This essay will investigate the cause and management of a long term condition. In order to holistically assess and appraise the patient’s needs, the outline of the Roper, Logan and Tierney (RLT) model of care framework shall be examined as well as the strong points and weak points of this model in comparison to Orem’s model of care. This essay will show how the Roper, Logan and Tierney framework was used to assess, design, execute and evaluate the patient’s care.
For the objective of this essay and in compliance with the Nursing and Midwifery Council Code of Conduct (NMC, 2015) regarding the protection of patient privacy, no actual names shall be mentioned and all references to the affected person are made under the pseudonym Angy. The student’s placement was at a local trust where patients were often referred to for assessment and diabetes management.
It was at this facility that the student met 38-year-old Angy. Since her diagnosis in 2008 with type 2 diabetes mellitus, Angy has been treating her condition with a premixed preparation of 75% insulin lispro protamine suspension and 25% insulin lispro preparation (Humalog 75/25).
Her dosage requires her to take 33 units of this preparation before breakfast and 23 units before supper. However, the patient admitted that even though she has received no prior information or instructions regarding insulin adjustment algorithm, she occasionally increases the amount of insulin she usually administers to herself at times when her blood glucose levels read higher than usual.
A detailed history showed that she suffers from the adverse side effects of her medication which has resulted in poor medication compliance.
The patient also confessed that the night shifts she does at work make it rather difficult for her to remember to take her medication.Based on clinical presentation and aetiology, diabetes mellitus is typically differentiated into three types; type 1, type 2 and gestational diabetes mellitus. Type 2 diabetes is a long term condition which affects the body and is usually characterised by the unavailability of insulin that is needed to inhibit ketoacidosis and it regarded as the most common form of idiopathic diabetes accounting for about 90% of diabetes cases (Goyal and Jialal, 2019). Usually the body breaks down food into glucose and distributes it throughout the bloodstream where insulin secreted by the pancreas helps to distribute the glucose in the bloodstream to the cells where it will be used for energy.
However, in type 2 diabetes, the pancreas either makes inadequate insulin or lacks the ability to properly to properly secrete insulin or both. The pancreas slowly loses its ability to makes insulin as the body’s need for insulin increases thus resulting in insulin resistance (Goyal and Jialal, 2019). The cause of type 2 diabetes mellitus is not due to a single factor but rather is multifactorial because involves an aggregation of multiple genetic constituents that affect compromised insulin secretion and insulin resistance as well as environmental determinants such as obesity, sedentary lifestyle and ageing (Kaku, 2010).
Insulin resistance has been linked to raised levels of free fatty acids and also proinflammatory cytokines in the plasma with the resulting effects including the reduction of glucose transport into the muscle cells, increased production of hepatic glucose and elevated fat breakdown (Khadori, 2019). Most people diagnosed with type 2 diabetes mellitus show visceral obesity. In type 2 diabetes mellitus, there is the absence of a mutual interrelation between the glucagon-secreting ±-cells and the insulin-secreting І-cells which leads to hyperglucagonemia and consequently results in hyperglycaemia (Unger and Orci, 2010). Type 2 diabetes mellitus has a latent, asymptomatic stage which allows most of the people suffering from this condition to go undiagnosed for years.
The decision of picking Angy as a case study was made because of the ever-rising prevalence of type 2 diabetes mellitus in England which according to NHS England (2018) is constantly challenging the NHS and general healthcare systems all over the world. According to Kok et al. (2019) every year 22,000 people die prematurely as a result of type 2 diabetes and its complications. Public Health England reports that there are currently 3.8 million England residents living with type 2 diabetes with 200,000 new diagnoses occurring every year (Smith, 2018). In 2008, the National Collaborating Centre for Chronic Conditions reported that the estimated cost of the type 2 diabetes mellitus on the economy of the UK is about Ј2.8 billion which makes up 7%-12% of the total budget for the National Health Service (NHS). By 2018, this figure has increased to Ј8.8 billion which accounts for just under 9% of the total NHS budget (Smith, 2018).
The methodical means of dispensing patient-centred treatment regardless of the individual’s state of health or illness is known as a nursing process and it is divided into four phases; assessment, diagnosis, planning and evaluation. The conjunction in the use of a nursing process and a nursing model leads to the development of a nursing approach. In order to assist nurses in visualising goals that must be achieved in regards to patient care and also implementing continuity of treatment, the application of a model of nursing is important. The assessment model chosen in this case study is the RLT model. In order to provide a comprehensive procedure to care, this model has been carefully designed to consider the psychological, social and biological requirements of an individual (Roper et al., 2001). The significance of adopting a comprehensive procedure when assessing a patient is heavily emphasised in this model as well as the importance of nurses gathering details from the patient as well as relevant evidence about the patient so as to achieve a more thorough and comprehensive assessment (Roper et al., 2001). The RLT model is has wide applications within the United Kingdom and has its basic concepts built upon Henderson’s need theory; the activities of daily living forms the basis of this model (Rwakonda, 2017).
