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by
Louise Diehl, RN, MSN, ND, CCRN, ACNS-BC, NP-C
Nurse Practitioner - Owner
Doctor of Naturopathy
Lehigh Valley Wellness Center

Before you begin your teaching plan be sure to define the characteristics of the clinical site and patient population. The teaching plan
should be customized to this population. This is a sample teaching plan that you can use and customize to your needs. You may want to
design a pre-test and post-test to give your patients would are attending the teaching program.

Based on statistics from the Centers for Disease Control website, 17.0 million people in the United States, approximately 6.2% of the
population, have diabetes. Of this 17 million people, 11.1 million are diagnosed and 5.9 million are undiagnosed. In the different age
groups, about 151,000 people less than 20 years of age have diabetes, approximately 0.19% of people in this age group. In the 20 and
older age group 16.9 million and 8.6% of people have diabetes. The 65 and older age group has 7.0 million and 20.1% of all people with
diabetes (www.cdc.gov/diabetes).

The Identified Learning Need

Patients with Diabetes have very comprehensive learning needs. The learning needs are focused on managing their glucose levels and
preventing complications of diabetes. Learning needs for managing diabetes are complex and include: monitoring blood glucose levels,
menu/food planning, exercise, medications, skin care, management of co-existing disease processes, knowledge of medications,
knowledge of the disease process and how to manage hypo/hyperglycemic episodes. Many patients are diagnosed with diabetes every
year and many are unaware that it requires lifestyle changes, especially in the areas of nutrition and physical activity. Making these
lifestyle changes is one of the greatest challenges they will encounter in managing their diabetes. The main goal of the teaching plan is to
provide the patient with the knowledge to be able to make self-directed behavioral changes to improve their overall health and manage
their diabetes.
The Behavioral Objectives for the Teaching Plan

1.? The patient will be able to describe the diabetic medications that they are on and how to properly take the medications
2.? The patient will be able to demonstrate proper skin and foot care.
3.? The patient will be able to perform self-monitoring of blood glucose using a blood glucose meter as evidenced by demonstration of
the technique to the nurse or nurse practitioner.
4.? The patient will be able to describe the benefits of regular exercise and how regular exercise can improve blood glucose control.

Teaching Plan

The diabetes teaching plan is aimed at helping the patient make educated lifestyle choices and changes that will promote health and
promote a stable blood sugar. Each patient needs a comprehensive treatment approach. This includes: (a) an individualized food/meal
plan appropriate for his/her lifestyle, (b) education related to diabetes and nutrition therapy, and (c) mutually agreed-upon short term
and long term goals for lifestyle changes.

The teaching plan should stress the importance of complying with the prescribed treatment program. This teaching plan should be
tailored to the patient͛s needs, abilities, and developmental stage. The teaching plan for a patient with diabetes should include: diet,
administration, possible adverse effects of medication, exercise, blood glucose monitoring, hygiene, and the prevention and recognition
of hypoglycemia and hyperglycemia (McGovern, 2002).

The teaching plan is an education program designed to help patients with newly diagnosed diabetes or patients who need a review of
concepts for managing their diabetes. However, diabetes management requires on-going education and nutritional advice with regular
review and modification as the disease process progresses and the needs of the patient changes. This continued education can take place
as needed on a one-on-one basis and can be included with the routine office visit or at a separate time that is convenient for the patient
and health care practitioner.

The teaching plan can be tailored to the needs of the patients who will be attending the classes. It can be tailored to the patient͛s
abilities, developmental stage and learning styles. The teaching plan can be a combination of lecture format, handouts, videos,
powerpoint presentations, demonstrations and group discussion. The fee charged for the teaching program has to be determined by the
person, group or facility offering the teaching program. Many insurances do not reimburse for this type of education. This has to be taken
into consideration with the intended audience.

Teaching Plan for Diabetes

Teaching Plan would include 6 evening or day classes consisting of 2-3 hour sessions of education and group discussion. The topics and
discussions would be as follows.

Day 1

›? General overview of Diabetes (2 hours)

Day 2

›? Blood glucose monitoring and goals of blood glucose monitoring (3 hours)

Day 3

›? Medications and Insulin (2 ʹ 3 hours)

Day 4

›? Complications from Diabetes (1 hour)

›? Skin and Foot Care (0.5 hour)
›? Exercise and Diabetes (1.5 hour)

Day 5

›? Diet and Diabetes (2 hours)

›? Coping with Diabetes (1 hour)

Day 6

›? †uestions and Answers (1 hour)

›? Review of any concepts requested by patients (1 hour)

