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Step 1 To complete this discussion, you will be logging into The Neighborhood. The Neighborhood is a virtual community that enables you to achieve a deep understanding of total patient care. The Neighborhood’s stories, activities, and case studies on more than 40 characters provide a 360°-view of a client’s life. The Neighborhood will enhance the skills you use daily in the nursing profession.Click on Accessing and Using The Neighborhood for directions to enter the virtual community.Select the link watch the video for further instruction on The NeighborhoodClick on “Neighborhood” to access the neighborhood simulation and to navigate to and read the following Neighborhood episode:Jenna Riley, Season 3 Episodes 14-15: In these episodes, you will continue to follow Jenna Riley. It has now been several months since her diagnosis of diabetes.Step 2 Review The Neighborhood assignment from Week 5, when Jenna was diagnosed with diabetes. You should now be reviewing Episodes 14 and 15, after Jenna has been seen for a follow-up appointment. In this assignment, you will evaluate the health-promotion interventions that Jenna should have been following. WEEK 5Jenna is a healthy but overweight 13-year-old girl who lives with her mother, Evelyn, and brother, Jason. Her older sister, Jessica, lives a short distance away in her own apartment with her infant son, Ryan. Jenna misses having her older sister around and looks up to Jessica. Jenna has had minimal contact with her father and does not really even know him.Because her mother works a few evenings each week, Jenna is responsible for her younger brother Jason. She gets along okay with her brother, but she thinks he is weird. She is a good student in the seventh grade at the local middle school. She has many friends and spends a great deal of time on the phone or in computer chat rooms talking with friends in the evening. Jenna is self-conscious about her weight. She knows she should try to lose weight, but she doesn’t really know how and doesn’t have much discipline when it comes to resisting snacks. She finds it very hard not to join in with her friends when they eat.Jenna goes to Bible school class each Sunday. Her mother is the teacher for her class this year, and she is not too thrilled about this. She loves her mother but does not like the fact that she is her teacher for these sessions. Jenna does not feel as though she can be “herself” and also worries that her mother will do something to embarrass her in front of her friends.Jessica’s baby spends time at the house several times in the evening this week. Jenna likes it when Ryan is there and fantasizes about the day she will have a baby of her own. She hears her mother wondering out loud when her sister is going to pick up Ryan and take him home. Jenna goes on an outing with the youth group at her church to an amusement park located in a city 3 hours away. She boards a bus at 7:30 a.m. and does not arrive back until 11:30 p.m. Jenna and her friends take photos of themselves at the amusement park. Jenna posts these to her Facebook page. She specifically brags about riding the “Widowmaker” roller coaster six times in one day. Jenna is careful only to post pictures of herself from the shoulders up so it is not so evident how heavy she is. Jenna attends a slumber party at her friend’s house. They stay up all night, eat popcorn and pizza, and drink soda while watching movies. The girls also practice applying makeup, painting their fingernails and toenails, and doing each other’s hair. One of the girls asks Jenna about a dark streak across the back of her neck near her hair line; Jenna looks in the mirror and sees the streak but doesn’t know what it is. She unsuccessfully tries to wash it off. Because it does not hurt and is hidden by her hair, she doesn’t think much more about it. The following day, Jenna sleeps the entire afternoon and does none of her chores.Jenna’s brother comes home with new glasses this week. Jenna is quick to tell him the glasses make him look weirder than he already did.Jenna is aware that her mother and sister are fighting about Jessica’s boyfriend and about the baby. She finds this upsetting and eats half a package of cookies after school. Jenna’s mother becomes angry when she learns this and tells Jenna that she needs to start watching what she eats.Jenna has her first menstrual period. She recognizes what it is because of classes she had at school and because of things her friends told her. She is actually relieved to have her first period because all of her friends had periods and she wondered if something was wrong with her.Evelyn buys Jessica some tampons and feminine napkins and tells Jenna not to flush these down the toilet. Jenna does not want Jason to see her tampons in the trash and figures they are small enough to flush. The following day, the toilet is stopped up and overflows onto the floor. Jenna