These activities are interrelated and Lakhan et al. (2012) opine that activities of daily living are in agreement with care given to one’s body, they are also paramount to surviving and promoting an individual sustenance and welfare. The RLT framework is of significant import because it diverts attention of the healthcare providers from the illness and allows them to focus more on designing a person-centred care plan founded on any perceived and/or impending requirements of the patients that will be identified based on the twelve activities of living and inadvertently results in the development of improved health outcomes (Li Fang, 2015). According to Roper et al. (2001), the twelve activities of daily living are maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobility, working and playing, expressing sexuality, sleeping, and death and dying. These activities are utilised as a framework for assessment during the nursing process. When utilising the RLT model, each of the activities of daily living has to be carefully assessed so as to determine how dependent or independent the affected person is in performing each of these activities.
During the assessment stage, the dependence or independence of each activity is mapped then continuously re-evaluated throughout the process of nursing so that the affected person’s increasing dependence/independence in each activity in relation to any or all of the treatment being provided can be confirmed. Since the activities of daily living are interrelated to each other, increasing independence or dependence in one activity might mean increasing independence or dependence in some or all of the activities as well.Roper et al. (1999) further categorise five components which directly affect these activities of living; psychological, politico-economic, sociocultural, biological and environmental components. The biological components relates to the severity of the disease as well as the genetic makeup of the affected person (Rwakonda, 2017; Stonehouse, 2017). Sociocultural components are societal expectations, ethics, religion and community while politico-economic factors pertain to important services that are indispensable in the home such as transport, insurance and also other legal and economic constituents (Rwakonda, 2017). Psychological factors are related to a person’s intellect and emotions and environmental factors pertains to both natural and artificial environments of the patient’s abode (Stonehouse, 2017).
Beh Hui (2012) observes that the RLT model not only has the advantage of outlining the activities of daily living but also equips the healthcare professional with the required knowledge to assess how biological, psychological, sociocultural, environment and politico-economic concepts aid with determining the results of the activities of living on the patient’s quality of life. However, according to Baker and Kakora-Shiner (2009), a limitation to this framework is that it is too rigid and it places all emphasis on the activities of living without considering other situations that involve spirituality or coping mechanisms. This is in contrast to Orem’s model of self-care which according to Hagran and Fakharnay (2015) has broader concepts that make it flexible enough to be applied to a wide range of situations. Despite having more flexible concepts than the RLT model, studies have referenced the difficulty in comprehending Orem’s language (Hagran and Fakhatnay, 2015). According to a study by Mendoza (2004), when studying Orem’s model of care, most students were confused by the varying terminologies that have similar meaning but, there seems to be no report of such complexity in the RLT model as the language used in this model appears to be uncomplicated.
A major strength of the RLT model is the manner in the activities of living are objectively measured and this makes its application to Angy’s situation relatively easier however Walsh (1998) warns that there is a tendency of evaluation using the 12 activities of living resulting in these activities being used as a checklist by nurses and have other factors besides the biological and physical factors overlooked thus observing that patient as a condition rather than objectively as an individual. This could lead to the omission of crucial knowledge that could be pivotal to the treatment of the patient thereby causing more harm than good. Despite the benefits of the RLT model in regards to providing a structured system for the comprehensive assessment, a major limitation to the utilisation of the RLT model is that going through all the activities of living during assessment takes up an inordinate amount of time which would lengthen stay of an affected person in the healthcare centre.
During the assessment of Angy, two care needs were identified, one of which is mobility. Mobility is pertinent to preventing complications linked to immobility and in the case of type 2 diabetes, complications linked to reduced mobility includes obesity which results in reduced glycaemic control. Mobility, according to Timmerman (2008), also fosters a mutual interrelation between the body’s corporeal and psychological systems. On assessment, Angy’s problem was the sedentary lifestyle she has grown into due to her working the night shifts at work. This meant that she had abnormally long periods of inactivity during the day. The goal statement in Angy’s case would be for her to reduce the amount of time she spends inactive by participating in moderate physical activities during the day. Further assessment showed that Angy also seemed to suffer from a psychological experience known as diabetes distress which is a fairly common anxiety-inducing condition among type 2 diabetes patients that have been diagnosed and managing their condition for a long period.
It is also associated with poor drug compliance and reduced glycaemic control which can increase the incidence of diabetes-related complications. Her anxiety prompts her to increase her regular insulin dosage from time to time when she notices high glucose readings despite having received no prior medical instructions to do so. The prescription of care recommended for her was dependent on assessment which was done by monitoring her blood glucose levels as well as carbohydrate intake. The goal set for addressing this need was for Angy to reduce her sedentary lifestyle by participating in moderate physical exercises during the day. In order to achieve this goal, Angy’s care plan required her to participate in at least 10 minutes of exercise every day. The rationale behind this intervention is for Angy to avoid extended sedentary periods in order to aid her glycaemic control. Exercising has also proven to improve well-being by aiding weight loss and enhancing glycaemic control (American Diabetes Association, 2019). Another intervention that was recommended as part of Angy’s care plan was yoga. Yoga has been shown to reduce insulin resistance, improve the prognosis of diabetes, reduce stress and alleviate psychological experiences by promoting a healthy body as a by-product of a healthy mind (Cui et al., 2017). Generally increased physical activities have the benefits of ameliorating Angy’s diabetes distress-induced anxiety and also improving her quality of life (Rwakonda, 2017).
