Wednesday, October 10, 2007

Research drafts and final papers

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Paula Straley said...

Best Nursing Practice for Promoting Successful Care in Adolescent Type 1 Diabetes:
Psychosocial Risks, Adherence to Preventive Care, and Barriers to Nursing Interventions

Paula Straley
John Miller
October 26, 2007

Psychosocial Risks and Adherence to Preventive Care
Adolescent diabetes has been increasing in epidemic proportions. “In the United States the risk for developing Type 1 diabetes is higher than almost all other chronic illnesses of childhood” (Urban & Grey, 2006, p. 517). A diagnosis of diabetes, while significant, is manageable if the individual is committed to monitoring blood glucose levels and practicing lifestyle modifications. The rising incidence of Type 1 diabetes triggers many stressors in young people during their teenage years; the best nursing practice for promoting successful care in adolescent Type 1 diabetes is achieved by managing psychosocial risks and adhering to preventive care. Nursing strategies include therapeutic communication, providing education, and promoting self-efficacy.
The first important nursing strategy required to promote a successful plan for an adolescent with Type 1 diabetes is to establish a therapeutic relationship. The nurse can begin by reading the patient’s chart to identify any issues of concern to explore. During the initial interview with the adolescent and their parents, the nurse must establish a rapport of trust and empathy to facilitate the sharing of ideas and concerns. The nurse needs to observe and address them in the plan of care. The family’s coping mechanisms need to be monitored for their ability to cope with managed care of the adolescent. The adolescents need to be closely observed for emotional response and encouraged to express themselves.
One reason this nursing strategy is so important is because adolescence is a time of emotional turmoil. The majority of adolescents struggle with parental control and the need to define their own self identity. The need to gain autonomy and independence from parental control poses significant problems, especially for an adolescent with diabetes. Parents face anguish over teenagers’ abilities to manage their diabetes and the rejection of parental influences and guidance. According to Preto (cited in Leonard, Garwick , & Adwan, 2005), parents reported concerns relating to adolescents’ long term well-being, whereas adolescents were concerned about their present situation; the opposing perspectives causes conflict between the parents and adolescents. (Leonard et al.) also report that “parental involvement has been directly associated with better outcomes among youth with Type 1 diabetes” ( p. 406). The authors also suggest that family involvement directly correlates with improving metabolic control and compliance. Parents and teens with strong supportive relationships gained better glycemic control and teens assumed more responsibility for their diabetes. The adolescents with conflicting relationships with their parents had less metabolic control and were less likely to adhere to diabetes management.
Another benefit of developing a therapeutic relationship is that it can allow the nurse to identify symptoms of depression in those adolescents with Type 1 diabetes. According to Hood et al. (2006), nearly 1 out of 7 adolescents with Type 1 diabetes suffers from conditions related to depression. This is nearly double the rate of depression reported for all youths. The authors state that factors associated with the increase of depressive symptoms are diabetes specific and the family’s decreased ability to cope. The authors also noted that poor glycemic control tends to be higher in girls than in boys. An increase in hormonal changes may have some correlation factor in girls having higher blood sugar levels. Parents report diabetes-specific conflict associated with lower levels of emotional functioning in youth. Hood et al. (2006), also points out that parents experience anxiety from the pressures associated with successfully managing the care of teenagers who lack adherence. They become stressed and provide less support. Since the implications of profound psychosocial risks are well-established, the nurse needs to be aware of the risk factors when implementing care of adolescents with Type 1 diabetes and educate parents on the signs and symptoms of depression.
