PICOT – Diabetes 2 Barriers
PICOT – Diabetes 2 Barriers
Medical Examiner
South University
October 7th, 2021
Table of Contents
Abstract 2
1.0 Introduction 4
2.0 Overview of the Problem 6
3.0 Problem Statement 9
4.0 Review of Literature 9
4.1 Role of AC1 in older patient with Diabetes 11
4.2 Modification of Lifestyle 11
5.0 Critical Appraisal of Evidence 12
6.0 Implications for Future Research 27
7.0 Implications for Clinical Practice 28
9.0 Summary and Conclusion 33
References 34
Abstract
Evidence Based Practice is usually accessible for different geriatric patients with diabetes 2; however this practice is often not realized in most hospital and a number of health institutions can grow. A lot of studies concentrate on information to realize the issues that call for more training in nursing care for people living with diabetes 2 which is meant to promote the wellbeing of patients. In addition there is also few studies does in regard to how issues are addressed (Abbatecola, Paolisso, & Sinclair, 2015). This means that there can be more positive results when it comes to address the barriers of diabetes 2 care for geriatric patients when evidence based training for nurses is put in to care practice. This has often proved to be a challenge for many and call for different techniques in meeting the needs of the top authority in hospitals, the specialists and changing the view of the society regarding people living with diabetes 2.
The aim of this project is to find out whether for geriatric patients (above 65 years of age) with Type 2 diabetes at DaVita Medical Group Fountain Oaks (P), lifestyle modification coupled with medication compliance (I) compared to only medication compliance (C) leads to decreased Hgb A1C and increased self-reported diabetes control (O) over a 6-month timeframe (T)?
The results of the literature review study for this PICOT indicated that even though there are studies done on the impact of lifestyle modification and compliance of medication on decreased Hgb A1C and self-reported diabetes control, the project shows that lifestyle modification is very important in the success of controlling and managing Hb 1AC among elder patient with diabetes. Future studies related to evidence based practice in diabetes management among elder patients will be required in completion of long term impacts of lifestyle modification for the management of Hgb A1C and increased self-reported diabetes control.
Keywords: Hgb A1C, Diabetes II management, Medication, lifestyle modification
1.0 Introduction
The prevalence of type 2 diabetes keeps increasing consistently as more individuals live longer and grow heavier. Older persons (>65 years) with diabetes are at risk of acquiring a similar spectrum of micro vascular problems as their younger counterparts, albeit possibly at reduced absolute risk if they start diabetes later on in life, which will restrict duration. On the other hand, their absolute risk for macro vascular problems is much higher than for younger patients with diabetes. In addition, they are at significant risk for polypharmacy, functional limitations, and other typical geriatric disorders that include cognitive impairment, depression, urine incontinence, falls, and persistent pain (Awoyemi et al., 2018). Goals for glycemic control, as well as health risk management, must be based upon the individual's overall health (particularly, significant comorbidities, cognitive processes, and functional status) as it effects the life span and risk of complications.
Acute hyperglycemia can worsen dehydration and increase the chance of falling, as well as contributing to orthostatic. In addition, chronic hyperglycemia and its accompanying effects on neuropathy and cognition increase this risk and may hasten the onset of functional loss as a result of ageing. However, older patients may be able to tolerate significantly higher blood glucose levels before experiencing symptoms of an osmotic diuresis. This is due to their lower glomerular filtration rates (GFR) and lower glucose load delivered to the tubules for reabsorption in comparison to younger patients (Awoyemi et al., 2018). The prevention of hypoglycemia, hypotension, and drug interactions as a result of polypharmacy are more important concerns in older patients with diabetes than in younger patients with diabetes. In addition, the management of concomitant medical disorders is critical since it has an impact on the ability to conduct self-management tasks.
For individuals over the age of 65 who are being treated with medication, there are few studies that expressly address optimal glycemic objectives. The following suggestions are based on results of studies conducted in the general population as well as on clinical experience and knowledge. According to the American Geriatrics Society (AGS) guidelines, the American Diabetes Association (ADA), the Canadian Diabetes Association, the Endocrine Society guidelines, the European Diabetes Working Party guidelines, and the American College of Physicians guidelines, they are largely in agreement (Komkova et al., 2019).
Older adults with diabetes are a diverse population that includes people who live independently in their communities, people who live in assisted living facilities, and those who live in nursing homes. They can be in good shape and healthy, or they can be fragile and suffering from a variety of comorbidities and functional limitations. The appropriate target for glycated hemoglobin (A1C) must be determined on an individual basis, taking into consideration factors such as overall health and life expectancy, as well as identified patient-specific risks for hypoglycemia and the ability of the patient populations to adopt and conform to specific treatment regimens, among other things (Komkova et al., 2019). According to the findings of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, intensive glycemic therapy in people at high risk for cardiovascular disease (CVD), particularly in those who take multiple medications, may increase the likelihood for both total and CVD mortality in people with diabetes.
2.0 Overview of the Problem
In the United States, the number of older patients with diabetes is quickly increasing, with substantial implications for both population health and economy as a result of this growth. In the United States, older individuals (those over 65 years of age) account for more than a quarter of the overall population with diabetes at this time (Migdal & Abrahamson, 2016). Even if diabetes incidence rates stabilize, the prevalence of diabetes is expected to more than double in the next 20 years as the population continues to get older. The risk of both acute and chronic micro vascular and macro vascular complications from diabetes is higher in older adults than in any other age group (Migdal & Abrahamson, 2016). These complications include major lower- myocardial infarctions, extremity amputations, visual impairments, and end-stage renal disease, among other things. If you compare patients who are >75 years old to those who are less than 75 years old, you will find that they are more likely to develop problems, die from hyperglycemic crises, and attend the emergency department for hypoglycemia more frequently.
In a recent examination of the economic cost of diabetes, it was discovered that patients with diabetes who are over the age of 65 account for around 61 percent of all health-care costs linked to the disease. Adults over 65 years of age spent on average $13,239 per year, compared to $6,675 for those under 65 years of age (Table 1). As a result, older persons with diabetes are becoming a larger proportion of the population, placing significant quality of life and economic costs on society (Migdal & Abrahamson, 2016). Because of the wide range in clinical presentation, psychosocial context, and resource availability that exists in this population, diabetes management in older adults provides a unique set of obstacles. The living condition of an individual, as well as the availability of social support, can have an impact on both their glycemic goals and also the ways in which they manage their diabetes. Depending on where older patients reside (e.g., whether they live in the community, an assisted-living facility, or a nursing home), diabetes management can change... Some elderly adults with diabetes have excellent functioning and are medically stable; they can take care of themselves and may or may not require the assistance of carers.
