ATrain Education

 

Continuing Education for Health Professionals

Diabetes: Teaching Patients Self-Care

Module 3

Pragmatic Guidelines

Armed with an understanding of diabetes and what motivates people to change, it is necessary to know how to teach effectively in order to help patients achieve favorable outcomes. The determinants of learning can be addressed by answering the who, what, when, where, and how of teaching people with diabetes (Redman, 2004).

Who, What, Where, When, and Why

The who includes who you are teaching and, hopefully, family members. Parents of children with type 1 diabetes especially need education and support. Although there is no actual type 3 classification of diabetes, family members who care for a patient with diabetes have coined the term for themselves. Their lives are touched directly as they care for a family member with diabetes even though they don’t have diabetes themselves. It is important to involve the family members who may be buying and preparing food and/or administering medication. There is a very real phenomenon of diabetes burnout, and caregivers also experience this and need support.

Deciding what needs to be taught may be easy if it is prescribed—such education for insulin injection or blood glucose monitoring—however, most topics are up to the diabetes educator. You must decide between the nice-to-know and the need-to-know. Because formal diabetes education may be limited by insurance companies to a maximum of ten hours in the first year, teach first survival skills such as basic physiology and medication administration. Long-term goals and special topics such as eating during the holidays, travel, and cooking ideas should be chosen after essentials such as weight loss and blood glucose monitoring. All topics must be in accordance with the ADA national standards for DSME.

Topics such as the use of alternative therapies should be limited if there is no position statement from the ADA. For example, patients will want to know if they should be taking cinnamon pills or chromium or cactus pear because they read about it on the Internet or heard it from a friend. Unless the ADA has endorsed such products, you need to tell the patient that they are not approved. Patients will highly value your opinion as a healthcare professional so you must be careful what you say about vitamins, complementary therapies, and practices not validated by evidence-based medicine.

Stay with the seven approved topics and interventions for diabetes management:

  • Weight loss
  • Medications
  • Diet
  • Exercise
  • Monitoring
  • Mental health and stress management
  • Self- management strategies
  • Avoidance of complications

A simple way to remember this are the “seven daily MnMs,” which include:

  • M   Mass reduction (weight loss)
  • M   Movement (exercise)
  • M   Meal Planning (diet)
  • M   Monitoring (blood glucose, weight, lipids, blood pressure, etc)
  • M   Medications
  • N   No complications (avoiding hypoglycemia, DKA and HKS)
  • M   Mental Health

Make sure your patient understands you are not advocating eating M&Ms to manage their diabetes! Once you know this is understood, the seven daily MnMs is a “sweet” way to remember the daily strategies recommended by the ADA to control daily blood glucose levels and overall diabetes. The use of mnemonics and acrostics help some people remember action items.

How to teach is grounded in understanding basic principles of teaching. As mentioned earlier in this module, you can ASSURE effective teaching by analyzing the learner’s unique needs, stating the objectives for a teaching session, selecting appropriate teaching methods, using effective instructional materials, requiring learner performance, and then evaluating the learning.

Where diabetes education takes place includes both healthcare settings and non-healthcare settings such as the home. Because time and insurance coverage may limit the formal teaching, referring patients to public libraries, community support groups, the Internet, and diabetes organizations can expand their learning resources.

When diabetes education can begin depends on the physical and emotional readiness of the learner. Acute settings such as an emergency department may not be ideal for diabetes education, especially when the patient is in pain or discomfort; however, initial seeds may be planted as patients become newly motivated to avoid acute diabetic emergencies. Other factors that may impact a patient’s readiness to learn include their state of fear, open vs. closed dialog, sense of safety or perceived threat to self, and discussing realistic or unrealistic goals. Telling an obese patient to lose 20 pounds may be unrealistic and overwhelming to the patient and close the patient off to any future discussions. Discovering what is of most interest to the patient is key. Discussing erectile dysfunction may actually become the right motivator to get a man interested in testing his blood sugar.

