Managing Diabetes and Fatigue

This assignment delves into the intersection of diabetes management and stress reduction. It examines various methods for managing stress in individuals with diabetes, particularly highlighting mindfulness-based stress reduction (MBSR) as a potential intervention. Additionally, the assignment explores the complex relationship between diabetes and fatigue, investigating its impact on quality of life and identifying strategies for effective fatigue management.

Introduction
The purpose of this educational portfolio is to enable you to identify and achieve the
prescribed learning outcomes within the overall context of NUR09721 - Management of
Chronic Disease (Singapore)
Learning Outcomes
The learning outcomes are as follows:
LO1: Evaluate the evidence-base underpinning current practice in the management of
people affected by chronic diseases.
LO2: Examine the social and psychological impact of conclusive diagnosis of a chronic
disease on people and their family/ carers.
LO3: Explore the role of the multidisciplinary team in promoting self-management to
enable people to live positively with a chronic disease.
LO4: Analyse current local practice and identify possible changes to improve
psychological symptoms and health, and well-being for people living with one or more
chronic diseases.
You will be required to provide evidence of achievement for each learning outcome within
your portfolio.
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Management of chronic Disease Assessment
Introduction( My Condition is Management of diabetics in Singapore )
Briefly introduce your allocated condition in your introduction(Diabetics). This should
include a definition of what a long-term condition is and an explanation of your allocated
condition along with a brief overview of its epidemiology and aetiology. The introduction
must also outline how you searched for academic evidence to support this portfolio to
answer the learning outcomes for this assessment (500 words)
The common site used for evidence
- Cinhal
- Science direct
- MEDLINE
- MOH
- Singapore Nursing journal
- Can use any site that easy acess for student
A search strategy outlining the relevant search terms you used, the research databases
you searched and the number and type of results you obtained should be provided. This
can be given in a table format to ensure you stay within the word count for this section.
Introduction
Diabetes is a chronic disease, which is mainly characterized by the elevated level of blood
glucose. Diabetes can lead to various kinds of complications and morbidities. In the
chronic illness of diabetes the ability of the body produce or to respond to the insulin
hormone becomes impaired. The level of the blood glucose increases and the metabolism
of carbohydrates become abnormal. Therefore, in diabetes body becomes unable to
effective process the food into energy. Therefore diabetes can be defined as the “ chronic
disease that occurs either when the pancreas does not produce enough insulin (a
hormone that regulates blood glucose), or when the body cannot effectively use the insulin
it produces” (World Health Organization, 2016, p. 11). American Diabetes Association has
define diabetes as “a group of metabolic diseases characterized by hyperglycemia
resulting from defects in insulin secretion, insulin action, or both” (American Diabetes
Association (2014, p. S81).
Diabetes is of two main types: type 1 diabetes and type 2 diabetes. Type 1 diabetes is also
considered as the insulin dependent and mainly found as the childhood-onset
diabetes.Though type 1 diabetes can occur at any age, but the incidence of this kind of
diabetes are higher in the children of 14 years of age or older (Forouhi & Wareham, 2014).
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The pancreatic cells of the body become unable to produce insulin hormone and therefore,
the patients require the daily dose of insulin to regulate the amount of glucose in the blood.
The patients suffering from type 1 diabetes could not survive without insulin. Also, in the
causation of type 1 diabetes, the genetic susceptibility is important but not sufficient,
because the environmental factors play more significant role in the onset of type 1
diabetes.
Type 2 diabetes is characterized as non-insulin dependent because the pancreatic cells
produce the insulin hormone, but body do not use this insulin effectively, as the result the
level of glucose in the blood increases (Forouhi & Wareham, 2014). Type 2 diabetes is
mainly considered as the problem that is associated with gens. The family history of
diabetes increases the risk of occurrence of type 2 diabetes. Some of the environmental
factors, such as lack of exercise, sedentary lifestyle and unhealthy living is associated with
type 2 diabetes. Therefore, the biological, environmental and genetic factors play a
significant role in the onset of diabetes.