Diabetes treatment, on the other hand, can be difficult and even dangerous for those who are unable to adhere to guidelines and manage their own prescription regimens properly. In addition, the older population with diabetes is at increased risk for a variety of additional illnesses (known as "geriatric syndromes"), which include cognitive impairment, depression, physical handicap, pain, polypharmacy, and urine incontinence, among other things. The objectives of diabetes management for older persons must be tailored to the presence or absence of various comorbidities, as well as the patient's living environment and available resources, among other considerations (Rodriguez-Saldana, 2019). Additionally, the higher frequency of acute illnesses and constant changes in overall health in this population might have an impact on glucose regulation and contribute to deterioration of cognitive functioning and physical status. In such situations, it is critical to change treatment objectives as necessary.
A global guideline, "Managing Older People with Type II Diabetes," was published by the International Diabetes Federation (IDF) in 2013. The guideline recommended that older adults' functional status, medical conditions, risk of developing hypoglycemia and presence of micro vascular complications be taken into consideration when setting individualized glycemic goals. It also separated older persons into three broad categories with varying glycemic objectives according to the recommendations. The International Diabetes Federation (IDF) advises an A1C goal of 7–7.5 percent for functionally independent older persons, but an A1C goal of 7–8 percent is indicated for functionally dependent, frail patients, or patients with dementia (Rodriguez-Saldana, 2019). IDF suggests that patients receiving end-of-life care avoid setting a specific A1C target and instead concentrate on avoiding symptoms of hyperglycemia.
The American College of Physicians produced a guidance statement on the selection of targets for the pharmacologic treatment of type 2 diabetes in the year 2018. In this document, Guidance Statement 4 relates to older adults, and it states that "Clinicians should treat patients with type 2 diabetes to minimize symptoms associated with hyperglycemia and avoid targeting a HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, severe chronic obstructive pulmonary disease or congestive heart failure) (Rodriguez-Saldana, 2019).
3.0 Problem Statement
The incidence of type 2 diabetes rise rapidly with age, affecting more than 30 percent of persons in the United States who are 60 years or older. An additional 25% of the population has milder types of hyperglycemia, such as impaired glucose tolerance, both of which increase the likelihood of developing diabetes. However, micro vascular complications may also cause considerable morbidity in this age group). The most serious consequence of incident diabetes in the elderly is a 2-fold increased risk of coronary heart disease (although micro vascular complications also may cause significant comorbidities in this age group). There is also evidence to support the notion that various patterns of hyperglycemia (fasting versus post challenge) may occur at different ages, which may have implications for diagnosis and treatment). In order to effectively treat and prevent diabetes in the elderly, it is critical to recognize aberrant glucose metabolism in these individuals and establish age-appropriate prevention and treatment techniques (Mañas et al., 2017). Whether diabetes prevention strategies are as helpful in elderly people as they are in younger folks is still up in the air. The findings of this study shows that a lifestyle modification program can be extremely effective at preventing diabetes in older individuals. The findings are mainly determined by greater weight loss and physical activity, and it suggests that a lifestyle modification program can be highly suggested for older individuals who are at rising risk for type 2 diabetes.
4.0 Review of Literature
Type 2 diabetes mellitus (T2DM) is a fast growing problem that is affecting more than 415 million people across the globe. In 2013, the rate of T2DM in Indonesia was about 13% of the overall population, and it has been increasing year after year. A growing number of unmanaged T2DM patients may have an economic impact on people’s health, health systems, and the economy overall, imposing a financial strain of healthcare costs and reduced productivity. As a result, managing blood glucose levels is critical. Diabetes self-management behavior patterns are required to achieve optimal glycemic control, lower the risk of health problems, and improve patient outcomes (Mañas et al., 2017). Diabetes management is complicated since patients should indeed reconcile their resources, moral standards, and desires for a healthy diet, physical exercise, self - control from alcohol intake, medical compliance, self - monitoring of blood, and diabetes morbidity and mortality prevention.
Persistence of self-management is incredibly significant in diabetes management, as unmanaged Patients with type 2 diabetes demand ideal communication and cooperation among themselves, their family members, healthcare professionals, and other decision makers. According to the American Diabetes Association, the level of patient engagement in care has a significant impact on diabetes mellitus self-management practice (Onofrei & Smith, 2019) Based on multiple literature, some studies found that DMSM practice can reduce patients' perceived barriers to cognitive and behavioral compliance, which is necessary to attain optimal glucose and insulin control and medication adaptation in the context of everyday living. However, performing DMSM for the long-term regulation of glucose levels is difficult. Several studies on conflicting self-management behavior patterns from various social situations surrounding patients, such as family members, colleagues, and healthcare professionals, have been evidenced (GUO & XU, 2018). Warmth, collaborative effort, and acceptance, as well as active participation in daily activities, were discovered to be different social contexts that impacted DMSM practice.
4.1 Role of AC1 in older patient with Diabetes
Elderly people in good health – Until long-term clinical trial data in fit aging people and those with life expectancy of more than 10 years are available, an A1C goal of 7.5 percent (58.5 mmol/mol) should be considered in patients who are taking diabetes medication to control their blood sugar. Fasting and pre-prandial glucose levels should be between 140 and 150 mg/dL (7.8 and 8.3 mmol/L) in order to accomplish this target (GUO & XU, 2018). The glycemic goal should be slightly higher in older adults with significant comorbidities (A1C 8 percent, fasting and pre-prandial glucoses between 160 and 170 mg/dL [8.9 to 9.4 mmol/L]) in medication-treated, frail older adults with medical comorbidities and in those with a life expectancy of less than 10 years (A1C 8 percent, fasting and pre-prandial glucoses between 160 and 170 While individualized goals for older adults in poor health (e.g., severe comorbidities and/or cognitive and functional disability) may be even higher (for example, A1C 8.5 percent), such goals should include efforts to protect quality of life, avoid hypoglycemia and associated illnesses, and severe hyperglycemia (e.g., >350 mg/dL [19.4 mmol/L]. A hemoglobin A1C of 8.5 percent corresponds to an estimated average glucose of 200 mg/dL (11.1 mmol/L) in the bloodstream (Awoyemi et al., 2018).
