Teaching Plan for Newly Diagnosed Diabetes 1 Teaching Plan for Newly Diagnosed Diabetic Patient The Identified

Learning Need Patients with Diabetes have very comprehensive learning needs. The learning need s are focused on managing their glucose levels and preventing complications of d iabetes. Learning needs for managing diabetes are complex and include: monitorin g blood glucose levels, menu/food planning, exercise, medications, skin care, ma nagement of co-existing disease processes, knowledge of medications, knowledge o f the disease process and how to manage hypo or hyperglycemic episodes. Many pat ients are diagnosed with diabetes every year and many are unaware that it requir es lifestyle changes, especially in the areas of nutrition and physical activity . Making these lifestyle changes is one of the greatest challenges they will enc ounter in managing their diabetes. The main goal of the teaching plan is to prov ide the patient with the knowledge to be able to make self-directed behavioral c hanges 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 di abetic 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 patien t 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 prac titioner. 4. The patient will be able to describe the benefits of regular exerci se 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. E ach patient needs a comprehensive treatment approach. This includes: (a) an indi vidualized food/meal plan appropriate for his/her lifestyle, (b) education relat ed to diabetes and nutrition therapy, and (c) mutually agreed-upon short term an d long term goals for lifestyle changes. The teaching plan should stress the imp ortance of complying with the prescribed treatment program. This teaching plan s hould be tailored to the patients 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, hygi ene, and the prevention and recognition of hypoglycemia and hyperglycemia. The t eaching plan is an education program designed to help patients with newly diagno sed diabetes or patients who need a review of concepts for managing their diabet es. However, diabetes management requires on-going education and nutritional adv ice with regular review and modification as the disease process progresses and t he needs of the patient changes. Teaching Plan for Diabetes Teaching Plan would include 6 evening or day classes consisting of 2-3 hour sessions

Teaching Plan for Newly Diagnosed Diabetes 2 of education and group discussion. The topics and discussions would be as follow s. Day 1 o General overview of Diabetes (2 hours) Day 2 o Blood glucose monitoring and goals of blood glucose monitoring (3 hours) Day 3 o Medications and Insulin (2 3 hours) Day 4 o o o Complications from Diabetes (1 hour) Skin and Foot Care (0.5 hour) Exercise and Diabetes (1.5 hour) Day 5 o o Diet and Diabetes (2 hours) Coping with Diabetes (1 hour) Day 6 o o Questions and Answers (1 hour) Review of any concepts requested by patients (1 h our) General Overview of Diabetes Patients with diabetes need to understand what diab etes is. Patients who understand what diabetes is and the complicated process as sociated with the disease are more likely to comply with the prescribed regimen. Diabetes Mellitus is a syndrome with disordered metabolism and inappropriate hy perglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes i s a chronic progressive disease that requires lifestyle changes, especially in t he areas of nutrition and physical activity. The overall goal of medical and nut ritional therapy is to assist persons with diabetes in making self-directed beha vioral changes that will improve their overall health. Blood glucose monitoring and goals of blood glucose monitoring: Testing blood gl ucose levels pre-meal and post-meal can help the patient with diabetes make bett er food choices, based on how their bodies are responding to specific foods. Pat ients

Teaching Plan for Newly Diagnosed Diabetes 3 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 Ther e 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 patients visual a cuity and dexterity skills should be assessed prior to selecting a blood glucose -monitoring device. 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 sympt oms 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 glycosy lated hemoglobin (HbA1c) should include the reasons for doing the test, how it i s performed and how the health care practitioner will interpret the data. These laboratory tests are ordered on a routine basis along with other laboratory test s that are being monitored for the patient. A simple method to describe the HbA1 c is to tell the patient that the test measures the amount of sugar that attache s to the protein in the red blood cell. The test shows the average blood sugar d uring the last three months. The higher the blood sugar the higher the HbA1c. Th e high blood sugar over a long period of time causes damage to the large and sma ll blood vessels therefore increasing the risk of complications from diabetes. M edications and Insulin The patient with diabetes needs to be reminded that the a ddition of medications to help manage his/her diabetes is not because they are f ailing at diet management. Many patients with diabetes become depressed or despo ndent when they have to begin taking oral hyperglycemic medications and/or insul in. 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 insu lins should also be discussed. Teach the patient about self-administration of in sulin or oral agents as prescribed, and the importance of taking medications exa ctly as prescribed, in the appropriate dose. 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 patient should be taught how to manage their diabetes when he/she has a minor illness, such as a cold, flu o r gastrointestinal virus. The patient should also be taught how to watch for dia betic effects on the cardiovascular system, such as cerebrovascular incidents/st roke, coronary artery disease, and peripheral vascular disease. Assessment for s igns of diabetic neuropathy should also be included in the teaching plan. Patien ts with diabetes should also receive education on the importance of smoking cess ation, cholesterol and lipid management, blood pressure monitoring and managemen t and management of other disease processes. Skin and Foot Care Teach the patien t to care for his feet by washing them daily, drying them carefully particularly between the toes, and inspecting for corns, calluses, redness, swelling, bruise s, 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 pati ent to wear non-constricting shoes and to

