Medicine

Assignment Prompt

The purpose of this assignment is to identify a clinical practice guideline in your specialty area. You will be challenged to evaluate this guideline and discuss its use in clinical practice. This assignment is due at the end of Week 8 but can be completed anytime during this course. This assignment requires a considerable amount of time for completion. Do not wait until week 8 to begin this assignment.

Choose a health problem that you may commonly see in primary care nurse practitioner practice. Describe the health problem and recommended medical management for it. Research published clinical practice guidelines and evaluate the practice guideline you have selected based on the components listed in the Clinical Practice Guideline Template below.

Clinical Practice Guideline Prompts:

HEALTHCARE PROBLEM IDENTIFIED: Briefly describe the health problem you have identified. Include a discussion of morbidity, mortality, epidemiology and pathophysiology related to this health problem

PRACTICE GUIDELINE: Describe the clinical practice guideline used for this problem. Reflect on the questions included. Expand on your answer using support from evidence

Does the clinical practice guideline adequately address the health problem? Describe.
Is this practice guideline based on current evidence (within 5 years)? What is the strength of this evidence?
Does this clinical practice guideline adequately direct the healthcare provider in the management of a patient with this problem?
How effective is this clinical guideline in the management of patients with this healthcare problem? Think about how you would assess the effectiveness of patient management.
ANALYSIS: Think about future healthcare needs of patients with this problem, changing demographics, and changes in healthcare policies. Address these questions.

Does this clinical practice guideline need revision(s)? Please explain your answer in detail.
If you were going to revise this clinical practice guideline, what would you change? What evidence would you use to base your changes on?
How might changes in US demographics and healthcare reform affect this clinical practice guideline?
What strategies would you use to increase the likelihood that a new or modified clinical practice guideline would be adopted and used in clinical practice?
EVALUATION How would you determine its effectiveness of this revised clinical practice guideline in directing care for patients with the identified health problem? Outline the steps you might employ.

LEARNING POINTS (3-5 bullet points outlining key learning in this case.)

REFERENCES (APA formatting, current within past 5 years.)

ANSWER

Diabetes

Diabetes is a health condition that affects how food is turned into energy in the body. The condition is long-lasting and one of the most common conditions in the primary care setting. Most of the food eaten is usually broken down to sugar, also known as glucose, which is later released into the bloodstream (CDC). If one has diabetes, it is either because the body does not make enough insulin or it cannot use all its insulin. When cells stop responding to insulin or there is not enough insulin, the blood sugar stays in the bloodstream. It can cause other severe health problems such as heart disease, vision loss, and kidney disease in the long-term. There is no cure for diabetes, but it can be controlled by losing weight, eating healthy food, and remaining active.

There are three types of diabetes, type 1, type 2, and gestational. Type 1 diabetes is caused by an autoimmune reaction which means the body attacks itself by mistake and it stops making insulin. Out of the people with diabetes, 5-10% of them have type 1 diabetes. Type 1 diabetes symptoms develop quickly and are usually diagnosed in children, teens, and young adults. People with type one diabetes have to take insulin every day to survive. Unfortunately, there is no known method of preventing type 1 diabetes. Type 2 diabetes s whereby the body does not use the insulin produced and cannot keep the blood sugar levels normal. Most people with diabetes have this type, accounting for 90-95% (CDC). This type of diabetes is mostly diagnosed in adults, and lately, it is seen more and more in children, teens, and young adults. Type 2 diabetes has no symptoms, and thus it is important got get one’s blood sugar tested if they are at risk. However, this type of diabetes can be delayed or prevented by changing one’s lifestyle and adapting to a healthier one.  Gestational diabetes is diabetes that develops in pregnant women without a history of diabetes. Having gestational diabetes puts the baby at risk of having other problems. This goes after the baby is born but puts the mother at the risk of developing type 2 diabetes.

Epidemiology and Pathophysiology

The most common type of diabetes in the primary care nursing unit is type 2 diabetes. Type 2 diabetes is a disorder resulting from the interaction between genetic predisposition and environmental factors. The prevalence of diabetes is rapidly increasing, and according to the world health organization, by 2030, the number of adults with diabetes will have doubled in the world (CDC). Environmental factors, together with genetic factors, are the contributors to the high number of people developing diabetes, environmental factors such as the fast pace at which life moves have led to the prevalence of the disease as people no longer take the time to care for their bodies. The population that is most affected by diabetes in the US is Native Americans, especially those in the disease southwest, Hispano-Americans, and Asian-Americans. Type 2 diabetes is characterized by insulin resistance.

