Shaping the Course of a Marathon: Using the Trajectory Framework for Diabetes Mellitus
Walker, Elizabeth A. Rn, DNSc, Scholarly Inquiry for Nursing Practice
Persons with either insulin-dependent or non-insulin-dependent diabetes mellitus live with a chronic illness that can have both acute and long-term complications. The therapeutic regimen for glycemic control in diabetes is often complex and is lifelong; it requires special knowledge and skills for both patients and health care providers. In this article, the Corbin and Strauss trajectory framework for chronic illness management is clinically applied to the planning of patient care in two case studies of persons with diabetes. The benefits of using the trajectory framework as a model for care in diabetes include: introduction of the concepts of "locating" the patient on the trajectory and assessing the trajectory projection for both patient and provider, and a more realistic evaluation of incremental change in chronic illness. Two possible barriers to clinical application of the framework for diabetes management are: difficulty in translating the framework for clinical use, and some terminology in the framework that does not seem to describe reimbursable care. The trajectory framework provides a necessary shift in focus to quality of life issues in diabetes management over the lifespan.
Application of the Corbin and Strauss trajectory framework to build a model for nursing care for the person with diabetes appears, at first glance, to be a simple task. The purpose of this response, however, is to move through the "first glance" to attempt specific clinical application of the major concepts of the framework, and to describe perceived benefits of and barriers to using the trajectory framework for diabetes nursing care.
Diabetes mellitus encompasses a group of genetically heterogenous chronic disorders which are characterized by abnormalities in carbohydrate, protein, and fat metabolism; the common denominator is hyperglycemia (Rifkin & Porte, 1990). Prolonged hyperglycemia is a toxic condition which can produce both microvascular and macrovasular damage over time. Two major clinical subclasses of this disorder are insulin-dependent diabetes mellitus (IDDM), known as type I diabetes, and non-insulin-dependent diabetes mellitus (NIDDM), or type II diabetes (Sperling, 1988). Both types of diabetes are chronic disorders, but their etiology, clinical presentation, acute complications, and course of illness can be quite dissimilar.
The acute complications of diabetes include severe hyperglycemia, resulting in diabetic ketoacidosis or hyperosmolar nonketotic coma, and profound hypoglycemia. Chronic or long-term complications of diabetes are generally the result of macrovascular, microvascular, or neurologic pathologies. Persons with diabetes face increased risk of cardiovascular disease, with greater incidence of myocardial infarction, hypertension, and lipid abnormalities. Neuropathies can occur as distal polyneuropathies or autonomic neuropathies such as impotence and orthostatic hypotension. Persons with diabetes are 25 times more at risk for retinopathy leading to blindness than the general population. Nephropathy, leading to end-stage renal disease, and lower extremity amputation are complications for which persons with diabetes are at increased risk (Centers for Disease Control, 1990).
Minimizing the acute complications and avoiding or delaying the chronic complications of diabetes are often the major goals of therapy. Depending on the type of diabetes, there are various levels of complexity for a therapeutic regimen to meet these goals (Lebovitz, 1988). Patient adherence to the complex regimen for control of blood glucose is one of the more problematic aspects of diabetes care. Both health provider and patient may have the knowledge and skills to control blood glucose. But patients, with their support systems, have to enact this knowledge in their daily routines without, at present, any guarantee that control of their blood glucose will decrease their risk of developing chronic complications. …