General Overview of Diabetes

Patients with diabetes need to understand what diabetes is. Patients who understand what diabetes is and the complicated process
associated with the disease are more likely to comply with the prescribed regimen. Diabetes Mellitus is a syndrome with disordered
metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and
inadequate insulin secretion to compensate (Davis, 2001). Diabetes is a chronic progressive disease that requires lifestyle changes,
especially in the areas of nutrition and physical activity. The overall goal of medical and nutritional therapy is to assist persons with
diabetes in making self-directed behavioral changes that will improve their overall health (Franz, 2001). Blood glucose monitoring and
goals of blood glucose monitoring
Testing blood glucose levels pre-meal and post-meal can help the patient with diabetes make better food choices, based on how their
bodies are responding to specific foods. Patients should be taught specific directions for obtaining an adequate blood sample and what to
do with the numbers that they receive. Research has found that patients who have had education on the use of their meters and how to
interpret the data are more likely to perform self-blood glucose monitoring on a regular basis (Franz, 2001).

There are many different glucose monitors available for patients. The patient needs to have a device that is easy for them to use and
convenient. A patient͛s visual acuity and dexterity skills should be assessed prior to selecting a blood glucose monitoring device. A device
is usually selected to meet the patient͛s needs in collaboration with a diabetic educator at a health care facility.

The patient needs to be reminded to record the blood glucose values on a log sheet with the date and time and any associated signs and
symptoms that he/she is experiencing at the time the specimen was obtained. This log should be shared with his/her primary care
practitioner.

A discussion of glycosylated hemoglobin (HbA1c) should include the reasons for doing the test, how it is performed and how the health
care practitioner will interpret the data. These laboratory tests are ordered on a routine basis along with other laboratory tests that are
being monitored for the patient. A simple method to describe the HbA1c is to tell the patient that the test measures the amount of sugar
that attaches to the protein in the red blood cell. The test shows the average blood sugar during the last three months. The higher the
blood sugar the higher the HbA1c. The high blood sugar over a long period of time causes damage to the large and small blood vessels
therefore increasing the risk of complications from diabetes.

Medications and Insulin

The patient with diabetes needs to be reminded that the addition of medications to help manage his/her diabetes is not because they are
failing at diet management. Many patients with diabetes become depressed or despondent when they have to begin taking oral
hyperglycemic medications and/or insulin. The teaching session should include a review of the different types of oral diabetic agents. A
review of the different types of insulins and how to mix insulins should also be discussed.

Teach the patient about self-administration of insulin or oral agents as prescribed, and the importance of taking medications exactly as
prescribed, in the appropriate dose (Davis, 2001). Patients should be provided with a list of signs and symptoms of hypoglycemia and
hyperglycemia and actions to take in each situation.

Complications from Diabetes

The teaching regarding the complications encountered from diabetes should stress the effect of blood glucose control on long-term health
(McGovern, 2002). The patient should be taught how to manage their diabetes when he/she has a minor illness, such as a cold, flu or
gastrointestinal virus. The patient should also be taught how to watch for diabetic effects on the cardiovascular system, such as
cerebrovascular incidents/stroke, coronary artery disease, and peripheral vascular disease. Patients should be taught how to be alert for
signs of urinary tract, respiratory tract infections and signs of renal disease. Assessment for signs of diabetic neuropathy should also be
included in the teaching plan. Diabetes is the leading cause of death by disease in the United States, it also is a contributing factor in
about 50% of myocardial infarctions and about 75% of strokes as well as renal failure and peripheral vascular disease. Diabetes is also the
leading cause of new blindness (McGovern, 2002).

Patients with diabetes should also receive education on the importance of smoking cessation, cholesterol and lipid management, blood
pressure monitoring and management and management of other disease processes. Skin and Foot Care

Teach the patient to care for his feet by washing them daily, drying them carefully particularly between the toes, and inspecting for corns,
calluses, redness, swelling, bruises, blisters, and breaks in the skin. The patient should be encouraged to report any changes to his/her
health care provider as soon as possible. Advise the patient to wear non-constricting shoes and to avoid walking barefoot. The patient
may use over-the-counter athlete͛s foot remedies to cure foot fungal infections and should be encouraged to call their health care
provider if the athlete͛s foot doesn͛t improve (McGovern, 2002). The patient should be reminded that he/she needs to treat all injuries,
cuts and blisters particularly on the legs or feet carefully.