Just as children want to know the “why” of parental rules, many people with diabetes want to know why they are being given certain medications and prescriptions. Again, being able to explain the pathophysiology to them in a manner they understand can help them make connections with the prescribed regimen. The overall goal of diabetes self-management education is to help patients live as full and healthy a life as possible within their limitations.

One overarching strategy to achieve this is through controlling chronic hyperglycemia. Once patients understand the overall goal, monitoring their blood sugar levels throughout the day can give them feedback on the effects of exercise and food on their body. The goal is self-management, and information is key to being able to make adjustments. Blood glucose monitoring or insulin is no longer the enemy, but rather the tool to help them achieve better health.

How to teach effectively has been the overall question this continuing education course attempts to answer. Strategies discussed have included:

  • Understand learning styles
  • Understand learning principles for patients’ ages
  • Understand motivation and compliance factors
  • Adjust teaching for cultural preferences
  • Control flow of time and pacing
  • Identify purpose of teaching session
  • Require learner to take an action
  • Organize the material
  • Be prepared
  • Have a sense of humor
  • Be flexible and adjust the teaching as needed

General principles of effective teaching include being prepared with the material you may need. Give positive feedback and reinforcement rather than chastisement. Always demonstrate an attitude of respect and compassion. After teaching a concept, allow patients to rephrase it in their own words to evaluate understanding. Be flexible when the patient asks questions about a topic you may not have planned for. Sometimes a patient may ask general questions until gaining confidence in you and then the deeper questions of sexual dysfunction or eating disorders may surface.

 

Clinical Scenario

The diabetic patient refuses to test his blood sugar and states he can just guess his blood sugar by how he feels.

Q:   What questions could you ask the patient to better help him?

A:   Tell me how you feel when your blood sugar is high? When it is low? How do you know? What benefits are there in testing your blood sugar? What barriers do you have to testing your blood sugar? Do you have a meter? Would you like me to show you how to use it? Let me tell you about hypoglycemic unawareness.

 

Creating a Lesson Plan

Creating a plan for effective teaching begins with identifying the overall purpose of the teaching session. Writing your plan down helps focus on the overall goal and the topic for learning. What are the learning objectives you want your patient to achieve? Outline the related content to identify the topics you will need to cover, including the realistic time it will take to cover the material. Choose the materials and instructional resources you will use and how you will evaluate the learning.

The following table shows how you may outline a simple lesson plan to teach about blood glucose monitoring.

 

Topic

Content

Time

Materials

Evaluation

Blood glucose monitoring

a. What is it?

b. Why do it?

c. How to use the monitor

d. How to record results

e. How to interpret results

a. 2 min

b. 2 min

c. 10 min

d. 5 min

e. 5 min

Get monitor w/instruction manual

Get log book

Demonstrate first and have patient give return demonstration of meter use and record in log book

 

Even though your lesson plan was perfectly organized and delivered, the patient may have a less than impressive retention or understanding of the information you presented. There are many factors that influence learning. Environmental elements may affect the learning experience (eg, temperature, noise). If the environment isn’t conducive to learning, you may need to reschedule or return at a different time. Simply ask your patient “Is this a good time for you to discuss this?”

Emotional elements impact learning (eg, depression, readiness for change, fear). A patient who is anxious while waiting for a test result may not be ready for a lecture on weight loss. Social issues such as family dynamics can impact learning. Support or lack of support from family members or loved ones can change the learning experience. A man who doesn’t feel supported by his wife may reject a learning session and stay in denial or anger. Physical condition can impact patients’ learning if they are in pain or tired. It’s generally not a positive experience to try to teach someone who is waiting for a pain medication or who keeps falling asleep from anesthesia. Ideally the planets will align and make all the elements perfect while you have the opportunity to teach about diabetes; however, reality is that you probably will need to teach in small segments of time based on the patient’s preference and not your own schedule.

Even cultural values impact the learning experience. While teaching a Spanish-speaking woman about diabetes, a bilingual nurse was surprised when the patient stated “Si Dios quiere” (If God wants it) when asked “Would you like to learn more about how to monitor your blood sugar?” Even though there wasn’t a language barrier, the deeper barrier was the belief system of the patient that God is in charge and she had no power to control her blood sugar levels. When confronted with a wall of resistance, endeavor to identify the barriers you are facing.

