INTRODUCTION

The document describes the essential care points for chronic conditions, including self-

management, empowerment, nursing actions and local community resources. The essential

components are discussed through the case study of 55-year old patient Jean, suffering from

type-2 Diabetes and have recently experienced exaggeration of her symptoms. She has gained

weight over the years and is hesitant to discuss the weight management plan with the nurse. She

is worried about the lack of support from the healthcare professional and the breach of her

privacy on sharing information. Her diet mainly consists of sugar drinks and canned food items.

KEY FACTORS

The activities of care for individuals like Jean suffering from chronic conditions include

education, health promotion, risk identification, screening, counselling, and clinical management

(Reyes et al., 2018). The factors that might influence the optimal care in Diabetes include the

patients, healthcare professionals and healthcare system factors (Ndumele,et al., 2019). The

patient factors include literacy, socio-economic conditions, accessibility to healthcare services

and social environment. The healthcare system factors are informal and formal healthcare

delivery system, the structure of the organisation, national and state policy. The health

professional factors include skills, competency and knowledge (Wakerman et al., 2017). The

facilitators for optimal care include social inclusion, cultural competency, holistic care, self-

management and patient care approach to the chronic condition. The generalised factors that

reflect the overall optimal care outcome are the acceptability, affordability, adequacy and

accessibility of the care program or plan. Along with these, certain community factors may
restrict or enhance the optimal care for a chronic condition like Diabetes. These may include peer

influence, resource availability, accessibility and social practices (NHSF, 2020).

EMPOWERMENT

As Mrs Jean lacks knowledge about her disease and its management, collaborative self-

management plans should be developed to address and evaluation of her current situation of the

chronic condition (van Grieken et al., 2018). The self-management priorities should include self-

governing health behaviour and pharmacological drug adherence, including insulin therapy. The

integrated care program should be developed for adopting a better healthy lifestyle and avoid

complications secondary to Diabetes (Carpenter,et al., 2018). She should collaborate with the

physiotherapist, dietician and community nurse to assist her with practical self-management

skills and address the holistic requirement. The nurse can encourage Jean for diet management;

exercise regime; medication intake;smoking and sugary drink cessation; however, this should be

delivered to Jean in an individualistic and personalised manner as she fears neglect with privacy

breach (Hessler et al., 2019). Being knowledge deficient, she will continue with her diet and

lifestyle-related activities, resulting in complications; hence, the nurse should emphasise

information sharing to facilitate self-management. For this, she should be encouraged to follow

the care plans and self assess her needs (van Grieken et al., 2018).

Powerlessness is defined as the absent sense of responsibility of care to the patient and complete

dependency on the health care system hence patient has no role in her care plans (Borgermans et

al., 2017). Contrary to this, self-management is the care taken by individuals on their own

(Carpenter et al., 2018). The self-care management of a chronic condition like Diabetes should

include long term treatment adherence for preventing complications, whereas the acute goal
should be to prevent an acute attack of hyperglycemia. Jean will play a significant role in

compliance, lifestyle changes, introduction to healthy habits, and reduction or avoidance of risky

behaviour like smoking and sugary drinks (Zhu et al., 2019).

Empowerment is the patient-centred and collaborative approach that helps the patient discover

and develop the capacity for being responsible for decision making for their own life and health.

Empowerment is a vision that guides the roles of nurses and patient as partners and collaborators

in achieving the goals and overcoming the barriers (Zhu et al., 2019). The nurse can provide

education, expert advice and support, guiding Jean to take a better decision through nurse

knowledge of medicine and disease (Borgermans et al., 2017).

LOCAL RESOURCE

WentWest, is a non-governmental organisation that provides community support to the

individual suffering from Diabetes and its complications, and the organisation provide
intervention to reduce the impact of Diabetes in the community (WentWest, 2020). The
organization works to address both regional and national commitment and challenges.

The organisation provide awareness, education and assistance for type 1, type 2 and gestational
Diabetes to people diagnosed and individuals at risk of developing Diabetes. The resource works
in partnership with The Royal Australian College of General Practices (RACGP). The
organisation focus on behavioral, psychological and social aspects of Diabetes with a focus on
improving the quality of life.