denies flushing tampon Jenna is teased at school by several of the boys in her class about being a “piggy.” This hurts Jenna’s feelings tremendously. Jenna and her friends make a pact not to talk to the boys until they apologize. Jenna eats three pieces of cake at Jason’s party.s and suggests that Jason just uses too much toilet paper. Jenna’s youth group holds an annual pancake breakfast fundraising event. She gets to the church very early to help set up the tables and chairs and then spends time in the kitchen helping to serve the pancakes. She loves pancakes and has three plates over the course of the morning. She posts to her Facebook page so that everyone can see she is involved with volunteer work with her church.Jenna gets her report card at school this week and is pleased that she has all A’s again. She likes the fact that people consider her smart. Jenna is aware that her brother has been in a fight at school again. She does not understand why he fights all the time and why he just can’t sit down and do his homework the way she does. She is angry at him for making their mother upset. Jenna also knows that her mother is very worried about Ryan and Jessica. Jenna spends most evenings this week on Facebook while eating chips and drinkingJenna knows that Jessica is pregnant, but she still does not have a good understanding of how that all happens. Her mother is so wrapped up in that situation and with Jason that Jenna feels almost invisible. She has gained several pounds over the past few months, but she does not feel she has any control over her eating. She sometimes hates the way she looks and feels.Jenna goes to a slumber party with several girls. The girls talk about their boyfriends at school. Jenna does not have a boyfriend, and she suspects the reason is that she is fat. Although she remains friends with the girls, she begins to feel like an outsider because of her weight. She wonders why she can’t be skinny like her sister, Jessica.Jenna’s brother was kicked out of Boy Scouts this week. She wonders why he can’t control himself.There is an announcement at school that tryouts for the school Spirit Squad will be held in a couple of weeks. Jenna’s friends talk about the tryouts and ask Jenna if she plans to try out. The girls on the Spirit Squad tend to be the popular girls at school. Jenna would love to be on the squad, thinking it could help her to become popular. However, she is becoming increasingly self-conscious about her weight and worries that people might laugh at her. She tells her friends that her mother doesn’t have enough money for the uniforms and other expenses associated with Spirit Squad, because all their money goes to help her pregnant sister. She posts this information on her Facebook page in order to gain sympathy. Jenna likes getting this type of attention.Jenna is unhappy when her mother informs her that Jason will be attending Bible class with her starting next week. It is bad enough that her mother teaches the class, but now her brother has to be there, too. Jenna hates being embarrassed by her family!jenna goes out of town with her mother and Jason to visit her grandmother. Jenna loves to spend time with her grandmother, but she knows she has been sick lately with thyroid problems.Jenna learns that all of her friends have made the Spirit Squad. She wishes she had tried out, but she did not want to face the possible embarrassment of not making the squad because of her weight. She is sure that her friends feel sorry for her because of what she posted on her Facebook page. However, she is told by some of her friends she was just “having a pity party.”Sometimes Jenna feels really tired in the middle of the afternoon. One day she goes to the school nurse’s office and ends up taking a nap there.Jenna is a healthy but overweight 13-year-old girl who lives with her mother Evelyn and brother Jason. Her older sister, Jessica, lives a short distance away in her own apartment with her son, Ryan, and boyfriend, Casey. Jenna misses having her older sister around and looks up to Jessica.Because her mother works a few evenings each week, Jenna is responsible for her younger brother Jason. She also often watches her nephew Ryan when he spends time in their home. Jenna is self-conscious about her weight. She knows she should try to lose weight, but she doesn’t really know how and doesn’t have much discipline when it comes to resisting snacks; she always feels hungry! She finds it very hard to not join in with her friends when they eat. Jenna goes to an overnight Bible camp with her youth group. Her mother is a chaperone but fortunately she does not directly supervise her activities. She has a lot of fun with the girls in her group and posts several of the activities to her Facebook page.Jenna had planned to hang out with her friends after school this week, but they now have Spirit Squad practice. Because Jenna is not on Spirit Squad, she feels hurt and left