Other special considerations are patients with low literacy, attention deficit disorder, or mental illness. For more effective teaching with these persons consider the following strategies:

  • Personalize all messages.
  • Repetition is key.
  • Use concrete illustrations.
  • Allow hands-on learning.
  • Be sensitive to word usage.
  • Identify family members to assist.
  • Word check for readability.
  • Provide education in short time segments.
  • Identify 1 to 2 main messages.
  • Allow patients to teach back to clarify understanding.

Teaching all there is to know about diabetes is a daunting task—and unrealistic. Being able to connect your patient with reputable resources supports the patient’s ability to become a lifelong learner with diabetes. Self-management education means you do not have to be the sole person to educate about diabetes, which is a relief. Look at the Resources at the end of this course for many options for you and your patient.

 

Maria

You are an RN working in a women’s clinic when 24-year-old Maria arrives for her regularly scheduled obstetric appointment. She is 5'3" and weighs 153 pounds, with her pre-pregnancy BMI 29. She is a 26-weeks’ gestation primigravida and speaks basic conversational English. She is scheduled to complete her 50-g glucose challenge. Her mother has diabetes.

Q: What is the purpose of the 50-g glucose challenge?

It is a screening test for diabetes and identifies how much sugar the body can metabolize after two hours of a glucose load.

1. What is the process of the screening test?

The patient needs to fast for at least 8 hours. The patient drinks a bottle of 50 grams of pure glucose. Blood glucose values are measured before the beverage is consumed, at the half-hour, 1-hour, and 2-hour mark. If the blood glucose remains above 140 mg/dL, the person has diabetes.

2. The results came back 201 mg/dl after 1 hour. What does this mean?

This patient has diabetes and her body cannot metabolize the sugar adequately.

Maria was then scheduled for a 100-g glucose load. The lab tests are shown in the following table.

 

Time of test

Patient value

Normal value

Fasting

131 mg/dl

<95 mg/dl

1 hour

193 mg/dl

<180 mg/dl

2 hour

182 mg/dl

< 155 mg/dl

3 hour

151 mg/dl

< 140 mg/dl

 

4. List at least three risk factors that predispose Maria for gestational diabetes mellitus (GDM).

She is Hispanic, overweight, and has a family history of diabetes.

5. You now give Maria nutrition guidelines for her GDM. She gives a diet history mainly of rice and beans, fried meats, and tortillas. She tells you her grandmother in Mexico had diabetes and cured it with nopales (prickly pear) and cinnamon. She says she gets nauseated with dairy products. What are your dietary goals for Maria?

Support her nutritional needs during the pregnancy. This is not a time for weight loss. Provide her a realistic diet plan based on her dietary and cultural preferences and provide calcium in forms other than dairy.

6. What survival skills that you will teach Maria this first session?

She needs to learn how to measure her blood glucose and how to create a realistic diet plan she can follow during the pregnancy.

7. Maria returns in 4 weeks and has gained 10 pounds. Her FBG today in the clinic is 238. You now instruct her to measure her FBG and 2 hours after eating twice daily. What type of monitor would you suggest for Maria? What is your approach for education at this visit? What resources do you have for her?

She needs a simple monitor. She also needs education in Spanish. Refer to the ADA for Spanish videos and pamphlets.

8. What are the potential complications for GDM to both Maria and her baby?

She could continue to gain excess weight and create complications for herself and the baby. With excess blood glucose the baby may grow too much and make a vaginal birth difficult (eg, a baby >9 lb). She is at greater risk of developing diabetes mellitus.

9. When she comes 1 week later you will teach her insulin injections TID. What are your teaching approaches and considerations?

She needs to understand why she will be taking insulin and that it will help her baby grow normally. She needs to know how/where she can get supplies and how she can afford them.

10. During the next months, she will return to the clinic every 4 weeks. What are other topics you will assess and teach her?