Some of the common symptoms of diabetes are frequent urinations, fatigue, excessive
thirst, weight loss, problem in vision, excessive hunger, very dry skin as well as numbness
in hands (American Diabetes Association, 2014). Diabetes can also led to the micro-
vascular and macro-vascular diseases, by which it affects several organs of the body such
as skin, muscles, eyes, brain, heart and kidneys. The mechanism of the vascular disease
in the diabetes patients included the “ pathologic effects of advanced glycation end product
accumulation, impaired vasodilatory response attributable to nitric oxide inhibition, smooth
muscle cell dysfunction, overproduction of endothelial growth factors, chronic
inflammation, hemodynamic dysregulation, impaired fibrinolytic ability, and enhanced
platelet aggregation” (Cade, 2008, p. 1322)This portfolio is based on discussion discussing
the chronic condition of diabetes in Singapore. As, according to the latest reports, diabetes
has become a significant health problem in Singapore and it has the second highest
proportion of diabetes in all the developed nations (Singapore, 2016). The research for the
portfolio will be very comprehensive and evidences will be selected from the peer reviewed
studies from the academic journals, such as, Cinhal, Science direct, MEDLINE, MOH and
Singapore Nursing journal
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Portfolio Entry 1
Describe the pathophysiology of the allocated condition, supported by relevant academic
literature. (500 words)
You must demonstrate your ability to understand the anatomical and physiological
changes that occur for your allocated condition. This should include describing normal
physiology and the changes that occur at the cellular, tissue/organ or bodily system
level in relation to your allocated condition. This must be evidence based using
appropriate academic sources.
Portfolio Entry 1
1
Pathophysiology of Type 1 Diabetes
Type 1is caused by the combination of the environmental and genetic factors. It is mainly
caused by the destruction of the autoimmune function of the pancreatic insulin-producing
β-cells. According to the evidences, this type of diabetes can be triggered by the
combination of one or more environmental factors, which can result in developing the T-
cell dependent autoimmunity, in the individuals who are genetically susceptible. The
gradual β-cell destruction when combined with Insulitis can lead to diabetes mellitus
(Siddiqui et al, 2013). The patients may also be susceptible to some other autoimmune
diseases, such as, celiac disease, Hashimoto’s thyroiditis, Addison’s disease and also
myasthenia gravis (Atkinson, Eisenbarth, & Michels, 2014). The studies have also found
that forty genetic loci are associated with the condition of T1DM. The risk of type 1
diabetes is 5% higher, if there is the history of the affected first degree relative. Also the
risk of diabetes is higher, when the affected parent is father and not mother. The
individuals, who are genetically at the risk of diabetes, the interventional trials also do not
work in preventing the onset. The destruction of the β-cell results in the deficiency of the
insulin. Therefore, this condition is considered as autoimmune disease. It also represents
the presence of the anti-islet cells and anti-insulin cells in the blood. The presence of these
cells results in lymphocytic infiltration and also destroys the pancreatic islets. The
destruction of the cells may take time. However, studies have considered that onset of the
disease is very rapid (Zaccardi et al, 2015).
The metabolism of the people with diabetes is different from the normal people. In the
normal people the pancreatic beta cells function normally and the insulin is produced and
helps in metabolizing the glucose. However, in the type 1 diabetes patient, due to the
destruction of the beta cells, the insulin is not produced effectively to metabolize the
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glucose and the level of glucose rises in the body. Therefore, the body requires insulin
delivery.
Pathophysiology of Type 2 Diabetes
The primary pathogenic event that leads to the development of type 2 diabetes is chronic
fuel surfeit (Siddiqui et al, 2013). This disease can occur in the individual, who are
genetically or epigenetically susceptible. The occurrence of diabetes is also associated
with obesity. The condition of type 2 diabetes is considered as relative deficiency of insulin
and not the absolute deficiency of insulin. The two main conditions are associated with the
occurrence of type 2 diabetes. In this kind of diabetes the body can become insulin
resistant. In the normal body the glucose enters the blood stream and pancreas releases
the insulin to allow the glucose to enter the body cells and converting the glucose to
energy. However, in the type 2 diabetes patient, this process is hampered and body
becomes insulin resistance and level of glucose rises inside the patient’s body. First is that
either body is not able to produce adequate amount of insulin and second is that body
develops the resistance towards insulin. Insulin resistance is the condition, where the body
cells, such as that of liver, muscles or fat cells fail to respond to insulin. The deficiency of
the β-cell can also couple with peripheral insulin resistance (Zaccardi et al, 2015). The
triglycerides present in the fat cells, are broken down to produce free fatty acids for
energy. However, the muscle cells become deprived of the energy and the cells of the liver
fail to store the glycogen (Kahn, Cooper, & Del Prato, 2014). This could result in peripheral
insulin resistance, which means that the glucose level in the blood becomes high. The high
intake of the saturated sugar and high fatty acids results in producing more glucose, but
that insulin resistance do not allow to convert that glucose in energy. Therefore, the level
of sugar becomes very high resulting in causing type 2 diabetes. Obesity and lack of
physical exercise are significantly associated with the occurrence of type 2 diabetes.
