Developing a Plan of Care for a Patient with Type 2 Diabetes and Hypertension

This essay develops a plan of care for a patient with type 2 diabetes and hypertension, exploring relevant theories and concepts supporting assessment planning and delivery of healthcare interventions. The essay examines the patient's complex needs from a biophysical perspective and evaluates the role of nurses in providing care to patients with changes in dependency level and healthcare needs. The essay also discusses local community services required for addressing the complex healthcare needs of the patient.

Running head: NURSING
NURSING
Name of the Student:
Name of the University:
Author Note:

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Introduction
The essay would develop a plan of care for Mr.Jameson, who had been suffering from
type 2 diabetes and hypertension. The main aim of this essay is to examine the needs and the
evidence based care for patient with complex health and social problems. The clinical
judgement and the decision making will be supported by the national policy guidelines.
While chalking out the care plan the local community needs in relation to the patient will also
be assed in the essay. The essay would commence by providing a brief overview of the case
scenario, followed by a vivid discussion exploring the relevant theories and the concepts
supporting the assessment planning and the delivery of the health care interventions. The
background of this essay would give a descriptive idea of the journey and the life style of the
patient, including the medical cues, past medical history, the present situation, an idea about
the personal and the social history of the patient. The discussion part of the essay would
further review the complex needs of the patient from the biophysical perspective. The essay
would further explain the local community services required for addressing the complex
health care needs of the patient. The essay would also evaluate the role of the nurses in the
assessment and planning of the delivery of health care to the patient and would critically
analyse role of the nurses in providing care the patients with changes in the dependency level
and the health care needs of the patient. All the facts should be supported by the evidence
based literary sources.
Background
The case study is about Mr. Jameson, who is a 63 years old African- Carribean suffering
from Diabetes type 2 and hypertension. Mr. Jameson has had poor glycaemic control and his
glucose level was found to be elevated. On diagnosis the blood sugar level has been found to
be more than the standard level. The BMI of Mr. Jameson is 36, which is towards marginal

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obesity. The blood pressure of Mr Jameson is 190/100 which is much higher than the normal
value. He had been receiving Angiostenin converting enzyme (ACE) inhibitor for many
years. Recently, he had been facing with some problems with his visions. Mr. Jameson had
been working as a long distance lorry driver and have diabetes for long 15 years. He could
not control his diabetes probably due to his work role and hence could not adhere to
medication regimen and had missed several clinical appointments. He did not even bother to
test his blood sugar level regularly in spite of being given a blood sugar testing kit from the
clinic. His father had lost vision for the last few years, which could have been due to high
diabetes and have died of stroke three years ago, that indicates that his father would have
similar conditions as Mr. Jameson. Mr. Jameson is married and has four children from 19 to
35 years old and he is married and stays is a three bedroom house at London. Mr. Jameson’s
diabetes is triggered by his sedentary life style and his inclination towards fried food.
Unhealthy fats, sweetened beverages, processed grains increases the risk of type e diabetes
(Diabetes, U.K.2015). Once he gets back from work, he likes to go to a pub with his friends
and consume lots of fried foods. Jameson’s wife also suffers from type 2 diabetes, but has a
good glycaemic control. Jameson has put on more weight and is a bit depressed, and had been
planning to retire soon. Mr. Jameson’s sedentary life style and living on fried foods has
probably increased the blood glucose level in the patient.
Hence the, clinical priority of Mr. Jameson is, his uncontrolled diabetes and
hypertension. Other comorbidities associated with this are his increasing weight, depression
and impaired vision. Other clinical priorities involves health care access to the entire family
as, since it is known from the case study, Jameson’s wife has also been suffering from
diabetes type 2 and hence education to should also be provided to her , helping her to control
her diabetes . Mr. Jameson, had been working as a lorry driver and he is a father of four
children, which signifies that they were not economically affluent. Nutritious fresh fruits and

