What are diabetic care plans?

Diabetic care planning is a process which aims to provide patients with more control over the management of their condition.

Diabetes is a multifaceted condition that affects numerous body systems altering their function. As such, diabetic patients must attend regular appointments with a multidisciplinary team of doctors and health professionals to optimally manage their condition.

As diabetes can affect everyone differently, these health professionals work with the patient to create and follow a diabetic care plan based on the patients’ individual needs. Diabetic care plans are an integral component of successful, long-term diabetes management. 

Essential components of a diabetic care plan include:

• Diet and exercise plan
   
• Compliance to prescribed medications
   
• Scheduled appointments with health professionals (podiatrists, dietician, diabetes educators)
   
• Individual health goals
   
• Regular care plan appointments give the patient a chance to discuss set goals, experiences, worries and results of diabetic checks.

Owing to the nature of diabetes, there are a number of lifestyle and dietary changes that are required to prevent complications.

On a regular basis, patients must monitor their blood glucose levels, participate in physical activity, consume specific medications, and eat a healthy diet. Diabetic care plans assist patients in maintaining this schedule and provide greater control of their self-care.

How are they used?

Diabetes management care plans are used by health professionals, particularly general practitioners, to assist patients in setting clinical goals as well as reminding them about tasks in relation to diabetes care.

Care plans also include information about patient referrals to allied health professionals for more specific self-management support services.

Care plans can assist health professionals by engaging patients in their own care. The use of evidence-based targets can provide patients with clarity in regards to their health status and provide motivation to modify unhealthy behaviours.

Care plans are also highly useful in reminding patients about the treatment and monitoring needed on an ongoing basis.

Care plans include information to assist nurses and allied health professionals in treating patients.

This is usually more personalised patient information such as certain barriers to achieving evidence-based goals that the allied health professionals can use to aid their patient treatment plan.

Why are diabetes care plans important?

Diabetes is a condition that impacts each body system differently. The pathophysiology of diabetes involves both hormonal actions and metabolic processes, and these vary greatly from one person to the next.

Human behaviour and personal preferences also vary between individuals, and the combination of biological processes and varying human behaviours results in an infinite range of responses to diabetes.

This is primarily why diabetes care plans are developed on an individual basis.

There is growing evidence that patients with chronic conditions have improved outcomes when granted greater control of the management of their condition.

Mismanaged diabetes can lead to more serious complications including kidney disease, amputations, blindness, stroke and heart attacks. Personalised care plans have been proven to help reduce the risk of such complications.

How are they developed and monitored?

Several aspects are taken into consideration when developing an individualised diabetes care plan. Health professionals’ key responsibilities as part of a diabetes care plan include:

• Educating patients regarding their role in optimally managing their condition.
   
• Educating patients regarding important dietary changes. Patients may be advised to follow a predominately Mediterranean diet if there are any heart concerns. A dietician may also advise patients to lose 5-10% of body weight if their weight is in the overweight range alongside a minimum of 30 minutes of physical activity per day. These weight loss goals must be monitored every 6 months.

The patient’s general practitioner should carry out routine biomedical checks to observe improvements/issues in key parameters. These include:

• Cholesterol levels- Blood test, (LDL-C < 2.0, HDL-C >1.0)
• BP- to acceptable national target (<130)
• HbA1c- blood test every 3 months, acceptable levels < 53mmol/mol
• Blood glucose levels- blood test, healthy between 6-8mmol/L fasting

The patient’s medication should be monitored according to their biomedical test results. These medicines should be targeted at maximising benefits and minimising side effects.

If a health professional identifies any complications of diabetes then the patient should be referred to specialised health professionals to help manage and control these complications.

The critical role of nurses in diabetes management

Nurses play a pivotal role in helping patients manage their condition in both primary and tertiary healthcare settings. Key responsibilities of nurses include:

• Initially assess diabetic patients and implement personalised diabetic care plans
   
• Evaluate tools and techniques used for assessing diabetic patients. These tools include blood glucose monitors, pathology and monofilaments
   
• Recognise patients with metabolic syndrome, pre-diabetes or issues managing their glucose levels then develop an appropriate nursing care plan to help prevent further complications
   
• Identify the impact of lifestyle factors on the patient’s condition and develop strategies for patient education

Duties of nurses include giving patients insulin via intravenous infusion as well as carefully monitoring vital parameters that include blood pressure, temperature and eyesight.


Sources:

• RACGP
• ShareCare
• MJA
• Nursing Times
• Ausmed