It is crucial to note that the measurement of A1C may not be reliable in a number of conditions that are common in older persons, including: Anemia and other illnesses that shorten the life span of red blood cells, chronic kidney disease, previous transfusions and erythropoietin infusions, recent acute illness or hospitalizations, and chronic liver diseases are among the risk factors for this syndrome. Residents in long-term care facilities are more likely than the general population to suffer from various medical disorders (Awoyemi et al., 2018). In this context, glucose monitoring with finger sticks and a glucose meter, or constant glucose monitoring (CGM) in selected individuals, may be utilized to assess glycemic control for management. Separate consideration is given to biologic and patient-specific factors that may contribute to misleading A1C levels (Wu et al., 2019).
In the case of elderly persons, hypoglycemia should be avoided. The prevention of hypoglycemia is a critical factor when selecting treatment drugs and setting glycemic targets. If you have a fragile older adult, you should utilize insulin secretagogues like sulfonylurea and meglitinides with caution (Onofrei & Smith, 2019). You should also use all types of insulin with prudence. In elderly persons, the risk of hypoglycemia is significantly increased compared to younger adults. When compared to adrenergic signs of hypoglycemia (tremors, sweating), older persons may experience greater neuroglycopenic indications of hypoglycemia (dizziness, weakness, delirium, disorientation) (Wu et al., 2019). As a result, older adults may experience delayed detection of hypoglycemia. These neuroglycopenic symptoms may be overlooked or misinterpreted as main neurologic illness (such as a transient ischemic attack), resulting in patients reporting fewer hypoglycemia episodes than they should. Hypoglycemia can lead to a variety of negative consequences, including traumatic falls, severe cardiovascular events, and cardiac autonomic dysfunction (Onofrei & Smith, 2019). In furthermore, extreme hypoglycemia requiring hospitalization has been linked to an increased chance of acquiring dementia, with the risk being larger in people who have experienced multiple episodes. However, the direction of causality, if any, is unclear at this time.
Even a minor episode of hypoglycemia can have a negative impact on the health of frail elderly individuals. For example, periods of dizziness or weakness enhance the likelihood of falling and fracturing when they occur (Onofrei & Smith, 2019). The A1C test, which measures long-term glycemic control in the management of diabetes, continues to be the gold standard. It is now also being used to diagnose diabetes in some cases. A number of conditions that are typically observed in older persons can cause A1C to be mistakenly raised or decreased. The process of becoming older is connected with an increase in A1C. Furthermore, the time it takes for red blood cells (RBCs) to circulate in the blood to be measured is depending on the amount of time the patient has been fasting. The increased exposure time to glucose and protein glycation caused by a variety of situations that increase RBC circulation time can result in an erroneous elevation of A1C readings (Rodriguez-Saldana, 2019). Conditions that limit RBC circulation time, on the other hand, can cause A1C readings to be mistakenly reduced. hemodialysis, Iron deficiency anemia, , erythropoietin therapy, metabolic acidosis, anemia of chronic disease, hemolytic anemia, sickle cell anemia, anemia of chronic disease, thalassemia, polycythemia, and other haemoglobinopathies, as well as recent blood transfusions, are among the conditions that can result in anemia of chronic disease (Rodriguez-Saldana, 2019). This is an important consideration in all diabetic patients, but is particularly important in the case of elderly patients and nursing home residents, who have a higher incidence of these circumstances and for whom A1C-derived average glucose values may well not correlate with average glucose values measured by continuous glucose monitoring (CGM).
It is also vital to remember that the A1C test measures the average glucose over a 90-day time span. It is a poor predictor of glucose fluctuation or the risk of hypoglycemia in the long term. As a result, another clinically significant issue about the use of A1C in older patients is that just lowering A1C objectives in this demographic does not reduce the danger of hypoglycemia in this population. It is critical to avoid relying on the A1C as the sole criterion for glycemic control in frail elderly patients with many comorbidities that may interfere with A1C measurement in these patients (Komkova et al., 2019). When the A1C test is deemed unreliable, the best current alternative is to use the results of finger-stick blood sugar testing to guide treatment.
4.2 Modification of Lifestyle
In terms of glycemic control and the management of many other cardiovascular risk factors, older persons with diabetes differ significantly from their younger-adult counterparts. They also frequently suffer from comorbidities and geriatric syndromes, which make it difficult for them to care for themselves (Migdal & Abrahamson, 2016). It is critical for healthcare providers to be aware of these distinctions in order to conduct an accurate assessment and establish pharmacotherapeutic strategies that are tailored to each patient's specific needs.
It is critical to begin with lifestyle modifications for all diabetic patients, especially older persons, as a beginning point. The use of counseling to avoid excessive carbohydrate loading at any one meal can lower glucose excursions without the need for needless dietary restriction in older persons (Komkova et al., 2019). Exercise is also beneficial for people of all ages. When establishing an exercise program for patients, it is critical to take their physical ability into consideration. In order to prevent falls in older persons who are not particularly active and at risk of falling, it is recommended that they walk for 5–10 minutes, two to three times each day, inside the home. The intensity of the workout regimen can be gradually raised as tolerated.
Older patients with diabetes are at an increased risk of acquiring a similar spectrum of macro vascular problems as their younger counterparts with the same condition. Their absolute risk for CVD, on the other hand, is significantly higher than that of younger adults. Smoking cessation, treatment of hypertension, treatment of dyslipidemia, aspirin medication (where tolerated), and exercise should all be prioritized in older individuals with type 2 diabetes, just as they should be in younger people. Individuals over the age of 65 are more likely than younger patients to benefit from cardiovascular risk reduction, such as treatment of hypertension and cholesterol lowering with statin therapy, rather than from strict glycemic control. Diabetes, as well as being over the age of 50, are significant risk factors for coronary heart disease (CHD) (Migdal & Abrahamson, 2016). Consequently, it is not unexpected that coronary heart disease (CHD) is the primary cause of mortality in older diabetic individuals. In the field of optimal cardiovascular risk reduction in elderly individuals, there are few studies that have been conducted. Studies in older persons with or without diabetes, as well as studies in patients with diabetes that included some older adults, have been used to draw conclusions about the benefits of cholesterol lowering and blood pressure control. The benefit of cardiovascular risk reduction is similar to that of glycemic control in that it is dependent on the patient's frailty, general health, and expected duration of survival (Mañas et al., 20170. The cessation of smoking is critical since smoking in people with diabetes mellitus is an independent predictor for all-cause mortality, which is mostly attributable to cardiovascular disease (CVD) (Mañas et al., 2017). Although there are no high-quality trial data on smoking cessation, it is important to promote it as much as possible.