Once a nurse has established a positive therapeutic relationship, the nurse can begin the second nursing strategy of educating adolescents and their parents about necessary blood glucose monitoring, medication and lifestyle changes. A dietician consult is implemented in the plan of care, and the adolescent is taught to monitor his or her own glucose levels and recognize the physical signs and symptoms of excessively high or low levels. Parents are taught how fluctuations in blood sugars can produce mood changes. Repeat demonstrations of drawing up insulin and injections are essential in evaluating the understanding and ability of the process. Support is crucial. Adolescents and their families must be able to restate prescribed insulin dosages as it relates to carbohydrate intake and onset, peak, and duration of medication. The adolescent will understand the need to alternate sites to prevent hypertrophy of subcutaneous tissue. The educational process for Type 1 diabetes is ongoing and is usually initiated by a diabetic nurse educator.
Education is an essential part of the third nursing strategy, promoting self-efficacy, and is supported by a collaborative multidisciplinary team. Nurses can help reinforce autonomy in adolescents by initiating more choices and collaborating with the nurse in establishing a plan of care by allowing teens to be a part of their own care team.
A pilot program, The Nurse Case Managed Integrated Care Model, was initiated by the American Diabetes Association in 1997 (Caravalho & Saylor, 2000). The purpose of the program was to provide a continuum of care through a variety of multidisciplinary teams to educate families and provide self-efficacy in managed care of adolescents’ diabetes. The program initiated the nursing process to evaluate the continuum of care provided. The program also considered the maturity level and age of the individuals during the educational process and self-care management. The program directors, furthermore, considered the psychosocial needs of the patients and their families, and the need for counseling to help build healthy coping skills. Caravalho & Saylor (2000) stated that “Increased self-efficacy is an integral part of an empowerment education program” (section 3, para. 3). The authors also report that self-efficacy was associated with better metabolic control. In the past ten years, a similar multidisciplinary approach has been implemented in the educational process for patients who have diabetes. Among the disciplinarians involved are endocrinologists, dieticians, diabetic nurse educators, support groups, and psychologists. The multidisciplinary approach provides a much needed holistic approach to the management and education of diabetes.
One of the ways the nurse can help adolescent diabetics achieve their goal of self- sufficiency is the insulin pump. The insulin pump enables adolescents to manage their care without the complexities associated with transporting myriad syringes, insulin and diabetic supplies. The pump simulates the pancreas and provides better metabolic control, improving the adolescents’ self-efficacy. The pump programming can be modified to accommodate individual lifestyles. This allows teens to be more spontaneous with their diet. For instance; they can program the pump so they can sleep later without getting up early to administer insulin injections. The flexibility that the pump provides allows self-care management for adolescents and builds autonomy. Nurses assess the adolescent’s readiness before insulin pump therapy can be initiated. Interested adolescents must demonstrate motivation, be developmentally capable in their diabetic management, and show an increase in metabolic glucose levels. They must also be prepared to adhere to instructions mandated by diabetic nurse educators and have strong family support.
When developing a plan of care specifically for the adolescent with Type 1 diabetes, the best nursing practice is to establish a multidisciplinary approach to manage psychosocial risks and encourage adherence to preventive care. The nurse needs to be aware of the teen’s need for autonomy and self-efficacy. Promoting self-care management in the adolescent requires effective therapeutic communication and a positive relationship between the nurse, the adolescent, and the families. The parents and teens need to commit to a neutral ground and trust, to gain support and adherence for an overall better outcome, and the nurse needs to establish a therapeutic relationship to assess the psychosocial risks and educational needs of the adolescents and their families. By clarifying the educational needs and risk factors that can affect the teenagers’ ability to manage their own care, nurses can be more successful in implementing the nursing process to collect data for a knowledge base needed to promote strong self-care management and self-efficacy in adolescents and initiating multidisciplinary approach. Nurses can help reinforce autonomy in adolescents by initiating more choices and collaborating with the nurse in establishing a plan of care by allowing teens to be part of their own care team.