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vegetables should be consumed instead of ready-made, fried food (Hsu et al. 2015). It might
be due to his economic constraints that he has to live on fried food and cannot afford fresh
food. Hence the care plan for the patient and the family would be cost effective and should
suit the economic condition of the patient. The care plan should serve beneficial for the entire
family as children might get diabetes due to the shared genetic factors combined with the life
style influences (eating habits and physical activities).
Discussion
Theories
Patients with diabetes are the people suffering from chronic diseases who are adapted
to deal with the varied health care needs and the arising fear. One of the important aspect of
adapting to chronic illness is to screen and take measures during the early stages of the
disease, as this facilitates the acceptance of the disease and the early identification and
management of the potential complications (Buckingham et al. 2017).
Patients suffering from diabetes are afraid of the socio-economic effect of the disease
and the decline of the economic and the occupational status. This can be linked to the fact
that Mr Jameson had been trying to quit his job. According to a study by Papaspurou et al.
(2015), it has been found that drivers with diabetes are faces difficulties while driving which
can be linked to hyperglycaemia.
Huang et al. (2014) have stated that diabetes causes a reduction in the life expectancy
with an augmented rates of mortality and morbidity due to Some health complications linked
to nephropathy, retinopathy, the and neuropathy and the enhanced risk of the diseases like
cardiovascular diseases and poor quality of life. Hence Jameson’s might feel depressed owing
to the fear that he might not live more.

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The role of the theory in the behavioural diabetes is not understood very clearly. Many might
see the theory as grandiose conceptual scheme with very little relevance to the research. A
recent study has tested the behavioural interventions based on the Trans theoretical model
against the standard care. It should be remembered that self-management of diabetes is
crucial to diabetes care overall that entails individual change in the behaviour .Behaviour
change is associated with particular dietary patterns and physical activities. Several
behavioural theories can be used to inform the diabetes management education. The health
belief model theorizes that all the health related behaviours are influenced by the severity of
illness, by the perception of threat (Jalilian et al. 2014). Thus the patient should at first realise
that they are at the risk of the disease before the behaviour change might occur to minimise
the risks.
The theory of planned behaviour refers to the fact that the individual behaviour of
the individuals are determined by the intention of the person to do it and the apparent control
over the performing the behaviour. The intention of the person is determined by the weighted
comparative significance of the behavioural attitudes and subjective norms (perceived social
pressure, for performing a behaviour) (Peek et al. 2014). Hence, it is the duty of the health
care teams to modify the beliefs and the attitudes of the diabetes related health behaviour.
Bandura’s theory of self-efficacy has been identified as the ability of the person to do
an activity and is an essential precursor to the behavioural change (Powers et al. 2017).
Helping the person to develop self-efficacy in a patient is another step towards intervention
for diabetes. Peek et al. (2014) have discussed about behavioural and virtual theoretical
framework that guides the development of the second life impacts diabetes education and
support. The goal of this intervention is to provide a realistic appearing virtual community for
the diabetes self-management training and support, promoting social support and transfer of
the behaviours learned in the community of the virtual environment (Vorderstrasse et

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al .2015). Self-management of diabetes is possible with virtual diabetes community on the
internet with the real time interaction among the peers suffering from Type 2 diabetes (Peek
et al. (2014).
Bio psychosocial complex needs of the patient
Discussion about the psychosocial needs of the patient, one of the greatest concern of
the diabetic patients is fear for the family. Poor control of diabetes deteriorates the quality of
life by hampering the professional and the personal life (Browne et al. 2014). Mr. Jameson
had always been a financially independent person and the fear that he might be a burden for
his children if he quits working, as most of them know that diabetes can have a direct effect
on the entire family.
Fears of stigmatisation is another psychosocial aspect that determines the needs of
these patients. Societies might hold prejudices against this chronic disease because everybody
is well aware of the fact that high blood glucose level is associated with inactive lifestyle and
the consumption of sweetened and might link them with obese people and those people who
are lazy and inactive , which is not at all true. Fears of deprivation for food and hence the
restriction of food in the diabetic patients should not be forced for the glucose regulation,
although some restrictions are necessary for the glycaemic control (Browne et al. 2014).
Nurses should understand the feelings and the expectations of the patients that can be
hidden behind the words and the sentences. The nurses should only pay heed to what the
patient will say verbally only, but would also comprehend the non-verbal expressions,
different tones and the intensity of the voices (Stuckey et al. 2014). The case study reveals
that Mr Jameson has been found to be depressed for a while and was planning to retire from
work. Hence, it is necessary to understand of what was actually troubling Jameson that he
was depressed and was trying to quit the job. As stated by Stuckey (2014), giving time to the

