Change Strategy and Implementation
Change Strategy and Implementation.
Type II Diabetes is caused by various dysfunctions. Resistance to the action of insulin, decreased insulin secretion, and inappropriate glucagon secretion are the etiological factors (Zhao et al., 2019). The signs and symptoms of type II diabetes mellitus are insidious. Some of the classical signs and symptoms include polyuria, polydipsia, increased hunger, fatigue, and blurred vision. Paresthesia in the lower extremities and yeast infections can also occur. Diagnosis of diabetes is based on the measurements of the fasting plasma glucose, random plasma glucose, and oral glucose tolerance test.
Poorly managed type 2 diabetes mellitus is associated with two main complications. They include macrovascular and microvascular complications. Microvascular complications include diabetic nephropathy, neuropathy, and retinopathy (Ceriello, 2020). Diabetic neuropathy affects both peripheral and autonomic nerves. Macrovascular complications include cerebrovascular disease, peripheral vascular and cardiovascular diseases (Ceriello, 2020). Diabetic complications of concern based on the concept map: cardiovascular complications, nephropathy, and neuropathy. Appropriate management of diabetes mellitus significantly mitigates these complications.
Cardiovascular complications and Diabetes Mellitus.
According to Dal Canto et al. (2019), cardiovascular complications occur due to insulin resistance, elevated cholesterol, decreased HDL cholesterol, and elevated triglyceride levels. Hypertension and elevated fibrinogen are the other risk factors. Cigarette smoking, physical inactivity, and obesity are the other risk factors. Insulin resistance causes an increase in the levels of lipids in the liver and smooth muscles. This causes persistent lipid abnormalities in diabetic patients (Dal Canto et al., 2019). Cardiovascular complications manifest as atherosclerosis, heart failure, and arrhythmias.
Nephropathy and Diabetes Mellitus.
Diabetic nephropathy is a progressive disease. It manifests with albuminuria. Urinary albumin levels of less than 30 milligrams (mg) are considered normal (Thamrin et al., 2019). Microalbuminuria occurs when the levels of albumin are between 30 to 300 mg. Macroalbuminuria occurs when the levels of albumin are above 300 mg per 24 hours. When nephropathy is detected during the initial stages, it is managed effectively (Thamrin et al., 2019). Late diagnosis of nephropathy is associated with progress to end-stage renal disease. This will necessitate the need for dialysis.
Neuropathy and Diabetes Mellitus.
Diabetic neuropathy refers to nerve damage caused by hyperglycemia. Peripheral neuropathy affects the lower limbs, followed by the upper limbs. Its signs and symptoms usually worsen at night. It presents with numbness, tingling, weakness in the limbs, and burning pain (Dal Canto et al., 2019). Autonomic neuropathy affects the nerves of the autonomic nervous system. This can lead to hypoglycemic unawareness and decreased libido. Gastroparesis can also occur. Proximal neuropathy affects nerves around the gluteal region, thigh region, and legs. Mononeuropathy can be cranial or peripheral.
Change Strategies.
Diabetic complications require interprofessional collaboration. Different strategies can be used to initiate these changes. The first strategy is patient education. This can be achieved by physicians, nurses, and dieticians. Education should entail the need for lifestyle modification. Lifestyle modifications help to improve the prognosis of diabetes mellitus and minimize complications. The dietician should guide patients on the type of diet. Fresh fruits and vegetables, complex carbohydrates, low saturated fats, and decreased alcohol and cigarette smoking are useful (Becerra-Tomás et al., 2020). Regular aerobic exercise is also important in the management of diabetes management.
Physicians and nurses should educate the patient about the disease process. Patients should be able to recognize the signs and symptoms of hypoglycemia and know their management. Patients should also be taught different foot care strategies, such as using lukewarm water and comfortable shoes (van Netten et al., 2020). Patient education improves the prognosis of the disease and reduces the incidences of diabetic complications. The drawback of this strategy is that its success depends on the patient’s willingness and ability to learn.
