KENYA METHODIST UNIVERSITY

SCHOOL OF MEDICINE AND HEALTH SCIENCES

DEPARTMENT OF NURSING

NAME : EZEKIEL FRANKLINE MWITAH

REG. NO : BSN-1-9815-3/2016

COURSE : NRSG 215

COURSE TITLE : COMMUNITY HEALTH III (CLINICAL)

LECTURER : MADAM ELIZABETH KIRINYA

TASK : HOME VISTING REPORT FOR A CLIENT WITH TYPE 2 DIABETES MELLITUS

DUE DATE : 17 TH MAY, 2019

INTODUCTION TO HOME VISTING AND THE BACKGROUND OF MY CLIENT

Home visiting is a process of providing nursing care to patient at their door steps. It is essential
as many patients are found at home. Services offered during home visiting require the nurse to
have technical skills, knowledge of preventive and therapeutic measures, teaching ability,
judgment and full understanding of human relations.
I was able to visit the Runogone village chief who actually helped me to find my client at runogone
village.

Calgary Family Assessment Model was the model that I used to assess the family

According to Wright and Leahey (2009), “The Calgary Family Assessment Model (CFAM) is an integrated,
multidimensional framework…” (p. 47). This model is widely used among nurses for assessing a family in
the goal of resolving issues among the family. CFAM is composed of three major categories which
include: structural, developmental, and functional. As a nursing student, i used this model for assessing
Mr. K.P. who holds the chronic illness of type two diabetes mellitus.

Structural assessment

As stated in Wright and Leahey (2009), structural assessment is an important category of CFAM as it
examines the structural component of the family. These structures can be more closely identified using
the three aspects comprised of the internal structure, external structure, and context. To further
understand the structure of K.P.’s family, for example.

Wright and Leahey (2009) state that internal structure includes six subcategories which include: family
composition, gender, sexual orientation, rank order, subsystems, and boundaries. I asked Mr P.K about
his family composition. He answered that his family is composed of his wife whom he lives with, as well
as his children who are adults now and live their own lives. When asked about who he would consider
his family not related biologically, he responds that it would be his neighbour whom he gets along with
quite well. According to K.P., he believes that family is love, understanding and composed of people who
can talk with one another. As stated in Weigel (2008), the concept of family and what family means
differs from person to person. With K.P., love and understanding are the most important components to
him.

K.P. believes that a person is a person no matter which gender they are; we are all people and decide
who we want to be. When it comes to the rank order of her children, he has three living children.

Contextual structure is the family background with includes ethnicity, race, social class, spirituality (or
religion), and environment (Wright & Leahey, 2009).

says that he is a Catholic; he always go to church, and prays every night. he loves God and thanks him
before going to bed in wishing that nothing more will happen to him.

Developmental assessment

Developmental assessment is the second category of the CFAM. Along with the structural assessment,
this component is also essential as it explains the family’s developmental life cycle (Wright & Leahy,
2009). Families progress through certain stages of development similar to Erik Erikson’s Theory of the
psychosocial developmental stages (Potter & Perry, 2014). There are six stages in the developmental life
cycle according to the CFAM and it is clear that P.K. is in the last stage because she is now a grandfather
and his children have left the household onto the building of their own lives. Developmental assessment
also includes tasks and attachments depending on the developmental stage the family in situated in.

P.K. is in the sixth stage of the developmental life cycle which is named “Families in Later Life” (Wright &
Leahy, 2009). Looking back over his life, P.K. says that marriage gave him the most happiness along with
his children being all grown up, healthy, and well in their skins

Functional assessment

According to Wright & Leahy (2009), functional assessment is the last major category of the CFAM. This
component deals with how the individuals in the family deal with one another, known as interaction.
The two basic aspects of family functioning include the instrumental and expressive. Instrumental
functioning is about routine activities in daily living. For K.P’s health, he tries to walk on the plots he
owns for about five minutes daily. Knitting, crocheting, and cleaning the house are all things that K.P.
loves doing and mentions in the interview many times how much he loves his house.

K.P. claims that he has no trouble performing activities of daily living (ADL) unless he is having an
episode from the illness. he explains to me that he do not know when to take it easy.

