Diabetes nursing is one of the priorities of the World Health Organization today, so the nursing must have a solid and up-to-date basis to provide a diabetological education that allows preventive measures and improve the quality of life of diabetic patients .
The essential components of the act of caring are preventing and curing. The prevention has a primary character when it is directed to avoid the illness or a secondary and tertiary character when it acts in groups of risk or in sick people to try that there are no complications.
Preventing the onset of chronic disease is a pre-care challenge involving professional competence, health policies and the way of life of the community and in which health promotion and education programs are essential, both for prevention in at-risk populations to cope with actions aimed at the healthy population to verify and improve their health status. In the case of diabetes this is especially important if one takes into account its high prevalence.
It is therefore of utmost importance that the nursing professional acquire the necessary skills and abilities so that people with diabetes can achieve the therapeutic objectives proposed.
This course of the Virtual Classroom of the Editorial DAE is an opportunity for all nursing professionals to update or acquire knowledge of the field of Diabetes, in a fast, convenient and very accessible way.
Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia secondary to a defect in the action and / or secretion of insulin, which is accompanied by alterations in the metabolism of lipids and proteins, which leads to microvascular and macrovascular involvement which affects different target organs. one
Microvascular complications include retinopathy, nephropathy, neuropathy, and macrovascular diseases (coronary artery disease, peripheral cerebrovascular disease, and peripheral vascular disease), 2-5 the latter being the most common and responsible for nearly 70% of deaths in people with diabetes. for cardiovascular diseases. 4
In the global context, DM is a public health problem, as it is one of the most prevalent chronic diseases associated with high morbidity and mortality. 6-8 Currently more than 382 million people in the world suffer from this disease and it is estimated that it reaches 592 million by 2035. Around 5.1 million people between 20 and 79 years old died from diabetes in the world. year 2013, representing one death every six seconds. 9
In Colombia, a prevalence of 7.5% is estimated in older than 30 years, which, adjusted for sex, yields data for men of 7.3% and women for 8.7%, constituting the first five causes of death, which It grants all the importance to its prevention and adequate treatment. 7
When analyzing the previous figures and knowing the serious complications that patients with a diagnosis of diabetes have to face, 10 the socio-health costs associated with the treatment and its complications draw attention, which represents a serious burden for the health services, the patient, the family and society, therefore, it is important the participation of the nursing professional, through educational interventions aimed at strengthening self-care in people with DM. 9.3
Education applied to a chronic disease such as diabetes, facilitates the diabetic person and his family learning the skills and knowledge necessary to assume a positive attitude to their illness, empowering responsible choices so that they assume self-care actions, as well as support necessary for them to be an active part of the treatment; 11 so as to prevent, delay or reduce the likelihood of developing complications that generate so much impact in the social, psychological and economic spheres of the affected people and their families. 6
From the nursing perspective, self-care is a strategy that responds to the goals and priorities of the discipline, which can be considered as a useful tool for the promotion of health and the prevention of the disease and its complications, relying preferably on theories of nursing as is the case of the General Theory of Self-Care of Dorothea Orem. 12
Theory of Dorothea Orem contemplates three sub-theories of intermediate rank related to each other: Theory of Self-care, which describes and explains why and how people take care of themselves; Self-care Deficit Theory that describes and explains how nursing can help people, and the Theory of the Nursing System that describes and explains the relationships that need to be maintained. 13
Within the framework of the Middle Range Theory of Self-care, this concept is defined as “The practice of activities that individuals initiate and perform for their own benefit for the maintenance of life, health and well-being”. 14,13 Self-care actions are learned and developed by people in both stable and changing environments, within the context of their patterns of daily life. 13
In this way, applying the General Theory of Self-care of Orem through the Process of Nursing Care (PAE), considered this one of the most important methodological underpinnings of the professional discipline of Nursing, provides the scientific basis in the assessment of the state of health, the formulation of the nursing diagnosis, in the planning and execution of care actions, and finally in the evaluation of activities in relation to the compliance of the interventions and the scope of the proposed goals. fifteen
Taking into account the previous context and the policies promoted by the World Health Organization (WHO), for the control of chronic diseases, 16 the present case study aims to apply the Orem Self-Care Theory to the person with diabetes mellitus , through the Nursing Care Process (PAE), in order to promote self-care practices for the benefit of one’s health and well-being.
The present work corresponds to a case study selected in the Internal Medicine Unit of a Health Institution of the Second Level of Care, during the training practice developed by a group of students of III Level of Nursing. It was carried out with the aim of promoting the critical thinking, analysis and reflection of the application of Nursing models and theories from the Nursing Care Process, as part of holistic and integral care within the training of Nursing professionals.