out. Jenna goes home and eats cookies. She hides the box of remaining cookies under her bed.Later this week she cares for Ryan. While caring for him she doesn’t think about the Spirit Squad once.Jenna wakes up one morning this week with a huge pimple. She has been noticing little pimples lately, but she thinks this one can be seen from a mile away. Her mother does not even comment on the pimple. Jenna realizes her mother has been very distracted between worrying about Jason and Jessica.Jenna frequently stays after school to watch her friends at Spirit Squad practice. One day after school this week, the Spirit Squad girls are making posters for the assembly. When Jenna offered to help, she is told that only Spirit Squad members could make the posters.She watches Ryan one evening again this week.Jenna is irritated with her mother for commenting on her weight and is further annoyed when she suggests they go out for a walk or to the gym. Jenna feels very tired in the afternoon and evening – too tired to get into an exercise routine.Jenna becomes further annoyed when she is unable to find her favorite chips or cookies in the kitchen after school. Using her allowance, she buys candy from the store and hides it in her room so that her mother won’t know she has it.Jenna is asked to babysit for a family from her church. She has watched her nephew, Ryan, before, but she has never had a real job or been paid to do this. She loves making money and tells her mother she wants to babysit more in the future.Jenna recognizes that her clothes are fitting tightly. She asks her mom if they could go shopping sometime soon, but she does not explain why. She is relieved when her mother does not comment about her weight gain. Jenna has more pimples on her face and is beginning to really hate the way she looks.Jenna helps her mother make a cake for their family get-together. She secretly eats four pieces of cake over the course of the day and is glad that her mother doesn’t notice. She feels very tired and spends the entire evening lying on the couch and watching TV.Jenna takes care of her nephew, Ryan, twice this week while Evelyn works at the mall. Jenna and Jason absolutely love taking care of Ryan. They find many games to play with him during the evenings.Jenna hates the fact that she has more pimples. She washes her face three times a day, but the pimples continue to develop.Jenna has not been included in any activities with her friends on the Spirit Squad for quite some time now. She posts on her Facebook page indirect insults to them such as, “The truth comes out who your REAL friends are.” She sees their posts that are directed at her that read, “Don’t you HATE people who throw themselves pity parties?” She notices she has only 137 friends and they each have over 400 friends.Jenna hates the fact that there is (in her opinion) nothing good to eat at their house anymore and hates the lunches her mother makes for her. She usually trades most of her lunch away to other kids for foods that she likes. She constantly wants to drink soda pop and often drinks five cans in a day. She frequently needs to get up in the middle of the night to urinate. Jenna thinks this is causing her to be even more tired, and she vows to quit drinking sodas after 9 p.m.Jenna spends an increasing amount of time on Facebook. She wants to prove to the mean girls on the Spirit Squad (who used to be her friends) that she is popular. She sets a goal of having over 500 friends. She sends out friend requests to many people she does not know, but look interesting. She also accepts friend requests from anybody, whether she knows them or not.Jenna is pleased with the number of friends she now has – she is up to 316 friends. She does not have as many friends as some of the girls on Spirit Squad, but she has many more than she did. She does not actually know many of her new Facebook “friends” – many of these are people that she sent friend requests to.Jenna has a new Facebook friend by the name of Tom. He sent her a friend request and she accepted. Since then he has been sending her private messages telling her she is very pretty. Jenna loves the attention. He tells her he lives in a nearby city. She tells Tom all about her school and tells him she is a cheerleader.Jenna’s sister has her baby this week. Jenna loves holding the new baby. She also found out that Casey hit Jessica and had to go to jail. Jenna wonders why her sister has such a jerky boyfriend. Jenna and Tom (her new friend on Facebook) send private messages back and forth several times a day. She tells him all about what has been going on. She begins to think of him as her boyfriend.Jenna is disappointed that no boy asks her to the roller skating party. All of her friends on the Spirit Squad were asked by boys from school. Jenna decides to go to the party anyway. Her friends on the Spirit Squad practically ignore her at the party, so Jenna spends time with some of the other