Treatment of hypertension in elderly people, including those above the age of 80, has been shown to be beneficial. The recommended therapy goals and pharmacological alternatives for patients with diabetes and older individuals are discussed in greater depth elsewhere on this site (Afable & Karingula, 2016). When lifestyle adjustments alone are insufficient to achieve desired treatment outcomes, pharmaceutical therapies should be considered. In the current market, a wide range of oral and injectable medicines are available, with the majority of them being well accepted by older adults.
5.0 Critical Appraisal of Evidence
In a study conducted by Guo and Xu (2018) Cardiovascular disease (CVD) seems to be the world's leading cause of illness and death in type 2 diabetic patients mellitus (T2DM), with a stroke risk that is two times that of the general population. Previous studies show that pioglitazone and GLP-1RAs offered stroke protection, whilst DPP-4 inhibitors and insulin had no effect on cardiovascular morbidity and mortality. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have evolved as an important and convincing category of oral antihyperglycemic agents that foster insulin-independent hypoglycemia by preferentially lessening renal glucose as well as sodium reabsorption. The authors discovered no meta-analyses or comprehensive reviews exploring the effects of SGLT2 inhibitors on stroke risk in T2DM patients. As a result, the authors conducted a meta-analysis of all published studies and trials to qualitative as well as quantitative evaluate the impacts of multiple SGLT2 inhibitors on stroke risk, including responsiveness and subgroup assessments (Guo & Xu, 2018).
This study is significant as it presents impotent facts about the risk factors that increase rates of type 2diabetes such cardiovascular disorder, lifestyle behaviors, stroke, and non-compliance to medications. Moreover, the article has proposed various interventions that help prevent T2DM particularly in primary care such as pioglitazone and GLP-1RAs, DPP-4 inhibitors and insulin as well as Sodium-glucose cotransporter 2 (SGLT2). The article is important to nurses and patients as it elaborates the role of each party in the prevention of T2DM.
The study by Guo and Xu (2018) has a level V confidence level demonstrating high validity, reliability as the various research databases and publications used in the study provided useful information that can be used in the prevention efforts to prevent and manage T2DM.
In a cross-sectional study conducted in 2018 by Awoyemi et al (2018) to evaluate the markers of metabolic endotoxemia and their relationship with metabolic syndrome in an elderly male population at high cardiovascular risk, the author found that, Metabolic syndrome (MetS) is a group of diseases that, when combined, increase the risk of developing heart disease by 1.5–2.5 times. Recent research suggests that gut dysregulation and bacterial composite spillages may make a significant contribution to the metabolic abnormalities and systemic inflammation seen in MetS patients. Experiments have shown that chronic exposure to lipopolysaccharide (LPS) induces MetS-like symptoms. LPS communicates with the innate immunity through the LPS-binding protein (LBP) and the co-receptor CD14, both of which are considered indicator of gut leakage. The authors also argue that, there is no universally accepted definition of MetS, which is a testament to its complexities. MetS is a group of hematological and biochemical situations that frequently coexist, implying an underlying pathological basis. Central obesity, insulin deficiency intolerance, dyslipidemia, and high blood pressure are the common factors, also known as Norman Kaplan's "deadly quartet." The exact pathophysiology is still unknown and widely debated.
The results of their study indicate that LBP and sCD14 levels don't really differ among individuals with and without MetS. However, a pattern toward enhanced MetS risk can be seen through LBP quartiles. In terms of MetS constituent elements, patients who fulfill the waist circumference requirement have a significantly higher concentration of LBP compared to those who do not. In addition, the researchers discovered a weak but significant relation between LBP and waist measurement. The study is important because it looked into whether circulating levels of LBP and sCD14 are linked to the presence of MetS and its constituents, as well as any link to systemic inflammation. The population sample for this study allows the article to achieve high validity and reliability because the researchers examined 482 men aged 65 to 75 years, all of whom were at high CVD risk. MetS criteria for the Adult Treatment Panel III of the US National Cholesterol Education Program were fulfilled in 182 subjects (38%).
The article by Awoyemi et al (2018) has a level III confidence level as it entails an observational randomized controlled trials study of people with T2DM and an appropriate control (comparison, reference) group of people who do not have the disease The connection of a characteristic to disease is evaluated by analyzing the diseased and non-diseased people in terms of how commonly the characteristic is present or, if quantitative, the levels of the characteristic in each group.
An observational study conducted by Komkova et al (2018) to evaluate the impact of an eHealth intervention on diabetes patient populations in a real-world state and city setting. The authors found that the eHealth intervention is centered on an initial conversation to determine a strong compassionate relationship, accompanied by digital lifestyle mentoring and collaborative effort endorsed by a patient-led Web-based community. The intervention includes evidence-based behavioral change techniques (BCTs) including tailored information, constant self-monitoring, health and wellness coaching, in-person responses, reminders, and peer-to-peer support. The intervention empowers customized care and prolonged patient participation over time with a limited extent of HCP insight in the process of strong organizational lifestyle and maintaining this transformation by instituting a close connection at first in a face-to-face discussion, which is then followed digitally through the eHealth intervention. The authors stressed that the most of premature mortality from non-communicable diseases can be avoided by encouraging healthy lifestyles. Reports and studies assert that Web-based and mobile digital electronic health (eHealth) alternatives can enhance healthy behaviors; however, they emphasize the lack of affordable treatment options appropriate for the real-world PC environment, with most studies and framework synthesis undertaken within educational organizational boundaries, and the need for long-term interventions to assess sustainability. The authors found that eHealth health and wellness training using multiple behavioral change methods (BCTs) like tailored information, self-monitoring, health and wellness training, in-person responses, reminders, and participant assistance characterized by a strong close connection resulted in a dramatic weight loss of 7.0 kg over a period of several months. The authors used a participant observation approach to investigate the first statistical results on self-reported weight change among type 2 diabetic patients who participated in an eHealth intervention within the municipality HCPs for at least 3 months.
