NRS490 GCU Shared medical appointments with RN Diabetic control

Running head: CAPSTONE PROJECT CHANGE PROPOSAL Capstone Project Change Proposal Gregory Catania RN

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Grand Canyon University NRS 490 1/20/19 CAPSTONE PROJECT CHANGE PROPOSAL 2 Shared Medical Appointments with Registered Nurse for Better AIC Control in Diabetes Background Diabetes described as a complex, chronic illness that requires tight glycemic control to prevent risk factors associated with Diabetes. There is evidence of tighter glycemic control helping reduce risks associated with diabetes like vascular damage and organs failure. The chronic hyperglycemia associated with long-term damage, dysfunctional organs and potential organs failure. Uncontrolled diabetes affects the eyes, kidneys, the heart, nerves, and blood vessels (American Diabetes Association, 2014: S83). The growing incidences of diabetes without a comparable level of care and glycemic control exposes individuals to the risk factors associated with diabetes. However, research on lifestyle interventions has demonstrated delayed onset of diabetes-related risks with people with impaired glucose tolerance (Chen, 2018: 13). This paper aims to validate the effect of consistent medical intervention exploring the mediating role of the registered nurse. The PICOT study shades light using empirical evidence. Problem Statement of PICOT Study Diabetes has persistent being a health concern globally despite improvement in treatment and growing knowledge in its management. The prevalence of non – communicable diseases is on the rise with 19 million mortality associated with cardiovascular diseases; diabetes is remaining a significant contributor (Vakili et al., 2015). Globally 1.7 billion people are overweight with a substantial 315 million being obese. The population with type 2 diabetes estimated at 250 million people and the number is projected to increase to 400 million by 2025 according to Marseglia et al. (2016). CAPSTONE PROJECT CHANGE PROPOSAL 3 PICOT Question: 1. An increased glucose level is independently related to an increased A1C level. Does reducing the A1C levels with specialized teaching from the nurse, practitioners, and dieticians help to control diabetes on adult patients? 2. Do shared medical appointments improve glycemic control through Registered Nurse Mediation? Population: The populations for the study are American adult patients diagnosed for type 2 diabetes, aging 40 to 60 years old. This population is heterogeneous concerning co-morbidities and general health status, which is essential to establishing the appropriate intervention. Intervention: The proposed intervention involves active Registered Nurses involvement in assisting patients with type 2 Diabetes keep appointments, observe strict adherence to medications, dietary and other recommendations. The nurse would help monitor record keeping with regard to fasting blood sugars, time of taking medication in the 12 weeks during the study. The study will note the essential parameters like blood sugar, weight, and other vital measurements at the beginning of the study and the end of the study. Comparison: To determine whether the intervention is successful; A1C levels would be measured before and after the changes in lifestyle and diet. Outcome: At the end of the study, it is expected that the A1C levels of adult diabetic patients that adhere to study recommendations would reduce. CAPSTONE PROJECT CHANGE PROPOSAL 4 Timeframe: The research proposed to take 12 weeks. PICOT Purpose Statement Control of type 2 diabetes for American newly diagnosed adult patients has been problematic (P) due to the poor lifestyle and diet, which leads to an increased glucose level. Specialized teaching from the nurse, practitioners, and dieticians is an effective strategy to make the patients live appropriately by eating the right food and doing exercises (I), which can enable them to control their A1C levels (C) and live the normal life (O) within 12 weeks (T). Education as regards to lifestyle modifications has been proved to be an effective intervention for controlling type 2 diabetes. Kuo et al. (2015) indicate that lifestyle interventions such as regular exercises and diet changes reduce the incidence of diabetes by 53 percent compared to the control group. People assigned to these interventions reported reduced A1C levels than the control group. In a similar study by Islam et al. (2014), changing the lifestyle plays a crucial role in reducing the glucose levels, which further minimizes the cases