The expected outcome of these interventions is first of all, for Angy to have improved her blood glucose level control. Also these interventions are expected to help ease her anxiety regarding her blood glucose readings. Even though increased physical activity in the form of exercises are beneficial to Angy, there are still some risks attached to these interventions. The American Diabetes Association (2019) points out that in individuals like Angy who have been placed on insulin medications, these physical exercises have the possibility of actually causing hypoglycaemia if the patient’s dosage has not been adjusted or are yet to modify their carbohydrate intake. These hypoglycaemic attacks can cause dizziness which would make mobilisation difficult. Peters and Laffel (2013) suggest that rather than reducing blood glucose levels, increased physical activities or intense activities are more likely to increase a person blood glucose levels if the said person has already elevated glucose levels before exercise. Another care need identified for Angy was elimination. This activity focuses on problems relating to bowel and bladder as well as the frequency in which the patient uses the toilet.
Discussion of bowel and bladder elimination is usually a sensitive topic for patients and discussing this topic require utmost dignity and respect (Rwakonda, 2017; Stonehouse, 2017). Assessment of Angy revealed that she suffers from a symptom of type 2 diabetes known as polyuria. Polyuria, also known as excessive urination, is a type of symptom associated with type 2 diabetes mellitus that has very high levels of hyperglycaemia. It occurs as a result of osmotic diuresis where glucose is passed through the urine because of its abnormally high levels in the blood. The goal for meeting this need for Angy to effectively reduce her blood glucose levels thereby reducing the amount of glucose in her urine. The care plan prescribed for Angy required her to be put on a diet in order to reduce her carbohydrate intake and increase her fibre intake. The prescription of care recommended for her was dependent on assessment which was done by monitoring her blood glucose levels as well as carbohydrate intake. The rationale behind this intervention is to ameliorate the polyuria symptoms by reducing blood glucose levels though the reduction of carbohydrate intake. Chao et al. (2018) advocates the need for strong counselling to reduce the intake of high glycaemic load carbohydrates.
This intervention is expected to improve Angy’s excessive urination. It is imperative that Angy is aware of the locations of restrooms wherever she goes and the option of using a commode was offered to her for times when she feels like she cannot make it to a restroom. When considering Angy’s condition as well as her needs, a multidisciplinary team was needed for proper care. Angy was referred to a diabetes-specialist nurse who specialises in assisting patients with diabetes and diabetes-related conditions. This nurse instructed her on the use an insulin adjustment algorithm and taught her how to properly manage her blood glucose levels. The nurse also assisted her in designing a proper exercise regimen. She was also referred to a dietician who helped her work out a healthy eating plan that included less carbohydrate and more fibre. After a meeting of the members of Angy’s multidisciplinary team, the conclusion that she needed a care package was reached and she was referred to social services for further assessment of her future. It is pertinent to note that while setting these goals for Angy, the SMART goals appraisal tool was used to ensure that the objectives established were custom-made for Angy, rather than adopting a one-size-fits-all-approach, as well as achievable within a reasonable duration. The evidence Angy provided about her lifestyle was pivotal in mitigating any possibility of setting unrealistic, unachievable targets for her since a baseline will be recorded thus effectively measuring progression. SMART (Specific, Measurable, Achievable, Results-focused, Timely) goals is utilises goal setting a means of effectively modifying or altering behaviours with the use of person-specific plans (Michie et al., 2011).
SMART goals appraisal ensures that any targets established are achievable within the person’s ability and resources and measurable in terms of quantity, time or cost-effectiveness.The interventions prescribed for Angy has received positive results and she has been able to keep her blood glucose levels under control. A multidisciplinary team took part in designing a treatment plan for the patient and also in meeting the treatment goals. Right from the onset of her treatment, Angy has been reassured by the multidisciplinary team that details regarding her treatment would be treated with utmost confidentiality.
Application of the RLT model of care was beneficial in aiding the student to focus and achieve their objectives despite the challenging situation. Although assessment based on the RLT model takes time, it was preferred for Angy’s case because it holistically assesses her needs and gives her overview of her health status. The model also assisted the medical team in designing a care plan for Angy which was particular to her needs. Angy’s problems where identified and managed by interventions provided by the healthcare facility and she was discharged and allowed to go home. Upon reflection on Angy’s care plan, it is evident that the combined use of the RLT model of care together with the nursing process provided an effective way of assessing, planning, implementing and evaluating Angy’s treatment.