Cindy Johnston

Clinical Conditions

2014

Development Paper
Section I.

Clinical Condition

Description: Diabetes Mellitus with amputation

Diabetes Mellitus is a progressive disease caused when the body does not
make insulin or does not use it as it should. Glucose is the fuel that the body
prefers to burn for energy. This challenges the body with maintaining a
healthy control of a normal blood glucose level.
Energy for the cells of the
body is made when food that is digested goes into the blood stream as
glucose. For the glucose to pass from the bloodstream into the cells, it
needs to go through a receptor site that is closed. Insulin opens this
receptor. Insulin is made by the pancreas as a hormone that opens the
receptor and allows glucose to enter the cell where it is used right away or
stored to use later as glycogen.
People who have diabetes, have a hard time using glucose for energy as
there is a challenge with the way their body makes and/or uses insulin. They
are not able to make enough insulin or the way its working is not effective.
This means glucose cant enter the cells, thereby making the blood glucose
level stay higher than normal, causing the cells to be low on energy. For
someone who does not have diabetes, the pancreas handles all this without
a problem, but for someone with diabetes, they have to think about how they
can help their body manage the glucose with diet, insulin injections, or
insulin tablets and checking their glucose level in their blood. A normal level
is between 70 and 110 milligrams per deciliter of blood.
Diagnostic Criteria
There are four types of diabetes. They are type 1, type 2, gestational, and
other diabetes.
Type 1 happens mainly to children and adults under the age of 30, but
can happen at any age. People with type 1 are unable to make their own
insulin. They have to take insulin shots everyday to do what their pancreas is
not doing for them. Without providing the body with insulin, these people
could go into a diabetic coma and die.
Type 2 diabetes is the most common form. Nine out of ten people in the
United States have this form. In the past, it has been diagnosed in older
people, but there is an increase in younger people down to teenagers these
days. Type 2 diabetics either have insulin deficiency or insulin resistance,

meaning adequate amount of insulin is not being made or the body isnt
using it right.
Gestational Diabetes appears temporarily in the second half of pregnancy.
It is usually managed with a special diet, but if that does not work, insulin
shots may be needed. It usually ends when the baby is born, but women
who have had GD are at a higher risk for getting diabetes later on in life and
may develop it in following pregnancies.
A fourth category of diabetes occurs in other ways such as in a minority of
other people who may develop diabetes due to side effects from medications
used to treat other afflictions of the pancreas such as cancer, which may
affect the pancreas ability to make insulin. Maturity onset diabetes of the
young, MODY, sometimes inflicts children and young adults. It is passed on
generationally within certain families. It can have different forms caused by
different genetic defects in insulin secretion. It is usually treated like type 2
diabetes.
Symptoms of diabetes are polydipsia, (excessive thirst), polyuria,
(excessive urination), polyphagia, (excessive appetite), dryness of the skin,
blurred vision, weight loss, vaginal itching, bladder infections, wounds or
ulcers or gums that do not heal.
Etiology and prognosis
For type 1 diabetes, an experience of an autoimmune response causes
the body to make antibodies, which accidently destroy the beta cells in the
pancreas that make insulin, because they think it is a virus that could hurt
the body. This is a slow process that goes unnoticed until enough cells are
destroyed and insulin can no longer be made by the pancreas.
Environmental causes, genetics and viruses may trigger this autoimmune
response, but it remains under study. Sometimes there is simply no known
reason why someone develops it. For example diabetes happens more often
in African or Asian backgrounds.

For type two diabetes, causes seem to be age and genetics, lifestyle and
obesity, and environmental factors.
For gestational diabetes, hormones and weight changes in later
pregnancy may be a cause. The role that genetics, obesity, and lifestyle
have is being studied.
Diabetes is a progressive disease, but can be managed by attention to
diet, exercise, medication, weight management, blood glucose tests, and
managing stress.

Implications for function and OT treatment

Motor: Daily exercise regimen of walking or other form of exercise that is
preferred as long as it is regular and within diabetes control. Plan ahead for
lower glucose levels with exercise and adjust or reduce amount of insulin
taken to compensate.
Sensor: Feet may become numb due to neuropathy and so care must be
taken to check for cuts, bruises, warm areas, that may become open and
lead to infection. Foot care is very important. Feet should be checked daily
for these things and washed and dried, especially between the toes every
day. Infection of an open wound can lead to osteomyelitis, septic arthritis,
gangrene and advancing soft tissue infection. Osteomyelitis is an infection of
the bone.
Amputation can result from any of these conditions.
Cognitive: Give material to read on diabetes. Charts for recording blood
glucose levels may be helpful. Recipe books for diabetic diet may be helpful.
Medication organization.
Intrapersonal: Encourage a support group. Encourage forming a cooking
club between diabetic persons. Keep friends and family informed about
diabetes. Stay active and do not become isolated due to fear or shyness
about having diabetes. Refer to ones self as someone who has diabetes,
rather than referring to ones self as a diabetic.
Self Care: Maintain good blood glucose levels and blood pressure control to
reduce risk of stroke and heart disease. Do blood glucose checks faithfully.
Do good foot care. Learn about the many options one may eat or drink with
diabetes so foods are not tempting toward unhealthy eating. Get regular eye
exams.