of diabetes by 27 percent. Hence, there is an essential relationship between increased glucose level and increased A1C level as well as the lifestyle change and reduced A1C levels, which leads to effective control of diabetes. Among patients with pre-diabetes, it is worth to control their diet and do regular exercises to help in a decrease of diabetes occurrence. Failure to prevent diabetes means increased mortality. It is, therefore, the responsibility of each person to ensure they are living a healthy life to lower the risk of diabetes. CAPSTONE PROJECT CHANGE PROPOSAL 5 Literature Review There is evidence of the efficacy of oral anti-glycemic agents in controlling diabetes. In the PICOT statement, do socioeconomic factors, biochemical characteristics and oral medications relate to the complications of diabetes? This question aims at investigating the clinical features of patients with type 2diabetes on oral drugs and determines the complications and risk factors in the patients. (Islam, 2014:7). Does uncontrolled diabetes affect cognitive function-a predisposition to dementia? This other research question aims at finding out the effect of uncontrolled diabetes on the risk of dementia. (Marseglia, 2016:1072) Is there a difference in cost between Nursing practitioners and primary care physicians? This research question aims at investigating if there is a difference in cost and level of care between Nursing practitioners and primary care physicians. It also consists of an explored eye examination, cholesterol, HbA1C, neuropathy, referrals, and costs between Nursing practitioners and Primary physicians (Kuo, 2015:1982). Does medication adherence have any effect on glycemic control among diabetic patients? This research question aims at looking at the quantitative study of medication in relevance to diabetic patients. (Almadhoun, 2018:3). The research questions relate closely with the aim of finding out more information and statistics about diabetes and the precautions that can be taken to prevent its development. My capstone project research question; does diabetes nursing visits and improving A1C levels to the required status over 12 weeks help control diabetes? This question aims at finding out if regular visits of the patients by nursing practitioners and improving their A1C levels will help control diabetes. CAPSTONE PROJECT CHANGE PROPOSAL 6 Theory of Planned Behavior The PICOT study is grounded in the theory of planned behavior advanced by Ajzen (1991). The approach has been used in many fields to explain behavior and intentions. The approach is relevant in the current study because there are aspects of patients desiring health that can be achieved through lifestyle modification, adhering to medication treatment protocols and exercising. The motivation to modifying lifestyle is triggered to avert risks associated with uncontrolled diabetes. Implementation plan The study will recruit 20 types 2 diabetic patients with uncontrolled diabetes, ten male and ten female between the ages of 40-60 years. The respondents’ vital data will be collected at the beginning of the intervention and monitored over twelve weeks and at the end of the study. The data will then be analyzed to determine the effect of registered nurses in facilitating adherence to treatment and lifestyle modifications by the study respondents as suggested by physicians, dieticians, and pharmacists. The intervention plan is a multi-dimensional and holistic to determine the mediating role of the registered nurse influence in diabetes control. Potential Barriers to the Intervention There are inherent limitations to the PICOT study; first, the respondents may drop-off during follow-up thus affecting the survey. Secondly, the study sample size may be too small to allow generalization. Thirdly, there is the possibility of data interference reducing reliability and validity of the study. Lastly, the follow-up period may be too short to experience a remarkable change in outcome. The limitations were overcome by the nurse taking leadership in communicating and creating professional relationships with the respondents. Calls were made in CAPSTONE PROJECT CHANGE PROPOSAL 7 advance to confirm clinic days, reminder respondents to take medication and adhere to the study protocol. Conclusion In conclusion, as evident in the article, there have been various research projects that offer factual support to the PICOT study. Research projects are relatable in a way that they aim at finding out the best applicable methods of controlling diabetes and AIC levels. There are reports