As stated in Wright & Leahey (2009), there are nine aspects included in expressive functioning which
were all covered during the interview (emotional, verbal, nonverbal, and circular communication,
problem solving, roles, influence and power, beliefs, as well as alliances and coalitions). When asked
how he would rank his emotional state, K.P. responded that he is easily bothered, and quite emotional.
he is content with where children are at in their lives and is not worried about them. he says, “No news
is good news”. K.P. understands that he cannot hold his children on a string, and has to cut it at one
point.

When it comes to verbal communication, he has trouble saying what bothers her, so he keeps it to
himself and also he has a hearing problem. P.K. will not initiate communication because as a child he
had no discussions with his parents. His parents would always tell him to play outside, but his siblings
were busy doing their own thing most of the time.

When it comes to circular communication, K.P. avoids conflict to refrain from confrontation. he refrains
because he claims it helps him deal with the situation. As mentioned earlier, he has difficulty voicing her
opinion and trouble vocalizing emotions which can be a difficult time for him when confronted.

Her problem solving strategies include thinking and reflecting. he will think on what he feels and how he
will say what he want to say. When conflict arises, he leaves someone else to problem solve and
mentions that he has always been a good listener. When asked what his roles were in his family, he
replied being a father, teacher, listener, and friend.

When it comes to influence and power, he is asked what he feels his responsibilities are as a father. he
replies that his role as a father was to teach his children to be individuals. As a grandfather, he felt he
had a big influence on the grandchildren, and says that he had the same relationship with his grandkids
as with his own children.

Lastly, he believes that him and his wife’s message went across to the children. If there are arguments
between family members, K.P.’s wife would be more likely to help resolve the issue or attempt to
intervene. When asked if he thinks he has any influence on how close or distant his family is, he says
that their love holds them together, and that it is carried on through the generations. he also enjoys that
his children have their own lives.

Case Presentation

K.P. is a 59-year-old man with a 8-year history of type 2 diabetes. Although he was diagnosed in 2017, he
had symptoms indicating hyperglycemia for one month before diagnosis. He had fasting blood glucose
records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline
diabetes.”

He does not test his blood glucose levels at home and expresses doubt that this procedure would help
him improve his diabetes control. “What would knowing the numbers do for me?” he asks. “The doctor
already knows the sugars are high.” He reveals that he has no idea about low and high blood sugar, he
do not know any complications brought in by diabetes mellitus

P.K. states that he has “never been sick a day in my life.” He lives with his wife of 48 years and has two
married children. P.K. has limited knowledge regarding diabetes self-care management and states that
he does not understand why he has diabetes since he never eats sugar. In the past, his family members
has encouraged him to treat his diabetes by avoiding sugary food and taking medications

P.K.’s diet history reveals excessive simple carbohydrate intake in the form of white bread, banana,
melon, red meat tea with sugar and sometimes he forgets taking his medication.

K.P. has never had a foot exam as part of his primary care exams, nor has he been instructed in
preventive foot care. However, his medical records also indicate that he had surgeries involving gastric
ulcer and has a history of hospitalizations due to diabetes mellitus.

The Identified Learning Need

Patients with Diabetes have very comprehensive learning needs. The learning needs are focused on
managing their glucose levels and preventing complications of diabetes.
Learningneeds for managing diabetes are complex and include: monitoring blood glucose levels,
menu/food planning, exercise, medications, skin care, management of co-existing disease processes,
knowledge of medications, knowledge of the disease process and how to manage hypo or
hyperglycemic episodes. Many patients are diagnosed with diabetes every year and many are unaware
that it requires lifestyle changes, especially in the areas of nutrition and physical activity. Making these
lifestyle changes is one of the greatest challenges they will encounter in managing their diabetes. The
main goal of the teaching plan is to provide the patient with the knowledge to be able to make self-
directed behavioral changes to improve their overall health and manage their diabetes. (Franz,2001).
Environment needed an improvement in terms of hygiene e.g. disposal of waste and general cleaning
and education on the importance of maintaining clean environment.