Mortality and morbidity

Mortality and morbidity in diabetes have increased over the years. In 2014, 8.5% of adults who were 18 and older had diabetes. In 2019 diabetes was a direct cause of the deaths of 1.5 million people, and out of the deaths that occurred, 48% were under the age of 70 years. In addition, the rate of premature mortality as a result of diabetes increased between 2000 and 2016 (CDC). In high-income countries such as the US, premature mortality due to diabetes decreased from 2000-2010 but increased in 2010-2016. In the low and middle-income countries, these rates increased in both periods.

Practice Guideline

According to the ADA, there are three ways in which diabetes can be diagnosed. Each of the methods should be on a subsequent day unless there are symptoms of Hyperglycemia. Although the 75-g oral glucose tolerance test is the most effective method, fasting plasma glucose is used to diagnose diabetes due to its acceptability to many patients, lower cost, and ease of use. When it comes to diabetes, a complete medical evaluation is supposed to be performed on the patient to nurse that the presence or absence of diabetes is ascertained so that the healthcare provider can formulate a management plan and provide the basis for continuing care. If the patient already has a diagnosis of diabetes, the evaluation should review previous treatment and the degrees of glycemic control. In addition, laboratory tests should be done for each patient’s general condition. This is because patients react differently to different types of medication, and therefore, it is important to ensure that all the patients are tested for comprehensive care.

Management

People with diabetes are required to receive care from a physician-coordinated team. The teams providing care should include physicians, nurses, dieticians, pharmacists, and mental health professionals. The team is required to have these personnel to ensure the patient is receiving the best care possible. It is also essential for the patient to also be involved in the active role of their care. The management plan should be made so that it is individualized among the patient and family, and other team members. All the management plans should put into consideration self-management education (ADA, 2021). The plan should also consider factors like work schedule, school schedule, and age of the patient. Other factors should include physical activities, social situation and their personality, eating patterns, and the presence of complications from diabetes or other conditions. In management, patient-self management is supposed to be emphasized. The goals of the treatment plan should also be reasonable.

Glycemic Control

There are available techniques for health providers and patients to assess whether the management plan on glycemic control is effective. Most of the assessments on glycemic control include the use of self-monitoring blood glucose. SMBG gives patients a chance to evaluate their response to therapy and assess where the targets are achieved. SMBG is useful as it helps in preventing hypoglycemia and adjusting medication and physical activity. The timing and frequency of SMBG should be determined by the needs and goals of the patients; daily SMBG is important for patients who are treated with insulin (ADA, 2021). ThisThis is because it helps monitor and prevents asymptomatic hypoglycemia. Patients with type one diabetes and pregnant women taking insulin are recommended three or more times daily for SMBG. The frequency of SMBG for patients with type 2 diabetes is not known. When a patient is due for modification of therapy, type one and two diabetes patients should test more often.  The A1C test should be performed at least two times a year for patients who are meeting treatment goals. These patients should also have stable glycemic control. For patients who are not meeting the goals or whose therapy has changed, the A1C test should be performed quarterly.

The ADA guidelines adequately cover and address diabetes and the management of the disease. Diabetes is a chronic disease that requires management through the help of a medical team. The guidelines cover all the current changes that have happened in medicine, such as telemedicine. This is where patients can access care easily with the help of technology. The guidelines have included all people, including those in rural areas, and the effectiveness of glycemic control. The guidelines also address issues such as the underuse of insulin as a result of lack of finances to facilitate the management of the condition and suggest options such as cost-sharing for the insured people with diabetes and health plan that ensure that people with diabetes access insulin without undue administrative burden. The guidelines also utilize the use of recent credible research done within the last five years. The credibility of the research is guaranteed as the articles used by the guidelines are peer-reviewed and based on evidence-based practice.

The guideline adequately guides the health practitioner on how to deal with patients with the problem by providing recommendations on how to deal with patients in different hypothetical situations. For example, a doctor can tailor treatment for social context by referring the patient to local community resources when available (Cefalu et al., 2018). Some patients come from low-income areas, and thus it is important to point them in the direction of resources such as healthy meals, low-cost physical activity facilities, and pharmacies that offer insulin at lower prices for patients who use insulin. The providers are also guided to consider factors such as patients facing housing insecurity, homelessness, and food insecurity. For example, those facing food insecurities can be advised on areas where they can obtain nutritious food to avoid uncontrolled hyperglycemia and severe hypoglycemia. Those facing homelessness also need secure places to store their insulin supplies, and the healthcare provider can direct them to social workers who can help them find secure housing.