The second strategy is tight glycemic control. Tight glycemic control leads to a good prognosis by reducing the incidences of hypoglycemia and hyperglycemia (Koliaki et al., 2020). This requires collaboration among healthcare providers and patients. According to Szafran et al. (2019), pharmacists must ensure that the correct doses of the appropriate drug are administered to the patient. Nurses, pharmacists, and physicians must demonstrate how to use insulin. Nurses should ensure that all in-patient diabetic patients take their medication on time and in the correct dosages. Pill calendars can be used to enforce patient compliance. Metformin is the first-line monotherapy and is the standard component of combination treatments. Monotherapy failure warrants the addition of a second drug rather than substitution. For obese patients, sulfonylurea, exenatide, glitazone, or insulin is added (Dal Canto et al., 2019). For elderly patients, the treatment of choice is a low-dose secretagogue.
Triple therapy is used when dual therapy is not successful after 2 to 3 months. Exenatide is preferable because it avoids hypoglycemia (Ceriello, 2020). When basal insulin is used, it is adjusted to the fasting blood glucose levels. Just like patient education, this strategy requires patient compliance. Lack of patient compliance can hinder the achievement of this strategy.
The other strategy is the management of the patient’s comorbidities. Several comorbidities, such as hypertension, obesity, and hypercholesterolemia, increase the development of diabetic complications (Zie et al., 2020). An interprofessional collaboration of all healthcare providers will ensure that the patient’s comorbidities are managed. Antihypertensive medications and lipid-lowering agents should be initiated as soon as the comorbidities are identified. They reduce the development of diabetic cardiovascular complications. Obesity can be managed by encouraging aerobic exercise, bariatric surgery, and dietary modification (Loundou et al., 2021). A Mediterranean diet comprising vegetables, grains, unsaturated fats, and fruits is desirable in obese diabetic patients. Pharmacists, physicians, and nurses should work in concert to ensure that the drugs are administered in the right quantities. The right choice of drug is also important. The drawback of this strategy is it can lead to polypharmacy, and its success depends on patient compliance.
The last strategy is conducting follow-up activities. Diabetic patients attending clinics should be followed up regularly. This can be achieved by increasing the number of clinics that the patient should attend every week. It increases the contact time between healthcare providers and patients. Patients’ drug use is monitored, and their vitals are checked on every visit. It enables early identification and management of any complication. Early detection and management of any diabetic complication will improve its prognosis. Patients may not be willing to attend more than one diabetic clinic in a week. This hinders the implementation of this strategy.
The shortcomings of the strategies include patient compliance, patients’ ability to learn, and the possibility of polypharmacy. Patient compliance can be enhanced by pill calendars. Pharmacists must ensure that all outpatients attending diabetic clinics have calendars. Patients should also be encouraged to set alarms to act as reminders. Patients’ ability to learn can be improved by regular education forums. Furthermore, they should be asked to perform demonstrations of their learning activities. This helps the healthcare providers know whether they’ve understood the instructions. The problem of polypharmacy can be managed by a close collaboration between healthcare providers.
Data Table.
| Current Outcomes | Change Strategies | Expected Outcomes |
| Diabetic patients usually have various microvascular and macrovascular complications.
Cardiovascular complications are the most prevalent cardiovascular-linked complications. Diabetic nephropathy and neuropathy are the most prevalent microvascular complications. |
To ensure that the complications are minimized, various measures can be taken
ü Patient Education ü Tight glycemic control ü Appropriate management of co-morbid conditions to prevent complications. ü Conduct follow-up activities for diabetic patients. |
The number of diabetic macrovascular and microvascular complications will decrease significantly.