Barriers to Successful Nursing Interventions
Nurses can experience barriers to promoting a successful therapeutic relationship that is essential to the long term management of Type 1 diabetes in adolescents. One barrier in promoting a strong therapeutic relationship can occur when an adolescent lacks financial resources or has insufficient insurance. According to Klein, Funnell, and Piette (2006), diabetes related costs are expected to increase significantly to an estimated $192 billion by 2020, for both inpatient and outpatient services (p. 500). Nurses are burdened with limited time and resources to build a positive therapeutic relationship between adolescents and their families. Because of high medical costs there is a lack of follow-up and increased non-compliance. Nurses are unable to provide consistency of care and develop intrapersonal relationships that are indicative to building a sense of trust among adolescents and their families with their nurse.
The lack of follow up can make it difficult for the nurse to assess and evaluate knowledge deficits as it relates to adolescents’ diabetes and complications related to their illness. The limited ability to assess individual’s specific needs can lead to slowed response to providing community resources and can lead to further secondary complications. According to Hood et al. (2006), among the highest risk factors that affect adolescents who have diabetes are depression, parental pressures relating to managed care, and teens’ lack of adherence. Nearly one out of seven adolescents with diabetes suffer from depression. The profound psycho- social risk involved in successful managed care and a good nurse patient relationship cannot be established during sporadic medical visits. The need to seek counseling is essential, but the lack of medical attention and inconsistencies in follow up care can mask underlying issues that can lead to barriers in adolescents’ and families’ self care management success.
A second barrier to promoting a therapeutic relationship among adolescents with Type 1 diabetes is a lack of age appropriate interventions. An essential tool in successful adolescence care management is to keep them fully involved with their personal care. If a nurse fails to acknowledge the teen’s needs in the decision making process when developing a successful plan of care, the adolescent is less likely to comply with the plan of care. Without an active participant the nurse hits a brick wall. The nurse needs to talk with the teens and listen to their concerns and respect their need for autonomy. According to Wong and Perry (2006), the development of independence and the ability to make decisions based on their own medical regimen is crucial to compliance in self care management (pp. 1238-1240). The nurse must always address age appropriate interactions when implementing the nursing process.
Nurses can also experience barriers to promoting a successful educational plan for an adolescent with Type 1 diabetes. A significant barrier to implementing a successful educational plan of care for the adolescent with Type 1 diabetes is once again economic (Krein et al., 2006). They report that “During the past decade, diabetes was ranked among the fifteenth most costly medical conditions treated in the United States” (p. 500). Nurses have played a crucial role in the education and maintenance of diabetes care with in a continuum of care management among individuals on both an inpatient and outpatient basis. Diabetes is a chronic disease and diabetes education is maintained through a multi disciplinary approach over a prolonged outpatient education service plan. Inpatient diabetes education is based on an anticipated stay of less than three days to teach adolescents and their families or any other newly diagnosed diabetic outpatient survival skills. Outpatient referrals are essential (Habich, 2006).
The process for ongoing diabetic education is very costly and can prevent individuals from seeking help. According to Krein et al. (2006),many patients pay some out-of-pocket expenses for their diabetic supplies and diabetic related services. The overwhelming cost of diabetic services and supplies can lead to decreased compliance and decreases use of prescribed medications that can lead to secondary health complications.
When evaluating the plan of care for the adolescent and their families, nurses need to be aware of the issues of compliance related to lack of insurance or lack of monetary resources.
Nurses can familiarize themselves with community programs that help support families with cost effective interventions. Nurses should always reinforce the importance of diabetes management and preventive care. The Balanced Budget Act acknowledges the value of diabetes self training and provisions of diabetic supplies to those in need (Krein, 2006, p. 504). “Because diabetes care is so costly, diabetes management has been singled out through mandated benefit and insurance coverage initiatives at both the state and federal levels” (p. 504).
Another barrier to a nurse implementing a successful plan of care for adolescents and their families with Type 1 diabetes is language and literacy barriers. According to Garcia and Benavides- Vaello (2006), “In the United States, non Hispanic blacks and Mexican Americans are two times more likely to develop diabetes than non Hispanic whites” (p. 605). It is extremely important that the nurse faced with the challenge of promoting a strong knowledge base of diabetes management evaluates the knowledge of the family in light of possible cultural or language barriers. Nurses can provide educational material in the family’s preferred dialect if needed to help facilitate understanding or provide staff who speak the same dialect. Educational material should be provided in the native language of and at the literacy level of the adolescent or their family. “Patient provider interactions seem to be an important component of diabetes care that can profoundly influence whether and to what degree a patient engages in diabetic self management “(Garcia, p. 613). The nurse should facilitate community involvement and resources (p. 615).

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