She needs to learn about fetal kick counts and plan for a safe delivery. She also needs to begin to think about weight loss after the delivery to avoid fully getting diabetes type 2 after her gestational diabetes.

11. In preparation for her labor, she wants to know if she will be on insulin for the rest of her life like her mother. What pre- and postpartum counsel do you have for her?

Explain to her how the pathophysiology of gestational diabetes compares to type 1 and type 2. Assess what kind of diabetes her mother had. Explain that she will have her blood sugar tested after delivery and may not need to be on insulin anymore.

 

Frank

Frank comes to the clinic where you are employed. He has been complaining of chronic fatigue, increased thirst, constant hunger, and frequent urination. He denies any pain or burning on urination. He admits to smoking since losing his job but has recently found a new job at a loan company. He also complains of having difficulty reading numbers and reports and making more mistakes in his paperwork.

He reports that his feet hurt as he stands at a bank teller station for many hours and so he sits and watches TV when he gets off work at night, not having enough energy to do anything else. His weight is 245, BP is 152/97, random BG is 291 mg/dl. His labs reveal the following: FBG=184 mg/dl, HgbA1C=10.4, negative for ketones on urine, cholesterol 256 mg/dl, triglycerides 346 mg/dl, LDL 158 mg/dl, HDL 32 mg/dl.

1. What is the probable diagnosis?

Type 2 diabetes mellitus.

2. What are his risk factors for this diagnosis?

Obesity, sedentary lifestyle, high lipids, hyperglycemia, ethnicity, age.

3. What are four methods of diagnosing this type of DM?

Fasting blood glucose >100 mg/dL, random BG >200 plus symptoms, A1C >5.5, OGTT >200 mg/dL.

4. Frank was started on lispro (Humalog) and glargine (Lantus) insulin with carb counting.

What is the most important point to make when teaching the patient about glargine?

Lispro is fast-acting and glargine is long-acting. They cannot be mixed together even though they are both clear in the vials.

5. Frank wants to know why he can’t take NPH and regular insulin. He has a friend who does.

Each body and type of diabetes requires different medication regimens and really can’t be compared to another person’s diabetes.

6. Frank is confused with counting carbs and says he doesn’t want to have to calculate foods. What are your options for teaching him meal planning?

He can use the plate method, portion control, food guide pyramid, or other food management systems.

7. What other complications does Frank have with his diabetes? What questions would you ask to assess other complications?

It appears he is already developing retinopathy, neuropathy, lipodystrophies, and possible cardiovascular complications.

8. What are some changes Frank can make to reduce the risk or slow the progression of both microvascular and macrovascular disease?

The seven self-management strategies endorsed by the ADA.

Interpret the following record of his visits and list your treatment suggestions.

 

Tests and other services

Dates and results

Flu shot

9/28/00

 

 

Urine protein or microalbumin (mg)

2/1/15

40

6/11/15

38

9/28/15

35

Creatinine

1.0

1.0

.8

Total Cholesterol (mg/dL)

256

225

199

HDL cholesterol (mg/dL)

32

35

40

LDL cholesterol (mg/dL)

146

140

135

Triglycerides (mg/dL)

250

240

228

Tobacco use

5 cigars a day

2 cigars

0

Eye exam (dilated)

10/1/00

10/4/2001

10/20/2002

Foot exam

ulcer

ulcer

healing ulcer

 

1. Interpret the following blood glucose log book. What are your recommendations?

 

 

Insulin Type

Breakfast

Lunch

Dinner

Dose

Blood Sugar

Dose

Blood Sugar

Dose

Blood Sugar

Mon

Reg

8

141

3

287

4

158

NPH

20

 

 

Tue

Reg

8

112

2

204

4

215

NPH

20

 

 

Wed

Reg

8

159

3

178

4

261

NPH

20

 

 

Thur

Reg

8

191

2

114

4

110

NPH

20

 

 

Fri

Reg

8

132

2

152

3

68

NPH

20

 

 

Sat

Reg

8

124

3

161

4

118

NPH

20

 

 

Sun

Reg

9

175

2

99

4

110

 

The fasting blood sugars are still higher than the recommended 110 mg/dL and the patient may need to take p.m. insulin or decrease carbohydrate consumption at dinnertime.