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According to the results of the study, the eHealth intervention drastically decreased weight among patients with type 2 diabetics, by 4.3 percent of the original body mass, or 4.8 kg, over an average time frame of 7.3 months. Patients who participated in the intervention for more than 9 months lost 6.3 percent of their body weight, or 6.8 kg. The research is important because it provides support for the positive impact of real-life eHealth lifestyle modifications on the lifestyle of diabetic patient in a municipal setting. Future research is required to determine whether the outcome is long-term.
The study by Komkova et al (2018) has a level II confidence level as it evaluates people who presently have a T2DM who undertook eHealth intervention over time and compared with another group of people who are not affected by the condition thus demonstrating a high level of validity and reliability. The connection of a characteristic to disease is evaluated by analyzing the diseased and non-diseased people in terms of how commonly the characteristic is present or, if quantitative, the levels of the characteristic in each group.
A systematic review and meta-analysis study conducted by Mañas et al (2017) to formulate clinical practice guidelines for the treatment of diabetes in older adults found that more than 90% of elderly adults have type 2 diabetes mellitus (T2DM), and in one study, this figure was 96 percent. T2DM is an age-related deadly disease, with an incidence of 33% in the 65+ people in the United States, and nearly 50% of elderly adults satisfy the definition for pre-diabetes. The age group 65 to 79 years has the highest prevalence of recently diagnosed diabetes. Given the diversity of the pathogenesis of type 2diabetes in older adults, the contribution of the endocrinologist or diabetes care professional in the treatment of an individual patient may vary significantly over the course of the illness. The researchers also note that in patient populations aged 65 and older with recently diagnosed diabetes, an endocrinologist or diabetes care specialist should collaborate with the healthcare professionals, an interdisciplinary team, and the patient to establish individually tailored diabetes therapeutic goals. Making decisions about this role necessitates direct engagement and open and honest communication between the endocrinologist or diabetes care specialist, the family physician, and the patient. Due to the obvious high prevalence of diabetes and its comorbidities on overall wellbeing, many elderly patients stand to gain from multidisciplinary care.
According to Mañas et al (2017) the diabetes care professional and the diabetes care personnel are responsible for diabetes management for patients and work collaboratively with providers who handle the patient's other health complications and comorbid conditions. If the patient does not have a primary care physician or is already under the care of a diabetes care practitioner for long-term T1D or other endocrine situations, this issue can occur by default. Highly complicated hyperglycemia diagnosis, reoccurring severe hypoglycemia, multiple diabetes problems, and a long history of diabetes are special signs for the endocrinologist to take over on overall diabetes management for an elderly adult.
This study is significant because the authors assert that the utilization of fibrates, as evidenced in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, contributes to no considerable value in terms of the primary endpoint or premature death, and thus it is not advised for CVD prevention in diabetic patients. Interestingly, fibrates should be used with caution in conjunction with lifestyle interventions due to an increased risk of myopathy, although the combined effect can be effective in treating patients with triglyceride levels >500 mg/mL who may be at risk for pancreatitis.
The study by Mañas et al (2017) has a level VII confidence level and indication that it has a low reliability and validity as the data and information are gathered from expert committees who cannot be fully relied as their sources might be doubtful.
The risk of developing type 2diabetes is substantial in older adults and is anticipated to rise in the coming decades. Diabetes is associated with functional disability, multiple comorbidities, and early death in the weak proportion of older people. A thorough geriatric evaluation, including properly functioning, cognitive, mental, and position in society, it is recommended for determining glycemic benchmarks and glucose-lowering therapeutic interventions based on patient choices, needs, and potential dangers. The treatment approaches for diabetic older adults are the same as those for the general population. In a systematic review analysis conducted by Migdal and Abrahamson (2016) to evaluate effective interventions to manage T2DM among older adults, the authors found that Therapeutic interventions must be advised and monitored with care, bearing in mind the patient's cognitive capabilities, presumably life drug reactions, cardiovascular events, and the ultimate intention of preventing hypoglycemia. A thorough nutritional assessment using necessary tools, and a balanced and regularly monitored physical exercise, also contribute to the effectiveness of a customized care plan, which is required by older adults with type 2 diabetes.
The authors also adds that modifications in body composition accompany aging, most notably a reduction in lean mass and skeletal bone quality in contrast to an increase in overall body fat. Non-fat tissue damage includes lean muscle loss, which leads to sarcopenia and declined muscle capabilities, whereas changes in total body fat mass are linked with an increased incidence of developing diabetes. Diabetes is commonly accompanied by health problems and/or comorbid conditions in older patients, with at least one in 60 percent and four or more in 40 percent experiencing health problems and/or comorbidities.
The study Migdal and Abrahamson (2016) is important as it provides appropriate interventions to the treatment of T2DM highlighting that T2DM treatment begins with active education designed to promote proper diet and sufficient physical activity, especially among older patients. The identification of glycemic benchmarks and glucose-lowering therapeutic approaches must then accompany, putting the focus as much as possible on patient preferences and needs, and in any case with the objective of minimizing CV risk. Furthermore, a comprehensive needs assessment CNA), which tailors psychiatric treatment to the patient's individual needs and strengths, should be incorporated into daily practice. CNA allows for the evaluation of older patients' diverse characteristics regarding physical and cognitive behavior, comorbid conditions, and family/social support.
The study by Migdal and Abrahamson (2016) has Level I confidence level whereby various research studies that address the issue of T2DM are critically assessed and evaluated. The researchers have also employed a systematic approach to locating, compiling, and analyzing a range of literature on managing T2DM among older adults with T2DM, an indication that the various literature reviews used by that authors are reliable and congruent with the research problem or question. This aspect makes the results of the study be reliable and valid.
Another systematic review and meta-analysis study conducted by Nyambuya, Dludla & Nkambule (2018) to explore T-cell function and cardiovascular events in T2DM patients, as well as the therapeutic efficacy of blood glucose-lowering prescription medications in reversing hyperglycemia-induced T-cell dysfunction and myocardial infarction in patients with type 2 diabetes. The researchers argue that in an age of rapid urban development, the global burden of diabetes complications has risen dramatically, particularly in developing countries. T2DM, a low-grade inflammatory responses condition characterized by chronic hyperglycemia (high blood glucose level), insulin sensitivity, and chronic T-cell activation, is of specific interest. Over the years, the burden of non-communicable illnesses such as type 2diabetes and heart disease has risen dramatically in developing economies. Although emerging research shows that chronic immune activation plays a role in the pathophysiology and progression of T2DM and CVDs, the precise role of T cells remains unknown. The authors suggest that T2DM patients have significant concentrations of pro-inflammatory cytokines, which can lead to systemic inflammation and a greater risk of cardiovascular disease (CVDs). Remarkably, the risk of morbidity and death from CVDs is more than fourfold greater in people with T2DM than in people who are not diabetic. The reversible connection between T2DM and inflammatory responses has been well characterized, with inflammation playing an important role in both insulin sensitivity (IR) and impaired glucose tolerance, both of which increase inflammation.
