title: [Joint home follow-up of a patient with complicated diabetes mellitus by the case manager and the community nurse: II].
abstract: This is a continuation of the article published in this journal (Enfermeria Clinica), entitled "Integral approach by the case manager and the community nurse to a complex case of diabetes mellitus in the home". We present the case of a 76 year- old patient with long-term and clinically complex Diabetes Mellitus. The patient was taking part in the Primary Care home care program. This article describes the follow-up of the case in which new complications appeared in the right limb, which led to the amputation of the second limb. A new evaluation following Virginia's Henderson model was performed six months after the initial care plan. Nursing diagnoses were made following the North American Nursing Diagnosis Association (NANDA). These diagnoses led to changes in objectives and performance criteria using, nursing outcomes classification (NOC) and nursing interventions classification (NIC). One of the results obtained was the improvement of her well-being by enabling the patient to interact and integrate socially within her environment after mobilising the corresponding social and family resources.Involvement in clinical practice is important in the prevention of diabetes mellitus and diabetic foot complications. Difficult and complex situations are sometimes beyond the ability of the community nurse. It can be beneficial to take advantage of the clinical support offered by the case management model and the integrated approach of a multidisciplinary team.
authors.affiliation: Área Básica de Salud Gavarra, ICS, Cornellà de Llobregat, Escuela Universitaria de Enfermería, Universidad de Barcelona, Barcelona, España. rlopez.cp.ics@gencat.cat
authors.forename: Rosa María
authors.initials: RM
authors.lastname: López-Pisa
authors.forename: Marta
authors.initials: M
authors.lastname: Prats-Guardiola
mesh_terms: D000368:Aged; D019090:Case Management; D003152:Community Health Nursing; D048909:Diabetes Complications / Q000451:nursing*; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services; D006801:Humans