PHARMACOLOGY
Part A
Introduction
The intent of this paper is to provide a critical analysis of the provided patient scenario on basis of empirical evidence and best practice guidelines. Part A of the paper begins with a presentation of nursing assessment of the patient (Vivette). I then provide an in-depth pathophysiology of the patient’s condition. Thirdly, I relate the pathophysiology of the condition to nursing care. Fourthly, I present a critical evaluation of nursing management the condition. In Part B of the paper, I start with a discussion of the pharmacology of insulin in the context of the patient scenario. I then justify nursing care for Vivette in relation to her non-compliance and associated legislative and empirical frameworks. Finally, I evaluate the role of medicines optimization in addressing the patient’s non-compliance.
Definition of terms
Insulin Dependent Diabetes Mellitus
Insulin dependent diabetes mellitus (IDDM), also called Type 1 diabetes is a condition that occurs when the beta cells of the pancreas are unable to produce insulin, a hormone which plays an important function of regulating glucose in blood (Mulvaney et al., 2010). Affected patients need insulin injections. IDDM usually begins before the age of 15 but it also affects adults (Patterson et al., 2014).
Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) refers to a serious complication which occurs due to excessive production of acids called ketones by the body of a patient with diabetes (Chimen et al., 2012). Lack of insulin and the resultant inadequate glucose in cells cause the body to break down fats for energy. This results in the buildup of ketones and the development of diabetic ketoacidosis (Hovorka et al. 2010).
Non-compliance
Non-compliance refers to refusal or failure to conform to prescribed course of treatment or medications (Mulvaney et al., 2010). Patients who demonstrate non-compliance are said to be non-compliant. Non-compliance specifically describes behavior of patients who fail or refuse to coincide with therapeutic plans recommended by healthcare providers and treatments that are agreeable to family members (Chimen et al., 2012).
Nursing Assessment
The ABCDE approach is the most appropriate for nursing assessment of Vivette. The Resuscitation Council of UK (2016) provides that the ABCDE approach should be applied in the nursing assessment of deteriorating patients. Vivette’s condition is would be deteriorating owing to the fact that she is non-compliant to the prescribed plan of care. On the basis of the ABCDE approach, the nursing assessment of Vivette should begin with evaluation of her airways. The assessment of the airways is important as it will determine whether or not Vivette is experiencing airway obstruction. If there is an obstruction, it has to be treated as a medical emergency (Resuscitation Council of UK, 2016). Vivette’s breathing should also be assessed. In her case, the breathing assessment should seek to determine any signs of distress in breathing. Her respiratory rate should be taken since shortness of breath indicates medical emergency (Chimen et al., 2012).
Vivette’s circulation should also be evaluated through the measurement of her heart rate. Her heart rate should be assessed since diabetes is associated with poor circulation (Mulvaney et al., 2010). The ABCDE approach also provides for assessment of patients for signs of disability, such as unconsciousness (Resuscitation Council of UK, 2016). Therefore, Vivette’s level of consciousness should be evaluated through proper nursing procedures, such as examining her pupils and reaction to light. More importantly, Vivette’s exposure should be assessed to determine if she is exposed to complications. This is vital for Vivette due to her non-compliance to medication. In assessing the exposure of a patient, clinical history is normally applied (Hovorka et al. 2010). Vivette’s clinical history is critical in determining her exposure and required level of care.
Pathophysiology
IDDM affects 15-20% of young patients with diabetes in the UK (Patterson et al., 2014). It occurs as a result of destruction of beta cells in the pancreases. Beta cells are endocrine cells that serve the role of producing insulin. The specific etiological factors of the disorder are unknown (Chimen et al., 2012). However, researchers attribute the destruction of pancreatic beta cells to autoimmune responses (Van Belle et al., 2011). Borus and Laffel (2010) reveal that the autoimmune responses that lead to the destruction of insulin producing cells involve the expansion of antibody producing B cells and autoreactive CD8+ T cells and CD4+ T cells. Therefore, it is the innate immune system that is activated prior to the destruction of pancreatic beta cells. Palmer et al. (2011) indicate that treatment with insulin leads to temporal improvement in insulin levels. This means that Vivette’s insulin levels will worsen if she remains non-compliant to the prescribed treatments. Aschner et al., (2010) demonstrate that treatment of patients with IDDM alters the autoreactive immune system causing improvement in insulin levels. McKnight et al. (2015) reveal that IDDM occurs in patients who have genetic susceptibility. However, environmental factors are also reported to contribute to the chronic autoimmunity that occurs in IDDM (Mulvaney et al., 2010).