This study is applicable in the nursing practice as the authors articulate that Contemporary T2DM medications have been shown to be strongly useful in the treatment of hyperglycemia, although with limited cardio-protection. Metformin, a first-line oral anti-diabetic stimulant that decreases blood glucose levels by directly suppressing hepatic glucose output and activating adenosine-monophosphate-activated protein kinase (AMPK), is one of many drugs. AMPK, surprisingly, helps to regulate cellular energy balance in the body as well as T cell distinctions. However, the precise effect of metformin on T cell function and cytokine production is unknown. Even though previous researchers have noted immune impairment in patients with diabetes mellitus, the role of adaptive immune system, particularly T cells, continues to remain constrained and contested. T cells, on the other hand, appear to be an important factor in the growth of T2DM and its complications, including CVDs. Moreover, there are a prospective diagnosis and treatment focus in disease control and management. The findings of this study will point to new opportunities to investigate at the molecular level in order to solve problems in the diagnoses and prevention of diabetics. As a result, the workload of diabetes complications on universal healthcare funding levels will be reduced.
The study by Nyambuya, Dludla & Nkambule (2018) has Level I confidence level whereby various research studies that address the issue of T2DM are critically assessed and evaluated. The researchers have also employed a systematic approach to locating, compiling, and analyzing a range of literature on managing T2DM among older adults with T2DM, an indication that the various literature reviews used by that authors are reliable and congruent with the research problem or question. The findings of this study will point to new opportunities to investigate at the molecular level in order to solve problems in the diagnoses and prevention of diabetics. As a result, the workload of diabetes complications on universal healthcare funding levels will be reduced.
In an advocacy research conducted by Onofrei & Smith (2019), the researchers argue that he advocating role of neuropsychology nursing professionals, comparable to others directly implicated healthcare providers is to assist the patient and the primary caretaker through active engagement in evaluating needs during the disease process and hence work on improving an existing conditions of state. Advocacy is an exercise to respond in the patient's best interest, in accordance with instructions. The neuropsychology nurse must keep patients adequately informed and undertake treatment and care strategies with professionalism and dedication while establishing patients' personal privacy when caring for their health. The authors adds that With the help of a research study of a neuro-oncology patient, it is proved how neuropsychology nurses will indeed be interested in determining and comprehend needs, represent the views of others when necessary, and support the planning and implementation to effect change and, as a result, enhance the quality of care. Within care coordination, the neurology nurse can serve as a patient's treatment explorer. When a neurology nurse is recognized as a patient advocate, she is able to provide awareness for the patient populations she cares for. Neurologists are frequently particularly worried, and rightly so, that their competences, knowledge, and hours invested with patient populations are not paid appropriately. Cognitive solutions and counseling services are not given enough attention in regions of the world where physician reimbursements are based on a rigidly defined protocol. Processes and investigations are compensated more than others. Neurology associations have already been continuing to work on these issues for a long time. Interest group is more likely to be more successful if, in particular with respect to office bearers, ordinary representatives who have been taught in advocacy and activist group’s skills join in on a wide array of topics.
The study by Onofrei & Smith (2019) is important in the nursing field stating that the relevance of advocacy for health professionals has recently been recognized, not least because of the socially constructed and regulatory environment. The latter has a significant impact on a physician's rights and responsibilities, independence, and the types of treatment they can provide to his patients. Nothing could be further from the truth than limiting the science and technology of healthcare to establishing a diagnosis, drafting a prescribed medication, or performing surgery. It is extremely broad and comprehensive. This awareness is frequently wrongly believed to be present a false premise, and there is no need to identify and characterize it in a standardized manner.
This study falls under level VII of confidence with low validity and reliability. The results of this article cannot be relied as they do not explain the exact approaches that can be used to treat type 2diabetes among different population groups. The article however highlights the importance of continued research on the most effective approaches to treat type 2diabetes like behavioral therapy. Moreover results of the study are applicable as they emphasize on physicians to access more education of the field of diabetes as this would enable them to effectively manage complex pains like type 2diabetes.
A qualitative research study conducted in 2019 by Wu and co-authors as an attempt to evaluate the self-management experiences of middle-age and older adults with type 2 diabetes found that diabetes is associated with an increased risk of early mortality, functional impairment, and intermingling illnesses. Diabetes affects 425 million adults globally, with the Western Pacific region accounting for 37% of those affected. If T2DM is not well managed in middle-aged people, the resulting difficulties place a significant effect on patients, their families, and public health. Medical treatment may be needed, or the associated complications may result in a decrease in productive output, forcing the individual to exit the labor force. As a result, disease management and improved glycemic control are critical for diabetics in their 40s and 50s. The authors also found that, Type 2 diabetes has a negative effect on various aspects of a person's life. In broad sense, systematic personal care is linked to better blood sugar control. Diabetes self-management enhances health of the public and well-being significantly. Diabetes independent learning is the process of obtaining the knowledge and skills needed for self-care. Daily diabetes monitoring (via diet, workout, glycemic control, and adherence to medication) is predominantly the patient's obligation; thus, patients must be provided with the necessary knowledge and training to self-manage.
Many studies have been conducted to explore the variety of factors connected to diabetes self-management in people with type 2 diabetes. From 2001 to 2005, Taiwan's National Health Insurance Administration established an interdisciplinary diabetes support program designed to improve diabetes care. This study shed new light on the perceptions of Taiwanese middle-aged and older adults with diabetes self-management. The authors recommend that Healthcare team members should indeed be engaged in diabetes independent learning as early as necessary to limit patients' nervousness and establish more patient-centered, culture-sensitive professional experience. In addition to tracking patients' self-management, healthcare faculty should focus more on patients' successful transition to and cooperation with the disease.