Jean can be benefited from resources through their empowerment and support campaign that
counsel individual with Diabetes for behavioural changes required for adopting healthier
lifestyles. They also provide assistance and advocacy to promote self-management techniques
and strategies. It works along with the local agent of the community . As Jean has privacy,
confidentiality and trust issues, the organisation can provide personalised assistance and sessions
with health coaches and healthcare professionals through Collaborative Commissioning that
will facilitate her with local co-commissioning groups identifying and prioritising her health
needs and developing care pathways to improve her health outcomes (Tinetti et al., 2019). The
recommendation for Jean utilising the resource should include diet control, initiation of physical
activity and self-management activities.

CHALLENGES

Implementing the clinical recommendations is a scientific approach that healthcare professionals

adopt; however, the implementation process has numerous barriers and challenges in practice

(Rankinet al., 2018). The knowledge of challenges associated with implementing the complete

process helps correct the complete referral system. The challenges may be present both at the end

of resources and Jean.. From the end of the resource, there can be a lack of communication,

leadership, governance and advocacy (Reyes et al., 2017). As organization run with the various

educational campaign, continuous adherence to the resource is required for recommendation

implementation. For marinating her diet and regime, she needs to develop trust within the

healthcare workers. Lack of competent healthcare professionals also prove as a hindrance in

implementing the recommendation including dietician, diabetes nurse and physical therapist. As

the organisation run based on the educational support, continuous adherence to the resource is

required for recommendation implementation. This can be only achieved if the worker of the

organization are trained and have appropriate communication skills. The appropriate

communication model needs to be adopted so that Jean's hesitation and trust issues can be

resolved and recommendations can be implemented (Tinetti et al., 2019). There should be a

system adopted by the resource where Jean can feel individualise patient care rather than the fit

to all approach to implement her lifestyle changes (Tinetti et al., 2019). This should be facilitated
through information sharing so that the recommendations can be implemented through long term

commitment and dedication from the patient side (Rankinet al., 2018).

NURSING INTERVENTIONS

Three nursing that should be taken in the case of Jean with type 2 diabetes should include care

for her nutritional needs, preventing the risk of diabetic complications and maintaining the blood

glucose levels (Cárdenas-Valladolid et al., 2015). Due to risky behaviour followed by Jean and

being diagnosed with type 2 diabetes, Jean is exposed to the development of multiple

complications that may include diabetic retinopathy, neuropathy and nephropathy (Lambrinou et

al., 2019). She needs to be referred to the ophthalmologist for regular eye visits (Cárdenas-

Valladolid et al., 2015). The neurological examination should be conducted regularly, assess the

peripheral pulses for proper oxygenation. Educate Jean to always wear stocking for protection

from injury and attend to any wound with attention. As there might be a loss of sensation with an

increased tendency for ulcer formation in type 2 diabetes, she needs to take care of skin integrity

(Lambrinou et al., 2019).

Jean should be educated about home glucose monitoring regularly to strictly control blood

glucose levels and strictly adhere to her medication or insulin regime (Hessleret al., 2019).

Educate her on how her ant diabetic medication work and why it is essential to take these

medications. Educate about the combinations of drugs that might be administered and probable

side effects they may produce. Instruct about the types of insulin used, suitable site of injection

and methods of administration (Lambrinou et al., 2019).

For analysing the nutritional needs for Jean, asses the body weight and Body mass index.

Monitor the daily calories need of Jean. As she is consuming caned and saturated food, she needs
to be encouraged for switching to more healthy options. Her sugar intake needs to be regulated.

She is drinking six cans of carbonated drinks. She needs to switch to some healthier options. She

might include complex carbohydrate and vegetables with a low glycaemic index (Cárdenas-

Valladolid et al., 2015). The food low in high sugar, simple carbohydrates, and fat content helps

in reducing eth sudden spikes of blood glucose or postprandial hyperglycaemia. Eating a more

balanced diet with multi-nutrient will help in decreasing glucose intolerance and facilitate the

uptake of glucose by the peripheral tissues hence maintaining the balance in the blood (Hessleret

al., 2019).

After analysing the information provided in the case, the implementation of the nursing action

helps in adopting future nursing practice helpful in positive patient outcome (Nikitaraet al., 2019).

During implementing the action as a healthcare professional, the nurse can learn to adopt specific

skills necessary for building positive relation, ensuring the partnership for desirable health

outcomes and learning skills such as effective communication, patient-centred care, self-

management and information sharing (Nikitaraet al., 2019). Key points from the case study and

nursing care will also facilitate the implementation of treatment plans through privacy and trust.