Section II. Personal and Social History:

Marta Taveres Silva Almeida was born on January 17, 1900, the Feast Day
of St. Anthony, to Aluisio and Maura Taveres Silva in the Azores, a group of
islands and islets in the North Atlantic Ocean, on the Island of Pico, which is
situated about 800 miles from mainland Portugal. Her father worked a whale
hunter and was recruited along with with a group of men to work on
American whaling ships in California, resulting in the family immigrating to
San Diego, California, in 1910. Marta was the first born of 8 siblings. She
was baptized within 2 weeks of her birth in the Roman Catholic Church.
Although her mother and father were illiterate, upon their settlement into the
United States, Marta was enrolled in public school as required by law, and

graduated from high school within the usual 12 year time frame. Her siblings
followed suite, although many of their neighboring Portuguese friends
attended only as long as required by law, and did not graduate from high
school. Many Portuguese immigrants worked in crops and fishing to support
their families, and children were expected to work rather than attend school
in order to maintain family support and loyalty.
Marta was united in the Holy Sacrament of Matrimony to Armando Almeida
on September 23, 1918. They moved to Corpus Christi, Texas and raised a
family of 6 children. Late in her second pregnancy, Marta was challenged
with gestational diabetes, which she managed with diet. After the birth of
that child, with each subsequent pregnancy, she developed gestational
diabetes once again. She was able to manage it with diet. Marta lost any
extra weight within 4 months of the birth of each child, due to exercise and
breast feeding her babies. The gestational diabetes subsided with a week of
the birth of each baby.
Armando had a Portuguese background as well and came from a family of
barrel makers who handcrafted barrels which held the port produced from
Portuguese vineyards. Armando had acquired wood working skills from his
family prior to marriage and worked as a carpenter around San Diego until
they moved to Texas after their marriage.
At the age of 35, Marta developed type 2 diabetes, which she managed with
diet and exercise. Marta died at the age of 72, on July 4, 1972, the feast day
of St. Elizabeth of Portugal. Marta was survived by her husband and 6
children, 18 grandchildren and 23 great grandchildren. She received
viaticum, (meaning her last Holy Communion), and the Prayers for the Dying
administered by Father Cradle, at her bedside, and was also attended by her
husband and 4 of her children as she breathed her last. A rosary was said at
her wake, the night before the funeral. She received the final rites of the
church at her funeral Mass at St. Rose of Lima Catholic Church in Corpus
Christi, Texas which was attended by a large gathering of friends and family.
She was interned in St. Rose of Limas Catholic Cemetery.

Section III
Developmental Stages from Birth-Death
Birth to Seven Years:
Piagets cognitive development
diabetes

This area is not impacted by the

Marta was born at home after a normal pregnancy and delivery. Her mother,
Maura, immediately put her to breast and Marta suckled normally. Maura

would continue to nurse her child for many months, and at each feeding,
Marta would turn her head toward her mothers chest with an open mouth
rooting for the breast.
Sometimes her mother would place a small piece of soft cloth in Martas
tightly clenched fist by opening her little palm and allowing her to have her
fingers close upon it. She grew accustomed to this soft cloth and would suck
on it. A homemade string of orange, white, and green beads interlaced with
little bells was tied across the opening of her bassinet and sometimes when
she kicked or moved, a jingly sound was made. Eventually, Marta used
voluntary motions to repeat the action that made the musical sound in time
with beads shaking before her eyes.
As she continued growing, when hungry, she would reach and pull on her
mothers blouse in search of the breast which she could not see, but knew
was there.
At one year of age, Maura began to walk Marta to the seashore and they
would dig holes in the dark volcanic sand using a clam shell. They would
then pour water into the hole with a small pail and watch it empty as the
water disappeared. Eventually, after having her mother repeatedly do the
sand and water game with her, Marta learned to manage this play on her
own, using the clam shell to first dig a hole and then fill the pail with water
from the ocean to pour it into the hole. Marta would repeat these actions for
a long time. Often she would have dug up to 4 holes to occupy her time with
filling. There were many times, when it was time to leave, Marta would cry
because she wanted to continue this play. It was hard to understand that it
was time to return home for a nap or because her mother needed to do
chores. As she grew to around 4 years of age and on, she better understood
when it was time to go eat or nap and was able to leave the seashore behind
without a fuss, to move onto other requirements for the day. Nearing 5 years
of age, Marta also realized that sometimes her mother was too tired to go to
the seashore even though Marta wanted to go there, and she would accept
this and play around the home. She loved to play an imaginative game of
being the mommy and had a homemade doll she would feed and carry
around.
She also learned from her mother that everyone has a guardian angel.
Marta loved this and included her guardian angel in her daily life as a silent
friend who was always there to keep her safe. Marta would talk to her
guardian angel to calm her fears, like when she would find herself frightened
of the dark because she imagined a monster from the sea was outside their
home.
Around 5 years of age, Martas mother helped her to memorize her first
prayer ever, The Hail Mary. Marta also learned how to make the sign of the
cross from the family ritual of saying prayers to bless their food before
eating, which they called saying grace. She would initiate making the sign

of the cross on her own around age four when she played teaching her doll
the sign of the cross, and while saying prayers at bedtime as well.
Nearing age seven, Marta liked to sort seashells she collected into different
groups by noticing the differences and similarities between them. Her
father also told her of the differences between the sperm whales they would
hunt and the Northern Bottlenose whales, Pilot whales and Orca whales, with
stories told from their oral tradition. She would practice telling these stories
to her two younger siblings, including any description of the differences and
similarities between them that she could remember.
Around age five, she asked where the water would go and why it would sink
into the sand more slowly when she lined the hole with mud. She would
wonder to herself, How deep is the ocean? and she would ask her father,
How do whales and fish breathe in water? Marta had acquired two siblings
by age seven and asked her mother, Where do babies come from? At this
age, she wondered about the sign of the cross and how it expressed belief in
the Holy Trinity as her parents had taught her. How are there THREE
persons in ONE God? she would ask herself and her parents many times.
They would give her the same response, It is a MYSTERY. But what is a
mystery? Alisio would answer, Something we cannot understand, but
believe in anyway! The same back and forth pattern of these two
questions would go between her and her parents and sometimes, if she had
the courage, she would ask the parish priest. The answer was always the
same. At age 6 she grew more confident and stated with deliberation to her
guardian angel, Someday, I will find out so I may understand how there can
be three persons in one God, Father, Son and Holy Spirit!
As an infant, Marta also cooed and laughed soft little giggles and squeals as
oral skills developed. She used her mouth and lips to blow bubbles with her
saliva and spent periods of time totally engaged with this. Her parents found
this quite entertaining. By age 3, Marta had learned to speak many
Portuguese words, such as bom dia, (bong-DEE-a), meaning good morning,
boa tard, (BOH-uh-tard), meaning good night, obrigada, (obrae-GAH-doo),
meaning thank-you, and adeus, (a-DEH-oosh), meaning goodbye. By age
four she would say these and many other words without prompting from
others in order to express herself.
Physical Development
In the first few weeks of life, when hungry, Marta would cry and her arms
would flail and her legs would kick in random circular movements. Three
months later she would prop herself up on her arms and hold her head up to
see around the home. While on her back, she managed one day to grasp one
of her feet and then the other. What fun to play with these! From this, her
trunk grew stronger. One day, her mother went to pick her up from her crib

