RLT model

Table of Contents

According to WHO (2005), health problems which need to be continuously managed or treated over a long period of time (years or decades) are referred to as long term conditions. However, Eaton et al. (2015) contends that this definition neither does justice to the consideration of the burdens (personal, social and economic) that these conditions places on the patients, their families and/or their larger community nor recognises the fact that few hours in a year are spent by these patients with physicians and healthcare services while the patients spends a considerable amount of their lives continually managing their conditions. Diabetes, dementia, chronic heart failure and osteoporosis are examples of common long term conditions (George and Martin, 2016). This essay will investigate the cause and management of a long term condition. The outline of the Roper, Logan and Tierney (RLT) model of care framework which will be used to holistically assess and evaluate the needs of the patient will be examined alongside the strength and limitations of the model in comparison to Orem’s model of self-care.

For the purpose of this essay and in accordance with the Nursing and Midwifery Council Code of Conduct (NMC, 2015) regarding protection of patient confidentiality, no actual names will be mentioned and all references to the patient is made under the pseudonym Angy. The student’s placement was in a North London NHS health facility where patients where often to referred to for assessment and diabetes management. It was at this facility that the student met 38 year old Angy. Since her diagnosis in 2008 with type 2 diabetes mellitus, Angy has been treating her condition with a premixed preparation of 75% insulin lispro protamine suspension and 25% insulin lispro preparation (Humalog 75/25). Her dosage requires her to take 33 units of this preparation before breakfast and 23 units before supper. However, the patient admitted that even though she has received no prior information or instructions regarding insulin adjustment algorithm, she occasionally increases the amount of insulin she usually administers to herself at times when her blood glucose levels reads higher than usual. A detailed history showed that she suffers from the adverse side effects of her medication which has resulted in poor medication compliance. The patient also confessed that the night shifts she does at work makes it rather difficult for her to remember to take her medication.

Based on clinical presentation and etiology, diabetes mellitus is typically differentiated into three types; type 1, type 2 and gestational diabetes mellitus (Goyal and Jialal, 2019). Type 2 diabetes is usually characterised by the unavailability of insulin which is required to prevent ketoacidosis and it is regarded as the most common form of idiopathic diabetes accounting for about 90% of diabetes cases (Goyal and Jialal, 2019; Ozougwu et al., 2013). The cause of type 2 diabetes mellitus is due to a single factor but rather is multifactorial and involves a combination of multiple genetic factors that affects impaired insulin secretion, insulin resistance and environmental factors such as obesity, sedentary lifestyle and aging (Holt, 2004; Kaku, 2010). Insulin resistance has been linked to increased levels of free fatty acids as well as proinflammatory cytokines in the plasma with the resulting effects including the reduction of glucose transport into the muscle cells, increased production of hepatic glucose and elevated fat breakdown (Khadori, 2019). Baynes (2015) reports that most people diagnosed with type 2 diabetes show visceral obesity. In type 2 diabetes mellitus, there is the absence of mutual relationship between the glucagon-secreting α-cells and the insulin-secreting β-cells which leads to hyperglucagonaemia and subsequently results in hyperglycaemia (Unger and Orci, 2010). Most type 2 diabetes patients usually have their condition go undiagnosed for years because type 2 diabetes mellitus has a latent, asymptomatic stage (International Diabetes Federation, 2013).

This patient was chosen because of the ever rising prevalence of type 2 diabetes mellitus in England which according to NHS England (2018) is constantly challenging the NHS and general healthcare systems all over the work. According to Kok et al. (2019) every year 22,000 people die prematurely as a result of type 2 diabetes and its complications. Public Health England reports that there are currently 3.8 million England residents living with type 2 diabetes with 200,000 new diagnosis occurring every year (Smith, 2018). In 2008, the National Collaborating Centre for Chronic Conditions reported that the estimated cost of the type 2 diabetes mellitus on the economy of the UK is about £2.8 billion which makes up 7%-12% of the total budget for the National Health Service (NHS). By 2018, this figure has increased to £8.8 billion which accounts for just under 9% of the total NHS budget (Smith, 2018).

The nursing process is a methodical process of delivering patient-centred care regardless of the individual’s state of health or illness and it comprises of four phases which are assessment, diagnosis, planning and evaluation (Baraki et al., 2017). When a nursing model is used in conjunction with a nursing process, a nursing approach is formed (Aggleton and Chalmers, 2000). According to Pearson et al. (2005), the application of a nursing model is vital to providing continuity of care through support and also in demonstrating to healthcare professionals what goals need to be achieved. The assessment framework that will applied in this case study is the RLT model. In order to provide a holistic approach to care, this model has been carefully designed to consider the psychological, biological and social needs of a patient (Roper et al., 2000). It places great emphasis on the significance of adopting a comprehensive approach when assessing patients, it also stresses the need for nurses to not only gather information from the patient but to also gather relevant information about the patient in order to achieve a more thorough and comprehensive assessment (Roper et al., 2001). The RLT model, which is based on activities of daily living, is widely applied in the United Kingdom and has its basic concepts built on the Henderson’s need theory (Ahtisham and Jacoline, 2015; Rwakonda, 2017). Tornquis and Sonn (2014) define activities of daily living as activities which are undertaken daily such as communication. These activities are interrelated and Lakhan et al. (2012) opine that activities of daily living are in agreement with care given to one’s body, they are also paramount to surviving and promote individual sustenance and welfare. The RLT model is of significant import because it diverts attention of the healthcare providers from the illness and allows them to focus more on designing a person-centred care plan based on the perceived and impending needs of the patients which will be identified based on the twelve activities of daily living which inadvertently results in the promotion of improved health outcomes (Li Fang, 2015). The twelve activities of daily living according Roper et al. (2001) are maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobility, working and playing, expressing sexuality, sleeping, and death and dying. According to Holland et al. (2008) these activities of daily living are used as a framework for the nursing process.