Patients should be aware that foot problems are a common problem for patients with diabetes. Informing them of what to look for is an
important teaching concern. The signs and symptoms of foot problems to emphasize are: feet that are cold, blue or black in color, feet
that are warm and red in color, foot swelling, foot pain when resting or with activity, weak pulses in the feet, not feeling pain although
there is a cut or sore on the foot, shiny smooth skin on the feet and lower legs
Exercise and Diabetes

A moderate weight loss of ten to twenty pounds has been known to improve hyperglycemia, dyslipidemia, and hypertension. The target
goal for body weight for patients with diabetes is based on a reasonable or healthy body weight. ͞Reasonable body weight is the weight
an individual and health care professional acknowledge as achievable and maintainable, both short-term and long-term (Franz, 2001,
p.8).͟ More emphasis is now placed on waist circumference, rather than on actual weight. A waist circumference greater than 40 inches in
men and greater than 35 inches in women indicates a risk for metabolic disease. This is now part of what is referred to as metabolic
syndrome. Reducing abdominal fat improves insulin sensitivity as well as lipid profiles. The benefits from exercise result from regular,
long term, and aerobic exercise. Exercise used to increase muscle strength is an important means of preserving and increasing muscular
strength and endurance and is useful in helping to prevent falls and increase mobility among the elderly (Franz, 2001).

Regular exercise can improve the functioning of the cardiovascular system, improve strength and flexibility, improve lipid levels, improve
glycemic control, help decrease weight, and improve quality of life and self-esteem. Exercise increases the cellular glucose uptake by
increasing the number of cell receptors. The following points should be considered in educating patients regarding beginning an exercise
program. Exercise program must be individualized and built up slowly. Insulin is more rapidly absorbed when injected into a limb that is
exercised, therefore can result in hypoglycemia (Ferri, 1999).

"Patients need to be informed that exercise of a high intensity can also cause blood glucose levels to be higher after exercise than before,
even though blood glucose levels are in the normal range before beginning exercise. This hyperglycemia can also extend into the post-
exercise state and is mediated by the counter-regulatory hormones (Franz, 2001, p. 62)."

The exercise program should include a five to ten minute warm-up and cool-down session. The warm-up increases core body temperature
and prevents muscle injury and the cool-down session prevents blood pooling in the extremities and facilitates removal of metabolic by-
products. Research studies show there are similar cardiorespiratory benefits that occur when activity is done in shorter sessions,
(approximately 10 minutes) accumulated throughout the day than in activity sessions of prolonged sessions (greater than 30 minutes)
(Franz, 2001). This is an important factor to emphasize with patients who don͛t think they have the time and energy for exercise.

Diet and Diabetes

The American Diabetes Association (ADA) has established nutritional guidelines for patients with diabetes. Their focus is on achieving
optimal metabolic outcomes related to glycemia, lipid profiles, and blood pressure levels. Patients with diabetes need to maintain a
healthy diet consisting of multiple servings of fruits, vegetables, whole grains, low-fat dairy products, fish, lean meats, and poultry (Franz,
2001). The exchange diet of the ADA includes protein, bread, fruit, milk, and low and intermediate carbohydrate vegetables (Ferri, 1999).

The food/meal plan is based on the individual͛s appetite, preferred foods, and usual schedule of food intake and activities, and cultural
preferences. Determination of caloric needs varies considerably among individuals, and is based on present weight and current level of
energy. Required calories are about 40 kcal/kg or 20 kcal/lb per day for adults with normal activity patterns (Davis, 2001). Emphasis
should also be placed on maintaining a consistent day-to-day carbohydrate intake at meals and snacks. It is the carbohydrates that have
the greatest impact on glycemia. ͞A number of factors influence glycemic responses to foods, including the amount of carbohydrate,
nature of the monosaccharide components, nature of the starch, cooking and food processing, and other food components (Franz, 2001,
p.13).͟ Maintaining a food diary can help identify areas of weaknesses and how to prepare better menu plans.

Recommendations for fiber intake are the same for patients with diabetes as for the general population. It is recommended that they
increase the amount of fiber to approximately 50 grams per day in their diet. Insoluble and soluble globular fiber delay glucose absorption
and attenuate the postprandial serum glucose peak, they also help to lower the elevated triglyceride levels often present in uncontrolled
diabetes (Ferri, 1999). The discussion of diet management should also include a discussion of alcohol intake. Precautions regarding the
use of alcohol that apply to the general public also apply to people with diabetes. Abstaining from alcohol should be advised for people
with a history of alcohol abuse, during pregnancy, and for people with other medical conditions such as pancreatitis, advanced
neuropathy, and elevated triglycerides. The effects of alcohol on blood glucose levels is dependent on the amount of alcohol ingested as
well as the relationship to food intake. Because alcohol cannot be used as a source of glucose, hypoglycemia can result when alcohol is
ingested without food. The hypoglycemia can persist from eight to twelve hours after the last drink of alcohol. When alcohol is ingested in
moderation and with food, blood glucose levels are not affected by the ingestion of moderate amounts of alcohol. If the patient plans to
consume alcoholic beverages they are to be included in the meal plan. The patient should be reminded that no food should be omitted
because of the possibility of alcohol induced hypoglycemia (Franz, 2001).