Managing diabetes can be challenging, especially for patients facing income problems, uninsured patients, those facing insecurity and homelessness. The success of management for a doctor helping a diabetic patient is measured using the A1C test. I would assess the success of patients I am helping manage their diabetes using the A1C test for those who are already diabetic. For patients who are obese and at risk of getting diabetic, I will test the management through the changes in eating habits and the changes they have made in physical activities. Different patients have different levels of success, and therefore I will assess the effectiveness of the management depending on the condition of the patient. For patients with gestational diabetes, I will ensure that the mother involves herself with physical activities and healthy eating to avoid getting type 2 diabetes. The effectiveness of management, in this case, will be judged if the patient does not get diabetes.

Diabetes highly impacts people from low-income areas due to different factors. The population of people acquire diabetes due to the lack of nutritious meals and leading sedentary lifestyles. The high number of people with diabetes is a result of people not being involved in the health of their bodies, and therefore, as a doctor, the first thing I would do is ensure that patients have information on how they should lead healthy lifestyles. The healthcare policies can also be adjusted to help the uninsured people to access insulin and develop strategies to ensure that all patients with diabetes can access the required care they need (ADA, 2016). Policies on smoking and the availability of nutritious food for the population to reduce the chances of people getting diabetes. There should also be policies that ensure that all patients receive patient-centered care to ensure that they receive proper care.

The guideline is almost perfect, but I would make some changes to the section where it addresses the issue of patients lacking insulin. Many patients are faced with the hard choice of either getting insulin or using the money to get medication. This is not a choice that one should have to make, but it is one that most people with diabetes find themselves having to make. The prices of insulin need to be reduced, or rather the government needs to make more efforts in ensuring that the people are getting enough insulin (ADA, 2019). Another thing I would change in the guideline is that I would increase information for healthcare practitioners on how they can help their patients acquire insulin. There is more than health practitioners can do to help their patients through advocacy and fighting for the rights of their patients to access affordable health. The guidelines on how health practitioners can help their diabetic patients would also be included in the guidelines.

The population in the US is steadily growing old, and the economic times are tough. People are barely paying attention to their age, and they need to lead a healthy lifestyle. Diabetes can be controlled by leading a healthier lifestyle. If lesser people are getting diabetes, then the prices of insulin are likely going to reduce. To ensure that the guidelines are adopted, I will present them to different hospitals and showcase the benefits of the guidelines to different boards and ensure that they are adopted. I also would use the guidelines in evidence-based practice, and if the new guidelines work better than the previous ones, I will present them for them to be used.

The effectiveness of the new clinical guidelines will only be determined if the guidelines are in practice. The guidelines, in this case, including ensuring that patients receive insulin and that healthcare providers are aware of what they should do in the case of a patient that does not have the financial ability to acquire insulin. It also involves the use of the evidence-based practice to ensure that the patients receive the best possible care. The effectiveness of the new guidelines will be determined by the number of patients benefiting from insulin. The number of patients should also reduce if the doctors follow the guidelines on advocating for healthier lifestyles which will prevent the number of people suffering from diabetes.

Learning Points

• Clinical guidelines are important when it comes to providing care for patients.
• Patients with diabetes require insulin which makes them avoid hospitals, thus worsening the condition.
• Diabetes can be prevented by eating healthy and staying healthy. Physical activities and eating nutritious food can reduce the number of people with diabetes and help reduce insulin prices.

Reference

American Diabetes Association. (2016). 1. Strategies for improving care. Diabetes care, 39(Supplement 1), S6-S12.

American Diabetes Association. (2019). Summary of revisions: Standards of medical care in diabetes—2019. Diabetes Care, 42(Supplement 1), S4-S6.

American Diabetes Association. (2021). 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S211-S220.

Cefalu, W. T., Dawes, D. E., Gavlak, G., Goldman, D., Herman, W. H., Van Nuys, K., … & Yatvin, A. L. (2018). Insulin access and affordability working group: conclusions and recommendations. Diabetes Care, 41(6), 1299-1311.

Center for disease control and prevention. What is diabetes? https://www.cdc.gov/diabetes/basics/diabetes.html