Portfolio Entry 2
Write a 2000 word report
Select one symptom and ( please choose a common one )
1. Explore how this could affect your patient (500 words)
2. Evaluate 1 assessment tool (consider advantages/ disadvantages) (750
words)please use common assessment tool where commonly used in
Singapore
3. Based on best evidence discuss the nursing management required to enable the
patient to maximise their health and well-being and self-manage their condition.
This must demonstrate a holistic approach (physical, emotional, social and
spiritual). You should include reference to the support of family/carers and
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the role of other members of the multidisciplinary team and the voluntary
sector where relevant. (750 words)
(Total 2000 words)
Portfolio Entry 2
How Fatigue affects patients?
According to the study of Goedendorp et al (2014), “fatigue is a classical symptom of
hyperglycemia” (p. 73). It is the most common and significant symptom of diabetes, which
have not been studied systematically. Study of Goedendorp et al (2014) also finds that
62% patients of diabetes type 2 suffer from chronic fatigue and fatigue was also found as
the second most frequently reported symptom of diabetes (Drivsholm et al, 2005). It has
also been found that with the treatment of diabetes and controlled level of glucose in the
blood, fatigue can be reduced. Fatigue is the common distressing symptom that can also
affect the ability of the patient to carry out the activities of daily life. Fatigue is the word that
is used to express tiredness and lack of energy. Providing the exact definition of fatigfue is
different because there has been a lack of research and poor differentiation between
causes, indicators and effects of fatigue (Fritschi, & Quinn, 2010). Fatigues is very
important symptom that requires the attention because it can be really complex and
multifaceted that also includes the various components associated with situational,
psychological and physiological factors of life and body (Menting et al, 2016). Though,
fatigue can normally occur in the daily life, it is associated with the variety of the
psychological and physiological conditions. Chronic fatigue is the condition that continues
to occur even after the modest efforts and rest. Therefore, the daily life activities, as well
as personal and work life of the patients suffering with diabetes can be affected.
Fritschi, & Quinn, (2010) also found that “fatigue results from one or a combination of
peripheral physiologic processes--alone or in combination with the brain and/or its
neurological systems” (p. 35). Also, the studies have differentiated and distinguished
fatigue in two different types- ‘peripheral’ and ‘central’ depending upon the type of systems
associated with causing fatigue. Chronic fatigue is also considered as the severe fatigue
that can persist for a long time and significantly affects the functioning of the patients (Seo
et al, 2015). Peripheral fatigue is considered as the completely physiological condition that
involves the cardiac muscles and skeletal muscles. The functioning of the patients reduce
due to the decline in the muscle tension with repeated stimulation. According to the study
of Singh et al (2016), fatigue is the condition caused by diabetes that also affects the
quality of life of the patients. The quality of life is reduced as fatigue can give rise to the
depressive symptoms, lower self-efficacy, lack of confidence and also sleep disturbances
(Menting et al, 2016). The functionality of the patients is also affected because of the low
cardiorespiratory fitness, high body mass index and lack of physical exercise. Some of the
other complications associated with fatigue include chronic pain and sleep disturbance
(Jensen, Bernklev & Jelsness-Jørgensen, 2016). Fatigues also contributes to loss of
interest in activities, need to go early to the bed, fear of losing job. Evidences have also
shown that use of insulin by the young individuals also impact their mental and physical
health and reduces their health related quality of life (Luk et al, 2014)
Fatigue Assessment Tool
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One of the common assessment tool to assess fatigue in diabetes patients is
Multidimensional Fatigue Inventory (MFI-20). Since, fatigue is the widespread clinical
complaint among the diabetes patients all over the world, it required effective assessment
tool to assess. Fatigue is mainly noticed in the non-insulin dependent patients. The
diabetes patients suffer from various physical, mental conditions. Therefore MFI is the tool
that helps in assessing the five main dimensions associated with fatigue. These five main
dimensions include “general fatigue, physical fatigue, mental fatigue, reduced motivation
and reduced activity” (Singh et al, 2016).