It is important to highlight that the Nursing Care Process is a system of own nursing interventions for the improvement of the health of individuals, families or community, 17the use of this process favors the individualization of care and prevents omissions or repetitions . It is composed of five stages: assessment, diagnosis, planning, execution and evaluation. 18
In order to elaborate the Nursing Care Process (PAE), the theory of Dorothea Orem, with its three theories, was used first of all; the theory of self-care: described the universal requirements of development and deviation of health present in the user; the self-care deficit theory: evidenced the ignorance of self-care actions in the user in relation to her illness; and the responsibility of the nursing staff to cover these demands, before which the theory of nursing systems was linked . From the total and partially compensatory systems, nursing addressed the needs of care and self-care in the user during the hospitalization period; and through theThe education-support system provided guidance, support and teaching for the control of the disease from the Nursing Process developed during home monitoring and the subject of this case study. ( Table 1 )
Subsequently, the assessment was conducted to obtain information regarding the health status of the user, the information was obtained through the interview and physical examination, conducted from the domain model of the NANDA taxonomy. The reasoning based on the domains determined the diagnoses from the North American Nurse Diagnosis Association (NANDA), 19 of which the main diagnosis was selected that was linked to the educational needs to be developed in the intervention stage ( Table 2 ).
- Evaluation Stage
Table 2 . Valuation by NANDA domains and formulation of diagnostic categories
|COMMITTED DOMAINS||DEFINITIVE CHARACTERISTICS||DIAGNOSTIC CATEGORY||RELATED FACTORS||CRITERIA OF RESULTS AND INTERVENTION|
|Promotion of health||-Express interest in learning about care for the management of the disease.
-Express difficulties in the incorporation of prescribed treatment regime in daily life.
|Ineffective management of one’s health
|-Deficit of knowledge in the management of the therapeutic regimen.
-Economic difficulties due to lack of employment linkage.
Self-control: chronic disease (00078)
Teaching: disease process (5602)
|Nutrition||– Upper body weight: BMI 28.50kg / m 2
– sedentary lifestyle due to the presence of varicose ulcers that have reduced the strength in their lower extremities.
|Nutritional imbalance: intake greater than the needs (00001)||-Excessive contribution in relation to metabolic needs / physical activity.||NOC:
Knowledge: prescribed diet
Teaching: prescribed diet (5614)
|Risk of unstable glycemia level (00179)||-Deficient knowledge about the management of diabetes.
– Inadequate dietary support.
– Inadequate control of blood glucose.
-Lack of adherence to the diabetes therapeutic plan.
-Level of physical activity
|NOC:Knowledge: control of diabetes (1820)
NIC: Teaching: disease process (5602)
NIC: Teaching: Prescribed diet (5614)
NIC:Management of hyperglycemia (2120)
NIC: Promotion of the year (0200)
|Deterioration of urinary elimination
|-Infection of the urinary tract: Positive urine culture for E. coli beta-lactamase of broad spectrum, UFC> of 100,000.||NOC: Urinary elimination (0503)
NIC:Management of urinary elimination (0590)
|-Edema in lower limbs
– Pain in the extremities
-Delay in the healing of peripheral and deep wounds
-Alteration in the motor function
|Ineffective peripheral tissue perfusion
|-Deficient knowledge about aggravating factors.
-Deficient knowledge about the disease process.
-Hypertensi n Arterial
-Deep venous thrombosis
-Critical Grade IV Venous Insufficiency
– Sedentary lifestyle.
Tissue perfusion: peripheral (0407)
Circulatory care: venous insufficiency (4066)
|-Deterioration of the ability to walk the required distances.||Deterioration of the ambulance (00088)||-Lack of physical condition to remain at rest all the time.
– Insufficient muscle strength in lower limbs: 2/5 on a scale of muscular strength
-Lack of knowledge in relation to physical activity
-Overweight: BMI 8.50kg / m 2
– Limb pain: 4/10 Analog Rating Scale
|NOC: Ambular (0200)
Teaching: prescribed exercise (5612)
|Risk of injury (00035)||– Abnormal blood profile: Hemoglobin 9.03gr / dl and hematocrit: 27.09%
-Malnutrition: BMI 28.50kg / m 2
-Physics: solution of skin continuity (varicose ulcers), mobility impairment (decreased strength, varicose ulcers, overweight).