and she had completely rolled over! Over and over, Marta rolled from
tummy to back and soon from back to tummy. Next, she was scooting her
knees up under her and her mother observed her come onto her hands and
knees after which, she began a curious head to tail rocking motion. This led
into crawling and various exploring of the home. Marta was determined to
stand. Her mother would let Marta prop herself against her body as they sat
on the floor and soon she was standing, walking around things in a sideways cruising fashion, with such a look of delight on her face! She moved
onto free walking at one year of age.
As she grew, her skill refined as she spent much time with her mother doing
household tasks. There was no running water, so water had to be carried
from springs and wells which led to strong legs and back. Childhood
illnesses were rare. Marta enjoyed picking grapes for the family and her
fingers and arms grew strong. She enjoyed playing the whale game with her
friend and could feel the strength of her legs as she ran dodging trees and
maneuvering the rough, but lushly covered grassy volcanic terrain to escape
from the whale hunter.
When she was 8, Alisio took Marta to the ocean and began to teach her how
to swim. Especially important was learning how to manage swimming when
a rip tide takes over and about the stinging jelly fish and so forth. Alisio
could see from her buoyant, lean body and coordination, that Marta would be
a good swimmer.
Ericksons Psychosocial Development
Marta was well attended by her parents from birth and so developed trust
through her needs being consistently gratified. She would be calmed when
her mother picked her up if she fussed from hunger or needed physical
comfort. As a baby, Alusio and Maura thrilled when Marta smiled and looked
to their faces. They adored receiving her bright eyes and toothless grins. It
seemed she was eager to have them pick her up as she snuggled into her
parents bodies.
As she grew to age 3 years, she tested the boundaries by trying to toddle
out the door to look outside. Her mother would restrict this, but tended to
her curiosity by maybe taking her for a walk around. Even though Maura
knew Marta could not totally understand, on their little strolls, she would talk
to Marta about the island and Mount Pico seated so majestic and beautiful in
the distance and how the island was formed from volcanic activity. Maura
told her about the ferrets and hedgehogs they sometimes saw and the bats
that lived there and how they were unusual because they would feed during
the day while other kinds of bats fed at night. One day, Marta was walking
ahead of her mother and was startled by one of these bats called the Azores
Noctule, flying out of the bushes beside her. She ran to the arms of her
mother for comfort and safety and her fears were calmed.

From age 5 and up, Marta liked to play with making sand castles and using
seashells for people. Another favorite game similar to tag, was made up in
which she pretended to be a whale escaping her friend, who played the
whale hunter. Marta preferred to play the whale and feel courageous and
clever in escaping her friend, the whale hunter, but, they would take turns
because her friend liked being the whale too.

Kohlbergs Moral development

Around age 6, Marta was allowed to walk to the seashore with a friend to
play for a morning or afternoon. Marta was shown a simple path that she
was to always walk on her way to the seashore and not to stray from it. She
was not to enter the ocean, other than the very edge. She must come home
for lunch at 12:30 and the evening meal at 8:00 or there would be
consequences of being restricted from this privilege. She was able to abide
by this rule to please her parents and not lose her privileges. One day, she
disobeyed the path rule and walked into the trees making her late for lunch.
Marta lied about why she was late, but later tearfully admitted to Maura that
she had left the path, which caused her to be late. Marta accepted that she
would not be able to take the path to the seashore for one week.
Martas father encouraged a domestic role for her by appreciating her
mothers role in the family. A favorite duty that Marta assumed from her
mother was to unstrap her fathers sandals any evenings he returned from
whaling. This she enjoyed because she saw it pleased her father so well and
helped him feel appreciated after a long day of work. Often he was around
the home as the whale season came and went and Marta sensed to respect
his leadership of the family.
Martas father made sure the family attended church each Sunday and
understood that obedience to parents was one of Gods commandments.
Her upbringing in the Catholic faith provided the grace to develop a clear
sense of right and wrong from an early age.
Eight Years to Eleven Years
diabetes

This area is not impacted by

Piagets Cognitive Development

Martas life changed significantly when at age ten, the family immigrated to
the United States. Marta had to make a plan to pick and choose her
treasures and personal belongings carefully as Maura told her she could only
bring a certain amount of items. This involved sorting through personal and
family items. Moving was a huge undertaking needing lots of planning,
packing and common sense.

