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Please Proofread and check that I’m on the right track and advise if I have repeated anywhere A Comprehensive Diabetes Care Plan for Barry: A Patient-Centred Approach to Managing Type 1 Diabetes ASSESSMENT 1. Medical History 51 year old male, with a history of living with type 1 diabetes for 21 years. Currently experiencing asymptomatic hypoglycemia with a recent hospitalisation due to a significant hypoglycaemic event. BMI 32kg/m2 is classified as obese as per BMI and has expressed the desire to lose 5-6 kg. 2. Family History Family history to be assessed currently unavailable 3. Social History (initial consultation only) Barry is currently employed as a truck driver working 12 hours shifts, 6 days a week Monday to Saturday. Currently occupation is causing barriers with access to healthier food options and opportunities for physical activity. On Sundays Barry often feels exhausted post week, smoke 2 – 3 cigarettes a day and consume 2 litres of red wine per week. Recent passing of a wife who supports meal preparation. 4. Previous Diabetes Knowledge Barry has limited knowledge around carbohydrates,how the foods and drinks affects his blood sugar levels.Barry also perceives that he does not need diabetes education unless it assists with his weight loss. 5. Physical Assessment Barry BMI 32kg/m2 no other data available 6. Medication Review Barry reports non compliance with prescribed insulin in order to avoid hypoglycemic events. Currently prescribed rapid acting insulin Lispro no data available of how many units per exchange. Long acting insulin Lantus (BD) twice a day, dosage unavailable and pravastatin 40mg once a day in the evening. 7. Blood Glucose Monitoring Review Irregular glucose monitoring has recently increased frequency of checking post hypoglycaemic events. Glucose levels ranging from 7.0 mmol/L to 12.0 mmol/L, demonstrating suboptimal control. 8. Biochemistry Unavailable 9. Investigations Unavailable 10. Nutrition Diet consists of high sugar, refined carbohydrates and high fat from fast food outlets. Frequency of meals consist of bagels, pancakes, fried foods, sugary beverages and snack which are high in simple carbohydrates. Minimal intake of wholegrains, vegetables and fibre. Drinks approximately 2L of water daily and 2l of red wine per week. Daily carbohydrates range from 262g to 552g as per report by barry intake journal 11. Physical Activity Barry reports no physical activity due to exhaustion and longing working hours. 12. Emotional Health Assessment Appearance:51-year-old male. No specific details provided Behaviour: No abnormal behaviour reported. Mood:Reports low mood and severe anxiety in regards to possible experience of another severe hypoglycaemic event. Affect:Unavailable Speech:Unavailable Thought Form:Unavailable Thought Content: Fear of having another hypoglycemic event expressed, and manages this by excessive eating to maintain higher than recommended glucose levels. Perception:Unavailable Cognition:Demonstrates minimal knowledge of carbohydrates, how foods and drinks affect glucose levels. Insight: perceives that he does not need education in regards to his diabetes and is only open is it helps with his weight loss. Judgement: partial judgement Barry’s current actions are demonstrating an emotional approach then a clinical approach to his diabetes management which is demonstrated by not having prescribed medications to reduce his chances of hypoglycemic event. MANAGEMENT PLAN Problem Area 1: Fear of Hypoglycaemia resulting in inappropriate insulin management, Taking Medication and healthly coping. Barry intentionally underdoses his insulin due to fear of hypoglycaemia following the hypoglycaemia episode which required emergency intervention. As a result of the mismanagement of his diabetes his blood glucose levels have remained elevated in between 8.0mmol/L and 12mmol/L above the recommended levels of 4.0mmol/L to 7.0mmol/L (Diabetes Australia, 2023). Causes and contributing factors Barry’s behaviour has adapted in response to his fear of hypoglycaemia by not having insulin as prescribed appears to be influenced by his psychological wellbeing with his heightened anxiety post his severe hypoglycemic event. Barry’s fear has been recurring leading to a non-beneficial self management behaviours, resulting in sustained elevation of blood glucose levels. His anxiety is further compounded by the lack of coping strategies that are structured and the absence of psychological support. In addition the recent passing of his wife, further makes his emotional vulnerability unstable. Barry’s minimal exposure and willingness to access structured diabetes education in particular with his titration of insulin requirements, dosage time and carbohydrate to insulin matching further declines his ability to be able to safely self manage effectively. Evidence and guidelines. The inconsistent pattern of behaviours demonstrated by Barry contradicts the national and international diabetes guidelines, which state that the insulin adherence is an important aspect to achieving the optimal glucose control (Diabetes Australia, 2022) and (ADEA,2021). In accordance with research it is recommended that all individuals living with diabetes have an individualised insulin education and emotional support. This is important in particular for Barry due to the fear of hypoglycemia (National institute for health and care excellence, 2022). A major barrier for Barry is the