girls. Jenna takes comfort in the fact that she regularly communicates with Tom on Facebook and knows that if he lived in the same city he would ask her out.Jenna wants to lose weight but doesn’t know how. Even though her mom has tried to force her to change her eating habits, Jenna can’t stay away from soda and can’t stop eating junk foods at school. She also feels too tired after school to exercise.Jenna brags on Facebook about her secret boyfriend. One of the girls from the Spirit Squad posts, “Your boyfriend must be an imaginary friend because nobody would want to date a fat girl like you.” At Tom’s request, Jenna has not revealed his identity. She figures he is just shy and guys don’t like to post things about girls on Facebook anyway. She also realizes he has not actually asked her to be his girlfriend, but based on the things he writes, she is sure he thinks of her in this way.Jenna is a healthy but overweight 14-year-old girl who lives with her mother Evelyn and brother Jason. Her older sister, Jessica, lives a short distance away in her own apartment with her boyfriend, Casey, and her children, Ryan and Carrie.Jenna has recently gained a lot of weight. She is very self-conscious about her weight and believes her friends avoid her because she is fat. She knows she should try to lose weight, but she doesn’t really know how and does not have much discipline when it comes to resisting snacks; she always feels hungry! She frequently hides the foods that she eats so that her mother will not make comments about what she is eating.Jenna has been babysitting several days a week – either for free for her nephew and niece or for pay for two families at church. She does not mind taking care of her nieces and nephews, but she hates to turn down paid babysitting jobs because she has to take care of Jessica’s kids. She knows Jessica does not have any money, but at the same time she does not think it is always fair. She posts comments on her Facebook page about having to babysit – AGAIN.Jenna tells her friends at school that her dopey brother is taking medication for his ADHD problem. She is asked by one friend if he is taking Adderall. Jenna is not sure. Her friend tells Jenna that Adderall is the best thing for losing weight and she should try it. Jenna goes home and checks. Sure enough, Jason is taking Adderall. Jenna takes some pills – thinking there are so many in there nobody would ever notice. She takes one and loves the way it makes her feel. If it could help her lose weight, it would be great!During a gym class activity, Jenna goes to the school nurse, Violet Brinkworth, complaining of a twisted ankle. After examining the ankle, Violet talks with Jenna about other things that might be bothering her. Jenna tells the nurse that nobody wanted her on their team because she is too slow and that one of the boys told her she had a body like a penguin.As the nurse talks with her more, Jenna shares that she has gained a lot of weight and is not happy about the fact that she is so heavy. She does not understand why she cannot be skinny like her sister. The nurse notices a dark pigmentation on the back of Jenna’s neck and suggests to her that perhaps she might need to see a doctor to determine why she is gaining so much weight. Violet gets Jenna’s permission to contact her mother about this matter.At home, Jenna’s mother surprises her when she asks if she knows why Jason is missing some pills. Jenna denies knowing anything about it. She decides she needs to take pills less often.Jenna continues to be rejected by her former friends on the Spirit Squad. She tries to join them at lunch, but she is frequently told that the table is already full. She goes to the practices to watch, but the girls ignore her presence. She is no longer invited to join them in any activities. She is sure they don’t want to hang around with her anymore because she is fat.She has an appointment with Dr. Rowe, the family physician, this week. Dr. Rowe takes a history and completes a physical exam. During the family history, Jenna is surprised to hear her mother report that obesity and diabetes run in her father’s side of the family. Both her father and paternal grandmother have the disease.Jenna’s blood pressure is 120/78 mm Hg, and her body mass index (BMI) is 24.8, which places her at the 90% percentile for girls aged 14. A capillary blood glucose test done in the office is 158, and a urine dipstick shows a trace of glucose. Dr. Rowe also notices acanthosis nigricans on the back of Jenna’s neck.Based on the history and clinical findings, Dr. Rowe recognizes the need to test Jenna for diabetes. He orders an outpatient thyroid-stimulating hormone blood test and a fasting blood glucose test to be performed on two different days. A follow-up appointment is scheduled for 2 weeks later. In the meantime, Jenna is encouraged to try to lose some weight by changing her dietary patterns and by exercising.Jenna goes to the