REFERENCES
Borgermans, L., Marchal, Y., Busetto, L., Kalseth, J., Kasteng, F., & Suija, K. et al. (2017).
How to Improve Integrated Care for People with Chronic Conditions: Key Findings from
EU FP-7 Project INTEGRATE and Beyond. International Journal Of Integrated Care,
17(4). https://doi.org/10.5334/ijic.3096
Cameron, L., Somerville, L., Naismith, C., Watterson, D., Maric, V., & Lannin, N. (2018).
A qualitative investigation into the patient-centered goal-setting practices of allied health
 clinicians working in rehabilitation. Clinical Rehabilitation, 32(6),
827-840.https://doi.org/10.1177/0269215517752488
Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of
type2 diabetes: An integrative review. International Journal Of Nursing Sciences, 6(1),
70-91.https://doi.org/10.1016/j.ijnss.2018.12.002

Cárdenas-Valladolid, J., Salinero-Fort, M., Gómez-Campelo, P., & López-Andrés, A.

(2015).Standardized nursing care plans in patients with type 2 diabetes mellitus: Are they
effective in the long-term?. Atención Primaria, 47(3), 186-189.
https://doi.org/10.1016/j.aprim.2014.05.014
Hessler, D., Fisher, L., Bowyer, V., Dickinson, L., Jortberg, B., & Kwan, B. et al. (2019).
Self-management support for chronic disease in primary care: frequency of patient self-
management problems and patient-reported priorities, and alignment with ultimate
behaviour goal selection. BMC Family Practice, 20(1). https://doi.org/10.1186/s12875-
019-1012-x

Łuczyński, W., Głowińska-Olszewska, B., & Bossowski, A. (2016). Empowerment in

theTreatment of Diabetes and Obesity. Journal Of Diabetes Research, 2016,
1-9.https://doi.org/10.1155/2016/5671492
Lambrinou, E., Hansen, T., & Beulens, J. (2019). Lifestyle factors, self-management and
patient empowerment in diabetes care. European Journal of Preventive
Cardiology, 26(2_suppl), 55-63. https://doi.org/10.1177/2047487319885455
National Strategic Framework for Chronic Conditions. Consultations.health.gov.au.
(2021).Retrieved 2 April 2021, from https://consultations.health.gov.au/population-
health-and-sport-division/national-strategic-framework-for-chronic
condition/supporting_documents/Second%20draft%20National%20Strategic
%20Framework%20for%20Chronic%20Conditions%20%20Online%20Public
%20Consultation%20%20May%202016%20D16458639.PDF.

Nikitara, M., Constantinou, C. S., Andreou, E., & Diomidous, M. (2019). The Role of
Nurses and the Facilitators and Barriers in Diabetes Care: A Mixed Methods Systematic
Literature Review. Behavioral sciences (Basel, Switzerland), 9(6), 61.
https://doi.org/10.3390/bs9060061

Reyes, J., Tripp-Reimer, T., Parker, E., Muller, B., & Laroche, H. (2017). Factors
InfluencingDiabetes Self-Management Among Medically Underserved Patients With
Type II Diabetes. Global Qualitative Nursing Research, 4,
233339361771309.https://doi.org/10.1177/2333393617713097
Rankin, D., Harden, J., Barnard, K., Bath, L., Noyes, K., Stephen, J., & Lawton, J.
(2018).Barriers and facilitators to taking on diabetes self-management tasks in pre-
adolescent children with type 1 diabetes: a qualitative study. BMC Endocrine
Disorders, 18(1).https://doi.org/10.1186/s12902-018-0302-y

Tinetti, M., Dindo, L., Smith, C., Blaum, C., Costello, D., & Ouellet, G. et al. (2019).
Challenges and strategies in patients’ health priorities-aligned decision-making for older
adults with multiplechronic conditions. PLOS ONE, 14(6), e0218249.
https://doi.org/10.1371/journal.pone.0218249

Wakerman, J., Sparrow, L., Thomas, S., Humphreys, J., & Jones, M. (2017). Equitable
resourcing of primary health care in remote communities in Australia’s Northern
Territory: a pilot study. BMC Family Practice, 18(1). https://doi.org/10.1186/s12875-
017-0646-9
Wentwest. Retrieved from https://wentwest.com.au/

Zhu, T., Mooi, C., & Shamsuddin, N. (2019). Diabetes empowerment scores among type
2diabetes mellitus patients and its correlated factors: A cross-sectional study in a primary
care setting in Malaysia. World Journal Of Diabetes, 10(7),
403-413.https://doi.org/10.4239/wjd.v10.i7.403