psychological stress which is demonstrated through the insulin adherence and studies have shown that individuals with the hypoglycaemia fear often will intentionally raise their glucose levels as a coping mechanism (Gobder-Frederick et al., 2011). Psychological interventions such as cognitive behaviour therapy, peer support and a structured education have proven to lower the anxiety related to the individual’s diabetes therefore improving their self management (Lloyd et al., 2019). Problem Area 2: Poor Nutritional literacy and High carbohydrate intake, Healthy eating and Monitoring Barry’s consumption of daily carbohydrates range from 262g to 552g coming from primarily high glycaemic index, high energy dense processed foods which includes fast food restaurants and sweetened beverages. Barry demonstrates a reduced knowledge around carbohydrates types and the effect on his blood glucose levels resulting in the mismatched insulin dosages which contribute to the persistent hyperglycemia. Causes and contributing factors Barry’s current work schedule and limited access to nutritional food on the road influence his poor nutritional habits and glycaemic control and monitoring. Barry’s minimal knowledge of carbohydrates and the appropriate size of portions contribute to his excessive daily intake of carbohydrates and suboptimal blood glucose control. The passing of his wife also demonstrates a barrier into his nutritional intake as she used to help create nutritional meal preparations. Another barrier is his minimal diabetes specific education in particular around nutrition and insulin requirements, which has left his foundational knowledge needed to make the right informed dietary. Lack of monitoring of glucose levels around nutrition have further impaired the ability to see the impact of the food decision on the glucose levels. Evidence and guidelines. The nutritional management is the foundational core of diabetes care. It is emphasized by the need for the carbohydrate counting and meal preparation education to support the individuals glycaemic control (NHMRC, 2011) and (Diabetes Australia, 2023). Evidence demonstrates that individuals living with type 1 diabetes such as Barry, benefit from an understanding of different types of carbohydrates and being able to match the needed insulin levels to food intake to reduce the postprandial glucose level spikes and any long term diabetes related complications (Smart et al., 2012). A flexible insulin therapy with the addition of carbohydrate counting to help support the glucose control to stay within recommended ranges (American Diabetes Association, 2023). The Minimal nutrition literacy and understanding demonstrated by Barry significantly undermines his potential ability to manage his Diabetes safely and effectively. Diabetes Education Plan Barry requires a more comprehensive and individualised diabetes education plan that will work for him and address both the emotional and practical challenges in his self management. Barry’s education will focus mainly on the insulin management and his understanding of nutrition and how it affects his glucose control to limit the risk of hypoglycaemia with the reassurance given throughout. This will be completed through hypoglycaemia prevention and response plan by education of the causes, symptoms and the stages of a hypoglycaemia. The response plan will need to be individualised to help Barry increase his confidence in being able to recognise and treat the hypoglycemia appropriately. Introduction of carbohydrate counting and insulin to carbohydrate ratios will be utilised with visual tools to help support Barry throughout the transition. Barry will be given tools and support on ways to track blood glucose levels either through using a log book, mobile app or using a continuous glucose monitor to demonstrate the patterns and to guide insulin adjustments. Education around nutrition will cover the different aspects of type of carbohydrate and their sources, differences in glycaemic index and how to label read. With this education and the practical meal options that will be completed with the dietitian to suit his daily schedule to reduce his carbohydrate intake and make healthier choices. The emotional wellbeing education will be included to help normalise the anxiety and fear for Barry have hypoglycemia by referring him to a psychologist who has experience in CBT training, and a referral to peer support options that will reduce his feeling of isolation and encourage an supported shared learning. Goals Short-term Goal: record blood glucose levels for 4 weeks at least 3 times a week Barry will measure blood glucose levels pre and post meals for at least 3 days a week using a structured logbook or mobile app to record these levels and complete one appointment with a Diabetes educator to develop an individualised hypoglycaemia action plan that will suit Barry lifestyle. This will be measured by Barry completing a recording of his blood glucose levels for 3 days per week. This will be archived through a modest change and the use of one appointment with the diabetes team with the multidisciplinary team input. This goal supports the improvement in Barry’s self confidence and awareness of how his blood glucose levels are pre and post meals and the correlation with carbohydrates to insulin.This will be achieved within a 4 week timeframe. Long-term Goal: To lower carbohydrate intake and get BGLS within range 80% of time Barry will reduce his carbohydrate intake