Patients will be able to take their Oral Hypoglycemic Agents and Insulin appropriately. Patients will modify their diet and lifestyle to enhance the management of their diabetes. The number of patients attending diabetic clinics will increase due to intensive follow-up programs. |
References
Becerra-Tomás, N., Blanco Mejía, S., Viguiliouk, E., Khan, T., Kendall, C. W. C., Kahleova, H., Rahelić, D., Sievenpiper, J. L., & Salas-Salvadó, J. (2020). Mediterranean diet, cardiovascular disease, and mortality in diabetes: A systematic review and meta-analysis of prospective cohort studies and randomized clinical trials. Critical Reviews in Food Science and Nutrition, 60(7), 1207–1227. https://doi.org/10.1080/10408398.2019.1565281
Ceriello, A. (2020). Glucose variability and diabetic complications: Isittimetotreat? Diabetes Care, 43(6), 1169–1171. https://doi.org/10.2337/dci20-0012
Dal Canto, E., Ceriello, A., Rydén, L., Ferrini, M., Hansen, T. B., Schnell, O., Standl, E., & Beulens, J. W. J. (2019). Diabetes as a cardiovascular risk factor: An overview of global trends of macro and microvascular complications. European Journal of Preventive Cardiology, 26(2_suppl), 25–32. https://doi.org/10.1177/2047487319878371
Koliaki, C., Tentolouris, A., Eleftheriadou, I., Melidonis, A., Dimitriadis, G., & Tentolouris, N. (2020). Clinical Management of Diabetes Mellitus in the Era of COVID-19: Practical Issues, Peculiarities, and Concerns. Journal of Clinical Medicine, 9(7), 2288. https://doi.org/10.3390/jcm9072288
Loundou, A., Crémades, A., & Gentile, S. (2021). Comorbidity Profiles among Obese – Diabetic End-Stage Renal Disease Patients : Data from REIN Registry of PACA Region of France.
Szafran, O., Kennett, S. L., Bell, N. R., & Torti, J. M. I. (2019). Interprofessional collaboration in diabetes care: Perceptions of family physicians practicing in or not in a primary health care team. BMC Family Practice, 20(1), 1–10. https://doi.org/10.1186/s12875-019-0932-9
Thamrin, H., Sutjahjo, A., Pranoto, A., & Soelistijo, S. A. (2019). Association of Metabolic Syndrome with Albuminuria in Diabetes Mellitus Type 2. Biomolecular and Health Science Journal, 2(2), 82. https://doi.org/10.20473/bhsj.v2i2.14964
van Netten, J. J., Bus, S. A., Apelqvist, J., Lipsky, B. A., Hinchliffe, R. J., Game, F., Rayman, G., Lazzarini, P. A., Forsythe, R. O., Peters, E. J. G., Senneville, É., Vas, P., Monteiro-Soares, M., & Schaper, N. C. (2020). Definitions and criteria for diabetic foot disease. Diabetes/Metabolism Research and Reviews, 36(S1), 1–6. https://doi.org/10.1002/dmrr.3268
Zhao, C., Wong, L., Zhu, Q., & Yang, H. (2019). Prevalence and correlates of chronic diseases in an elderly population: A community-based survey in Haikou. PLoS ONE, 13(6), 1–11. https://doi.org/10.1371/journal.pone.0199006
Zie, G., Kerr, Z. Y., & Moore, J. B. (2020). Universal Healthcare in the United States of America : A Healthy Debate. 1–7.
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Question 
Change Strategy and Implementation
OVERVIEW:
Develop a data table that illustrates one or more under performing clinical outcomes in a care environment of your choice. Write an assessment (3–5 pages) in which you set one or more quantitative goals for the outcomes and propose a change plan that is designed to help you achieve the goals.
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CONTEXT:
One area in health care that it is necessary to consider is the environment in which the nurse works. It is important that this environment evolves and changes so that all patients are adequately supported. For this assessment, you will develop a change strategy to improve the health care environment. These changes can be rooted in a desire to improve clinical outcomes and data related to assessment accuracy, drug administration, disease recovery rates, or another relevant metric or outcome. A key skill for master’s-level nurses is to be able to evaluate clinical data and create a change plan to help drive improvements in the data to reach set goals.
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QUESTIONS TO CONSIDER:
The assessment will be based on one or more outcomes that you would like to see improve. Think about experiences you have had working on setting goals for outcomes or using data to identify areas of need. Part of achieving your goal will be your ability to implement change in pursuit of improving outcomes. The Vila Health: Using Evidence to Drive Improvement simulation may be helpful in this regard.