outpatient lab for blood tests on two different days this week. She hates the fact that she is unable to have breakfast until after her blood is drawn. After getting to school on both mornings, Jenna eats some doughnuts purchased from the snack machine. Jenna’s mother announces to Jason and Jenna that 5 pills are missing from Jason’s medication bottle and demands an explanation. Jenna denies knowing anything about it and wonders what the big deal is. A few days later when she tries to take a dose, the container is gone. Her mother seems to be on to her and has hidden the medication.Jenna spends most of her time after school on Facebook. She posts many details about her medical workup and writes, “It sucks to be stuck by needles.” Also, her communication with Tom has intensified. In several messages, he tells her that he has fallen in love with her and wants to meet her in person. He asks Jenna where she lives. Jenna wants to meet Tom, but she is afraid that he won’t love her when he realizes how fat she is.Jenna returns to Dr. Rowe’s office this week for a follow-up visit. Dr. Rowe tells Jenna and Evelyn that, based on the history, lab results, and other clinical findings, Jenna has type 2 diabetes. He recommends that a pediatric endocrinologist manage Jenna’s diabetes and he provides her mother with a referral. Jenna has heard of diabetes before but doesn’t know much about it. Although she doesn’t think it is too big a deal, she enjoys posting many details of the experience on her Facebook page.Tom, Jenna’s Facebook boyfriend, continues to ask her to meet him. Jenna finally admits to Tom that she is a little overweight. Tom tells Jenna that it doesn’t matter – that he loves her and wants to meet her. He also admits to Jenna he is really 20, not 18 like he originally told her. Jenna is pleased with the fact that Tom still loves her but wonders if she should be dating a 20-year-old guy.Jenna finally tells her friends at school about Tom. They warn her not to tell him anything else and suggest that she stop communicating with him. Jenna thinks her friends are just jealous.It is report card time and, once again, Jenna has made straight A’s. The recent teasing from her peers has been difficult, but she feels very proud to see her name near the top of the honor roll list.Jenna has an appointment with Dr. Rena Yin, a pediatric endocrinologist, this week. Another history, work-up, and blood tests are completed. Dr. Yin elects to start Jenna on metformin, 500 mg twice daily, to be taken with meals.Jenna and Evelyn also meet with Marjorie, a nurse who is a certified diabetic educator (CDE), to begin the process of learning about diabetes self-management. Marjorie outlines the four major components of self-management: nutrition therapy, an increase in physical activity, self-monitoring of blood glucose, and drug therapy. Jenna immediately likes Marjorie because she doesn’t make her feel uncomfortable about the fact that she is fat. She seems to accept her just the way she is.Tom continues to suggest that he meet Jenna in person. He tells her he would like to drive to her city and take her on a real date. Jenna has been told not to completely trust everything people say online, but she is sure Tom is honest. Instead of agreeing to meet him, she gives him her cell phone number so they c Jenna continues to meet with Marjorie, the CDE. The primary focus of initial education efforts is self-monitoring of blood glucose. Marjorie teaches Jenna how to perform a finger stick and measure her glucose level. She is instructed to do this twice a day for a few weeks to see how the new medication is working. Jenna hates poking her finger.Over the course of meeting with Marjorie, Jenna opens up to her and tells her about the teasing at school and about her boyfriend Tom, whom she met on Facebook. Concerned about what Jenna might be telling this man, Marjorie talks with Jenna further about the situation and points out that it could be a very dangerous situation for her. Jenna tells Marjorie that Tom is not that way. Marjorie shares a brochure on Internet safety for teens and asks her to read it so they can discuss it on their next visit. She also suggests that Jenna talk with her mother about this.Jenna talks and texts with Tom on the phone regularly. She tells Tom about what Marjorie said and he tells her that there are a lot of bad people out there – “Good thing I am not one of them!” He asks Jenna when he can meet her.Jenna finally agrees to meet Tom in a public place at Neighborhood Mall. Feeling a bit nervous, Jenna asks Wendy, one of her friends, to go with her. Jenna puts on her best outfit and uses extra makeup. The girls get a ride to the mall from Wendy’s mother and they agree to be picked up in 3 hours. Shortly after arriving at the mall, Wendy sees some other friends and tells Jenna she will be right back. Jenna waits at the appointed place when a man approaches her. He tells her he is Tom and