Introduction

Nursing care plan is a comprehensive strategy that outlines the nursing care set to be provided to a patient suffering for a certain disease. According to Haste(1992),it includes a set of actions that a nurse who is taking care of the patient is set to implement after the diagnoses .

Nursing intervention is defined as the actions that are usually undertaken by a nurse with the intention of furthering a defined course of treatment in a patient. The goal of the nursing intervention is always directed towards the general improvement health and comfort of the patient. According to Sabacare (2007), a nursing intervention can be defined as a single nursing action, treatment, procedure or activity that is designed to achieve an outcome to a diagnosis, nursing or medical, all which the nurse is accountable and responsible.

Jeffrey (2004), explains that there are three stages in a nursing intervention. The first phase is the assessment stage. The nurse determines the problem of the patient, for example the disease they are suffering from or any other ailments based on the symptoms. After the assessment, the nurse then formulates an appropriate plan for intervention. In the third step, the nurse will evaluate the patient to determine whether the goals of the intervention are accomplished and decide whether additional interventions are necessary. In the course of this intervention, a nurse can work individually, or as apart of a group in patient care teams. However, there is no significant difference in the two approaches. In this paper, I will develop a nursing care plan following the three intervention stages mentioned above for a person suffering from diabetes mellitus.

Diabetes mellitus can be defined as a disorder in which the level of blood glucose is persistently raised above the normal range. It is a syndrome of a malfunctioning metabolism system and abnormal hyperglycemia that is caused by a deficiency of insulin secretion. It can also be triggered by a combination of a deficiency in the secretion of insulin and insulin resistance to compensate. Insulin is the hormone that helps the body to regulate and control level of glucose(sugar)in the blood. The type 2 diabetes is a disease in which the pancrease doesn’t produce enough insulin, or the body fails to make proper use of the insulin it produces. Over time, high blood glucose levels can cause complications such as blindness, heart diseases, kidney problems, nerve damage and erectile dysfunction. Diabetes mellitus occurs in two main forms; the type 1 is caused by absolute insufficiency of insulin, and the more prevalent type 2 is characterized by insulin resistance with varying degrees of insulin secretory defects.

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NURSING PROCESS NURSING CARE PLAS FOR DIABETES MELLITUS

Nursing Assessment

According to Jeffrey (2004), the main activity of the assessment phase is for the nurse to obtain a history of current problems, family history, and general health history. The nurse should investigate among other things, whether the patient has experienced the signs of diabetes mellitus such as polyuria,polydipsia, polyphagia and any other symptoms. Then consider the patient history. For example, the number of years that have elapsed since the patient was diagnosed with diabetes and whether there is any family member of his who has been diagnosed with diabetics. Consider also the subsequent treatment that was administered to the family member with a sharp concentration on any complications that may have developed. 

In the next phase of assessment, the nurse should perform a review 0on the systems and conduct physical examinations to look for signs and symptoms of diabetes and the general health condition of the patient as well as any other complications associated with the particular patient. The examinations to be carried out include the following:

• General tests: consider common and general issues like weight gain and loss, increased fatigue, anxiety and general body weakness occasioned by abnormal tiredness,
• Skin tests: look for skin lesions, skin infections, manifestations of dehydration on the skin, and any evidence of wounds with poor healing history
• check the eyes: consider checking the noted changes in the patient's vision, for example, floaters, halos or halo effects, blurred vision, dry or burning eyes, cataracts and signs of glaucoma,
• Mouth checks: consider mouth related problems such as gingivitis and periodontal diseases
• check the heart of the patient: carry out cardiovascular tests for orthostatic hypotension, cold extremities, the strength of pedal pulses and leg claudication
• GI tests: test for diarrhoea, constipation, hunger or thirst, increased flatulence, stomach bloating, and early satiety.
• Genitourinary tests: test for cases of increased urination, impotence, vaginal discharge, and nocturia.
• Neurological tests: test for decreased pain and temperature perception, numbness, and changes in gait and balance.

Nursing Diagnosis

In the case provided of Mr. Paul B., the following common cases in diabetes mellitus patients can be found. Firstly, imbalanced nutrition in the patient. Mr. Paul’s history shows that he doesn’t have a strict diet at home, and he eats whatever he likes. Some of the foods that he eats like fast foods from restaurants, high carbohydrate content foods such as potatoes and pastas are common causes of sharp nutritional imbalances. The patient ingests more sugar and carbohydrates than his body requires. Edmonds (2000) argues that this results in excess of sugars and glucose remaining in the body after normal metabolism. The second diagnosis is the fear of the patient towards insulin injections. The patients of diabetes mellitus are advised to take insulin injections to assist in their bodies insufficient insulin secretions. In a majority of cases of diabetes mellitus, the patients usually have the fear of taking the ingestions. The fear can be attributed to various reasons including embarrassments and general phobia.