The main benefits of this assessment tool is that it gives significance to the subjective and
objective data obtained from the patient, which is very significant for the evaluation of
fatigue. The physical examination and the laboratory reports of the patient are also
included in the assessment that provides the supporting data for fatigue assessment
(Segerstedt, Lundqvist, & Eliasson, 2015). This assessment tool includes the
questionnaire for the above mentioned five dimensions. Therefore, the significance of the
Multidimensional Fatigue Inventory (MFI-20) increases, because it provides the self-
reported data (Fritschi et al, 2012). This tool is called as the MFI-20 because it includes 20
items and considered as the multidimensional tool. The advantages of the tool includes
that it incorporates two different measures of fatigue.
The two different measures are motivations and activity. Another significant aspect of MFI
is that it uses the Likert-type scale from 1 to 5 and the total score is measured between 4
and 20. The five dimensions or the five subscales included in the assessment tool
consider all the aspects of patient’s health. The higher scores in the scale indicate the
higher level of fatigue, while the lower scores indicate the lower level of fatigue. Therefore,
it is very beneficial for the diabetes patients (Segerstedt, Lundqvist, & Eliasson, 2015). The
general fatigue scale can also be used with MFI in order to get the data related to overall
subjective fatigue experience of the patients. The studies have also found that MFI
provides the appropriate internal consistency and reliability (Fritschi et al, 2012). With this
assessment tool it becomes very esasy to identify the mental condition of the patient.
According to the study of Smets et al (1995) Multidimensional Fatigue Inventory (MFI) is
an instrument that has psychometric properties which, “were tested and determined to
have good internal consistency and construct validity in samples with Chronic Fatigue
Syndrome (CFS)” (p. 315). Fatigue is the condition that has been associated with causing
depression, anxiety and helplessness among the patients. Therefore, MAF has been
successful in assessing the multi-dimensional dimensions of fatigue in adults.
The advantage of the instrument that item presented in this are very easy to understand
and frequency of the responses can help in evaluating the condition of the patient over the
long period of time (Hewlett, Dures, & Almeida, 2011). Another benefit of the instrument is
that it is available in various languages and can be used to assess fatigue varied
population (Segerstedt, Lundqvist, & Eliasson, 2015). The study of Ashrafinia et al (2015)
has found that Multidimensional Fatigue Inventory (MFI-20) is a very significant tool, as it
can provide the information about the general fatigue, mental fatigue and physical fatigue
in the patients in Singapore. Therefore, helps in determining the patient’s condition and
forming the future interventions. The study of Sing et al (2016), also states that Chinese
version of Multidimensional Fatigue Inventory (MFI-20) is used in Singapore for assessing
fatigue in diabetes patients.
The disadvantage of the MFI instrument is that it does not include the information about
the interpersonal distress of the patients, which is causing fatigue. It has also been found
that language based versions of the MFI tool are different,. Such as, the French based
version of the MFI tool do not include the psychometric properties and validity of the data
is mainly found in the four significant dimensions, including ‘General Fatigue’, ‘Mental
Fatigue’, ‘Reduced Activities’ and ‘Motivation’ (Gentile et al, 2003). Sometimes it also
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becomes difficult to measure different fatigue levels of the patients in the English version
of the MFI tool. It is also very difficult to evaluate the level of fatigue among the patients
over the long period of time and in follow-ups. Some of the other disadvantages of MFI is
that some of the factors in the instrument are highly correlated and several items of the
tool are loaded on more than one factor. In some cases the two subscales provide the
same results. For example, Such as the subscale for physical fatigue and general fatigue
are same (Purcell et al, 2010). The lack of test and re-test reliability has been found in
application of MFI. MFI also fails to identify the effects of the regional lifestyle of the
patients, nor have any studies in the literature identified the regional lifestyle of the patients
for assessing fatigue through this instrument (Lin et al, 2009). However, the overall validity
of the MFI tool are consistent and also provide the information about depression,
functional impairment and anxiety among the patients.