According to Maahs et al. (2012), during the course of IDDM, long term complications are experienced to some extent and invariably by all patients. It is however notable that Vivette has not yet experienced complications of IDDM. This is demonstrated by the fact that she is not in diabetic ketoacidosis. However, she is most likely to experience these complications, especially due to her non-compliance to prescribed treatments. Other complications Vivette may experience as a result of refusal to comply with treatment include neuropathy, retinopathy and nephropathy (Chimen et al., 2012). However, the molecular basis of the aforementioned three complications is not completely clear (Hilliard et al., 2013). In the contrary Palmer et al. (2011) report findings of prospective clinical studies which demonstrate that the complications of IDDM are correlated to poor glycemic control that occurs due to metabolic derangement in affected patients. In this sense, the severity of complications Vivette would experience due to IDDM will be determined by her level of metabolic derangement or poor glycemic control. For this reason, a treatment plan aimed at maintaining near-normal glycemia should be indicated for Vivette.
Relevance to Nursing Care
The National Institute for Health and Care Excellence (2016) provides that young people and children with IDDM should be given appropriate insulin preparations, such as long-acting insulin analogues, intermediate-acting insulins, short-acting insulins or rapid-acting insulin analogues. This is related to pathophysiological evidence indicating that the pancreatic beta cells of affected patients are destroyed and cannot produce insulin. Therefore, nursing care for Vivette should involve the administration of insulin preparations that are aligned with her healthcare needs. Notably, the main nursing challenge in Vivette’s care is related to her non-compliance. Therefore, nurses taking care of Vivette should stress the importance of complying with prescribed medications by demonstrating that they are designed to maximize the quality of her life. Attending nurses should also provide relevant information related to the causes, possible complications and effects of her IDDM (Mulvaney et al., 2010).
Vivette’s non-compliance would be attributed to lack of adequate knowledge on her condition and associated health effects or complications. Therefore, it is the role of attending nurses to provide her with simplified pathophysiological information on her condition. For example, it should be explained to Vivette why her body is unable to produce insulin and the resultant need for insulin analogues. She should also be informed that if she refuses to take the insulin, she would experience complications, which would make it impossible for her to enjoy time with her friends. In this sense, she is likely to be convinced to comply with the treatment. It is notable that Vivette does not perceive her diagnosis to be serious. At age 14, her social needs dominate and therefore she prioritizes being with friends rather than undergoing treatment. This is the reason why attending nurses should demonstrate that her treatment is designed to promote her social wellbeing.
Evaluation of Care and Nursing Management
Borus and Laffel (2010) assert that young people newly diagnosed with IDDM should be evaluated by a team of experts, including a nurse educator, a pediatric endocrinologist, a mental health professional and a dietitian. It is therefore possible that Vivette’s non-compliance is associated with lack of incorporation of a multidisciplinary team in the assessment and management of her needs. It is notable that she needs education on the importance of her treatment and the undesired effects of not taking the prescribed medications. For this reason, education should be center of nursing care and management for Vivette.
Maahs et al. (2012) demonstrate that education in IDDM should be sensitive to the development stage and age of affected patients. Therefore, the content of the educational interventions and the educational approaches in Vivette’s case should be appropriate for a 14 year old girl. The presence of a nurse educator is important for successful treatment and management of her condition as she needs to understand how the complications of her condition would affect her health and social life. This will allow her to make informed decisions related to the prescribed treatment plan (Mulvaney et al., 2010). However, education for Vivette should be informed by the assessment and recommendations of a mental health professional. It is through this that her social needs, family contexts and developmental milestones will be taken into consideration in the assessment and management of her condition (Chimen et al., 2012).