and research findings that contribute to providing more information on the control and management of diabetes. These include; Effect of Uncontrolled Hyperglycemia on levels of Adhesion Molecules in Patient with Diabetic Mellitus Type 2 and the effects of health mentoring program in community-dwelling vulnerable elderly individuals with diabetes. The proposed PICOT study will illuminate the possible mediating role of the Registered Nurse in improving the treatment and management of type 2 Diabetes. The results from the PICOT study demonstrate that the part of the nurse is vital is achieving tighter glycemic control. All cases except one recorded a real reduction in AIC. CAPSTONE PROJECT CHANGE PROPOSAL 8 References Almadhoun, M.R (2018) Journal of Clinical and Experimental pharmacology 8 (3), pp.1-10 American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes Care, 37(Supplement 1), S81-S90. DOI:10.4172/2161-1459.1000250 Gong, Q., Zhang, P., Wang, J., Ma, J., An, Y., Chen, Y. & Chen, Y. (2018). Reducing Morbidity and Mortality in Type 2 Diabetes by Lifestyle Intervention: 30-Year Follow-Up of the Da Qing Diabetes Prevention Study. http://dx.doi.org/10.3233/JAD-160266 Islam, S.M.S., Alam, D.S., & Wahiduzzaman, M., Nielsen, L.W, Fresch, G., Ferrari, U, Seisoler, J, Rouf, H, M.A & Lechner, A. (2014). Clinical Characteristics and Complications of Patients with Type 2 Diabetes Attending an Urban Hospital in Bangladesh. Diabetes and Metabolic Syndrome: Clinical Research Reviews, 1-7 http://dx.doi.org/10.1016/j.dsx.2014.09.014 Kuo, Y., Goodwin, J.S. & Chen, N. Lwin, K.K., Baillargeon, J., & Raji, M.A. (2015). Diabetes Mellitus Care Providers by Nurse Practitioners versus Primary Care Physicians, Journal of American Geriatric Society. 63 (10), 1980-1988 Marseglia, A., Fratigioni, L., Laukka, E.J., Santoni, G., Pedersen, J., Backman, L. & Xu, W. (2016). Early Cognitive Deficits in Type 2 Diabetes A Population-Based Study. Journal of Alzheimer Disease. 53, 1069-1078 Ruszkowska-Giastek, B., Sollup, A., Wernik, T., Rupiecht, Z., Golalczkyk, K., Gadomska, G. & Rosc, D. (2015). Effect of Uncontrolled Hyperglycemia on levels of Adhesion Molecules in Patient with Diabetic Mellitus Type 2. Zhejiang University- Science (Biomedical and Biotechnology) 16 (5), 355-361 CAPSTONE PROJECT CHANGE PROPOSAL Vakili, S.T.T., Nezami, B.G., Shetty, A., Chetty, V.K. & Srinivasan, S. (2015). Association of High Dietary Saturated Fat Intake and Uncontrolled Diabetes with Constipation: Evidence from the National Health and Nutrition Examination Survey. Neurogastoral Motil, 27 (10), 1389-1397 Wol, S.K. (2018) Journal of Korean Academy of Nursing 48 92) 182-194 9 CAPSTONE PROJECT CHANGE PROPOSAL 10 Appendix Literature Evaluation Table Student Name: Gregory Catania RN Change Topic (2-3 sentences): Better Diabetic A1C control in outpatient adult clinic with specialized nursing visits that include education, lifestyle changes, medications and diet. Criteria Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article Article 1 Islam, S.M.S. et al. Journal of Diabetes & Metabolic Syndrome, Clinical Research & Reviews http://dx.doi.org/10.1016/j.ds x.2014.09.014 Article 2 Article 3 Article 4 Marseglia, A. et al. Journal of Alzheimer’s Disease Vol. 53, p.1069-1078 http://dx.doi.org/10 .3233/JAD-160266 Kuo, Y. et al. Almadhoun, M.R et al. Journal of Clinical and Experimental pharmacology 8 (3), p.1-10 Journal of American Geriatric Society (10), 1980-1988 https://doi.org/10.111 1/jgs.13662 DOI:10.4172/21611459.1000250 Article Title and Year Published Clinical Characteristics and Complications of Patients with Type 2 Diabetes Attending an Urban Hospital in Bangladesh (2014) Early Cognitive Deficits in Type 2 Diabetes A Population Based Study (2016) Diabetes Mellitus Care Providers by Nurse Practitioners versus Primary Care Physicians (2015) Research Questions (Qualitative)/Hypo thesis (Quantitative), and Purposes/Aim of Study To find out the relationship of social economic factors in T2D with complications of diabetes To explore biochemical characteristics in T2D and diabetic related complications To find out diabetic related complications among Pt taking oral medications and development of complications To find out if uncontrolled diabetes has an effect on cognitive function- a predisposition to dementia To explore differences in cost of care between Nursing practitioners compared with primary care physicians Study explored eye examination, cholesterol, HbA1C, neuropathy, referrals and costs between NP and Primary physicians. The study aim: to investigate if there is