In San Diego, California, Marta was enrolled in public school, and needed to
learn English. It was a difficult adjustment at times. She would just as soon
like to skip school some days but realized that missing school would only put
her further behind. She would cry to herself and put on a brave face telling
herself she could look forward to the weekend when she would be home
more with her family. Marta would think about why she missed the island.
She realized she was what is called homesick. Marta asked her mother to
take her to the beach so they could see the ocean again. This became a
soothing strategy for Marta to adjust to the new surroundings. This was the
Pacific Ocean rather than the Atlantic, she learned, but it was an ocean and
she found familiar feelings toward this body of water as she had when she
lived on Pico Island. The Pacific Ocean became a point of reference to feel
home again for the entire family. Maura praised Marta for the good
suggestion of visiting the beach.
Marta also planned to try to make a friend as she saw many other children
playing at recess. One day, as she stood apart from the laughter and activity
of the playground, another girl came over and said hello. Marta was thrilled
and could discern a genuine and cordial interest from this person. The girl
liked how Marta could speak another language and they taught each other
words and meanings between English and Portuguese. Her first new friend in
the new country!

Physical Development
One day, at age 11, Maura took Marta aside for a special talk. Marta knew
her mother had something important to discuss with her as she had told her
the day before that after school, just the two of them were going to the
beach to spend some time at the ocean in order to have a special mother,
daughter talk. Marta felt mature and anticipated the mystery of this time
with her mother. As they walked the beach, Maura told Marta about an
important event that marks when a girl is maturing to become a woman.
This event is when her first period happens that it is completely natural and
a sign that she is becoming ready to become a mother someday. Maura
even shared her recollection of her first period. Marta listened intently and
felt some surprised, but close to her mother that she would share this with
her. I wonder when I will have my first period? she thought to herself.
Marta was felt secure to ask Maura about when she could start to wear a bra
as she had noticed her breasts were developing. Maura made a plan that
they would go shopping for a bra together that weekend.

Ericksons Psychosocial Development

Marta could hardly keep the period talk with her mother to herself whenever
she was with her friend, Sharon. Eventually the two girls opened up to each
other about the period thing that was going to happen someday! They each
agreed to reveal to the other when they had their first period. They made
this decision because they were both fortunate enough to feel the value that
was place on their womanhood from their mothers and so felt comfortable to
plan to share their time when it happened.
The family found a parish to attend the very first Sunday after they arrived in
the United States. Marta took consolation in attending Mass at a new parish.
The Catholic Mass was the same as it was in Pico. The Mass was prayed in
the uniform language of Latin and the order and ritual were familiar to her
heart and soul. How welcoming to receive Jesus in Holy Communion as she
had on Pico. The bread and wine was transformed into the Body and Blood,
Soul and Divinity of Christ here in her new home of the United States, as it
had at the altar in Pico.

Kolbergs Moral Development

When Marta turned eight, she began to attend catechism classes at St.
Anthony of Padua Catholic Church on the island for more formal instruction in
her faith and to prepare to receive the next sacrament after her baptism as
an infant which was the Sacrament of Confession.
She learned in catechism class about sin as actions that hurt her relationship
with God. She reviewed the Ten Commandments to understand what actions
are considered sinful. Through her parents, catechism teacher and priest,
Marta received formation in her faith that God is a forgiving and loving God
and who is also her heavenly Father, making her one of His children. Thus,
she should be sorry for any sins against God and his son Jesus, who is the
Savior of all of Gods children. Marta was prepared to make her first
confession in which she thought of any sins to tell the priest. To do this, she
had to think about what she felt sorry for as actions against any of the Ten
Commandments. She had to be truly sorry to confess them and ask for
forgiveness. She was carefully catechized to not just make things up or to
confess something what she did not feel she was sorry for. As she thought
through the 10 commandments, Marta was happy to learn that there were
commandments that remained unbroken in her life. Yet, she felt her
conscience stir according to a few sins and eagerly anticipated telling them
to the priest. She was carefully catechized that she would be forgiven by
Jesus through the priest, not by the priest, who would speak Jesus words of
absolution to her for her to hear so she would know she was truly forgiven.
She pondered some of the more serious sins and wondered how people

would choose to do them. A prayer called An Act of Contrition was

memorized to express her sadness for wrong doing with a promise to try to
not do them again. This seemed fair to Marta and she felt a sense of
responsibility to be more like Jesus. During the next year, Marta prepared to
receive her First Holy Communion. She wanted to follow all she was learning
from her Catechism classes so she would be prepared for this special event
in her life. She made an effort to be good to her family and friends as Jesus
was the Good Shepard to his people. She was preparing to receive Jesus in
Holy Communion and she wanted to grow to be like Jesus for the rest of her
life.
11 years through 20 years This area is not impacted by diabetes
Piagets Cognitive Development
Marta was now more comfortable in her American school. She enjoyed
reading and writing the most, and so was excited to be assigned two papers
as an eighth grader, one in history and one in geography on two Portuguese
explorers, Prince Henry the Navigator, who was dedicated to world discovery,
improved ships and developed navigating instruments and better maps for
sailors and Vasco de Gama who made the first sea voyage from Europe to
India. Marta researched these people extensively to write reports that both
earned an A. She also began to keep a diary that was a source of expression
for her ideas, reasoning of problems, and sorting of thoughts as well as a
record of the events of her days. She also kept a scrap book of memorabilia
that was creatively put together.
Ericksons Psychosocial Development
Marta was dedicated to writing in her journal, but very protective of keeping
her privacy about it. She thought of the embarrassment and anger she
would feel if her privacy were ever violated and took great care to keep it
hidden. I dont even want my mother to find it and read it. She also
became very meticulous about being in the bathroom alone, and her mother
found that Marta no longer even wanted to share the bath with her even
briefly.
At 15, Marta began to attend school dances and loved to go bowling with a
group of friends. They would walk together and once they tried smoking a
cigarette one of them had swiped from their dad. They had a laugh of it and
recalled it as their big dare they took one day. Marta and Sharon decided the
smoking was not for them. They were more interested in trying to
experiment with makeup and lipstick and clothing to enhance their
appearance and figure out their style of dressing and grooming, which was to
most often fit in with what everyone else was wearing!