Teaching Plan for Newly Diagnosed Diabetes 4 avoid walking barefoot. The patient may use over-the-counter athletes foot remedi es to cure foot fungal infections and should be encouraged to call their health care provider if the athletes foot doesnt improve. The patient should be reminded that he/she needs to treat all injuries, cuts and blisters particularly on the l egs 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 imp ortant teaching concern. The signs and symptoms of foot problems to emphasize ar e: feet that are cold, blue or black in color, feet that are warm and red in col or, foot swelling, foot pain when resting or with activity, weak pulses in the f eet, 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 bas ed on a reasonable or healthy body weight. 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 metabo lic disease. This is now part of what is referred to as metabolic syndrome. Redu cing abdominal fat improves insulin sensitivity as well as lipid profiles. The b enefits from exercise result from regular, long term, and aerobic exercise. Exer cise used to increase muscle strength is an important means of preserving and in creasing muscular strength and endurance and is useful in helping to prevent fal ls and increase mobility among the elderly. Regular exercise can improve the fun ctioning of the cardiovascular system, improve strength and flexibility, improve lipid levels, improve glycemic control, help decrease weight, and improve quali ty of life and self-esteem. Exercise increases the cellular glucose uptake by in creasing 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 wh en injected into a limb that is exercised, therefore can result in hypoglycemia. 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 cooldown session prevents blood pooling in the extremities and facilitat es removal of metabolic byproducts. Research studies show there are similar card iorespiratory benefits that occur when activity is done in shorter sessions, (ap proximately 10 minutes) accumulated throughout the day than in activity sessions of prolonged sessions (greater than 30 minutes). This is an important factor to emphasize with patients who dont think they have the time and energy for exercis e. Meal Planning and Diabetis The American Diabetes Association (ADA) has establ ished nutritional guidelines for patients with diabetes. Their focus is on achie ving optimal metabolic outcomes related to glycemia, lipid profiles, and blood p ressure levels. Patients with diabetes need to maintain a healthy diet consistin g of multiple servings of fruits, vegetables, whole grains, low-fat dairy produc ts, fish, lean meats, and poultry.

Teaching Plan for Newly Diagnosed Diabetes 5 The food/meal plan is based on the individuals appetite, preferred foods, and usu al schedule of food intake and activities, and cultural preferences. Determinati on of caloric needs varies considerably among individuals, and is based on prese nt 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. Emphasis should al so 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. Maintaining a food diary can help identify areas of weaknesses and how to prepar e better menu plans. Recommendations for fiber intake are the same for patients with diabetes as for the general population. It is recommended that they increas e the amount of fiber to approximately 50 grams per day in their diet. Insoluble and soluble globular fiber delay glucose absorption and attenuate the postprand ial serum glucose peak, they also help to lower the elevated triglyceride levels often present in uncontrolled diabetes. The discussion of diet management shoul d 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. Abs taining from alcohol should be advised for people with a history of alcohol abus e, during pregnancy, and for people with other medical conditions such as pancre atitis, advanced neuropathy, and elevated triglycerides. The effects of alcohol on blood glucose levels is dependent on the amount of alcohol ingested as well a s 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 hyp oglycemia 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 pl ans 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 possib ility of alcoholinduced hypoglycemia. Coping with Diabetes The patient needs to understand that the diagnosis of diabetes mellitus as with any chronic illness c an be unexpected and potentially devastating. Grief is the most common reaction of an individual diagnosed with diabetes. Resolution of the grief is dependent o n variables such as education, economics, geography, and religious and cultural factors. The support of family and friends affects the long-term acceptance of t he disease progression. Patients need to be aware that depression is common with chronic diseases such as diabetes. The depression should be recognized and trea ted as soon as possible since depression can affect glycemic control and complic ate the management of the diabetes. The patient needs to understand that diabete s is a lifelong disease process that requires a lifetime commitment and lifestyl e changes. The patient should be educated about empowerment having the resources and knowing how and when to use them. The skills of empowerment that help the p atient reflect on life satisfaction in the following areas: physical, mental, sp iritual, family related, social, work related, financial, personal. The patient should be encouraged to establish goals which emphasize at least two of these ar eas in which he/she has control. In the session of coping with diabetes the pati ent should be assisted to develop better problem solving skills, which are neces sary to manage a life-long disease such as diabetes. Coping with diabetes should also include stress management concepts. Stress management concepts should incl ude: a definition of stress, the bodys reaction to stress, the effects of stress on diabetes management,

Teaching Plan for Newly Diagnosed Diabetes 6 identifying stressors, identifying methods of coping, relaxation exercises and i dentifying support systems to tap into. The patient should be instructed to cont inue taking his/her insulin and/or oral antidiabetic agents while ill and even w hen 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 b e given a list of foods that contain fast acting carbohydrates that they can con sume when they experience signs and symptoms of hypoglycemia. Patients should be encouraged to seek regular ophthalmologic examinations to detect for diabetic r etinopathy. Regular dental examinations should also be encouraged to evaluate to potential areas that can become infected and possible oral lesions. Summary The 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 l earning needs are focused on managing their glucose levels and preventing compli cations of diabetes. The patient needs to be educated on the multiple disease pr ocesses 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 whe n they are ill and warning signs that they are hypo/hyperglycemic. Diabetic pati ents should be advised to contact their health care provider any time they are u nsure what to do or have questions on how to manage their disease. Reference: Co llege of Nurses of Ontario (CNO). 2009. Teaching Plan for Diabetic Patient. Fenn P. (2007). Assessment and Management of Abdominal Obesity in Patients With Type II Diabetes. Nursing Standard. 21 (25), 37-44. Huther S. E., Brashers V. L. (200 8) Alterations of Hormonal Regulation in Huether, McCances Understanding Pathophy siology , 4th edition, chapter 18, 447-480. Lewis, S. M., Heitkemper, M. M., & D irksen, S. R. (2006). Medical-surgical nursing in Canada: Assessment and managem ent of clinical problems. 1st edition. St. Louis: Mosby. Registered Nurses Associ ation of Ontario (RNAO). 2006. Diabetic Care.