Part B
Pharmacology of Insulin
Insulin is classified as an antidiabetic. Maahs et al. (2012) reveal that the type of insulin administered to patients with IDDM varies depending on duration of action and time of onset. For instance, rapid-onset IDDM is appropriately treated using rapid-acting insulins (Chimen et al., 2012). On the other hand, short-acting insulins are used when the onset of IDDM is slightly slower. Borus and Laffel (2010) indicate that intermediate-acting and long-acting insulins are preferred for slow and long onset of drug action. Palmer et al. (2011) reveal that a combination of rapid-acting insulins and long-acting insulins closely mimics the normal use of insulin by the body. This is unlike older regimens which usually require 1-2 shots a day (Patterson et al., 2014). Therefore, Vivette’s IDDM would be managed more appropriately through the combination of rapid-acting insulins and long-acting insulins. Rapid-acting insulins are rapidly absorbed from subcutenous tissue or fat tissue into the bloodstream (Hilliard et al., 2013). Examples include insulin aspart, insulin glulisine and insulin lyspro. Their onset of action is between 5 and 30 minutes and they last for between 4 and 6 hours. Palmer et al. (2011) note that rapid-acting insulins are appropriate for controlling blood sugar during snacks and meals. Therefore, Vivette should be educated and advised on the importance of using rapid-acting insulins prior to snacks or meals for effective control of her blood sugar. Maahs et al. (2012) indicate that the onset of action of short-acting insulins is between 30 minutes and 1 hour. Their action lasts for up to 8 hours. Examples include regular insulin or novolin and velosulin.
The absorption of intermediate-acting insulins is slower and lasts relatively longer (Mulvaney et al., 2010). They are appropriately used to control blood sugar between meals or overnight. NPH insulin is the commonly used intermediate-acting insulin (Chimen et al., 2012). Its onset of action is between 1 and 2 hours and it can last for between 18-24 hours. Examples of long-acting insulins include insulin glargine, insulin detemir and insulin degludec. They cover the insulin needs of a patient for a whole day (Tuomilehto, 2013). It is notable that the type of insulin best for a patient is influenced by a wide range of factors. Factors that should be considered in the prescription of the right insulin to Vivette include her response to insulin, lifestyle choices and willingness to take multiple injections every day (O'grady et al., 2012). Her non-compliance indicates that she is not enthusiastic about insulin injections. For this reason, long-acting insulins would be more appropriate for her. However, her age should be considered in nursing management. This is because at 14, she may not be able to check her blood sugar as often as required. In addition, she is likely to dislike the idea of getting multiple injections every day. Borus and Laffel (2010) explain that effective collaboration with parents or guardian is required as it will allow her to manage the prescribed treatments appropriately.
Debate on Non-Compliance
The Standards for Medicines Management of NMC (2008) provide that Registered Nurses are legally and professionally accountable in the administration of medications, demonstrating competency and adhering to healthcare protocols and procedures within primary care settings. Registered nurses are also accountable for omissions and actions related to healthcare delivery processes. However, nursing regulation in the UK is a relatively complex matter due to the ethical dilemmas nurses face in their practice. Vivette’s non-compliance is an example of an ethical dilemma that impacts negatively on the professional and legal obligations of attending nurses to provide safe and high quality of care as provided by the NMC (2008). Maahs et al. (2012) argue that nurses should understand non-compliance in order to become more effective in improving the behavior of patients. The National Institute for Health and Care Excellence (2016) provides evidence-based recommendations on how nurses can support compliance and adherence to prescribed medications by patients. They include the integration of shared decision making and informed choice in the nursing management process.