Maintaining a safe environment

According to Stonehouse (2017a), maintaining a safe environment is related to the activities of living and as such should not be taken for granted. Rwakonda (2017) suggests that promotion of mobility is facilitated by maintaining a safe environment.

Communication Ineffective or loss of communication can often result in patients being non-compliant to their treatment regimens, it can also lead to self-isolation and disengagement (Hess and Altobelli, 2012; Morris, 2015). In order to encourage active participation in the activities of living, it is important to provide an environment in which the patient can communicate freely and without prejudice (Rwakonda, 2017)BreathingDyspnea is a condition in which an individual has difficulty breathing while performing exercise or during any of the activities of living (O’Donnell et al., 2013). At this point, the patient should be assessed for breathing difficulties which may include difficulty in breathing when sleeping or exercising. Questions about smoking habits of the patients or the use of breathing aids such as inhalers should be asked. According to Stonehouse (2017b), it should be incorporated into initial airway, breathing and circulation assessment.

Eating and drinking

This pertains to the assessment of the patient’s regular diet. Barusso et al. (2015) opine that poor participation of the activities of living can be caused by fat loss and muscle wasting as a result of poor nutrition. Diet assessment is important for diabetic patients since their condition requires them to have specific dietary needs however great care must be taken to ensure that their nutritional needs are met. EliminationDiscussing bowel and bladder elimination require dignity and respect as this activity is often a sensitive topic for patients to discuss (Rwakonda, 2017; Stonehouse, 2017).

Washing and dressing

Poor hygiene can be considered repulsive and disrespectful resulting in the isolation of the person whereas proper or high level of hygiene has the potential to increase an individual’s confidence and self-esteem. (Rwakonda, 2017). When relevant, nurses should assess a patient’s skin and also examine if said patient is at risk of developing pressure sores (Roper et al., 2006).

Controlling temperature

One of the key requirements for survival is thermoregulation or maintaining a suitable stable temperature as such, body temperature that is below or above average could be evidence of a disease that can potentially destroy the body’s organs or impair body system functioning temporarily or permanently (Rwakonda, 2017). MobilityAccording to Umei et al. (2016), mobility is important in order to prevent complications linked to immobility. On admission, ability of a patient could be severely affected and so there is a need for the nurses to provide comfort in terms of reassurance and support (Stonehouse, 2017a). Maintaining a safe environment and elimination can also be directly affected by mobility (Stonehouse, 2017a). During mobility, there is a mutual between the body’s physical and psychological systems (Timmerman, 2008).Working and playingIt is important to find out if the patient’s condition has adversely affected their work and/or quality of life. It is also important for not only children and young people to partake in recreational activities but adults as well (Hubbuck, 2009; Stonehouse, 2014; Tonkin and Whitaker, 2016). However, taking part in too many activities can result in both mental and physical fatigue but improvement can be made to a patient’s physical environment by keeping in mind safety and risk management when making private spaces or installing significant furnishings (Rwakonda, 2017). Quality of life can be improved when patients take part in activities that gives them a sense of belonging (Edvardsson et al., 2014)

Expressing sexuality

Like elimination, this is also a sensitive activity to discuss and it relates to choice of clothes, gender, makeup or hairstyles (Rwakonda, 2017; Stonehouse, 2017a). Stonehouse (2017a) suggests that more detailed question should be asked if the patient’s condition directly affects this activity.SleepingThe importance of sleep cannot be overemphasised as it is vital in maintaining quality of life, preserving health and provide the needed energy for living. Stonehouse (2017a) suggests that a patient’s regular sleeping pattern and the effect of their illness on their sleeping pattern should be inquired about. Death and dyingAlthough this activity is one of the twelve activities of life, Roper et al. (2006) state that it is a sensitive topic that should only be discussed when relevant or when the patient wishes to discuss it.