1. Where do you look for resources and evidence to help you get started when treating a specific condition?
a. Where do you look for resources and evidence to help you get started when setting clinical goals?
b. When there are no guidelines or policies for setting clinical goals, where do you look for resources and evidence to help you get started?
2. How do you use these resources and evidence to begin constructing evidence-based treatment, or developing evidence-based goals?
Change Strategy and Implementation
a. What data do you plan to use as a basis for setting improved outcome goals?
b. What care environment do you envision using as the context of your assessment?
– How would change models, strategies, or theories need to be applied to help ensure achievement of your outcome goals?
– Which change models, strategies, or theories seem to be the best fit for your goals and environments. Why?
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SCENARIO:
Consider the current environment. This could be your current care setting, the care settings presented in the Vila Health: Using Evidence to Drive Improvement or Vila Health: Concept Maps as Diagnostic Tools media, or a care setting in which you are interested in working.
For the setting that you choose you will need to have a data set that depicts sub-optimal outcomes related to a clinical issue. This data could be from existing sources in the course (Vila Health: Using Evidence to Drive Improvement), a relevant data set that already exists (a data set from the case study you used as a basis for your Concept Map assessment, or from your current place of practice), or an appropriate data set that you have created yourself. (Note: if you choose to create your own data set, check with your instructor first for approval and guidance.)
After you have selected an appropriate data set, use your understanding of the data to create at least one realistic goal (though you may create more) that will be driven by a change strategy appropriate for the environment and goal.
Potential topics for this assessment could be:
- Consider ways to help minimize the rate of secondary infections related to the condition, disease, or disorder that you focused on for your Concept Map assessment. As a starting point you could ask yourself, “What could be changed to facilitate safety and minimize risks of infection?”
- Consider how to help a patient experiencing traumatic stress or anxiety over hospitalization. As a starting point you could ask yourself, “How could the care environment be changed to enhance coping?”
Once you determine the change you would like to make, consider the following:
1. What data will you use to justify the change?
2. How can the team achieve this change with a reasonable cost?
3. What are the effects on the workplace?
3. What other implementation considerations do you need to consider to ensure that the change strategy is successful?
4. How does your change strategy address all aspects of the Quadruple Aim, especially the well-being of health care professionals?
5. Once the change strategy is implemented, how would you evaluate the efficiency and effectiveness of the care system if the desired outcomes are met?
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INSTRUCTIONS:
Your assessment submission should include a data table that illustrates the current and desired states of the clinical issue you are attempting to improve through your application of change strategies. Additionally, you will need to explain the rationale for your decisions around your chosen change strategies, as well as how the change strategies will be successfully implemented. The bullet points below correspond to the grading criteria in the scoring guide. Be sure that your change strategy addresses all of them. You may also want to read the Change Strategy and Implementation scoring guide and Guiding Questions: Change Strategy and Implementation to better understand how each grading criterion will be assessed.
1. Develop a data table that accurately reflects the current and desired states of one or more clinical outcomes.
2. Propose change strategies that will help to achieve the desired state of one or more clinical outcomes.
3. Justify the specific change strategies used to achieve desired outcomes.
4. Explain how change strategies will lead to quality improvement with regard to safety and equitable care.
5. Explain how change strategies will utilize interprofessional considerations to ensure successful implementation.
6. Communicate the change plan in a way that makes the data and rationale easily understood and compelling.
7. Integrate relevant sources to support assertions, correctly formatting citations and references using current APA style.
Additional Requirements
- Length of submission: 3–5 double-spaced, typed pages, not including the title and reference pages. Your plan should be succinct yet substantive.
- Number of references: Cite a minimum of 3–5 sources of scholarly or professional evidence that supports your goal setting, proposed change strategies, quality improvement, and interprofessional considerations. Resources should be no more than five years old.
- APA formatting: Use the APA Paper Template linked in the Resources. An APA Template Tutorial is also provided to help you in writing and formatting your analysis. No abstract is required.