At 18 she met Armando at the parish church. She had noticed him a few
times at Mass, but was unsure of how to get his attention. Then, one
Sunday, he sat in the pew directly across from her and caught her eye upon
exiting the pew when Mass was over. After Marta graduated from high
school, he proposed and they were married late that fall after her 18th
birthday.

Kolhbergs Moral Development

Marta and Sharon also felt awkward toward the smoking. They did not want
to appear to be losers nor break any laws and so avoided that activity. At 16,
they wondered about who they might marry someday and discussed
remaining virgins for whoever their future held for them as their husbands.
They laughed because they had not even had a first kiss from a suitor yet!
But they had their priorities straight! Marta thought a job after high school
would be good. She had not yet met anyone whom she was interested in and
random dating was not for her. Sharon wanted to go to college to become a
nurse.
Marta continued to practice her faith through high school by attending Mass
on Sundays, although from time to time she would go to a different time
from her family. Also, she would stop by the church to light a votive candle to
burn in special request for Gods guidance in her plans for the future.

Physical Development
Marta did not grow very tall and was rather petite. Her teeth were white and
straight and her hair shiny and dark. Her hips had widened some and her
breasts had grown so she now wore a real instead of a training bra. She
continued to swim for exercise and enjoyed the water activity. Walking along
the seashore gave her body exercise as when she was young on the island of
Pico.

20-35 Years
Piagets Cognitive Development

The beginning of the Martas life

impacted by diabetes.
Marta learned to cook and manage the household she and Armando were
creating. She felt that she could volunteer to teach an elementary catechism

class at the parish in Corpus Christi where they now lived and so joined study
group for her enrichment.
She learned to run a household budget and managed to tuck away money
so she and Armando could visit their families in San Diego.
In her childbearing years, Marta also had to learn how to manage
gestational diabetes and took a class recommended by her doctor.
Later, Marta developed type 2 diabetes at age 35, she had the opportunity
to be referred to an occupational therapist who was striving to promote
diabetes self- management as a means to improve health and life style of
those with diabetes. This therapist was interested in weaving diabetes selfmanagement activities within the activities of daily living to promote a
healthy long life. Marta took advantage of learning educational and
functional skills from this OT in the form of seven weekly 3 hour group
sessions, with content on nutrition, exercise, medication management,
complications of diabetes, how to cope, and skills for daily living.
Ericksons Psychosocial Development
Marta and Armando had a gift for entertaining their neighbors and organized
annual block parties in their neighborhood. This continued to be a tradition
all through the years of the raising of their six children. They had lived in
the same neighborhood for 17 years. Each year the block party celebrated
births and honored deaths and served to bond a cross section of people. It
was a good time.
Marta had to learn to adjust to avoiding desserts and so forth at the parties
and family gatherings to manage her gestational diabetes and also her type
2 diabetes which developed later at age 35.
With the development of type 2 diabetes at age 35, Marta was influenced a
great deal by the occupational therapist with whom she met in the group
sessions. An important choice she made as a result of this was after
completing the diabetes self management course, Marta opted to join a
monthly support group to continue toward long term success in dealing with
diabetes. With the help of the OT, she also took the skills she was learning
and made them into a more individualized plan for her life. For example, at
the annual block parties that she and Armando enjoyed planning, she
provided low sugar dishes for enjoyment, and also put out a sheet she had
put together with education about the symptoms of diabetes at the party
and answered questions people may have. She made diabetes an open
forum rather than hiding it from others.
Kohlbergs Moral Development
At age 32, Marta and Armando were faced with the loss of Martas mother
and father within two years. Martas grief was heavy at times but she leaned

on her faith with gratitude for the upbringing she had received from them.
She appreciated that they had cared to teach her right from wrong and about
the importance of faith, family and God. Marta marveled at their long
journey from Pico and how her parents had faced hard times and had not
become discouraged, but persevered to make good choices even when
sacrifice was involved.
Marta suffered some depression at the challenge of facing and managing her
diabetes, and chose to speak to her pastor about the discouragement. She
saw her faith as a main source of comfort in the ups and downs of diabetes.
Sometimes she felt out of sorts from blood sugars being low. She felt guilty
about taking her moods out on the family. The sacrament of confession
helped to ease her conscience and start anew at living with diabetes.
The support group that she began to attend monthly also provided a means
of realizing her potential to lead an influential life for the good of others who
were struggling with progressive illnesses. She began to support a child in
their neighborhood who was found to have type 1 diabetes. The child was
able to ask her questions about how to fun and make friends while having
diabetes. This brought great benefit to Martas courage and caregiver nature
and the child was supported by developing courage amid the challenges he
faced. His family was able to develop fortitude and gratitude as they helped
their son with the day to day routine of living with diabetes and with Marta as
a neighbor who understood the challenge and offered support.
Physical Development
Marta delivered her first baby at the age of 20 years. Pregnancy was
challenged with gestational diabetes developing late in her second
pregnancy. Marta had been feeling fine and was very surprised to find out
she had high blood sugar levels after a routine test at 24 weeks of
pregnancy. The test was an oral glucose tolerance test involving drinking a
sweetened liquid that had 50 grams of sugar in it. The doctor explained to
her that as her body quickly absorbs the sugar, blood sugar levels rise within
30-60 minutes. The blood test take from a vein in her arm about 30 minutes
after she drank the solution was not normal. Marta needed to return in a
couple of days to take a fasting blood sugar test in response to the abnormal
one and this test also read abnormal, meaning Marta had gestational
diabetes. Why and how? Marta quizzed her doctor. Hormones were
explained to her by her doctor to be the cause. These changes happen with
all women. Increased levels of certain hormones made in your placenta
interfere with the ability of insulin to manage glucose. This condition is
called insulin resistance. As your placenta grows, during your pregnancy, it
makes more hormones and this increases insulin resistance. Usually a
mothers pancreas can make more insulin, which is about 3 times more than

the normal amount, to overcome insulin resistance. If this doesnt happen,

as in your case, the effect of the higher hormones will cause blood sugars to
rise causing gestational diabetes. Each following pregnancy, Marta
developed gestational diabetes, which she managed by diet. She carefully
lost any maternal weight gain after each pregnancy. Her main source of
exercise was her household tasks and child care. The swimming which she
so loved was an activity she continued whenever possible. The gestational
diabetes disappeared after each pregnancy, but her doctor told she could be
more prone to developing diabetes later and so to watch for the signs of
excessive thirst, hunger, urination, and gums that bleed.