Based on information I gathered the family has very little knowledge regarding diabetes mellitus in
terms of definition, signs and symptoms of hyperglycemia and hypoglycemia, nutrition and collaborative
management of the disease. From the data, knowledge deficit related to disease process would be an
appropriate nursing diagnoses for my client and the family as evidenced by personal communication

From the above case presentation and the identified learning needs, I believe this client can actually
benefits a lot from a home visit

REASONS OF THE STUDY 

I chose type 2 diabetes mellitus as my case study because aside from it is still fresh in my minds; I was

interested in studying this. Am willing to do this case to challenge my own minds in analyzing the
problem and to enhance my knowledge, as well as to gain new experiences which could bring new
learning’s for me and others. This case study will also help me in understanding the disease process of
the patient. It would also help me in identifying the primary needs of the patient with a type 2 Diabetes
Mellitus. By identifying such needs and health problems arise i can now formulate an individualized
Nursing care plan for the patient that would address these needs and problems
effectively. Management of the identified problem will help the patient to recover faster and maintain
holistic sense of wellness. This will also equip me with knowledge, skills and attitude on how to manage
future patient with the same disease

MY GENERAL OBJECTIVE FOR HOME VISITING IS TO:

Promote health by teaching the family the nature of diabetes, its cause, complication, prevention and
treatment

The Behavioral Objectives for the Teaching Plan, AT THE END OF MY HOME VISITING:

1. My client will be able to understand the meaning of diabetes mellitus including the disease process
2. My client will verbalize the signs and symptoms of hyperglycemia and hypoglycemia and the action
to be taken in each
3. Situation
4. The patient will be able to describe the diabetic medications that he is on and how to properly take
the medications
5. The patient will be able to demonstrate proper skin and foot care.
6. The patient will be able to perform self-monitoring of blood glucose using a blood glucose meter as
evidenced by demonstration of the technique to the nurse or nurse practitioner.
7. The patient will be able to describe the benefits of regular exercise and how regular  exercise can
improve blood glucose control.
Teaching Plan for Diabetes

Teaching Plan would include 6 evening classes consisting of 2-3-hour sessions of education. The topics
and discussions would be as follows.

Day 1 general environmental cleaning, e.g. waste disposal bin establishment and education on hygiene
2-4hrs.

Day 2 General overview of Diabetes (2 hours) and a review of day one

Day 3 Medications and Insulin (2 – 3 hours) and Blood glucose monitoring and goals of blood glucose
monitoring (3 hours) and a review of day two

Day 4 Complications from Diabetes and (1 hour) Skin and Foot Care (0.5 hour) and a review of day three

Day 5 Diet, exercise, coping with Diabetes (1.5 hour) and a review of day four

Day 6 termination including Questions and Answers (1 hour) Review of any concepts requested by
patients.

The diabetes teaching plan will be aimed at helping the patient make educated lifestyle choices and
changes that will promote health and promote a stable blood sugar. The disease needs
acomprehensive treatment approach. 

This includes: (a) an individualized food/meal plan appropriate for his lifestyle, (b) education related to

diabetes and nutrition therapy, and (c) mutually agreed-upon short term and long-term goals for
lifestyle changes.

The teaching plan will stressnthe importance of complying with the prescribed treatment program. This

teaching plan should be tailored to the patient’s needs, abilities,
anddevelopmental stage. The teaching plan for a patient with diabetes should include: diet,administrati
on,possible adverse effects of medication, exercise, blood glucose monitoring, hygiene, and the
prevention and recognition of hypoglycemia and hyperglycemia. McGovern, 2002. The teaching plan is
an education program designed to help patients with newly diagnosed diabetes or patients who need a
review of concepts for managing their diabetes. However, diabetes management requires on-going
education and nutritional advice with regular review and modification as the disease process progresses
and the needs of the patient changes

THE CASE

BIOGRAPHIC DATA

Client name Kaimanyi P

Age;

Gender; Male

Marital status; Married

Religion; Christian

Residence; Runogone

Education; primary level

Nationality; Kenyan

CLIENT HISTORY Took place on 28th APRIL, 2019

History of the presenting complaints:

From home visiting this is what I was able to obtain from Mr. K.P. is a 59-year-old man with a 8-year
history of type 2 diabetes. Although he was diagnosed in 2011, he had symptoms indicating
hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of
118–127 mg/dl, which were described to him as indicative of “borderline diabetes.”

PAST MEDICAL HISTORY

He was diagnosed with type two diabetes mellitus in 2011. There has no known history of allergies of
food and drug, has no history of blood transfusion, has a history of surgery due to gastric ulcer.

Family health and social History

Second born in the family of five children all alive and well. history of chronic illness in the family. Has no
history of having dental problems. he is married, there is no history of twins in the family. he does not
smoke, drink alcohol or abuse any abusive drug. he is a Christian.