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patients for expressing his thoughts, feelings and concerns about his health condition is
necessary. The case study again reveals that he had been facing troubles with vision since his
glycaemic levels have increased considerably. Hence, it can be perceived that Mr. Jameson
might be anxious about his condition and might be in despair about becoming a burden to the
family. Successful prevention of the complications of diabetes requires shared decision
making, where both the clinicians work collaboratively to address a particular situation of the
patient. Shared decision making (SDM) helps in the implementation of core principle of the
evidence based medicine (den Ouden et al. 2015). Shared decision lures on the body of
evidence with regards to the different options of treatment and helps the patients to choose
any alternative care. Shared decision making in diabetes is necessary in diabetes as diabetes
often requires consideration of the different management options that have significant
demand on the life and the living of the patients (den Ouden et al. 2015). The initial step in
the decision making process is to create awareness regarding the equipoise; informing the
patient that there are no alternate choices, of if there are choices and some decision has to be
taken (Tamhane et al.2015). In order to make a shared decision making procedure, a
partnership has to be built that should go beyond the rapport and involves sharing of the
responsibilities (Elwyn et al. 2014). The preferred role of the patient has to be explored, but
not until all the information has been provided. Mr. Jameson, might not want to participate in
the decision making but can change their mind after suitable options has been laid down.
According Légaré et al. (2014) shared decision making to some patients can be assertive as
that they fear that this can affect the good doctor –patient relationship. Shared decision
making is the best option when it comes to self-management of diabetes. Involving Jameson
to plan the mean plan, exercise regimen and help in positive outcomes in the patient.

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Local community care services to serve the need of the family
The necessary factors for the community care related to diabetes, these are- interventions for
preventing diabetes, screening for diabetes by screening through the health check programs
or the targeted screening of the high risk groups (Cotter et al. 2014). community services also
requires regular reviewing of the patients including the screening for retinopathy or foot and
problems, achieving the target for the glycaemic levels using the oral and the injectable
agents including insulin, screening and treatment of the cardiovascular risks related to
diabetes, ensuring that the patients get structure education for the self-management of
diabetes (Chrvala, Sherr and Lipman 2016).
Mr. Jameson can get help from the community care services like drug benefit
programs that are meant for the seniors and the children. The program should cover the
prescription drugs, some nutritional products and some glucose test strips. There are also
provisions for health cards where the elderly people might get discounts on certain important
drugs (Cotter et al. 2014). Mr. Jameson can also be a part of the online community groups for
the peer support where similar people can support or talk with Mr. Jameson to give him
courage and advise him to manage his diabetes. Mr. Jameson can also be referred to the
important contacts related to diabetes care such as the foot care clinics. People with diabetes
are often vulnerable to wounds in the foot. It is already known from the case study that the
Mr. Jameson had been a lorry driver and is planning to retire, and probably this might affect
the economic condition of the family and they might find it difficult to juggle between getting
medicines and making the ends meet. Hence, Joseph can be referred to lower cost clinics
where cheap packages are available for serving both Mr. Jameson and his wife. Again there
are also different food programs for the people with low income like food banks, free drop in
Meals, community kitchens, community gardens (Ricci-Cabello et al. 2014).