Detection of risk (1908)
Identification of risk (6610)
|-Destruction of the layers of the skin: varicose ulcers that compromise the circumference of the right lower limb 15 cm wide and in the left limb on the medial side of 8×4 cm.||Impaired skin integrity (00046)||-Deterioration of venous circulation:
Deep Venous Thrombosis e
Critical Venous Insufficiency Grade IV.
Tissue perfusion: peripheral (0407)
Circulatory care: venous insufficiency (4066)
Then, in the planning stage , the objective to be achieved was established from the Nursing Outcomes Classification (NOC), 20 ( Table 3 ).
2 and 3. Diagnosis and planning stage
With this objective, the execution stage was developed using the Nursing Interventions Classification (NIC), 21 where the activities that supported nursing care were selected according to the self-care teaching needs of the client and the family ( Table 4 ) .
- Intervention Stage
Finally, in the evaluation stage, specific indicators were used according to the Nursing Outcomes Classification (NOC), which evaluated the effectiveness of nursing interventions based on the comparison of the initial and final results with the expected result proposed in the planning stage ( Table 5 ).
The guidelines of Resolution 008430 of the Ministry of Health of Colombia, 22 “by which scientific, technical and administrative standards for health research are established,” where it was classified as a risk-free investigation, were followed . The objective of the follow-up was reported and, after the voluntary participation with verbal and written informed consent, the home visits were scheduled for the development of the educational activities. Throughout the process, compliance with the ethical principles of fidelity, truthfulness, respect for autonomy, beneficence, nonmaleficence and justice was guaranteed.
PRESENTATION OF THE CLINICAL CASE
A 57-year-old woman lives with her daughter who is her primary caregiver; resides to the North of the city of Bucaramanga (Santander, Colombia). He entered the emergency department with a clinical picture of diaphoresis, dysarthria, disorientation, glucometry 43.2mg / dl. It was requested channel peripheral vein DAD pass 200cc of 10%, laboratory blood count (Hb: 9.03 g / dl, hematocrit: 27.09%, 85.7% Neutrophils Leukocytes 10,250 / mm 3 , 471,000 platelets / mm 3 ); creatinine (0.9mg / dl), urine culture (positive for E. coli betalactamase broad spectrum, CFU greater than 100000) and glycemia: 123.8 mg / dl. He moved to the internal medicine service to start treatment.
Medical diagnoses: decompensated type 2 diabetes mellitus, complicated UTI – E.coli BLEA + multiresistant, grade IV chronic venous insufficiency, deep vein thrombosis, lower extremity over infected ulcers, chronic normochromic normochromic homogeneous anemia, arterial hypertension, stage III acute renal failure .
- Evaluation stage
At the end of the nursing intervention, the NOC Knowledge Result Criterion was evaluated: control of diabetes, obtaining an extensive level of knowledge with a score of 5.0. In this way, the difference between the Initial NOC and the final NOC was 2.4, a result that shows that nursing interventions through the educational support system contributed to improving the level of knowledge, the development of skills and motivation. in the user to carry out and maintain actions in the management and monitoring of the disease.
The Nursing Process linked to Orem’s General Theory of Self-care, allowed the analysis of self-care requirements and the identification of self-care deficit in relation to: management of hyperglycemia, pharmacological treatment, diet and exercise regime; essential for the promotion of the quality of life and the prevention of chronic complications in people with Diabetes Mellitus.
The self-care deficit reflected the need to deepen the level of knowledge towards practices for the self-control of the disease, based on the educational support system, as a central part of the responsibilities of the nursing professional.
This led to extrahospital follow-up for a period of four months, with nursing home visits, where education was provided related to each of the proposed care interventions. Education was combined with support in self-care by setting goals in metabolic control, changes in their life habits and motivation to manage the disease; aspects that were constantly verified and reinforced in each encounter.
In this way, it was achieved in the person to promote self-responsibility in the continuity of pharmacological treatment, maintain a diet according to their needs, perform physical exercise, interpretation and records of glycemia, and recognition of signs that require professional assistance.
This work shows that using the educational support system in nursing care, allows empowering the person with diabetes to learn and develop self-care practices that lead to positive and lasting changes towards promotion, conservation and care of their own health.
Additionally, using disciplinary theories such as the one proposed by Dorothea Orem strengthens the body of knowledge, allows us to understand the task, guides the relationships between the professional and the individual in need of self-care and contributes to nursing professionalism.
With the above, the validity of the Dorothea Orem Theory in nursing care is confirmed, and as Orem describes it: “The nurse helps the individual to carry out and maintain self-care actions to preserve health and life, recover from illness and / or face the consequences of said disease “.