Coping with Diabetes

The patient needs to understand that the diagnosis of diabetes mellitus as with any chronic illness can be unexpected and potentially
devastating. Grief is the most common reaction of an individual diagnosed with diabetes. Resolution of the grief is dependent on
variables such as education, economics, geography, and religious and cultural factors. The support of family and friends affects the long-
 term acceptance of the disease progression. Patients need to be aware that depression is common with chronic diseases such as diabetes.
The depression should be recognized and treated as soon as possible since depression can affect glycemic control and complicate the
management of the diabetes (Buttaro, 1999).

The patient needs to understand that diabetes is a lifelong disease process that requires a lifetime commitment and lifestyle changes. The
patient should be educated about empowerment ʹ having the resources and knowing how and when to use them. The skills of
empowerment that help the patient reflect on life satisfaction in the following areas: physical, mental, spiritual, family related, social,
work related, financial, personal. The patient should be encouraged to establish goals which emphasize at least two of these areas in
which he/she has control. In the session of coping with diabetes the patient should be assisted to develop better problem solving skills,
which are necessary to manage a life-long disease such as diabetes. Coping with diabetes should also include stress management
concepts. Stress management concepts should include: a definition of stress, the body͛s reaction to stress, the effects of stress on
diabetes management, identifying stressors, identifying methods of coping, relaxation exercises and identifying support systems to tap
into.

Management of the disease process should include eliminating or minimizing other cardiovascular risk factors for example blood pressure
control, lipid control, and smoking cessation. Patients with diabetes should also be instructed on what to do when they become sick with
a cold, flu, gastrointestinal virus, or other minor illness. They need to be aware that these minor illnesses can affect their diabetes and
blood glucose levels (McGovern, 2002). Instruction on what to do when they become ill and the importance of continuing to take their
diabetes medications and/or insulin and other general care should be discussed. Some basic guidelines for management during an illness
or sick-day include maintain adequate hydration because of the risk of dehydration from decreased fluid intake, polyuria, vomiting,
diarrhea, and evaporative losses from fever. Patient should be instructed to drink at least eight ounces of calorie free liquids every hour
while they are awake. The beverages should be caffeine-free, since caffeine acts as a diuretic and can actually increase the chances of
hypovolemia. If the patient is unable to tolerate fluids by mouth, antiemetic suppositories or intravenous fluids may be required.
Vomiting that is persistent and intractable may require emergency room care. The patient should be encouraged to perform blood
glucose monitoring more frequently while he/she is ill and to initiate urine ketone monitoring with urine dipsticks, during the illness
(Franz, 2001).

The patient should be instructed to continue taking his/her insulin and/or oral antidiabetic agents while ill and even when unable to eat.
The omission of insulin is a common cause of ketosis and can result in a serious condition called diabetic ketoacidosis. The patient should
be given a list of foods that contain fast acting carbohydrates that they can consume when they experience signs and symptoms of
hypoglycemia.

Patients should be encouraged to seek regular ophthalmologic examinations to detect for diabetic retinopathy. Regular dental
examinations should also be encouraged to evaluate to potential areas that can become infected and possible oral lesions.

SummaryThe teaching program for the patients with diabetes is designed to be held for six sessions. However, the sessions can be
lengthened or shortened to meet the needs of the intended audience. These two to three hour sessions allow the patient to absorb the
material that is being taught and to be able to ask questions. The learning needs are focused on managing their glucose levels and
preventing complications of diabetes. The patient needs to be educated on the multiple disease processes associated with diabetes and
the factors affecting each of these areas. The patient also needs to have the knowledge of how to manage their diabetes when they are ill
and warning signs that they are hypo/hyperglycemic. Diabetic patients should be advised to contact their health care provider any time
they are unsure what to do or have questions on how to manage their disease. There are many teaching handouts and pamphlets that are
available free of charge from the various agencies. These handouts are available on a wide variety of subjects that can be used with the
teaching plan. The evaluation criteria for the teaching plan would include an evaluation tool in which the patients could complete
anonymously at the end of the program.

References

Buttaro, T.M., Trybulski, J., Bailey, P.P., Sandberg-Cook, J. (1999). V
   


V 
 Philadelphia, PA: Mosby, Inc.
Davis, A. (2001).   V 


 




 Philadelphia, PA; Mosby, Inc.
Ferri, F. (1999). 

 

  


    Philadelphia, PA: Mosby, Inc.
Franz, M. (Ed.) (2001). 
    
  
 
 
 
  

 4th Edition. Chicago, IL: American
Association of Diabetes Educators.
Herfindal, E. and Gourley D. (2000). ! 

"
  
    
   Seventh Edition. Philadelphia, PA:
Lippincott Williams and Wilkins.
McGovern, K., Devlin, M., Lange, E., and Mann, N. (Eds.) (2002). 
   
   V 


  Springhouse, PA:
Springhouse Corporation.
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