Marta had her last pregnancy at age 34. She felt each pregnancy to be
different. Two had included morning sickness and four had not. Her back
bothered her more and more after each pregnancy. Exercise was the day to
day running after children. This kept her slim and trim. Gardening provided
exercise and was provisional for nutritious food for all the family. Swimming
also continued to be her favorite activity whenever possible.
When she developed type 2 at age 35, within the diabetes self- management
program she attended, the OT stressed the importance of regular exercise.
Since this OT was interested in diabetes self-management in the midst of
ones daily activities in order to promote an individualized plan of consistent
diabetic self-care and wellness, daily chores were encouraged, such as to do
yard work with Armando rather than leaving it to him alone. Also, Marta
determined to use the clothesline rather than the dryer in the summer to get
additional exercise. Marta also added to enjoy the playground equip with the
children on trips to the park by swinging and playing tag with them.
Swimming at the public pool may be safer than the beach to avoid cuts,
however minor they may be to the feet. Armando was to help her with her
foot care.
A garden of flowers was begun with a special theme of diabetes
management as suggested by the OT. This garden became a real focal point
for the whole family in supporting Marta with her type 2. The little neighbor
boy and his family took part in its care as well. A sunflower seed was
planted by the young boy to grow tall before their eyes! It grew beyond
their expectations! The sunflower became a symbol to them of physical
amazement and survival standing as an individual among many flowers,
striving to follow the sun, as they noted its turning head that did just that!

35-65 Years
Piagets Cognitive Development
Marta liked to listen to music with Armando, especially John Philip Sousa, who
was of Portuguese heritage. The Stars and Stripes Forever was particularly
arousing to her senses. They spent time playing games with the children
and helping them with their homework. Marta took a night class to do with
creative writing. She decided she would like to read more to model an adult
love of books to her children and so got a library card to check out books for
her and the children.
At age 50, Marta, continued learned to adjust and manage her life through
diabetes self -management in occupation, participation and health as she
had been influenced by the OT.
She met with the OT who helped her determine to take her knowledge of
diabetic self-management amid daily activities and develop a similar group
for youth. Marta learned how to do some group leadership with ages 12-15
which included the young neighborhood boy, now 15 years old, as a peer
leader.

Ericksons Psychosocial Development

Marta became active in organizing a support group for the catechists of her
parish. She wanted to encourage catechesis for future generations and saw
this as a way to promote the value of teaching the faith to others. Marta
even recruited her oldest child to serve as a catechist in the parish. She felt
a valuable long lasting contribution from her life would be to help bring
people closer to God.
Marta made catechists aware of diabetes, in case any had a child with
diabetes within their group. She also stressed that other chronic illnesses
may be present within their groups and to be sensitive toward them.
Disease and illness is an area that could be addressed within faith education
and children could find faith to be a comfort. Questions to do with their
conditions could arise within the context of catechesis and catechists should
be prepared to take advantage of helping the young person from this stand
point.

Marta had well learned not to isolate herself because she had diabetes. If
she needed to do a blood glucose test while at a social event, she went to a
private area and quickly without stress, did the test. She wore a bracelet to
let emergency personnel know in case she ever went into a diabetic coma.

Kohlbergs Moral Development

At 63 Marta had been faithfully married for 45 years. Their children planned
a special party for their milestone. Marta and Almando asked for a blessing
upon their marriage from the parish priest. They were also ecstatic to learn
that a grandson of theirs was planning to enter minor seminary to study for
the priesthood. Marta and Almando supported him with their prayers.
Marta did not feel sorry for her diabetic condition, but made it something
that she offered up in her prayers to suffer for others who needed help in any
way. She was determined not to let diabetes define her.
Physical Development
Around 40 years of age, Marta became somewhat depressed about having
diabetes. Sexual intimacy was an important part of Marta and Almandos
marriage. Diabetes control was tiring at times. She had been having
frequent yeast infections that irritated the delicate vaginal tissues and made
sexual intimacy painful. Although she had antibiotic treatment from the
doctor that cleared up the infection, sex could still be painful and she failed
to mention to her doctor that this had affected the intimacy between her and
Almando. In her support group, little was mentioned about sexual problems.
She knew that urinary tract infections could be common as well with
diabetes. Almando could sense the discomfort Marta was having when they
had sexual contact. He chose to refrain from approaching her for sexual
intimacy causing Marta to feel she must not be as desirable to him, which led
to her feeling depressed at the loss of their former healthy sex life. She also
felt that she had lost some sensitivity or responsiveness as well. It was hard
to understand. They both were suffering. After a support group meeting
one evening, Marta approached the OT about her problem. The OT
encouraged Marta to see her doctor and share this. The OT also shared that
this was often a silent issue with persons who have diabetes. This was an
area that needed attention within the support group. The OT had been
learning about how diabetes affects the sex life, but had neglected so far to
attend to it in the meetings. She educated Marta how yeast infections can
affect delicate tissues and that there were products she could use to
lubricate to avoid painful intercourse. Also, diabetes affects the circulation
and so this would affect the tiny blood vessels affecting intimate sensation.
High blood sugars can even impact vaginal lubrication which may affect
sensation and make sex uncomfortable and painful. Marta was relieved that

