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Clinical Decision Making Using Evidence-based Practice: a Case Study

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Evidence based practice has gained momentum in nursing since the development of Evidenced based practice medicine. Evidence based practice offers opportunities for nursing care to be more individualized, more effective, efficient, and dynamic, and to maximize effects of nursing clinical judgment. When evidence is used to describe best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments. However, Quality and nature of the research, attitude of clinicians, and organizational factors are well known barriers to evidenced based practice. The need for studies that directly address wide range of pressing clinical issues and for replicating studies in a more diversified settings remains a challenge. This paper will evaluate the meticulous integration of evidenced practice components of diabetic therapy and outcome in middle age Latina.

Question

In Latina patients with Obesity and a Family History of Cardiovascular Diseases, are complementary medicines more effective than Metformin in treating Type 2 Diabetes?

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Evidence

The case study indicates that Martha is a 48 year old Latina woman with a 3-year history of Type 2 Diabetes. She also has a family history of cardiovascular diseases. Martha has been taking 800 mg of metformin once a day as a first-line treatment for Type 2 Diabetes. She also maintains diabetic diet along with daily exercise. However, her recent lab report indicates no significant improvement in her condition. First, the test indicates that her hemoglobin A1c has reduced to 8.5 which is still above the target. A normal level of hemoglobin should fall below 5.7 percent. Secondly, Martha’s fasting blood glucose levels range from 160-190 mg/dL. A normal fasting blood sugar level is below 100 mg/dL. Furthermore, the patient also complains of weight gain and heart disease. Coffman et al illustrates that it may be especially difficult for people who do not speak English well and have low health literacy to understand information related to their diabetes such as diet, weight management, and other self-management strategies.

Critical Appraisal of the Evidence

The evidence indicates that metformin is not treating the patient effectively. The only change that has been noticed is a slight decrease in the hemoglobin A1c which has fallen to 8.5 percent. The new level indicates a decrease but leaves the patient far above the normal level which is below 5.7 percent. However, the evidence does not tell other factors apart from metformin which could also be working against the treatment. For instance, the patient has been gaining weight despite the fact that weight gain is not one of the side effects associated with metformin. The main side effects associated with metformin include nausea, abdominal cramps, diarrhea, vomiting, loss of appetite, metallic taste, and flatus. Side effects such as diarrhea, vomiting and loss of appetite may affect eating patterns and cause loss of body weight among patients with Type 2 Diabetes. However, previous research does not tell any case where metformin has been associated with body weight. Therefore, despite the fact that metformin is not working effectively, there could also be other underlying factors affecting the treatment process.

Integrating Evidence with Clinical Practice

In a circumstance where one drug fails to achieve its purpose, it is always recommended to try other alternative treatment methods. For instance, evidence in this case indicates that the patient’s condition is not improving despite regular application of metformin and other measures including body exercise and diabetic diet. Trying another method may assist the patient to improve her condition. Besides, nurses and clinicians will have an opportunity to determine the effectiveness of metformin in comparison to other treatment methods.Intervention. Research shows that metformin can be replaced or used along with other alternative treatments known as complementary medicine. The role of a complementary medicine is to assist the primary or the conventional medicine to achieving its purpose. An example of a complementary medicine that this paper recommends is Sulfonylureas. The medicine can be taken along with metformin in cases where the patient is not responding effectively. Sulfonylureas is a second-line drug that has shown effective results in treating type 2 diabetes along with administration of metformin.

Another study suggests that a healthy diet and adequate exercise are important for diabetes self-management. Health education programs can promote the development of health literacy skills and disease-specific knowledge, enabling individuals to have greater control over their health. Besides the complementary medicine, the patient should maintain diabetic diet and regular exercise to minimize weight gain. Moreover, the patient should also avoid depressing situations to minimize negative conditions associated with weight gain.

The results will be used to compare the effectiveness of metformin alone as well as metformin along with complementary medicine. The current case study presents the first evidence indicating that metformin has not been effective towards treating type 2 diabetes among patients with obesity and a family history of cardiovascular diseases. The use of metformin along with sulfonylureas will provide a second evidence needed to a complete comparison and draw effective conclusions. The patient should also maintain regular body exercise and diabetic diet to make the comparison more effective.

Outcomes

The aim of this clinical decision is to facilitate the treatment of the patient. So far, the evidence indicates that metformin alone has not been effective towards improving the condition of the patient. Therefore, the use of metformin and sulfonylureas will provide more information needed to determine the most effective treatment for type 2 diabetes in female patients with obesity and a family history of heart diseases.

Evaluating Effectiveness of the Clinical Decision

The evidence indicates that metformin has not been effective towards treating type 2 diabetes in this case. Instead, there are indications that the patient is developing more complications. For instance, weight gain and heart disease are signs that the patient is developing further complications. However, using metformin along with complementary medicine such as sulfonylureas may assist the patient to overcome her current condition. The patient has also been advised to maintain regular body exercise as well as the recommended diabetic diet. The outcomes of this clinical decision will be evaluated using the following tools: Glycated hemoglobin (A1c) test. This blood test will indicate the average blood sugar level for the last three months. According to the case study, the current hemoglobin A1c is 8.5 percent. Although any figure below 8.5 percent will indicate success of the clinical decision, the aim is to reduce the average blood sugar level to a figure below 5.7 percent. The main aim of the treatment is to ensure the patient reaches a normal blood sugar level which falls below 5.7 percent. Any figure above 8.5 percent will indicate that the new clinical decision is not successful. Fasting blood sugar test. The purpose of this test is to determine blood sugar level after a body is deprived of food. The test is based on the fact that most of the blood sugar comes from foods that people eat. After an overnight of fasting, a sample of blood will be taken and tested to determine the blood sugar level. Any figure below 100 mg/dl indicates a normal fasting blood sugar level. However, a figure within a range of 100 mg – 125 mg/dl indicates a prediabetes level. Any figure above 126 mg/dl is an indication that one is suffering from diabetes. The current level is within the range of 160 – 200 mg/dl.

The aim of the treatment is to lower the fasting blood sugar level to any figure below 100 mg/dl. The success of the treatment will provide evidence that can be used by practicing advanced nurses to develop appropriate treatment plan for patients with type 2 diabetes.

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