The qualitative study by Wu et al (2019) falls under level V of confidence level. The researcher employed a quantitative approach of integrating the findings of peer reviewed studies (normally from the scholarly studies) and synthesizing summaries and findings that can be used to assess therapeutic efficacy, plan recent research, and so on. It is frequently a summary of clinical studies. The analysis of the results yielded three themes: paying close attention to the voice of the body and examining physical effects, re-recognizing diabetes and obstacles, and self-management deployment difficulties.
Diabetes mellitus is a complex, chronic disease that necessitates continuous medical care as well as multifaceted risk-reduction strategies that go beyond glycemic control. Continuous patient self-management training and awareness are crucial to preventing acute health problems and lowering the risk of long-term side effects. There is substantial evidence to support a variety of interventions designed to improve T2DM outcomes. The American Diabetes Association's (ADA's) endeavors to enhance and upgrade the Standards of Care so that healthcare professionals, healthcare plans, and decision makers can keep relying on them as the most influential and up-to-date diabetes care standards. As stated by Rodriguez-Saldana (2019), once healthcare professionals, scientific experts, regulatory bodies, and/or policymakers seek assistance and/or clarification on a medical or scientific issue associated with diabetes, the scientific proof is conflicting, emerging, or inadequate, a consensus report is required. Consensus findings may also identify the gaps in scientific proof and suggest areas for further research to fill these gaps. A consensus report is not really an ADA stance and only reflects expert analysis; however, it is generated under the umbrella of the Association by an invited expert. The author adds that scientific proof is only one part of the clinical decision-making process. Clinicians treat individuals, not groups; standards should always be translated with the specific patient in mind. Personal circumstances, like cognitive impairments and co-occurring diseases, age, education, functional limitations, and, most importantly, patients' beliefs and preferences, must be taken into account and may result in varying treatment objectives and strategies. Furthermore, traditional evidence oligarchies, such as the one adopted by the ADA, may overlook essential complexities in diabetes care.
The research sheds new light on the field of nursing because it shows that the area of T2DM care is changing dramatically as latest research, innovation, and therapeutic interventions that can enhance the care and well-being of people with type 2diabetes emerge. The American Diabetes Association (ADA) has long been an advocate in creating standards that reflect the most current state of the field, with yearly updates since 1989. According to the authors, patients with type 1diabetes, type 2diabetes, or pre-diabetes who are overweight or obese must manage their weight. To attain significant drops in obesity and overweight and enhance clinical predictors, lifestyle behavioral interventions should be rigorous and have frequent follow-up. There is convincing evidence that even modest long-term weight reduction can postpone the development from pre-diabetes to type 2diabetes.
The study by Rodriguez-Saldana (2019) has a high level of validity and reliability as it fall under level I of confidence level evaluating the impact of unjustified variations of medical practice in relation to clinical outcomes, the cost of healthcare and patients with T2DM. The results of the study indicates that various levels of clinical interventions will be required including administration of the condition and training for nurses to ensure the right intervention per individual patient. The results also shows that The study results in this article indicates that despite the increased efforts to handle type 2 diabetes, issues like acceptance, awareness and evaluations still exists The results of the study are applicable as they clearly demonstrates that the goals of CPG include reducing the unjustified variation in medical practice, improve the quality of health care, and accelerate adoption of effective interventions.
In a systematic review of literature conducted in 2016 by Afable and Karingula with an objective of identifying the newest approaches to type 2 diabetes (T2DM) prevention and control in the developing world context. The authors found that, diabetes causes early mortality as well as comorbidities like blindness, neuropathy, kidney problems, and cardiovascular problems. It is well understood that T2DM risk factors like physical exercise and eating habits are adjustable and can potentially be overturned with healthy lifestyle choices; there is a possibility to participate and avert or preventing the progression of diabetes. Diabetes development has been related to worldwide secular health and wellness shifts caused by upward socioeconomic progress and rapid population growth. Diabetes prevention and management endeavors have received a lot of attention in the United States and Other countries, but the disease's impact is felt all over the world. By restricting research to high-income nations, we risk overlooking the opportunity for low- and medium countries to gain knowledge from one another and leverage global capability to enhance more cost-effective approaches. The Diabetes Prevention Program (DPP), a National Institutes of Health-funded randomized clinical study in the United States, revealed a 58 percent drop in the risk for type 2 diabetes through thorough lifestyle modifications among people participating and who were obese and had pre-diabetes.
Their analysis also highlighted the different strategies to organized dietary changes in diabetes management that have been shown to improve outcomes like HbA1c. Further research is required in this regard, however, because all of the study results had small sample sizes and only one was an RCT. More measures should be taken to incorporate structured dietary components into diabetes treatment programs, such as the advancement of low-glycemic diets, according to a recent 2014 assessment on dietary strategies for preventing and treating diabetes. All diabetes preventative measures research findings demonstrated efficacy. It is worth noting that India dominated the world in the number of trials and is the only nation that has evaluated trials on children. As a result, it is necessary to observe India's advancement and acknowledge their research as a resource for improving strategies in developing and underdeveloped countries, as well as a resource for developing cost-effective strategies in more prosperous countries.
6.0 Implications for Future Research
Elderly patients suffering from diabetes II have a below average type of lifestyle modifications since they mostly need assistance and constant reminder on what they should eat, how frequent they should exercise and medication schedules. With good lifestyle modification and medication intake, the research suggest that there is going to be an improved blood sugar levels. It is important to implement such interventions as it can encourage better modification of lifestyle which help elder patients living with diabetes II control their sugar levels and thus reduce the number of complications in the process.
Lifestyle interventions can also play the role motivating the patient towards medication intake, health checks, and good mental health development. Current studies on the impact of lifestyle modification in the management of Diabetes II has continued to show the impact of such interventions in the long term, there is however need for more research in the area (Afable & Karingula, 2016). This research also calls for the need to look in to the different socioeconomic, cultural, and changing lifestyles which in essence contribute to prevalence of diabetes II among elder patients in the United States, by highlighting the need to empower more elderly patients to pursue good health and wellbeing based on individual terms. By doing that, the trends towards hospital admissions, palliative care and death or complications related to diabetes II among elder patients will also reduce (Komkova et al., 2019). There is need for further evidence based studies on whether lifestyle modification encourages adherence to medication despite the fact that it can help in the management of Hgb A1C and increased self-reported diabetes control. This is important as the implications of this study contributes to the general positive long term outcomes of patient care in both primary and secondary care settings.
