Professional Documents
Culture Documents
DM Case
DM Case
The specialized role of nursing in the Operating beyond the role of edu-
care and education of people with cator, advanced practice nurses holis-
diabetes has been in existence for tically assess patients’ needs with the
Geralyn Spollett, MSN, C-ANP, CDE more than 30 years. Diabetes educa- understanding of patients’ primary
tion carried out by nurses has moved role in the improvement and mainte-
beyond the hospital bedside into a nance of their own health and well-
variety of health care settings. ness. In conducting assessments,
Among the disciplines involved in advanced practice nurses carefully
diabetes education, nursing has explore patients’ medical history and
played a pivotal role in the diabetes perform focused physical exams. At
team management concept. This was the completion of assessments,
well illustrated in the Diabetes advanced practice nurses, in conjunc-
Control and Complications Trial tion with patients, identify manage-
(DCCT) by the effectiveness of nurse ment goals and determine appropriate
managers in coordinating and deliv- plans of care. A review of patients’
ering diabetes self-management edu- self-care management skills and appli-
cation. These nurse managers not cation/adaptation to lifestyle is incor-
only performed administrative tasks porated in initial histories, physical
crucial to the outcomes of the exams, and plans of care.
DCCT, but also participated directly Many advanced practice nurses
in patient care.1 (NPs, CNSs, nurse midwives, and
The emergence and subsequent nurse anesthetists) may prescribe and
growth of advanced practice in nurs- adjust medication through prescriptive
ing during the past 20 years has authority granted to them by their state
expanded the direct care component, nursing regulatory body. Currently, all
incorporating aspects of both nursing 50 states have some form of prescrip-
and medical care while maintaining tive authority for advanced practice
the teaching and counseling roles. nurses.3 The ability to prescribe and
Both the clinical nurse specialist (CNS) adjust medication is a valuable asset in
and nurse practitioner (NP) models, caring for individuals with diabetes. It
when applied to chronic disease man- is a crucial component in the care of
agement, create enhanced patient- people with type 1 diabetes, and it
provider relationships in which self- becomes increasingly important in the
care education and counseling is pro- care of patients with type 2 diabetes
vided within the context of disease who have a constellation of comorbidi-
state management. Clement 2 com- ties, all of which must be managed for
mented in a review of diabetes self- successful disease outcomes.
management education issues that Many studies have documented the
unless ongoing management is part of effectiveness of advanced practice
an education program, knowledge nurses in managing common primary
may increase but most clinical out- care issues.4 NP care has been associ-
comes only minimally improve. ated with a high level of satisfaction
Advanced practice nurses by the very among health services consumers. In
nature of their scope of practice effec- diabetes, the role of advanced practice
tively combine both education and nurses has significantly contributed to
management into their delivery of improved outcomes in the manage-
care. ment of type 2 diabetes,5 in specialized
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Diabetes Spectrum Volume 16, Number 1, 2003
diabetes foot care programs,6 in the A.B. states that he has “never no surgeries or hospitalizations, his
management of diabetes in preg- been sick a day in my life.” He immunizations are up to date, and, in
nancy,7 and in the care of pediatric recently sold his business and has general, he has been remarkably
type 1 diabetic patients and their par- become very active in a variety of healthy for many years.
ents.8,9 Furthermore, NPs have also volunteer organizations. He lives
been effective providers of diabetes with his wife of 48 years and has Physical Exam
care among disadvantaged urban two married children. Although both A physical examination reveals the
African-American patients.10 Primary his mother and father had type 2 following:
management of these patients by NPs diabetes, A.B. has limited knowledge • Weight: 178 lb; height: 5'2"; body
led to improved metabolic control regarding diabetes self-care manage- mass index (BMI): 32.6 kg/m2
regardless of whether weight loss was ment and states that he does not • Fasting capillary glucose: 166 mg/dl
achieved. understand why he has diabetes • Blood pressure: lying, right arm
The following case study illustrates since he never eats sugar. In the past, 154/96 mmHg; sitting, right arm
the clinical role of advanced practice his wife has encouraged him to treat 140/90 mmHg
nurses in the management of a patient his diabetes with herbal remedies • Pulse: 88 bpm; respirations 20 per
with type 2 diabetes. and weight-loss supplements, and minute