to under 250 grams or less by choosing healthier food options and having at least one low GI meal per day and appropriately adjusting insulin to achieve the aim of blood sugars between 4 – 10mmol/L at least 80% of the time. This will be done by focusing on the healthy choices, limiting soft drinks to sugar free drinks, using insulin to the right ratio and staying within the ranges for optimal blood glucose levels. This will be measured by logging carbohydrate intake for meals and the how much insulin is being given and blood glucose levels ranges. It is achievable by a gradual behaviour change in food, physical checking and mental health wellbeing. Its relevant for bary as barry has the desire to lose weight and healthy eating and limiting carbohydrates and using insulin appropriate will help achieve his personal goals with weight and health. This will be completed within a 12 week time frame. REVIEW PLAN Barry will return for a scheduled review in 4 weeks to assess the progress of recording his blood glucose levels and the pattern of his blood glucose levels. The review will have a focus on Barry’s self care through the management of insulin and blood glucose, psychological well-being, and nutrition. Early review at 4 weeks is essential due to Barry’s recent events and evidence of insulin under dosing and poor nutrition control. Which has resulted in sustained elevated blood glucose levels. During this 4 week review the dietitian, social worker, diabetic educator and endocrinologist will be a part of the plan making and any changes. A further review will occur at the 12 week and then every 3 months post unless a clinical deterioration occurs suggesting an earlier review. Progress will be measured and monitored using different strategies. Barry’s HbA1c will completed every 3 months with the target of less than 7.0% average, which can be adjusted depending on the risk of any hypoglycemia. His Blood glucose levels will be monitored by Barry himself individually, with him recording then pre and post meals at minimum 3 days a week. With the goal to maintain within the range of 4.0mmol/L – 10.0mmol/L at least 80% of the time. Barry’s weight and BMI will be monitored monthly to support his indvidualised goal to lose weight which correlates closely with the improvement of his glycaemic control and physical health. His daily intake of carbohydrates will be monitored with the target of reducing his average intake to below 250g carbohydrates a day while having at least one low glycaemic index meal per day. Barry’s psychological wellbeing will be continuously monitored with the particular focus on his severe anxiety and coping mechanism using the feedback provided by the psychologist to guide the required adjustments in his care. The potential barriers are Barry’s psychosocial and practical concerns that affect his self management of his diabetes. The psychological distress post losing his wife has resulted in a heightened anxiety and grief negatively affecting his emotional resilience and coping capacity. While the post experience of his severe hypoglycaemia event resulting in emergency intervention has also impacted his mental state by causing a heightened fear and anxiety which has contributed to him underdosing on insulin to have an above recommended blood glucose level. Barry’s low health literacy causes a potential barrier that demonstrates the poor nutrition choices that are being made. Barry’s life and work schedule also is a barrier in that having long work hours, and limited access to healthy food choices and a regular routine can cause a negative effect on administration of insulin and monitoring. Last potential barrier is the lack of structured support that Barry has had in the past around attending appointments, treatment plans and engaging with education. Therefore all there potential barriers will need a multidisciplinary approach in a holistic way to support both medical and psychosocial concerns. Referrals and Justification: A multidisciplinary team approach will be essential for the success for Barry’s care and goal achievements that will be done through referrals to different health sectors. The credentialled diabetes educator will be implemented to provide education around the management of insulin, a hypoglycaemia recovery plan and prevention, blood glucose monitoring via finger pricks or continuous glucose monitor and the introducing carbohydrate counting tools. The referral to dietitian will be focused on practical strategies on helping Barry to reduce carbohydrate intake to the recommended amount, learning to read labels, different portion sizes and suitable meals for Barry’s lifestyle. Referral to the mental health service of a psychologist with CBT experience will be an essential part to address the grief and anxiety that Barrys is currently experiencing to help improve his mental state which will then impact positively on his physical wellbeing. In addition a referral to a peer support group will encourage barry social connection which will help improve his self efficacy, confidence and feelings of isolation. The main aim of the plan is to restore Barry’s confidence in his ability to self manage his diabetes safely and effectively while having a supportive emotional recovery and lifestyle change; this is all addressed through the national and internal diabetes care standards which use psychosocial and clinical outcomes to support these changes.

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