she could find some answers that would help Almando and her regain their
physical intimacy once more. She knew Almando would be sensitive to
these issues along with her. Within a month, she scheduled an appointment
with her doctor and Almando attended the appointment with her. The OT in
the meantime created an activity for them to do together outside the
bedroom to encourage emotional sharing between the couple. They were to
write compliments on little slips of paper all week and put them into a
container of their choosing and read them one by one at the end of the
week. They were also encouraged to make prayers for successful union over
this issue as a part of the spiritual life they shared, as this was important to
them. Almando was able to be sensitive to Martas issues now that he knew
what was causing her discomfort and Marta regained confidence that
Almando still found her desirable.
At 50, Marta became premenopausal. Her periods became lighter and
father apart until she stopped menstruating all together. Her hair was
becoming gray and she needed to wear glasses now for reading. She still
kept a garden, but it was smaller and had more flowers than vegetables.
She started to swim at a public swimming pool but continued to dip in the
ocean from time to time. It was good for her joints and kept her muscles
quite toned. With the children almost all grown Marta looked forward to
having an empty nest with Almando. They had worked hard raising the
family.
Marta continued to swim so she could get exercise to manage her diabetes.
Marta noticed numbness and tingling in her feet. She was soon diagnosed
with diabetic neuropathy. She tried to pay attention to foot care, as
numbness in her feet could cause an injury, be it slight or more serious, to go
unnoticed, thereby making infection possible and amputation a threat. She
liked swimming because she could be off her feet, but the sand and rocks
could pose a threat to injury. The neuropathy had caused some unsteady gait
and poor balance and swimming avoided these obstacles to exercise. She
was adverse to wearing shoes or sandals to swim, because they inhibited her
ability and despite the availability of the public pool and swim shoes, Marta
was more free and easy with her ocean swimming and so she was not as
compliant in her diabetes self- care management as she should have been in
this area.

65t years

Impacted by diabetes

Piagets Cognitive Development

At age 65, Marta was mentally alert. She did notice she preferred more of a
quiet environment. Lots of activity and noise was more tiring and a simpler

schedule was welcome. She liked to do crossword puzzles now and took up
an enjoyment of doing jigsaw puzzles while listening to music. Almando
kept her engaged with conversation. They started to go to the movie theatre
together for something new!
At age 70, Marta had to learn how to manage her life differently with an
amputation of one toe.
Psychosocial Development
At 70 years of age, Marta had experienced having a number of
grandchildren, saw them baptized and go through the sacraments of the
church as she had seen her children do. How grateful she was to see this
trajectory of faith.
Marta continued to have type 2 diabetes. She wasnt as attentive to her diet
as previous years. If she was out with her family, she would indulge in
sweets and neglect taking her blood glucose level.
Marta had to visit her doctor because a tiny scrape on the bottom of her
foot, from the beach while swimming, had become infected. He prescribed
antibiotics first of all. Visits to the doctor had been routine up until now.
Marta felt worry at the sight of his concern about the sore. Suddenly, she felt
even closer to the many people who live compromised lives as result of
having diabetes. Even though Marta had done well, diabetes glared as an
unforgiving master as she realized she had come within bounds of a threat
for amputation. From her large public life and experience with diabetes in
the community, she was acquainted with persons with diabetes who had lost
limbs above the ankle that had started out with a simple toe amputation and
continued until a part of a limb was gone. This could be me, she solemnly
realized.
Moral Development
Marta decided to participate in a program that helped unwed mothers
receive help and support during their pregnancies. She volunteered her
time at the Corpus Christi Shelter for Unwed Mothers every Thursday from
10-2. At 70 years, she felt her experience as a mature woman and
experienced mother would be of great support to this sector of humanity.
She also felt that with her experience with gestational diabetes, she could
bring special knowledge and support to pregnant women experiencing this.

Marta determined that she should make a living will so that her end of life
wishes would be known to her family. She chose an end of life document
from the diocese of her church that was made especially for Catholics and
their unique end of life wishes, such as viaticum and having a priest present
to administer Prayers of the Dying and the last rites.

She had started to attend daily Mass more regularly at age 65, so to hear
the scripture and receive Holy Communion more frequently and not grow
spiritually stagnant. She was grateful to receive Jesus as spiritual food that
would nourish her soul and that it was free of any restriction or diet rule that
her diabetes demanded. This spiritual food from Jesus supported her in
being strong to manage her weaker resolve for diet management in her old
age.
In her weaker resolve, Marta felt more often that life is short and that now
she could break a few rules and eat desserts and cookies that she shouldnt.
Temptation! She wasnt as careful with her diet as food became more of an
emotional fix. She was weaker in two areas needing caution and selfcontrol, the diet and her swimming at the beach. Now that she was receiving
antibiotic to heal an open wound on the bottom of her toe next to her big
toe, she knew she would have to be courageous and alert in self- care. If the
wound did not heal, there could be surgical debridement of infected area or
incision and drainage if osteomyelitis or gangrene or surrounding soft tissue
infection developed.
Amputation of the toe would be necessary in the end.
Physical Development
At age 70, difficult physical losses for Marta were her teeth to dentures
and then a toe to amputation. She was still swimming at least 3 times a
week and felt creaky if she missed going more than twice a week. Marta
seemed to need to eat smaller meals and didnt cook as much.
The antibiotic treatment for her infected toe did not work as planned and
further soft tissue damage made amputation of the toe necessary. She was
referred to a surgical podiatrist who gave her a preop consultation. He said
that amputation of lesser digits generally results in a gait with minimal to no
disturbance. He would avoid the guillotine approach in order to make an
effort to close the wound mainly at the amputation site and perform more
proximal bone resection to allow tension free closure. He told Marta that
with partial foot amputation, preserving as much length as possible is
important, but in her case the risk of an open wound was more important to
consider than maintaining length that a guillotine amputation would. It
would be important to leave a segment of the toe intact to serve as a
buttress preventing neighboring toes from doing a shift in the transverse
plane. First, the doctor wanted to determine if this kind of healing could
happen by listening to the digital arteries via the Dopplar. If two or three
arteries can be heard, the amputation site would heal. The surgeon told
Marta that edema could hinder healing and so it would be important to
control edema. She would have to limit her activities for the first 3 to 5 days
post op as this is when hematomas develop which could eventually lead to
an infection if she is up and on her feet. This surgery is important for you to

decrease the need for a major amputation, Marta, the surgeon bluntly but
compassionately stated.
Marta underwent the surgery with Almando by her side. The wound healed
without complication as she abided by the post op orders from the doctor.