Another diagnosis common in diabetes is inefficiency of the body in coping with chronic diseases and complex self care regimes. In this case,Muhlhauser (2000) postulates the patient will always have a history of common chronic ailments and diseases in which the body is too weak to fight and they take a long time to heal completely. Mr. Paul's health history shows that he had been admitted in a hospital previously with hypertension, mild dystharia, atonomic dysfunction, and a previous stroke. The patient diagnosis therefore shows that the body has difficulties in coping with some diseases. Another diagnosis include risks associated with impairment of skin integrity that is related to a decrease in the sensation and circulation of the blood to very low extremes. The diagnosis of Mr. Paul in the musculoskeleton system shows this kind of diagnosis. It has been noted that he experiences mild weaknesses in his right and lower leg, and a decreased sensation in both of his legs bilaterally. This can be attributed from a general perspective to reduced circulation in the patients system.

Patients of this kind of diabetes are also likely to suffer from activity intolerance that is relate to deficiencies in the control of glucose and sugar levels in the blood. The patient may also be diagnosed with a relatively high risk for injury, or hyperglycaemia that comes as an effect of insulin and inability to eat. Mr. Paul’s lack of a proper diet exposes him to this situation. Lack of a good diet means that the patient is likely to have problems in eating, skips a meal or two. This increases the cases of this diagnosis.

Mr. Paul's Nursing Interventions

The subsequent paragraphs will discuss three nursing intervention that are related to the diagnosis of Mr. Paul. As noted earlier in the definitions, a nursing intervention is a set of actions that are usually undertaken by a nurse with the intention of furthering a defined course of treatment in a patient. The goal of the nursing intervention is always directed towards the the general improvement health and comfort of the patient. The nursing plan in this case will identify a nursing diagnosis in Mr. Paul and provide an intervention to deal with the detected problem. Each intervention will also have a method of evaluation to measure the relative success of the intervention.

Nursing Intervention1: Imbalanced Nutrition

The patient's history shows that he doesn't have a strict diet in hos home. It is provided that Mr. Paul eats whatever he likes eating, for example fish, high carbohydrate foods and Chinese foods. These are foods that end up depositing vast amounts of sugar and glucose than the patient's body can deal with.

To deal with this situation, the nursing intervention should first assess the current timing and content of the patient's meals. The nurse will advise the patient on the importance of a strict and personalized meal plan. Benner (1984) explains that this is to reduce the cases of taking more food than the body requires. This goes a long way in fighting obesity and helping the patient to reduce the body weight. The nurse should advise the patient on the benefits of reducing the intake of carbohydrates. The nurse should however be careful to note that the case of diet plans are individualized. The food plans should not insist on one food group in the expense of another. Rather, the plan should strive to achieve a balance diet.

The nurse should discuss with the patient and ensure he understands clearly the goals of dietary therapy. To do this, the nurse and the patient should agree to set an achievable goal of the dietary therapy. For example, setting a target of 10% weight loss of the patient actual body over several months. This is an achievable target and a very effective method of reducing blood sugar and lower other metabolic parameters.

A third intervention advocated for checking the nutritional imbalance is for the nurse to assist the problems discover some of the problems that may have an impact on the adherence to a strict diet. In many cases, it is important to note that no person would wish to be careless and eat anything given the repercussions of such actions. There might be problems that lead the patient to eating carelessly. The nurse should help the patient identify some of these problems and together they come up solutions to these problems. For instance, it is noted that Mr. Paul have a tendency of eating fast foods and high carbohydrate foods. The nurse should help the patient identify the cause of this, and come up with solutions. For example, may be Mr. Paul's wife never cooks at home and buys food from the store, or may be they both do not have time to make specialized meals because of their busy work schedules and other similar reasons. In this case, the nurse may advise the patient to hire expert help in planning the meals at home if he can so afford, or talk to Mrs. Paul and other immediate family members on the importance of a strict diet for Mr. Paul. It could be that they do not understand the importance, and the nurse can therefore explain to them why they need to check Mr. Paul's diet. In this case it is important that the nurse emphasizes that a change in lifestyle and dietary habits should be maintained throughout in life.

Fourthly, the nurse should explain the importance of exercises in reducing and maintaining weight. These advantages include the expenditure of excess calories of energy in exercise and a surplus of improved rates of metabolism and efficient utilization of food. Exercises help in improving the patient's body use of insulin, the burning of excess fat helps the in the decrease and control of weight. A decrease in body fats further leads to an improvement in insulin sensitivity. It has also been noted that exercises also help I improving the circulation and therefore reduces the risks of cardiovascular problems. The nurse should also be keen to explain that the exercises should not be overdone. Intense exercises can have a dysfunctional effect on the patient. This happens because the patient’s body recognizes intense exercises as stress and therefore releases stress hormones that prompt the patient's body to increase the level of blood sugar in order to fuel the overworked muscles. If this happens, the patient may need extra insulin injections. The nurse should therefore advise on the possible light exercises that the patient can engage in.

The nurse should also assist the patient to establish weekly goals for weight loss and suggest some incentives that can assist in achieving them. This can include guided exercises, restricted eating habits and a strict diet. The nurse may offer to guide the patient during the exercises to ensure he does not go beyond the limits. In the dietary measures, it may also be necessary if the nurse can provide a suggestion on the timing of meals and the content inclusion in the patient's diet. The nurse should give expert advise on the food to eat and be included in the diet on a need basis. In so doing, it is important to have a target and a deadline to beat. For example, a target of losing three pounds weekly.