Nursing Management of Fatigue
Fatigue can be an overwhelming condition for the patients. The patients suffering with
diabetes may experience tiredness, exhaustion and lethargic. Fatigue is considered as the
subjective symptom because it is a self-recognized condition that patients experience. The
physical symptoms of fatigue can be associated with malnutrition, expanded physical
exertion or poor physical condition. The nursing management of fatigue, requires special
assessment of the patient. Firstly, the nurses are required to assess the fatigue level
among the patient. The fatigue level will include the assessment of severity of fatigue,
changes in the severity, alleviating factors etc. This assessment requires the quantitative
assessment scale. The severity of the fatigue level can be measured with the help of score
from 1 to 10. The higher scores on the scale indicate the higher level of fatigue. It is very
important that scoring scale is appropriate, through which nurses can evaluate the
changes in the fatigue level. It is also important for the nurses to evaluate if the fatigue
level is persistent or constant.
Another important nursing management intervention is to determine the cause of fatigue.
The cause of fatigue can be associated with long term illness, depression caused due to
illness, anaemia, sleep disorder or the imbalance nutritional intake. By identifying the
potential cause of fatigue, nurses will be able to develop a comprehensive care plan for
the patient. Fatigue is the troublesome symptom that can also reduce the health related
quality of life of the patients. Therefore, the nurse must also assess the physical ability and
functioning of the patient. Nurse must assess the ability of the patient to carry out activities
of daily life, as it is very significant for the quality of life (Chew-Graham et al, 2009).
Mental fatigue in the diabetes patients is often associated with diabetes emotional distress.
The complicated medical regimes of diabetes can increase fatigue among the patients.
Therefore, the nurses have to address the depressive symptoms in the patients. Nurse
must maintain therapeutic relationships with the patients to communicate their distress and
problems. Nurse must provide the emotional support to the patient (Fritschi, & Quinn,
2010). Communication of nurse with patient can also work like a diversional activity and
can help patient to relieve stress. Nurse must also assess the sleep disturbance in the
patient, because sleep disturbance or disorder can cause excessive fatigue. Nurse can
also obtain the important information from the patient, to evaluate their condition.
Nurse can also help patient to manage their fatigue by encouraging them for physical
activities and taking balance and nutritional diet. The nutritional diet will help patient to get
energy and will reduce fatigue (Vogelaar et al, 2014).
Self-management is the most significant intervention for the diabetes patients. Nurse can
educate the patient about self-management and can also teach energy conservation
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principles (Schulman‐Green et al, 2012). This intervention can also include psycho
education for the patient. Cognitive behavioural therapy is also considered to be effective
fatigue in diabetes patients. Nurse can refer the patient for the cognitive behavioural
therapy (Menting et al, 2015). The study of Voet et al (2014) has found that combination of
aerobic exercise with cognitive behavioural therapy is also beneficial in reducing fatigue.
Mindfulness based therapy is also beneficial for reducing fatigue. Therefore, nurse can
refer patient for mindfulness based therapy that also helps in improving self-management
among diabetes patients (Sharma, & Rush, 2014).
The support of family, friends and carers is very significant for the diabetes patients, to
provide emotional and social support. Family members must be included in the care of the
patient. The social support encourages patients for self-management and to practice
changes in their daily life for decreasing fatigue. Social support is also important for patient
to increase their confidence and develop positive attitude towards their health. The
community based services are also beneficial in reducing fatigue. Patients can participate
in community based cultural and spiritual activities that can help in reducing fatigue and
increases the physical activity of the patient that is significant for preventing fatigue.
According to the study of Sugiyama et al, (2015), community based programs for the
diabetes patients are significant in empowering patients for self-management and also
improves their quality of life. The community based programs are very effective in
improving self-management and providing social support to the patients (Hendrie et al,
2014). Nurses can enroll the patients to the fatigue self-management programs, where the
patient can receive the training about self-management of fatigue as well as various other
symptoms of diabetes. This will also help to build partnership with the healthcare providers
and will improve patient’s self-efficacy.