One day, after the wound was well healed, Marta decided to go for one last
swim in the ocean. She even wore swim shoes of a sort- some old canvas
tennis shoes from her closet for protection. This will be my last swim, she
stated, because I must not take chances with beach swimming any more.
Adeus, Marta whispered in her native Portugese. A chill went through her
as she recalled her mother and father on Pico Island speaking to her as a
child.
Marta looked out at the ocean and relived the experience she had as a
child when she tried to figure out how there could be three persons in one
God, the Father, the Son and the Holy Spirit. It occurred to her that before
her was an explanation. She thought, The ocean is wide, the ocean is deep,
and the ocean has breadth, but it is one ocean. God has given me an
answer! she thought, It is an insight! Marta felt unusually close to the
Father, Son and Holy Spirit. She remembered the holy water used at her
childrens baptisms and in the holy water fonts whenever she entered the
church to bless herself with the sign of the cross. Water is powerful in many
ways, she thought.
There was a rip tide warning for the beach that afternoon, but Marta was
confidant with her strength and skill, even though it had waned in her 70s.
She had always been a fearless one. The rip tide overcame her and a
watchful young man rescued her from disaster. But, she had been under
water for about 5 minutes and was nearly spent. She was taken to the
hospital where she developed pneumonia resulting from aspiration, from
which she died. Thus her life that began around the sea, ended near there as
well.

Section IV: Impact of the clinical condition on occupational

performance.
Occupational role: mother
Occupations: cooking, energy,
Description of impairment: daily cooking for the family and balancing her
need for a special diet with the familys cultural likes, treats and cultural,
holiday events.

Occupational role: wife

Occupations: sexual activity
Descriptions of impairment: Sexual activity can cause changes in blood
glucose levels. High blood glucose can affect vaginal lubrication. Blood
glucose should be taken before and after sexual activity as one would in any
physical exercise. Diabetes increases the chance for yeast and urinary tract
infections. These may irritate delicate vaginal tissue and make intercourse
painful. Circulation problems can affect responsiveness in genital area.
Increased glucose in the blood begins to destroy the myelin which is protein
that covers the nerves leading to neuropathy, a type of nerve damage called
peripheral neuropathy. This may affect blood flow to genitals causing a loss
of pleasure sensation. Depression can result from a challenged sexual life on
account of these physical changes.

Occupational role: swimmer

Occupations: swimming with diabetic neuropathy and loss of toe.
Description of Occupational impairment: diabetic neuropathy cause
numbness of the feet and makes them vulnerable to injury and not noticing
the injury allowing infection to cause open sore and amputation.

Section v: Treatment Implementation:

Impaired occupation: wife sexual relations with husband
Goal: reclaim and maintain sexual intimacy
Activity: learn about the effect of sexual activity on blood glucose levels.
Take glucose levels before and after sexual activity. Blood glucose can drop
with activity. High blood glucose can affect vaginal lubrication. Checking
blood glucose before and after sexual activity may be done together to share
it as a part of their sex life and not so much a responsibility belonging only
to Marta. Read suggested material together and have a discussion as
husband and wife. Writing activity in which each one writes for 10 minutes
to the other on the topic of sexual intimacy and how they will manage
together in their sexual life after they have read the material. Each will read
what they have written to the other. Do this once a week. Husband and wife
learn about the causes of painful intercourse in women with diabetes.
Diabetes makes yeast or urinary tract infections more common which can
irritate delicate vaginal tissue and make intercourse painful. Diabetic
neuropathy may also hinder blood flow to genitals and cause decreased
sensation. Husband and wife manage to enjoy intimacy after learning of
how diabetes can change the physical aspects for a woman and the need to
maintain intimacy with openness and also to keep emotional and mental

health. An activity in which Marta and Almando write complements to each

other on slips of paper and put them into a container during days of the
week, to be read on the weekend together in order to increase emotional
sharing that may lead to greater emotional bonding and intimate physical
sharing which need not always include intercourse. Make a goal of increasing
other physical touch if intercourse may be painful on any occasion. Also,
important in maintaining physical intimacy because of decreased sensation
caused by diabetic neuropathy.

Resources:
http://en.wikipedia.org/wiki/Azores
http://en.wikepedia.orglwiki/Pico_Island
http://www.azoresweb.com/culture.
The Institute for Human Services for the Ohio Child Welfare Training Program.
October (2007)
Developmental Milestones Chart
Bouchez, Colette, reviewed by Nazario, Brunilda, MD. (2013) women, sex
and diabetes. Retrieved from:
http://www.webmd.com/diabetes/features/women-sex-and-diabetes
American Diabetes Association. (2011). Complete guide to diabetes. Fifth
edition.
Ali, Naheed.(2011). Diabetes and you. A comprehensive, holistic approach.
Roman &Littlefield Publishers, Inc.
Pyatak, Elizabeth A. the role of occupational therapy in diabetes selfmanagement interventions.(spring 2011). OTJR. Volume 31, number 2. 89-95
Reyzelman, Tom, DPM. Kim, Jamie, DPM. (September, 2011). A guide to
digital amputations in patients with diabetes. Podiatry Today. Vol. 24. Issue 9.
38-42.