Roper et al. (1999) further categorises five components which directly affect these activities of living; biological, psychological, sociocultural, environmental and politico-economic factors. The biological factors have to do with how critical the disease is as wells as the genetic makeup of the patients (Rwakonda, 2017; Stonehouse, 2017a). Sociocultural factors are societal expectations, ethics, religion and community while politico-economic factors pertain to important services necessary in the home such as transport, insurance and also other legal and economic factors (Roper et al., 2006; Rwakonda, 2017). Psychological factors are related to the patient’s intellect and emotions and environmental factors consider the natural or artificial environment of the patient’s abode (Stonehouse, 2017a). Beh Hui (2012) observed that the RLT model not only has the advantage of outlining the activities of daily living but also equips the nurse with the required knowledge to assess how biological, psychological, sociocultural, environment and politico-economic concepts aid with determining the effect of the activities of living on the patient’s quality of life. However, according to Baker and Kakora-Shiner (2009) a limitation to this model is that it is too rigid and it places all emphasis on the activities of living without considering other situations that involves spirituality or coping mechanisms. This is in contrast to Orem’s model of self-care which according to Hagran and Fakharnay (2015) has broader concepts that makes it flexible enough to be applied to a wide range of situations. Despite having more flexible concepts than the RLT model, studies have referenced the difficulty in understanding Orem’s language (Hagran and Fakhatnay, 2015).

According to a study by Mendoza (2004), when studying Orem’s model of care, most students were confused by the varying terminologies that has similar meaning but, there seems to be no report of such complexity in the RLT model as the language used in the RLT model appears to be uncomplicated. A major strength of the RLT model is the manner in the activities of living are objectively measured which makes its application to Angy’s situation relatively easier however Walsh (1998) warns that there is a tendency of assessment using the 12 activities of living resulting in these activities being used as a checklist by nurses which could result in the omission of vital information that could be pivotal to the treatment of the patient thereby causing more harm than good.

This essay will place emphasis on two activities of life for Angy, one of which is mobility. Rwakonda (2017) asserts that benefits of increased physical activity is the prevention of psychological experiences and also the improvement of a patient’s quality of life. One of the psychological experiences that Angy seems to suffer from is diabetes distress which prompts her to increase her regular insulin dosage from time to time when she notices high glucose reading despite the fact that she has received no medical instructions to do so. Diabetes distress is fairly common among type 2 diabetes patients that have been diagnosed for a long duration and require daily self-management when administering their medications (Mathiesen et al., 2019). It is also associated with poor medication compliance and reduced glycaemic control which can increase the incidence of diabetes-related complications (Hessler et al., 2014; Pandit et al., 2014). On further inquiry, Angy also admitted to working night shifts. This could mean that she has abnormally extended periods of physical inactivity during the day because she worked night shifts. An exercise intervention was recommended to Angy in which she would partake in regularly exercise that would be carried out daily or with 2 days intervals; the goal of this intervention is for her to have at least 10 minutes and at most 30 minutes of exercise which will help reduced her insulin resistance (Jelleyman et al., 2015; Little et al., 2011). Other activities such as yoga was recommended. Yoga has been shown to reduce insulin resistance, improve the prognosis of diabetes, reduce stress and alleviate psychological experiences by promoting a healthy body as a by-product of a healthy mind (Cui et al., 2017; Kumar and Poonia, 2017; Weinstein, 2018).

Although the increased physical activity in the form of exercises are beneficial to the patient, the American Diabetes Association (2019) points out that in individuals such as Angy who have been placed on insulin medications, these physical activities has the possibility of actually causing hypoglycaemia if the patient’s dosage has not been adjusted or they have yet to modify their carbohydrate intake. These hypoglycaemic attacks can cause dizziness which would make mobilisation difficult. Peters and Laffel (2013) suggest that rather than reducing blood glucose levels, increased physical activities or intense activities are more likely to increase an individual’s blood glucose levels if the said individual has already elevated glucose levels before exercise. It is important to note that while setting these exercise goals for Angy, the SMART goals evaluation tool was used in order to ensure that the goals set were custom-made for Angy rather than a one size-fits-all-approach and achievable within a reasonable time frame. The information Angy provided about her lifestyle was vital in reducing the chances of setting unrealistic, unachievable goals for her since a baseline will be recorded thus effectively measuring progression.SMART (Specific, Measurable, Achievable, Results-focused, Timely) goals is a NHS Health Check which utilises goal setting a means of effectively modifying or altering behaviours with the use of person-specific plans (Darker et al., 2010; Michie et al., 2011; Sniehotta et al., 2006). SMART goals evaluation ensures that any goals set are achievable within the individual’s ability and resources and are also measurable in terms of quantity, time or cost effectiveness (Revello and Fields, 2015).

Another one of the activities for living that will be focused on for Angy is elimination. Angy seemed to have no problem with elimination however her diabetes has resulted in her developing a condition called polyuria. Polyuria, also known as excessive urination, is a type of symptom associated with type 2 diabetes mellitus with very high levels of hyperglycaemia (Ramachandran, 2014). It is characterised by abnormally elevated urine output when compared to effective arterial blood volume and serum sodium (Lithgrow and Corenblum, 2017). It is imperative that Angy is aware of the locations of restrooms wherever she goes and the option of using a commode was offered to her for time when she feels like she cannot make it to a restroom. Assessment of Angy was a success and the use of the RLT model was beneficial in assisting the student to objectively assess Angy and develop a care plan for her despite the challenging situation and the lack of experience of the student.