she frequently scans the Internet for • Eyes: corrective lenses, pupils equal
Case Presentation the latest diabetes remedies. and reactive to light and accommo-
A.B. is a retired 69-year-old man with During the past year, A.B. has dation, Fundi-clear, no arteriolove-
a 5-year history of type 2 diabetes. gained 22 lb. Since retiring, he has nous nicking, no retinopathy
Although he was diagnosed in 1997, been more physically active, playing • Thyroid: nonpalpable
he had symptoms indicating hyper- golf once a week and gardening, but • Lungs: clear to auscultation
glycemia for 2 years before diagnosis. he has been unable to lose more than • Heart: Rate and rhythm regular, no
He had fasting blood glucose records 2–3 lb. He has never seen a dietitian murmurs or gallops
indicating values of 118–127 mg/dl, and has not been instructed in self- • Vascular assessment: no carotid
which were described to him as monitoring of blood glucose (SMBG). bruits; femoral, popliteal, and dor-
indicative of “borderline diabetes.” A.B.’s diet history reveals excessive salis pedis pulses 2+ bilaterally
He also remembered past episodes of carbohydrate intake in the form of • Neurological assessment: dimin-
nocturia associated with large pasta bread and pasta. His normal dinners ished vibratory sense to the fore-
meals and Italian pastries. At the time consist of 2 cups of cooked pasta with foot, absent ankle reflexes, monofil-
of initial diagnosis, he was advised to homemade sauce and three to four ament (5.07 Semmes-Weinstein) felt
lose weight (“at least 10 lb.”), but no slices of Italian bread. During the day, only above the ankle
further action was taken. he often has “a slice or two” of bread
Referred by his family physician to with butter or olive oil. He also eats Lab Results
the diabetes specialty clinic, A.B. pre- eight to ten pieces of fresh fruit per Results of laboratory tests (drawn 5
sents with recent weight gain, subopti- day at meals and as snacks. He prefers days before the office visit) are as fol-
mal diabetes control, and foot pain. chicken and fish, but it is usually lows:
He has been trying to lose weight and served with a tomato or cream sauce • Glucose (fasting): 178 mg/dl (nor-
increase his exercise for the past 6 accompanied by pasta. His wife has mal range: 65–109 mg/dl)
months without success. He had been offered to make him plain grilled • Creatinine: 1.0 mg/dl (normal
started on glyburide (Diabeta), 2.5 mg meats, but he finds them “tasteless.” range: 0.5–1.4 mg/dl)
every morning, but had stopped taking He drinks 8 oz. of red wine with din- • Blood urea nitrogen: 18 mg/dl (nor-
it because of dizziness, often accompa- ner each evening. He stopped smoking mal range: 7–30 mg/dl)
nied by sweating and a feeling of mild more than 10 years ago, he reports, • Sodium: 141 mg/dl (normal range:
agitation, in the late afternoon. “when the cost of cigarettes topped a 135–146 mg/dl)
A.B. also takes atorvastatin (Lip- buck-fifty.” • Potassium: 4.3 mg/dl (normal
itor), 10 mg daily, for hypercholes- The medical documents that A.B. range: 3.5–5.3 mg/dl)
terolemia (elevated LDL cholesterol, brings to this appointment indicate • Lipid panel
low HDL cholesterol, and elevated that his hemoglobin A1c (A1C) has • Total cholesterol: 162 mg/dl
triglycerides). He has tolerated this never been <8%. His blood pressure (normal: <200 mg/dl)
medication and adheres to the daily has been measured at 150/70, • HDL cholesterol: 43 mg/dl (nor-
schedule. During the past 6 months, 148/92, and 166/88 mmHg on sepa- mal: ≥40 mg/dl)
he has also taken chromium picoli- rate occasions during the past year at • LDL cholesterol (calculated): 84
nate, gymnema sylvestre, and a “pan- the local senior center screening clin- mg/dl (normal: <100 mg/dl)
creas elixir” in an attempt to improve ic. Although he was told that his • Triglycerides: 177 mg/dl (nor-
his diabetes control. He stopped these blood pressure was “up a little,” he mal: <150 mg/dl)
supplements when he did not see any was not aware of the need to keep • Cholesterol-to-HDL ratio: 3.8
positive results. his blood pressure ≤130/80 mmHg (normal: <5.0)
He does not test his blood glucose for both cardiovascular and renal • AST: 14 IU/l (normal: 0–40 IU/l)
levels at home and expresses doubt health.11 • ALT: 19 IU/l (normal: 5–40 IU/l)
that this procedure would help him A.B. has never had a foot exam as • Alkaline phosphotase: 56 IU/l (nor-
improve his diabetes control. “What part of his primary care exams, nor mal: 35–125 IU/l)
would knowing the numbers do for has he been instructed in preventive • A1C: 8.1% (normal: 4–6%)
me?,” he asks. “The doctor already foot care. However, his medical • Urine microalbumin: 45 mg (nor-
knows the sugars are high.” records also indicate that he has had mal: <30 mg)
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Diabetes Spectrum Volume 16, Number 1, 2003
Assessment dent. After further discussion, he real- to reduce GI side effects.
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Diabetes Spectrum Volume 16, Number 1, 2003