hands her a flower. He tells her she is even more beautiful in person that he imagined and asks her if she is alone. She tells him her friends are at the mall with her. Jenna is surprised to see that in person Tom looks much older than 20. They spend nearly two hours together at the food court. After having some lunch, he suggests they leave the mall together – promising to take her home. Jenna tells Tom she has a ride and that her friend Wendy is probably waiting for her. While Jenna is sending a text to Wendy, asking her to come by the food court, Tom gets up and tells Jenna he is going to the restroom and will be right back. Jenna never gets a response from Wendy, and Tom does not come back and does not answer his phone. Jenna ends up calling her mother to pick her up from the mall.Jenna does not hear back from Tom. He “unfriends” her on Facebook and later his account disappears. She texts him a few times but he doesn’t answer. She wonders what she did wrong and why he suddenly disappeared. Although she feels disappointed, she does not dwell on it very long.Jenna has completed most of the initial diabetic education. She feels like she learned a lot, but does not perceive her disease to be really all that bad. Marjorie suggests to Jenna that she attend diabetes camp to be held in a few months. Jenna likes the idea of going to a camp with other girls who have the same problem.Although she adheres to the finger pricks and medication regimen, Jenna does not stick to her diet or attempt to increase her activity. The new diet leads to many fights with her mother. There are so many limitations on what she can eat that she often feels left out among her friends at school. She posts detailed information about her diabetes on Facebook in order to gain attention and sympathy. She posts a picture of herself with the message “Sticking my finger with a needle. Diabetes sucks.”Jenna has no interest in following a diet. She finds herself thinking about food all the time and ends up eating compulsively at school. Jenna quickly figures out that, if she doesn’t stick to her diet, the elevated glucose level is stored in the memory of the glucose monitor. She tries to erase the higher numbers so that Marjorie and her mother will not see them, but she is afraid she might break the meter and get into trouble. Instead, she figures out she can use her friend’s blood to register good blood glucose measurements on the monitor.Jenna learns that Casey is in jail and sees his picture and story on the local evening news. She hopes none of her friends recognize him as the man who is with her sister. Jenna also learns that he has been beating up Jessica, and Jessica has been trying to get away from him. Jenna is afraid of Casey and hopes she never sees him again.Jenna continues to eat whatever she pleases at school. She frequently feels very tired and grouchy. Jenna has noticed that if her blood glucose levels are high, she can lose weight more easily. She does not understand how this works, but she likes the idea of losing weight. She continues to use her friend’s blood for the glucose measurements.Jenna’s sister Jessica goes to church and then brunch with them this week. Because her mother is with her, she is forced to order food from the menu that is on her diet plan. She wishes she could eat the chocolate chip pancakes that Jason eats. Feeling sorry for herself, Jenna takes a picture of her meal and posts to Facebook with the message “Forced to eat healthy because of my diabetes.”Darren, one of Jenna’s friends, figures out how to alter the memory on the blood glucose device. Jenna tells him what numbers to program into the monitor and figures out that this frees her from having to follow a diet (except when at home). She is quite sure that nobody will ever know the difference. Season 3 Episodes 14-15 It has been a couple of months since Jenna began a treatment plan for diabetes management. She has a follow-up visit with Dr. Yin (the pediatric endocrinologist) and Marjorie, the CDE. She proudly shows her record of blood glucose levels from her blood glucose monitor, which reflects excellent glycemic control. She claims to have been following the diet, exercising, and taking her medication. She also tells them she has lost some weight – maybe 7 pounds. Dr. Yin and Marjorie note that she has lost 4 pounds since her last visit and that her Hb A1c level is 10.2%. Dr. Yin and Marjorie recognize the need for additional education with Jenna and confront her about the measurements recorded on the glucometer.Jenna is excited about the fact that Jessica is moving back home with them. She has missed her older sister and loves her children. Despite some of her recent disappointments with the diabetes and excessive weight gain, Jenna takes comfort in the close relationships she experiences within her family. “Is this question part of your assignment? We Can Help!”
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