Interdisciplinary Care Plan For A Patient With Diabetes

Interdisciplinary Care Plan for a Patient with Diabetes and Heart Disease

Patient care in today’s healthcare landscape emphasizes collaborative, patient-centered approaches involving multiple health disciplines. This interdisciplinary care plan focuses on a 73-year-old female patient diagnosed with uncontrolled type 2 diabetes and cardiovascular disease, living alone in an assisted living facility. The goal is to incorporate evidence-based practices to optimize health outcomes, prevent disease progression, and ensure safe, effective care delivery tailored to her aging needs.

Understanding the complex interplay between diabetes and heart disease is essential, especially in the gerontological context where age-related physiological changes influence disease management. An integrated care plan must address not only the clinical manifestations but also the psychosocial aspects such as mobility, mental health, and social support, which are critical in older adults with chronic illnesses. This plan leverages concepts from gerontological nursing and health promotion, emphasizing comprehensive assessment, prevention, early detection, and management aligned with current evidence-based standards.

Patient Background and Assessment

The patient is a 73-year-old woman with a history of type 2 diabetes diagnosed over a decade ago and recent diagnosis of coronary artery disease. Her comorbidities include mild cognitive impairment, limited mobility, and social isolation. She reports difficulties in maintaining her blood glucose levels and managing her medications independently. Recent falls prompted evaluation of her stability and mobility. Laboratory results reveal elevated HbA1c (7.8%), triglycerides, and microalbuminuria, indicating poor glycemic control and early nephropathy, while her blood pressure remains elevated at 150/85 mmHg. Her physical exam shows signs consistent with long-standing diabetes and cardiovascular disease, including peripheral neuropathy, diminished pedal pulses, and auscultatory findings suggestive of congestive heart failure.

Goals of Care

• Achieve optimal glycemic control, targeting HbA1c less than 7%.
• Control hypertension to less than 140/90 mmHg to reduce cardiovascular risk.
• Prevent falls and mobility decline through tailored interventions.
• Enhance medication adherence and self-management capabilities.
• Address psychosocial factors affecting health, such as social support and mental health.

Interdisciplinary Interventions and Rationale

1. Medical Management

Primary care providers, cardiologists, and endocrinologists will collaboratively optimize medication regimens. This includes adjusting antihypertensives (e.g., ACE inhibitors), antidiabetics (e.g., metformin, insulin), and statins following current guidelines (American Diabetes Association, 2021). Regular monitoring of blood glucose, blood pressure, renal function, and lipid profiles will inform ongoing treatment adjustments, consistent with evidence-based practices to prevent complications such as nephropathy, retinopathy, and cardiovascular events (American Heart Association, 2020).

2. Nursing Care

Nurses will conduct comprehensive assessments focusing on blood glucose levels, blood pressure, and signs of volume overload or peripheral vascular insufficiency. Blood pressure and glucose monitoring should be performed at regular intervals, with adjustments made per clinical protocols (Toughy & Jett, 2018). Education on medication administration, dietary management, and symptom recognition, such as hyperglycemia or anginal symptoms, empowers the patient for self-care. Nurse-led fall prevention strategies involve environmental modifications, balance training, and assistive devices, aligning with gerontological principles to reduce injury risk (American Geriatrics Society, 2022).

3. Dietary and Lifestyle Modifications

Registered dietitians will tailor a nutritional plan addressing caloric needs, glycemic control, and cardiovascular health, emphasizing low-sodium, heart-healthy diets rich in fiber with consistent carbohydrate intake (Ebersole & Hess, 2018). Lifestyle counseling promotes physical activity suited to her mobility status, such as seated exercises or walking with assistive devices, to improve insulin sensitivity and cardiovascular endurance (Naik et al., 2015). Behavioral health services may address barriers like social isolation and depression, which impact adherence and quality of life.

4. Physical and Social Support

Physical therapy referrals will focus on mobility enhancement and fall risk reduction. Social work input provides resources for community support, transportation, and caregiver education to prevent loneliness and promote compliance. Incorporating family or caregiver involvement, when possible, fosters a supportive environment critical in aging populations.

5. Preventive Screenings and Health Promotion

Routine screening for vision, hearing, and cognitive function is essential. Vaccinations, such as influenza and pneumococcal, are scheduled to reduce infectious risks. Regular screenings for diabetic retinopathy, nephropathy, and cardiovascular disease facilitate early detection and intervention, consistent with guidelines (American Diabetes Association, 2021). Emphasis on smoking cessation, if applicable, and management of comorbid conditions further supports health promotion.

Protection of Client and Evidence-Based Support

This care plan adheres to contemporary standards for managing older adults with diabetes and cardiovascular disease, integrating gerontological nursing principles related to age-specific vulnerabilities—such as polypharmacy risks, sensory deficits, and diminished physiologic reserves (Toughy & Jett, 2018). The interventions follow evidence-based guidelines issued by authoritative organizations, ensuring safety and efficacy.

For example, blood pressure and glycemic targets are set according to the ADA and American Heart Association standards, which have proven to reduce microvascular and macrovascular complications among the elderly (American Diabetes Association, 2021; American Heart Association, 2020). Fall prevention strategies incorporate strength and balance exercises supported by research demonstrating injury risk reduction (Sherrington et al., 2019). Furthermore, medication management prioritizes safety, considering age-related pharmacokinetic changes and potential polypharmacy interactions.

Conclusion

This interdisciplinary care approach emphasizes collaboration, evidence-based practices, and holistic care tailored for the geriatric population. Through coordinated medical, nursing, dietary, physical, and social interventions, the plan aims to improve glycemic and blood pressure control, reduce fall risk, and enhance overall quality of life. Tailoring these strategies within a gerontological framework ensures that the unique needs of older adults with complex chronic diseases are addressed effectively, ultimately leading to better health outcomes and optimized aging.

References

• American Diabetes Association. (2021). Standards of medical care in diabetes—2021. Diabetes Care, 44(Suppl 1), S1–S232.
• American Geriatrics Society. (2022). Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 70(3), 697–712.
• American Heart Association. (2020). Guidelines for the Management of Hypertension in the Elderly. Circulation, 142(13), e329–e354.
• Ebersole, S., & Hess, P. (2018). Gerontological Nursing & Healthy Aging (5th ed.). Elsevier.
• Naik, V., Dave, R., Stephens, J. W., & Davies, J. S. (2015). Evidence based prevention of type 2 diabetes: Role of lifestyle intervention as compared to pharmacological agents. International Journal of Diabetes and Clinical Research, 2(6), 49-56.
• Sherrington, C., et al. (2019). Effective exercise for the prevention of falls in older people: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 67(4), 866–874.
• Taub, N. A., et al. (2017). Managing hypertension in older adults: Evidence from clinical trials. Age and Ageing, 46(2), 216–222.
• Trope, C., & Wenzel, J. (2020). Geriatric considerations in diabetes management. Endocrinology and Metabolism Clinics, 49(4), 657–669.
• Wood, H., & Heller, R. F. (2017). The impact of diabetes on the aging population: Clinical implications. Journal of Geriatric Oncology, 8(6), 419–427.
• Toughy, T., & Jett, K. (2018). Ebersole and Hess' Gerontological Nursing and Healthy Aging (5th ed.). Elsevier.