1. Case Presentation – Assessment 3 www.clipshrine.com

2. 1. Consider patient situation 2. Collect Cues / Information 3. Process Information 4. Identify problems 5. Establish Goals 6. Take Action 7. Evaluate Outcomes 8. Reflect on Process Clinical Reasoning Cycle (Levett-Jones et al, 2010)

3. Health Lifestyle Family (BPJ, 2012). (New Zealand Guidelines Group, 2012)

4. Biguanide – Metformin o Diabetes diagnosis = 2009 o 1 st line therapy o Renal function o Dose titration www.beautyglimpse.com Diabetes management therapy (Bullock, Manias, & Galbraith, 2007), (Ginourie, 2013) (New Zealand Guidelines Group, 2012), (Robbin, Shaw & Lewis, 2009 (UKPDS 33, 1998), (Violla, et al.,2012).

5. Sulphonylurea – Glicazide o 2011 o Second line therapy o Hba1c = 89 www.quantumday.com Diabetes management therapy (New Zealand Guidelines Group, 2012), (Polagani, Pilli, Gajula, & Gandu, 2013).

6. 2012 – 2013 o Hba1c 42 – 45 √ o Glycaemic control √ o Adherence √

7. Anti-hypertensive ACE inhibitor – Zapril 0.5mg Anti platelet therapy Aspirin 100mg Statin Atorvastatin 20mg Cardiovascular disease management therapy Commenced in 2013 ← ←←←←←← (Best Practice Advocacy Centre, 2014). (New Zealand Guidelines Group, 2012) (Remuzzi, Macia & Ruggenenti, 2006) www.quantumday.com

8. 2014 o Hba1c ↑ = 74 o Glycaemic control ↓ o Microvascular risk ↑ o Adherence ↓ (BPJ, 2012)

9. (Fowler, 2008), (Pabari & Ganesh, 2012) (Robbin, Shaw & Lewis, 2009), (Vithianl, 2010)

10. Manage risk of long term complications Feet Kidneys Eyes Manage Cardiovascular Risk Lower Lipids Lower BP Anti thrombotic therapy Managing DM type 2 EducationLifestyleLower BGLs Adapted from 'The type 2 diabetes care pathway'. BPJ (2012) (Mosley, 2012), (Zimmerman, 2010).

11. Adherence (Delamater, 2006), (Schectman, Schorling & Voss, 2008 ) (Solomon, Yemane & Alemayehu, 2014) http://hypnosis.personal-development.info/immune-system.html

12. Care Plan – Targets Hba1c 74 mmol/mol 50-55 mmol/mol Blood Pressure >140/90 mm Hg <130/80 mm Hg Cholesterol TC 5.9mmol/L, LDL n/a, HDL 1.08mmol/L Triglycerides 6.5mmol/L TC <4.0mmol/L, LDL <2.0mmol/L HDL >1.0mmol/L, Triglycerides <1.7mmol/L CVRA >15% <15% BGL’s >14mmol 4-8mmol Weight >104kg <100kg (Delamater, 2006) (New Zealand Guidelines Group, 2012)

13. . Monitoring & Evaluation (BPJ, 2014), (Delamater, 2006) (Inzucchi, et al. 2012), (Khardori & Griffing, 2014). www.webimages

14. Reflection o What went well o What could have gone better Conclusion … o what next for James … (BPJ, 2014) www.flickr.com

15. References Best Practice Advocacy Centre. (2014). Getting to know patients with type 2 diabetes and poor glycaemic control: One size does not fit all. Best Practice Journal. 58: 41-48. Best Practice Advocacy Centre. (2012). Care pathways for long-term conditions: Using type 2 diabetes as an example. Best Practice Journal. 47: 38-41. Best Practice Advocacy Centre. (2012). Hba1c in diagnosing type 2 diabetes. Best Practice Journal. 42: 14-19. Bullock, S., Manias, E., & Galbraith, A. (2007). Fundamentals of pharmacology. (5th ed.). Pearson Education: New South Wales. Delamater, A. (2006). Improving patient adherence. Clinical Diabetes. 24:2 71-77. Retrieved from: http://clinical.diabetesjournals.org/content/24/2/71.full http://clinical.diabetesjournals.org/content/24/2/71.full Fowler, M. (2008). Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes. 26:2, 77-82. Retrieved from: http://clinical.diabetesjournals.org/content/26/2/77.fullhttp://clinical.diabetesjournals.org/content/26/2/77.full Ginourie, A. (2013). Case Study 10: the person with diabetes mellitus type 2. In Barber, P. (Ed). Medicine management for Nurses case book. (pp. 79-87). London: McGraw Hill. Inzucchi, S., Bergenstal, R., Buse, J., Diamant, M., Ferrannini, E., Nauck, M., Peters, A., Tsapas, A., Wender, R., & Matthews, D. (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Diabetologia. Khardori, R., & Griffing, G. (2014). Type 2 Diabetes Mellitus. Retrieved from: http://emedicine.medscape.com/article/117853-overview http://emedicine.medscape.com/article/117853-overview