HEAD TO TOE EXAMINATION

Took place on 28th April, 2019

General appearance: he is conscious but with hearing problems. Head: Was normal in shape and size,
hair was normal and long and black in color no mass on the skull, no tender on the temporal lobe. Eyes:
no discharge, no signs of anemia, sclera blue whitish, no signs of infection. Neck: Normal, lymph nodes
not parabable thyroid gland not swollen and is mobile, carotid artery pulsating, jugular vein not swollen.
Upper extremities; both present and of normal length, no mass, no lesion, capillary refill good. Chest: of
normal shape. On auscultation pulse rate 73 beats per minutes. Abdomen: on inspection the abdomen
not distended, scar present. Lower limbs, no varicose veins observed and no deep vein thrombosis
noted, both present and equal, no mass, no lesion. Back area: There are no pressure areas in the back
and there were no abnormalities of the spine.
What Is This Disease?

This will help my client to understand “What is diabetes mellitus?” Diabetes mellitus has formally been
defined by the American Diabetes Association as “a group of metabolic diseases characterized by
hyperglycemia resulting from defects in the insulin secretion, insulin action, or both. The chronic
hyperglycemia of diabetes is associated with long-term macro- and microvascular damage, dysfunction,
and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels” (ADA, 2011).

My client needs to know that “Diabetes was recognized as a medical problem over 2000 years ago in
Greek writings, so it is not a new disease. It wasn’t until the early 1900s, however, that insulin was
identified as the hormone that controls blood sugar levels. Early scientists removed the pancreas from a
dog, thus creating a diabetic dog, which helped them confirm that the pancreas produces insulin from
beta cells within the islets of Langerhans. In 1921 insulin was finally purified for human injection by Eli
Lilly, an early pharmaceutical company, which began the treatment to save lives for type 1 diabetics who
produced no insulin”

What Is the Disease Process?

This is what I explained to my client. Without insulin, the food we eat, broken down into simple forms
of glucose, can’t enter the cells of the body and remains in the bloodstream. After a meal, glucose levels
in the body rise, which triggers insulin to be released from the beta cells of the pancreas. Glucose levels
in the blood fall as glucose moves into the cells, where it is used for energy production to fuel the body.
Extra glucose in the blood can be stored in fat and skeletal muscle tissue. Glucose stored in the liver
becomes glycogen.

An opposing hormone, glucagon, has the opposite effect of insulin, resulting in elevated levels of
glucose in the blood, where it can be sent for energy throughout the body. The perfect balance of insulin
and glucagon production keeps our blood sugar levels regulated between 60 and 100 mg/dL in a fasting
state and 100 to <140 mg/dl 2 hours after a meal.

When the body doesn’t produce any insulin (type 1 diabetes) or has a sluggish or resistant response to
insulin (type 2 diabetes), chronic hyperglycemia develops; this is known as diabetes mellitus. The
term diabetes means “to siphon through,” which refers to the loss of urine as the body attempts to rid
itself of the excess glucose and pulls water along with it. The term mellitus was added years later; it
means “sweet” or “honey,” referring to the glucose in the urine.

Early signs and symptoms of diabetic hypoglycemia include:

Frequent urination, increased thirst, blurred vision, fatigue, and headache

Later signs and symptoms

If hyperglycemia goes untreated, it can cause toxic acids (ketones) to build up in the blood and urine
(ketoacidosis). Signs and symptoms include:
Fruity-smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion,
coma, abdominal pain

Early signs and symptoms of diabetic hypoglycemia include:

Shakiness, Dizziness, sweating, hunger, irritability or moodiness, anxiety or nervousness, headache

Severe symptoms

If diabetic hypoglycemia goes untreated, signs and symptoms of severe hypoglycemia can occur. These
include:

Clumsiness or jerky movements, muscle weakness, difficulty speaking or slurred speech, blurry or double
vision, drowsiness, confusion, convulsions or seizures, unconsciousness, death

Blood glucose monitoring and goals of blood glucose monitoring:

Testing blood glucose levels pre-meal and post-meal can help the patient with diabetes make better
food choices, based on how their bodies are responding to specific foods. I was able to teach my patient
that specific directions for obtaining an adequate blood sample and what to do with the numbers that
he receives. “Research has found that patients who have had education on the use of their meters and
how to interpret the data are more likely to perform self-blood glucose monitoring on a regular basis
There are many different glucoses monitors available for patients. The patient needs to have a device
that is easy for them to use and convenient. A patient’s visual acuity and dexterity skills should be
assessed prior to selecting a blood glucose-monitoring device. The patient needs to be reminded to
record the blood glucose values on a log sheet with the date and time and any
associated signs and symptoms that he/she is experiencing at the time the specimen was obtained. This
log should be shared with his/her primary care practitioner”. We also had a discussion on glycosylated
hemoglobin (HbA1c) that include the reasons for doing the test, how it is performed and how the health
care practitioner will interpret the data. These laboratory tests are ordered on a routine basis along with
other laboratory tests that are being monitored for the patient. I used a simple method to describe the
HbA1c to my patient, that the test measures the amount of sugar that attaches to the protein in the red
blood cell. The test shows the average blood sugar during the last three months. The higher the blood
sugar the higher the HbA1c. The high blood sugar over a long period of time causes damage to the large
and small blood vessels therefore increasing the risk of complications from diabetes.

 Medications and Insulin

The patient with diabetes needs to be reminded that the addition of medications to help manage
his/her diabetes is not because they are failing at diet management. Many patients with diabetes
become depressed or despondent when they have to begin taking oral hyperglycemic medications
and/or insulin. The teaching session for my client included a review of the different types of  oral diabetic
agents. A review of the different types of insulins. I thought my client the about self-
administration of insulin or oral agents as prescribed, and the importance of taking medications exactly
as prescribed, in the appropriate dose. And I was able to provide him with a list of signs and symptoms
of hypoglycemia and hyperglycemia and actions to taken in each situation.

 Complications from Diabetes

The patient should be taught how to manage their diabetes when he/she has a minor  illness, such as a
cold, flu or gastrointestinal virus. I taught my client on how to watch for diabetic effects on the
cardiovascular system, such as cerebrovascular incidents/stroke,
coronary artery disease, and peripheral vascular disease. Assessment for signs of diabetic neuropathy
was part of discussion with my client. Also, I was able to give education on the importance of smoking
cessation, cholesterol and lipid management, blood pressure monitoring and management and
management of other disease processes.

Skin and feet care for a patient with diabetes

The following was among what I taught my patient concerning skin and feet care: to care for his feet by
washing them daily, drying them carefully particularly between the toes, and inspecting for corns,
calluses, redness, swelling, bruises, blisters, and breaks in the skin. To report any changes to his health
care provider as soon as possible. To wear non-constricting shoes and to avoid walking barefoot. The
patient may use over-the-counter athlete’s foot remedies to cure foot fungal infections and i
encouraged him to call his health care provider if the athlete’s foot doesn’t improve. I also reminded
that he needs to treat all injuries, cuts and blisters particularly on the legs or feet carefully. Patients
should be aware that foot problems are a common problem for patients with diabetes. Informing them
of what to look for is an important teaching concern. I educated him the signs and symptoms of foot
problems to emphasize on are: feet that are cold, blue or black in color, feet that are warm and red in
color, foot swelling, foot pain when resting or with activity, weak pulses in the feet, not feeling pain
although there is a cut or sore on the foot, shiny smooth skin on the feet and lower legs.

Exercise and Diabetes

“A moderate weight loss of ten to twenty pounds has been known to improvehyperglycemia,
dyslipidemia, and hypertension. The target goal for body weight for patients with diabetes is based on a
reasonable or healthy body weight. More emphasis is now placed on waist circumference, rather than
on actual weight. A waist circumference greater than 40 inches in men and greater than 35 inches in
women indicates a risk for metabolic disease. This is now part of what is referred to as metabolic
syndrome. Reducing abdominal fat improves insulin sensitivity as well as lipid profiles. The benefits from
exercise result from regular, long term, and aerobic exercise. Exercise used to increase muscle strength
is an important means of preserving and increasing muscular strength and endurance and is useful in
helping to prevent falls and increase mobility among the elderly” Regular exercise can improve the
functioning of the cardiovascular system, improve strength and flexibility, improve lipid levels, improve
glycemic control, help decrease weight, and improve quality of life and self-esteem. Exercise increases
the cellular glucose uptake by increasing the number of cell receptors”. From the statement above I was
able to educate my client regarding beginning an exercise program. Exercise program must be
individualized and built up slowly. Insulin is more rapidly absorbed when injected into a limb that is
exercised, therefore can result in hypoglycemia. The exercise program should include a five to ten-
minute warm-up and cool-down session. The warm-up increases core body temperature and prevents
muscle injury and the cool-down session prevents blood pooling in the extremities and facilitates
removal of metabolic by- products. “Research studies show there are similar cardiorespiratory benefits
that occur when activity is done in shorter sessions, (approximately 10 minutes) accumulated
throughout the day than in activity sessions of prolonged sessions (greater than 30 minutes). This is an
important factor to emphasize with patients who don’t think they have the time and energy for
exercise”