Portfolio Entry 3
In this final section, summarise the key aspects discussed in the portfolio and make
recommendations on how learning may influence your future practice (approx. 500 words)
Conclusion
This portfolio discussed the chronic condition of diabetes. The evidences included in the
paper are retrieved from scholarly articles and peer reviewed studies. The evidences have
shown that diabetes is a chronic illness that is highly prevalent all over the world. Diabetes
is considered as chronic, as this disease is not curable. However, it is preventable.
Diabetes also increase the rate of morbidity and mortality among the patients and it is
associated with many sever complications, such as cardiovascular problems, renal
diseases, liver disease etc. Therefore, Diabetes is the topic that has been well researched
because of its severity and high prevalence.
This portfolio discussed one of the most common symptoms of diabetes, which is fatigue.
Nearly every patient suffering with diabetes experience fatigue, which significantly affect
their quality of life, physical functioning, personal and professional life, as well as mental
condition. Fatigue can also cause depression and anxiety in diabetes patients. Fatigue can
really reduce the social engagement of the patients and can create isolation. Therefore,
fatigue is the most complex symptom found in diabetes patients. Fatigue can also pose
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barrier for the patient to live an active life. Some of the common reasons associated with
fatigue are high BMI, lack of physical activities and nutritional imbalance.
Another part of the portfolio discussed the assessment tool for fatigue. The tool that has
been discussed in the portfolio is Multidimensional Fatigue Inventory (MFI). This tool or the
instrument has been considered as very significant for assessing fatigue among the
patients. The portfolio includes the evidences from various empirical and quantitative
studies that determined the efficacy of this assessment tool. This assessment tool works
on the five different dimensions for measuring fatigue, and considers the various aspects
of mental and physical health of the patient. The risk explained through this tool can help
the healthcare professionals to understand severe complications associated with patient’s
condition and co-morbidities.
Nursing management of fatigues and self-management skills of the patients are very
significant for management of fatigue. Nurses play a very important role. Therefore,
portfolio also discusses the significance of nursing intervention and also explains that how
nurses can help patients to develop self-management skills for symptoms. Self-
management can be developed among the patients through educations, educational
programs and community based programs. Self-management skills can increase the
confidence among the patients and also encourage them to take control of their physical
and mental health and well-being.
Recommendations for future nursing practice (written in the 1st person)
This portfolio has been very effective in increasing knowledge and understanding about a
highly prevalent disease in Singapore. Fatigue is the common symptom in diabetes
patients, thus requires more attention of the healthcare professionals. Diabetes related
fatigue is not a symptom that can be assessed through physical assessment, but it is the
self-recognized condition and subjective explanation of patient’s experience. Therefore, I
would focus on improving my abilities and applying the evidence based practice. This will
also help to improve my practice skills and I would be able to provide effective care to the
patients. The evidence based practice and personal reflection will help me to understand
the effects of physical and mental fatigue in the patients. Therefore, through personal
development and skill enhancement, I would be able to provide quality care to the patients.
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References
Please include a list of the references you used in your Portfolio here. These must follow
the APA6th referencing style and be written in alphabetical order by first author’s
surname.
References
American Diabetes Association. (2014). Diagnosis and classification of
diabetes mellitus. Diabetes care, 37(Supplement 1), S81-S90.
Ashrafinia, F., Mirmohammadali, M., Rajabi, H., Kazemnejad, A.,
Haghighi, K. S., & Amelvalizadeh, M. (2015). Effect of Pilates
exercises on postpartum maternal fatigue. Singapore medical
journal, 56(3), 169.
Atkinson, M. A., Eisenbarth, G. S., & Michels, A. W. (2014). Type 1
diabetes. The Lancet, 383(9911), 69-82.
Cade, W. T. (2008). Diabetes-related microvascular and macrovascular
diseases in the physical therapy setting. Physical therapy, 88(11),
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Chew-Graham, C., Dixon, R., Shaw, J. W., Smyth, N., Lovell, K., & Peters,
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Fritschi, C., & Quinn, L. (2010). Fatigue in patients with diabetes: a \
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C. J., & Knoop, H. (2016). Severe fatigue in type 1 diabetes:
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