16. Levett-Jones, T., Sundin, D., Bagnall, M., Hague, K., Schumann, W., Taylor, C et al (2010). Learning to think like a Nurse. Retrieved from: http://journals.sfu.ca/hneh/index.php/hneh/article/viewFile/65/56http://journals.sfu.ca/hneh/index.php/hneh/article/viewFile/65/56 Mosley, M. (2012). UKPDS Follow-Up: Early Hba1c reductions linked to a decrease in MI, all-cause mortality: major benefits of sustained control are seen 5-10 years later. Cardiometabolic Implications. 1:2. Retrieved from: http://ahdbonline.com/issues/value-based-care-cardiometabolic-health/august-2012-vol-1-no-2/ http://ahdbonline.com/issues/value-based-care-cardiometabolic-health/august-2012-vol-1-no-2/ New Zealand Guidelines Group. (2012). New Zealand Primary Care Handbook 2012. (3 rd ed.). Wellington: New Zealand Guidelines Group. Pabari, R., Ganesh, A. (2012). Management of Retinopathy and Neuropathy in Diabetes. The University of British Columbia Medical Journal. Retrieved from: http://www.ubcmj.com/pdf/ubcmj_3_2_2012_22-26.pdfhttp://www.ubcmj.com/pdf/ubcmj_3_2_2012_22-26.pdf Polagani, S., Pilli, N., Gajula, R., & Gandu, V. (2013). Simultaneous determination of atorvastatin, metformin and glimepiride in human plasma by LC–MS/MS and its application to a human pharmacokinetic study. Journal of Pharmaceutical Analysis. 3:1, 9-19. Retrieved from: http://www.sciencedirect.com/science/article/pii/S2095177912001098 http://www.sciencedirect.com/science/article/pii/S2095177912001098 Remuzzi, G., Macia, M., & Ruggenenti, P. (2006). Prevention and treatment of diabetic disease in type 2 diabetes: the BENEDICT study. Journal of the American Society of Nephrology. 17 :4:2, 90-97. Retrieved from: http://jasn.asnjournals.org/content/17/4_suppl_2/S90.fullhttp://jasn.asnjournals.org/content/17/4_suppl_2/S90.full Robbins, N., Shaw, C., & Lewis, S. (2009). Diabetes Mellitus. In Brown, D., & Edwards, H. (Eds.). Lewis’s medical-surgical nursing: assessment and management of clinical problems. (pp. 1348- 1382). (2 nd ed.). Chatswood: Elsevier Australia. Schectman, J., Schorling, J., & Voss, J. (2008). Appointment adherence and disparities in outcomes among patients with diabetes. Journal of General Internal Medicine. 23(10):1685-7. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/18661189 http://www.ncbi.nlm.nih.gov/pubmed/18661189 References

17. Solomon, A., Yemane, B., & Alemayehu, W. (2014). Barriers to diabetes medication adherence in North West Ethiopia. 3:195. Retrieved from: http://www.springerplus.com/content/3/1/195http://www.springerplus.com/content/3/1/195 United Kingdom Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998. Violla, B., Garcia, N., Leclerc, J., Foretz, M., & Andreelli, F. (2012). Cellular & Molecular mechanisms of Metformin: an overview. Clinical Science. 122, 253–270. Retrieved from, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398862/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398862/ Vithian, K. (2010). Microvascular complications: pathophysiology and management. Clinical Medicine. 10:5, 505- 509. Retrieved from: http://www.clinmed.rcpjournal.org/content/10/5/505.full.pdfhttp://www.clinmed.rcpjournal.org/content/10/5/505.full.pdf Zimmerman, R. (2010). Microvascular Complications of Diabetes. Retrieved from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/microvascular- complications-of-diabetes References