a difference in cost Study aim: To investigate the clinical features of patients with type 2 diabetes, Purpose of the study is to find out if diabetes contributes to risk of dementia (196) Study Aim: To Assessment of Medication Adherence and its association with glycemic control among type 2 diabetes mellitus patient in Gaza (2018) To find out if medication adherence has any effect on glycemic control among T2D patients Quantitative study CAPSTONE PROJECT CHANGE PROPOSAL 11 on oral medication and determine the complications and risk factors in the patients (515). find out the effect of uncontrolled diabetes on the risk of dementia Design (Type of Quantitative, or Type of Qualitative) Setting/Sample Study was a cross-sectional quantitative inquiry The study was a cross-sectional quantitative study Sample size 515 patient at outpatient setting. Sample size was 196 in a home for the elderly in Sweden Methods: Intervention/Instru ments Mixed method data collected through questionnaire, face to face interview, laboratory investigations ECG, eGFR, Blood pressure machine, observation during outpatient visit The collected data was analyzed using descriptive statistics, and inferential statistics. The analysis deployed used t-test, logic analysis and simple logic regression analysis Methods included observation, laboratory tests, cognitive functions tests Analysis was done using multivariate linear regression to estimate differences and multi-nominal logistic regression to examine association Statistical Logistic regression model The study revealed that even in the best clinical setting the control of diabetes was suboptimal. Average HBA1C was 8.3; hypertension 51%, 71% had uncontrolled T2D. Uncontrolled diabetes led to eye complications (68.9%), chronic kidney disease (21.3%), CVD (11.8%) and Neurological issues (2.5) from the study subjects. There is need to have consistent screening using HBA1C goal, reduce BP and addition of statins to treatment regimens to help The study reported that uncontrolled diabetes exposes patient to risk of dementia. There was no significant difference the two groups regarding costs except Nursing practitioners rarely performed eye examinations, there is risk of Nursing practitioners Rx wrong medications Control is diabetes is essential in reducing risks associated with diabetic There is need to have a treatment protocol that investigates eyes, HbAIC, CVD, Neurological Analysis Key Findings Recommendations and level of care between Nursing practitioners and primary care physicians Retrospective cohort study Evaluating data provided by Medicaid from beneficiary of primary care N=64,354 The data collected was coded and analyzed with regard to study variables Cross-sectional study T2D in Gaza attending diabetic clinic Sample size 148 Patients were followed through face to face questionnaire, laboratory examination to monitor progress Descriptive statistics and inferential statistics done. Regression analysis to determine influence of independent variables The study found out that majority of the patients did not comply with treatment instruction leading to 56.1% having poor control. Need to improve medical adherence to improve T2D glycemic control CAPSTONE PROJECT CHANGE PROPOSAL lower high cholesterol. Explanation of How the Article Supports EBP/Capstone Project The article recommends control of blood sugar as a means of reducing diabetic complications. PICOT study seeks to enhance the use of HBA1C as measure of controlling T2D through education, screening and patient management in diet & lifestyle change because drugs alone are insufficient. Criteria Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article Article 5 Ruszkowska-Giastek, B. et al. Zhejiang University- Science (Biomedical and Biotechnology) 12 complication. Diabetic control will delay cognitive problems in patient T2D Controlling diabetes help delay cognitive function impairment, nurses can help patients gain proper control through education, diet, exercise and medication Article 6 Vakili, S.T.T. et al. Neurogastoral Motil, 27 (10), 1389-1397 https://dx.doi.org/10. 1111%2Fnmo.12630 complications to improve primary care Nurses have a significant role in helping patient with T2D manage tighter glycemic control. Nurses can help patient and doctors achieve targeted HbAIC < 6.4 The article is important because adherence to drugs leads to better glycemic control Article 7 Article 8 Wol, S.K. et al. Journal of Korean Academy of Nursing 48 92) 182-194 https://doi.org/10.40 40/jkan.2018.48.2.1 82 Kostev, K. et al. Journal of Diabetes, science and technology https://doi.org/10. 