Meal Planning and Diabetes

“The American Diabetes Association (ADA) has established nutritional guidelines

for patients with diabetes. Their focus is on achieving optimal metabolic outcomes related to glycemia,
lipid profiles, and blood pressure levels”. I educated my client on the importance of maintaining a
healthy diet consisting of multiple servings of fruits, vegetables, whole grains, low-fat dairy  products,
fish, lean meats, and poultry.

The food/meal plan is based on the individual’s appetite, preferred foods, and usual schedule  of
food intake and activities, and cultural preferences. Determination of caloric needs varies considerably
among individuals, and is based on present weight and current level of energy. Required calories are
about 40 kcal/kg or 20 kcal/lb. per day for adults with normal activity  patterns (Davis,2001). I also
emphasized on maintaining a consistent day-to-day carbohydrate intake at meals and snacks. It is the
carbohydrates that have the greatest impact on glycemia. Maintaining a food diary can help identify
areas of weaknesses and how to prepare better menu plans (Franz ,2001 pg13). Recommendations for
fiber intake are the same for patients with diabetes as for the general population. It is recommended
that they increase the amount of fiber to approximately 50grams per day in their diet. Insoluble and
soluble globular fiber delay glucose absorption and attenuate the postprandial serum glucose peak, they
also help to lower the elevated triglyceride levels often present in uncontrolled diabetes. Our discussion
of diet management also included a discussion on alcohol intake. Precautions regarding the use of
alcohol that apply to the general public also apply to people with diabetes. Abstaining from alcohol
should be advised for people with a history of alcohol abuse, during pregnancy, and for people with
other medical conditions such as pancreatitis, advanced neuropathy, and elevated triglycerides. The
effects of alcohol on blood glucose levels is dependent on the amount of alcohol ingested as well as the
relationship to food intake. Because alcohol cannot be used as a source of glucose, hypoglycemia can
result when alcohol is ingested without food.

Coping with Diabetes

The patient needs to understand that the diagnosis of diabetes mellitus as with any chronic illness can
be unexpected and potentially devastating. Grief is the most common reaction of an individual
diagnosed with diabetes. Resolution of the grief is dependent on variables such as education,
economics, geography, and religious and cultural factors. The support of family and friends affects the
long-term acceptance of the disease progression. Patients need to be aware that depression is common
with chronic diseases such as diabetes. The depression should be recognized and treated as soon as
possible since depression can affect glycemic control and complicate the management of the diabetes.
The patient needs to understand that diabetes is a lifelong disease process that requires a life time
commitment and lifestyle changes. The patient should be educated about empowerment – having the
resources and knowing how and when to use them. The skills of empowerment that help the patient
reflect on life satisfaction in the following areas: physical, mental, spiritual, family related, social, work
related, financial, personal. The patient should be encouraged to establish goals which emphasize at
least two of these areas in which he/she has control. In the session of coping with diabetes the patient
should be assisted to develop better problem-solving skills, which are necessary to manage a life-long
disease such as diabetes. Coping with diabetes should also include stress management concepts. Stress
management concepts should include: a definition of stress, the body’s reaction to stress, the effects of
stress on diabetes management, was my discussion with my client.

I managed to instruct him to continue taking his oral anti diabetic agents while ill and even when unable
to eat. The omission of insulin is a common cause of ketosis and can result in a serious condition called
diabetic ketoacidosis. I was able give him a list of foods that contain fast acting carbohydrates that he
can consume when he experiences signs and symptoms of hypoglycemia. I also encouraged him to seek
regular ophthalmologic examinations to detect for diabetic retinopathy. And regular dental
examinations to evaluate potential areas that can become infected and possible oral lesions.

DISCUSSION

K.P.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a
treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a
short discussion about the positive effect exercise can have on glucose control, the patient and his wife
agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

At the conclusion of the visit, Mr K.P assured me that he would share the plan of care that we had
developed