7.0 Implications for Clinical Practice
Based on this study, the clinical practice implication is lifestyle modification as an intervention towards decreased Hgb A1C and increased self-reported diabetes control among patients in both primary and secondary care settings as indicated in the picot question: When it comes to the geriatric adult patients with diabetes 2, clinical staff, organizational mission statement, and goals are at stake. How does it incorporate the use of evidence based practice to enhance the patient’s experience living with type 2 diabetes?
Even through the were limited studies regarding the long term impact of lifestyle modification in the management of diabetes II among older patients, the current studies show that lifestyle modification can indeed help in the reduction of Hgb A1C levels and increase medication intake.
The role of the practitioner in this manner will be to advice, education, and influence and refer the geriatric patients which will include referring them to physiotherapists and nutritional experts. The practitioner will also consider the willingness of the participants to enter in to the program and go through with the lifestyle modification practices which also includes a follow up on the lifestyle modification programs as required. ( eg. Dieticians, behavior change providers and physicians).
Current studies also indicate that nursing care practitioners may lack the required knowledge in the implementation of lifestyle modification programs for older patients with diabetes II. It will be important to ensure that the nursing care practitioners are proficient with the lifestyle modification practices since there is an increasing number of patients with Diabetes II that will benefit from the lifestyle modification programs. With continued education, the nursing care providers are able to prepare themselves to implementation of this lifestyle modification intervention among older patients with diabetes II.
8.0 Evidence-Base Practice (EBP) Implementation Model Application
Compared to therapies that did not include any theoretical underpinning, the intervention that followed was more effective in terms of promoting health-related behaviors than the intervention that before it. Given that an intervention that has been designed, along with guidelines, might be employed in the assessment of the intervention. Furthermore, when nursing intervention was implemented, the interpersonal parts that were best led by the Social Cognitive (Rodriguez-Saldana, 2019) Theory were the aspects that had the greatest impact on behavioral outcomes (SCT). SCT proposed that personal, environmental, and behavioral factors operated as mutual, interacting determinants of each other, and that these factors were influences of an individual's ability to control lifestyle modification and the determinants of lifestyle modification, according to the theory (i.e., personal, environmental, and behavioral factors).
The goal of this study was just to modify the older patient's lifestyle in terms of physical activity, social habits such as smoking and drinking alcohol, and eating. Participants in this study were above the age of 65. Activities of the lifestyle modification program included providing knowledge related to diabetes II, physical activity and diet plan, group brainstorming and discussion, presenting role model, going to practice gymnastic fitness, and self-monitoring of gymnastic fitness and eating plan for patients with Type 2 diabetes at DaVita Medical Group Fountain Oaks, and testing the effectiveness of the lifestyle modification program.
The activity worked with about 30 patients that have diabetes 2. All the interventions were evidence based and included the following:
- Ensuring that all forms of care is centered towards the wellness of the patient. It is important that all nurses in the line of care learn to practice recommendations whether they are evidence based or are based on the opinion of the charge nurse. This is because all of them are intended to ensure that there is an overall approach to continuum of care for geriatric patients living with diabetes 2 (Migdal & Abrahamson, 2016). The art and science of medicine will thus come in when the clinician is also experiencing recommendations for treatment especially for patients that may not have been able to meet the criteria for eligibility for the studies that all the treatment guidelines have been based (Nyambuya, Dludla, & Nkambule, 2018).
- Evidence Based Practice interventions will consider other illnesses that individual patients might be treating like asthma, blood pressure or cancer. This is because type 2 diabetic patients were often seen to increase in the risk of other illnesses like the cardiovascular disease, meaning when the nurse has a patient centered approach, this will entail coming up with a comprehensive plan that can reduce the risk for cardiovascular disease by also addressing the blood pressure and the control of lipids, cessation and smoking prevention, management of weight, health lifestyle choices and physical activities (Migdal & Abrahamson, 2016).
- Intervention will look at the issue of treatment and care for the diabetes 2 patient across the whole lifespan. Since an increasing population of patients living with type 2 diabetes are adults. This means that there they may have transformed from Type 1 as they grow older, a stage life for which there is need to call for more evidence required for any clinical trial or lead the required therapy. All the changes in demography means that there is a lot of challenges when it comes to the practice of high quality care for geriatric patient with diabetes 2, which calls for the need to improve the coordination required among the clinical teams as the patients grow from various lifespan stages.
- As part of intervention there was the issue of becoming advocates for evidence based practice for patients living with diabetes 2. Among the interventions include providing an active support and engagement for which they will require in advancing the policy cause. Advocacy is important and will be required in improving the lives of patients especially those with other chronic diseases. With the fact that there is the growing number of people with type 2 diabetes who are not able to perform several physical activities, while others are overcome by social lifestyle like smoking, the nurse will be a very important person in educating and encouraging the patient to address and change most of the societal determinants at the main cause of the problem (Migdal & Abrahamson, 2016). Within the community healthcare setting for nursing clinical practice, there will be standard evidence based guidelines and recommendation for practice that can be used in identification of various issues to be looked in to and more research to be done (Onofrei & Smith, 2019). The intervention would also mean that the nurse educates the patients about their choices for healthy lifestyle management of the disease like taking medications the right way and in time and prevention other diabetic related complications (Komkova, Brandt, Hansen Pedersen, Emneus, & Sortsø, 2018).
9.0 Summary and Conclusion
For all the 30 participants, there was a supervised exercise for evidence based practice which included diet, exercise, and management of medication among other factors that provided an active development for the geriatric patients with type 2 diabetes. Evidence based approaches were used as the control factors for the group for a period of 3 months. By use of this strategy, it is evidence that there could be prolonged life and increased activities among geriatric individuals with diabetes 2.
Evidence based Practice interventions can help increase the lifespan of geriatric patient with diabetes 2. The risk however will increase with various Protease Inhibitors and nucleoside reverse transcriptase inhibitor, meaning when the management of insulin is put in to practice, then diabetes 2 can be contained and the patient is able to live with it for a long time. In most cases in a community hospital setting, nurse for patients with diabetes 2 lack evidence based training which means that provision of care is often compromised in regard to the social, cultural, and economic aspects of the patients, however, when EBP is implemented, that the continuum of care is well documented. The study shows that
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