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One of the most important community care programs are diabetes health promotion
programs providing education to people in the self-care management of diabetes. This
involves education about using equipment to measure blood glucose level regularly and
importance of daily exercises to manage obesity (Li et al. 2014). The community care
programs are often associated with the free checks ups and consultation with the dietician.
Hence, community based activities, appropriately trained community health professionals
with the support of diabetes care specialist can provide complex care to Mr. Jameson.
Nurse’s role in the diabetes management
Assessing the patient with diabetes would require history taking of Mr. Jameson in
order to understand the behavioural factors behind the diabetic related behaviour in patients.
Some of the information that a nurse should seek from the patients are- the dietary habits of
the patient, whether the patient have any prior knowledge about the self-management of
diabetes, whether the patient had any medical history of diabetes, or whether the patient had
any symptoms of renal or ophthalmological complications of diabetes (Salmond and
Echevarria 2017).
The nurse should assess whether the patient is having any difficulties in monitoring
the capillary glucose, or when did they last calibrate the glucose monitoring equipment
(Brunisholz et al. 2014). The case study reveals that Mr. Jameson had been taking ACE
inhibitor foe the past few years and it might have some side effects. It is the duty of the
nurses to evaluate whether the client is adhering to the medication regimen, as Mr. Jameson
had low glycaemic control and has never bothered to take medicines on time or going for a
regular follow up (Salmond and Echevarria 2017). As per the case scenario, it seems that Mr.
Jameson is at the dependency level of long interval dependency.

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Role of the nurses change and rather becomes expanded as the dependency level of
the patient changes and the health care needs becomes more complex (Hollis, Glaister and
Anne Lapsley 2014). Being the players of the health care, the nurses should understand the
factors that are changing the health care needs, the mandates for the practice change and the
competencies. It is the duty of the nurses to escalate the matter to the concerned physician if
the health care condition of the patient deteriorates. According to the ‘Transforming your
Care’ health policy, the government has made it imperative for all nursing professionals to
place the individuals at the core of the healthcare model, by promoting enhanced health
outcomes for the clients, their family members and the carers as well (Department of Health
2018. Hence, the policy is accurate in emphasising on the need of providing appropriate care
at the right time and place. The ‘Health and Safety Policy’ also elaborates on the commitment
of the NHS towards ensuring and safeguarding the health and safety of all clients, which in
turn contributes to its ongoing success (NHS England 2017). Another potentially
advantageous policy is the ‘Leading Change, Adding Value’ framework that helps all nursing
and midwifery staff to deliver care services based on evidences, thus enhancing patient health
outcome (NHS England 2018).
Risk stratification is an important function that has to be conducted by the nurses to
reduce the risk of hospital readmissions and improve the quality and the experience of care
for the patients whilst the reduction of the costs for the taxpayers. An NHS organisation that
is interested in the beginning of the risk stratification should commence by the conduction of
an opportunity analysis (NHS. England. 2018). PARR++ is a valid risk stratification tool that
can be used by the nurses (NHS. England. 2018).
While planning for Mr. Jameson, the things taken in to consideration should be
Assessing the blood glucose level before the meals and the bed time, monitoring the patient’s
HbA1c-glycosylated haemoglobin, assessing Mr. Jameson for anxiety, tremors, temperature

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pulses, colour and sensation (NHS, England. 2015). All the patient’s records should be stored
by using an Electronic Client Record system (ECRS) (Miotto et al. 2016). After the planning
it can be necessary to administer basal and the prandial insulin. Patient should be instructed to
take oral hypoglycaemic medications as directed (NHS, England. 2015).
Conclusion
Summary
The report has emphasised on the various health promotion theories like the health
belief model and the theories of planned behaviour in order to support the interventions
suitable for Mr. Jameson. It has aided the understanding the health related behaviours of the
patient. The main bio-psychosocial complex needs of the patient involves fear of becoming
burden to the family, fear of stigmatisation, and fear for loss of vision. However, the paper
had also discussed the various community care services like online community groups, free
diabetic check-up and food bank and community kitchens. Finally the report has discussed
about the role of the nurses to serve the changing dependency level of the patient.
Recommendations
Some of the main recommendation for Mr. Jameson would be a regular monitoring of the
blood glucose level, adherence to the medications, attending the various community services
for the diabetes management, such as free screening of blood glucose levels, education
campaigns. Furthermore, Mr. Jameson should also bring a change to his sedentary life style
by the doing some incidental exercises regularly. The most important recommendation is to
follow a meal plan with less glycaemic food and more of fibres.

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