1177/1932296817 710477 Prescription Patterns in Disease control in T2D Mellitus in Nursing home and Home care setting: Retrospective Analysis in Germany (2018) To determine the influence of treatment setting on diabetes control https://link.springer.co m/content/pdf/10.1631 %2Fjzus.B1400218.pdf Article Title and Year Published Effect of Uncontrolled Hyperglycemia on levels of Adhesion Molecules in Patient with Diabetic Mellitus Type 2 (2015) Association of High Dietary Saturated Fat Intake and Uncontrolled Diabetes with Constipation: Evidence from the National Health and Nutrition (2015). The effects of health mentoring program in community dwelling vulnerable elderly individuals with diabetes (2018) Research Questions (Qualitative)/Hyp othesis (Quantitative), and Purposes/Aim of Study To evaluate the concentration of soluble forms of vascular adhesion in patient with controlled and uncontrolled diabetes type 2 Cross-sectional Quantitative study Hypothesis there is no relationship between diabetes and constipation. To determine the influence of mentoring in the community on health treatment outcome in T2D CAPSTONE PROJECT CHANGE PROPOSAL Cross –sectional study, randomized, control, quantitative design Korea setup with elderly at risk of dementia, diabetes complications 96 at the start and 70 at study end. Follow up, laboratory analysis Quantitative longitudinal comparative study Descriptive Statistical and inferential statistics analysis Statistical analysis using Wilcoxon tests and Chi squared test to compare analyze results There is a significant relationship between diabetic patients and constipation compared to no diabetic subjects Mentoring is an effective strategy in monitoring the diabetic patients in the community There was no significant different between the two groups. The mean age at the nursing homes 80.7 years and those at home 74.8 years. Patients in any set up provided adequate education is offered treatment goals will be achieved. The article is vital because nurses attend to patient’s outpatient and inpatient nurses facilitate glycemic control. Design (Type of Quantitative, or Type of Qualitative) Setting/Sample The Study was a quantitative controlled randomized inquiry Examination Survey Poland sample size 62 with 35 diabetic, 27 diabetic uncontrolled and 25 healthy subjects Diabetic patients non- Hispanic 6207 subjects Methods: Intervention/Instr uments Laboratory analysis, urine, blood and kidney function tests Analysis Statistical analysis involved test for normality, ANOVA for variance and Pearson correlation analysis to test relationship among variables Control of diabetes delays vascular impairment Physical and laboratory examination, BMI, diet water intake Descriptive Statistics and inferential statistical analysis was deployed Key Findings 13 Recommendations Doctors need to ensure tight control of diabetes to prevent vascular complications and neuropathy Diet is instrumental in managing diabetes and ensuring HbAIC targets are reached for tighter glucose control. Mentoring need to be incorporated in management of T2D in the community Explanation of How the Article Supports EBP/Capstone Control of Diabetes delays diabetic related complication including vascular impairment, CVD and heart disease The article is important because diabetic control can help reduce constipation in T2D pts The nurses are important as treatment facilitators in the community with regard to education Germany comparing T2D in nursing homes and at home 9850 subjects /2 Analyzed, stored data between 2011 and 2015 CAPSTONE PROJECT CHANGE PROPOSAL 14 Table of Respondents Data No Respondents Name Gender Age 1 Ann P F 42 2 Peter T M 3 Jane H 4 HBAIC start HBAIC end Remarks 30.5 7.2 6.5 Positive 56 28.5 8.3 7.8 Positive F 57 25.8 6.9 6.3 positive Grace O F 43 30 9.1 7.7 Positive 5 Hilary C F 45 29 7.7 7.7 Neutral 6 Barrack K M 40 32.5 9.2 7.2 Positive 7 Giuliani M M 59 28 6.9 6.2 Positive 8 Yuri J M 60 27 7.9 6.5 Positive 9 Doris M F 40 26 6.6 6.0 Positive 10 Fleur H F 41 30 7.0 6.1 Positive 11 Timothy G M 55 19 6.7 6.2 Positive 12 George H M 46 24 7.5 6.9 Positive 13 Hannah Y F 48 31 8.2 7.1 Positive 14 Jacobs M M 49 27 7.8 6.9 Positive 15 Shah T F 58 30 9.5 8.2 Positive 16 Georgas H M 52 29.9 8.9 7.2 Positive 17 Petrobras G M 47 28 7.3 6.3 Positive 18 Eve T F 57 27 6.9 5.9 Positive 19 Harish P M 53 29.5 8.8 6.4 Positive 20 Shah M F 45 30 7.8 6.1 Positive Table: Capstone Change Variables BMI CAPSTONE PROJECT CHANGE PROPOSAL Key BMI 30 Obese 15
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