment of intervention

MM was feeling good within her. She had noticed a reduction in her blood sugar reading they were down and ranged between 5-7 mmol/lit for fasting levels and range 6-8 mmol/lit for day time. She had done well with site rotation. Experienced no hypo’s and generally felt well. Has reduced appetite and aware there has been some with loss. Along with the medication change she has completed healthy helpings programme and now actively addressed exercise regime and working towards achieving her 10,000 steps not managing that every day as yet.

Reflection of the consultation

What? Description of the event

A review of MM’s progress of new medication choice. She is now taking maximum dose of Liraglutadie of 1.2 mgs daily. No adverse effects had been experienced by patient in relation to side effects or hypo’s. She showed good evidence of regular monitoring. She herself was more upbeat, more positive in terms of her diet, new exercise regime and new 3

^rd

line therapy that was commenced.

So What? Analysis of event

Encouraged to see patient doing so well not experiencing hypo’s this is a particular area to be vigilant as she was already on a SU. If hypo’s were experienced then SU would be reduced and regular monitoring continued till blood sugar readings were stable and no hypo’s were experienced. A reduction in home blood sugar readings and wt loss of 2 kgs were noted. MM praised for efforts so far.

What now? Proposed action following the event

To continue with current treatment regime, to be vigilant of possible hypo’s to cont with regular monitoring or at any time she didn’t feel right. Telephone me if any concerns. Continue with her good diet and exercise regime. To return to practice for repeat HbA1c and weigh in 2 months to see how treatment choice was going.

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