The issue of lack of informed choice is raised in the scenario. For instance, Vivette does not seem to consider her treatment to be as important as she thinks it excludes her from friends. Therefore, attending nurses should ensure that Vivette’s decision in regard to medication for her IDDM is adequately informed. This would be achieved through the collaboration of members of an interdisciplinary team in the assessment and influence of her perception towards treatment. The NMC regulatory framework provides that registered nurses should be aware of the collaboration and interrelationships occurring among members of multidisciplinary teams in the administration of medications (NMC, 2008). The specific members of multidisciplinary teams that should collaborate in the care of Vivette include a nurse educator, play specialist, dietician, child psychologist and a pediatric endocrinologist. They should work together in assessing Vivette’s information needs while considering the influence of factors, such as age, level of development and social and family relationships. Depending on her needs, a play specialist can integrate play into the assessment of Vivette’s with a goal of convincing her to comply with the prescribed medication. Support groups, such as family members and friends from school should also be used to encourage her to comply with the medication. For instance, her friends can be asked to spend some time with her in order to eliminate the feeling of being excluded from friends during the treatment. The professional obligation of registered nurses to be flexible will be achieved effectively though the integration of multidisciplinary teams and support groups to convince Vivette to take her medication.
Nursing Role in Medicines Optimization
NHS England (2016) defines medicines optimization as the process of ensuring that right medications are provided to the right patients at the right time and using the right routes of administration. Borus and Laffel (2010) add that through medicines optimization nurses are able to provide medications in the correct manner. It also prevents waste and improves safety as it provides that unnecessary medications should not be given to patients (NHS England, 2016). In the case of Vivette, medicines optimization should be used to encourage compliance to prescribed medications or treatments. For instance, Vivette should be given antidiabetics that are aligned with her unique healthcare needs, age, development stage, social needs and response to insulin. Since there are several medication options for the management of IDDM, it is important that she is given medications that are aligned with her lifestyle preferences and healthcare needs. It is argued that an appropriate combination of both rapid acting and long-acting antidiabetics should be used to manage Vivette’s condition. For instance, when she needs to spend more time with her friends, she should use long-acting antidiabetics. However, rapid-acting antibiotics should be used appropriately to manage her sugar, especially prior to high calorie meals (Mulvaney et al., 2010). These illustrations reveals why a dietician should be part of the healthcare team managing her condition.
Attending nurses play an important role of assessing the needs of the patient, including the preferred route of administration, in order to design and implement the most effective nursing care plan for her. More importantly, attending nurses play an important role of educating her on the options she has in the management of her condition (Tuomilehto, 2013). This will allow her to select what she considered to be the most appropriate option, such as taking long-acting antidiabetics. However, attending nurses must evidence-based alternatives, depending on the findings of her assessment (Chimen et al., 2012). Involving Vivette in informed decision making process is important as it will encourage compliance (Aschner et al., 2010). Attending nurses also play the role of explaining why specific routes of insulin administration are better or advantageous than others in order to assist Vivette to make an informed decision (O'grady et al., 2012). Furthermore, attending nurses should be caring and able to show empathy in order to demonstrate that the prescribed medications are meant to promote her wellbeing rather than isolating her from friends. In supporting compliance, attending nurses should adhere to the ethical principles of truthfulness, justice and fairness (NMC, 2015). This means that attending nurses should be truthful and fair in explaining the meaning of IDDM diagnosis to Vivette. This will prepare her psychologically for the experiences of life-long use of the prescribed medications.
Conclusion
A critical analysis of the provided patient scenario reveals that nurses have important roles to play in understanding, promoting and supporting compliance to medications among young people diagnosed with IDDM. The ABCDE approach should be used in nursing assessment of Vivette to ensure that any signs of deterioration are identified and addressed appropriately through the use of patient-centered and evidence-based interventions. The analysis of the scenario also indicates that nurses play an important role of applying their knowledge and competencies in promoting desired patient outcomes. They achieve this by working with multidisciplinary teams in assessing the needs of patients and ensuring that appropriate nursing plans and interventions are developed and implemented. A multidisciplinary team involving a nurse educator, play specialist, dietician, child psychologist and a pediatric endocrinologist should be involved in the assessment of the healthcare needs of Vivette and ensuring that they are appropriately addressed with a purpose of encouraging compliance to medications. Collaboration with support groups, such as family members and friends is another effective approach of encouraging Vivette to take her medication. More importantly, medications optimization should be integrated into her care to ensure that antidiabetics that are aligned with her healthcare needs and personal preferences, such as route of administration and frequency of injections are appropriately met.
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