 

Mr. Brown

Mr. Brown is a 59-year-old African American male. He and his wife have grown children and he works as a manager of a mechanic shop, which he states is very stressful. He has had type 2 diabetes for fourteen years, which has been “controlled by a pill” (metformin). He was put on insulin three years ago: Humalog 75/25 pen at breakfast and Lantus at bedtime. He is afraid of hypoglycemia because at work he had one episode when he felt sweaty and shaky and had to lie down. His last eye examination revealed a few microaneuysms and he was diagnosed with mild nonproliferative retinopathy in both eyes. He checks his fasting blood glucose most days and occasionally before bedtime. He complains that the test strips are expensive so he will just let the doctor do the lab tests once a year. He doesn’t keep a log book because he states his meter has a memory. He is in the office today because he’s inquiring about Viagra.

1. From this brief history, what are your priorities of teaching with Mr. Brown?

Blood glucose testing with a monitor and teaching him how to avoid and identify hypoglycemic episodes.

2. Interpret his 24-hour food recall and explain your suggestions for improvement.

 

Breakfast

7 a.m.

2 cups Starbucks coffee

2 donuts

Mid morning

10 a.m.

Chips

Orange juice

Lunch

1 p.m.

Double cheeseburger

Large fries

Diet Coke

Mid afternoon

3 p.m.

Apple, soda

Dinner

6:30 p.m.

Green salad with ranch dressing

2 rolls w/butter

1 pork chop w/gravy

collard greens

1 slice chocolate cake

1 beer

Bedtime snack

10 p.m.

cookies

 

He needs to cut out excess sugar consumption, such as the soda and cookies and desserts, until he gets his blood glucose levels stabilized. He needs to include lean protein in his diet and more vegetables.

3. After committing him to monitor his blood glucose for 1 week he shows you the following log book. Interpret the findings and make your recommendations.

 

Date

Breakfast

Lunch

Dinner

Bedtime

Other

Comments

 

Time

Blood Glucose

Time

Blood Glucose

Time

Blood Glucose

Time

Blood Glucose

Time

Blood Glucose

 

1/30

7:00

205

12:00

158

5:00

198

10:30

215

3:30p

250

Felt tired & some blurred vision, mid afternoon

1/31

7:30

220

11:30

178

5:30

190

11:30

175

 

 

Tried to eat smaller portions at dinner

2/01

7:00

172

11:30

142

5:30

185

11:00

170

 

 

Felt better today!

 

His morning fasting blood glucose values are still too high and needs p.m. medication or a.m. coverage. He does well for lunch testing so his breakfast meal is OK.

4. Discuss the following info for Mr. Brown and list your recommendations.

 

 

Initial visit

3 month F/U

6 month F/U

9 month F/U

Norm

Weight

226

220

224

221

180

BP

132/84

128/82

144/88

134/80

120/70

A1C

11.3

10.9

11.1

9.6

4–6

Monofilament foot check

Decreased sensation bilaterally

Decreased sensation in toe

Decreased sensation in toe

Decreased sensation in toe

Improving sensation bilaterally in feet

FBG

216

182

190

178

<110

Cholesterol

HDL

LDL

Triglycerides

216

35

116

300

201

40

110

293

200

39

112

306

195

38

102

288

<200mg/dl

>40 mg/dl

<100 mg/dl

<150 mg/dl

Creatinine

Microalbumin

.9

34

.8

30

.9

35

.7

32

0.5-1.4 mg/dl

<30 mg/g

 

5. Where is Mr. Brown making progress? What areas can he improve on?

He is losing weight. His blood pressure is improving, his FBG is better and he must surely be feeling better. He deserves congratulations. He can continue to watch his feet for wounds and healing. Be sure to engage with him on his initial question about using Viagra.

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