It I also important to include in the nursing intervention strategies to address any cause of problems from a social perspective that can have a negative effect on the weight loss campaign. This can be problems at home, ridicule from colleagues at work or stress from work. The nurse should work with the patient to know some of these dysfunctional elements and suggest ways of dealing with them.

The Intervention Evaluation

After the application of the above interventions, it is important to provide some metrics of assessment. The nurse should check whether the interventions applied are bearing fruits and if they are unsuccessful, know the causes of the problems and come up with correction measures. The evaluation to this intervention, I suggest the nurse and the patient ensure they maintain an ideal body weight with a specific body mass index, which in this case I attribute it to less than 25.

Intervention 2: Risks for impaired skin integrity and Reduced Circulation.

Mr. Paul cardiovascular and peripheral vascular system tests shows that his apical heart rate was at 62 a minute, which is less than the normal 72 heart beats. This can lead to problems in circulation. Further, the musculoskeletal system tests noted mild weaknesses in the right and lower leg and a decreased sensation in both of his legs. This are the reasons for which I advocate for the second intervention. The nursing intervention steps in this are as explained. The nurse should first assess the feet and legs of the patient with particular regard to temperature, sensation, soft tissue, corns, injuries, dryness, deep tendon reflexes, hammer toe or bunion deformation. The nurse should assist in maintaining the skin integrity to protect feet from breakdown; use heel protectors and foot cradles for patients on bed rest, avoid agents that lead to skin dryness, for example alcohol, apply skin moisturizers to prevent the cracking of fissures.

Mr. Paul has been noted to be a smoker. In normal conditions he smokes a pack of cigarettes and this climbs to two in the event of stress. Smoking is harmful to diabetics. The nurse should advise the patient to stop smoking or reduce if possible. Smoking contributes to vasoconstriction and impairs the free circulation of blood in the peripherals. The nurse should strive to help the patient to establish a pattern of behavior modification strategies that seek to eliminate smoking in the long run. This should start at the hospital where the patient is helped to avoid smoking and a follow up I done once the patient is discharged from the hospital. The nurse and the patient should come up with a smoking-cessation program that is achievable and comfortable to both.

Evaluation

The assessment of this intervention is to ensure that there is no reports of skin breakdown. Other measures of behavior modification suggested should also be evaluated to ensure they are followed to the letter. For example, cases of smoking should reduce to acceptable levels if not completely eradicated.

Nursing Intervention 3: Effective Coping with chronic Diseases

Mr. Paul reason for seeking medical attention is because he felt sudden headache, confusion, loss of balance and numbness which are signs of stroke. His client history also shows that he suffered stroke previously. The outcome of this intervention is to enable Mr. Paul to effectively cope with some of these chronic diseases. 

The nurse should discuss with the patient on his perceived effect of the diabetics conditions in his lifestyle, the financial implications , family life and the work place. Walsh (1996) note that the nurse should then explore the previous coping strategies if any, and any skills that have had positive effects on the particular patient. The nurse should further encourage the patient to be actively involved with family matters and encourage the entire family to actively support a diabetes self care program to foster the patience confidence. The patient will gain confidence and boost of personal esteem if immediate family members become and active part and take good care of him in the fight against diabetes. The purpose of this all inclusive approach is to help the patient feel accepted in the society and his immediate family regardless of his condition. The family support helps to reduce stress on the patient and this have a long positive effect in coping strategies.

The nurse may also identify any available support groups that can assist the patient in his attempts of lifestyle adaptation. For instance, the nurse will advise the patient against alcohol and smoking. It is a good and a positive step if the patient is introduced to support groups that offer counseling and training to ex- alcoholics ad those people who want to stop smoking. This will make the patient have an easy time in changing behaviors and adapting to a new lifestyle that is free of alcohol and cigarettes. The nurse may also consider assisting the family personally in providing emotional care and support to the patient. The nurse will always be in direct contact with the patient and she understands best the importance of emotional care. This she can share and instill it in other family members of the patient.

Evaluation

The most effective measure of achievement in this intervention is to check if the patient can verbalize the strategies that are being applied for coping with diabetes. It is also good to consider the patient's response to the strategies and the general impact of their application on the support groups and the immediate family. The nurse should ensure that the responses of this intervention are achieving the goals in the short term and in the long run.

Conclusion

A nursing care plan is a very important part of the nursing process. A nursing plan specifically allows the nurse to diagnose health problems and issues and come up with goals to overcome the problems. A care plan becomes part of the patient's chart and it allows every nurse and doctor and other specialists involved with the patient to monitor the progress and identify potential risks to the health of the patient.

A good care plan should not only treat the physical problem. It should be designed in a holistic approach tat ensures that the emotional needs of the patient that are usually occasioned by the treatment are also taken care of. A nurse should look for any sign of emotional disorientation and the self esteem of the patient and include it in he care plan

References

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