A DIABETIC TEACHING PLAN
in the health care delivery system as a whole have had a major impact on
diabetes education and training. Patients with new-onset type 1 diabetes have
much shorter hospital stays or may be managed completely on an outpatient basis;
patients with new-onset type 2 diabetes are rarely hospitalized for initial
care. There has been a proliferation of outpatient diabetes education and
training programs, with increasing support of third-party re-imbursement. For
some patients, however, exposure to diabetes education during hospitalization
may be the only opportunity for learning self-management skills and preventing
hospitals employ nurses who specialize in diabetes edu-cation and management
and who are certified by the National Certification Board of Diabetes Educators
as Certified Diabetes Educators. However, because of the large number of
diabetic pa-tients who are admitted to every unit of a hospital for reasons
other than diabetes or its complications, the staff nurse plays a vital role in
identifying diabetic patients, assessing self-care skills, providing basic
education, reinforcing the teaching provided by the specialist, and referring
patients for follow-up care after dis-charge. Diabetes patient education programs
that have been peer-reviewed by the ADA as meeting National Standards for
Diabetes Education can seek reimbursement for education.
are various strategies for organizing and prioritizing the vast amount of
information that must be taught to diabetic patients. In addition, many
hospitals and outpatient diabetes cen-ters have devised written guidelines,
care plans, and documentation forms (often based on guidelines from the ADA)
that may be used to document and evaluate teaching. A general approach is to
organize information and skills into two main types: basic, initial, or
“survival” skills and information, and in-depth (ad-vanced) or continuing
information must be taught to any patient with newly di-agnosed type 1 or type
2 diabetes and any patient receiving in-sulin for the first time. This basic
information is literally what the patient must know to survive—that is, to
avoid severe hypo-glycemic or acute hyperglycemic complications after
discharge. An outline of survival information includes:
a) Basic definition of
diabetes (having a high blood glucose level)
Normal blood glucose ranges and target blood
Effect of insulin and exercise (decrease glucose)
d) Effect of food and
stress, including illness and infections (increase glucose)
Basic treatment approaches
Administration of insulin and oral antidiabetes
Diet information (food groups, timing of meals)
Monitoring of blood glucose and ketones
Recognition, treatment, and prevention of acute
a) Where to buy and store
insulin, syringes, and glucose monitoring supplies
When and how to reach the physician
with newly diagnosed type 2 diabetes, emphasis is initially placed on diet.
Patients starting to take oral sulfonyl-ureas or meglitinides need to know
about detecting, preventing and treating hypoglycemia. If diabetes has gone
undetected for many years, the patient may already be experiencing some chronic
diabetic complications. Thus, for some patients with newly diagnosed type 2
diabetes, the basic diabetes teaching must include information on preventive
skills, such as foot care and eye care—for example, planning yearly or more
frequent complete (dilated eye) examinations by the ophthalmologist and
under-standing that retinopathy is largely asymptomatic until the ad-vanced
also need to realize that once they master the basic skills and information,
further diabetes education must be pur-sued. Acquiring in-depth and advanced
diabetes knowledge oc-curs throughout the patient’s lifetime, both formally
through programs of continuing education and informally through expe-rience and
sharing of information with other people with diabetes.
involves teaching more detailed information related to sur-vival skills (eg,
learning to vary diet and insulin and preparing for travel) as well as learning
preventive measures for avoiding long-term diabetic complications. Preventive
General hygiene (eg, skin care, oral hygiene)
Risk factor management (eg, control of blood
pressure and blood lipid levels, and normalizing blood glucose levels)
advanced continuing education may include alternative methods for insulin
delivery, such as the insulin pump, and al-gorithms or rules for evaluating and
adjusting insulin doses. For example, patients can be taught to increase or
decrease insulin doses based on a several-day pattern of blood glucose levels.
The degree of advanced diabetes education to be provided depends on the
patient’s interest and ability. However, learning preventive measures
(especially foot care and eye care) is mandatory for re-ducing the occurrence
of amputations and blindness in diabetic patients.
initiating diabetes education, the nurse assesses the pa-tient’s (and family’s)
readiness to learn (Beebe & O’Donnell, 2001). When patients are first
diagnosed with diabetes (or first told of their need for insulin), they often
go through various stages of the grieving process. These stages may include
shock and denial, anger, depression, negotiation, and acceptance. The amount of
time it takes for patients and family members to work through the grieving
process varies from patient to patient. They may ex-perience helplessness,
guilt, altered body image, loss of self-esteem, and concern about the future.
The nurse must assess the patient’s coping strategies and reassure patients and
families that feelings of depression and shock are normal.
the patient and family about their major concerns or fears is an important way
to learn about any misinformation that may be contributing to anxiety. Some
common misconceptions regarding diabetes and its treatment are listed in Table
41-7. Simple, direct information should be provided to dispel miscon-ceptions.
More information can be provided once the patient masters survival skills.
dispelling misconceptions or answering questions that concern the patient the
most, the nurse focuses attention on con-crete survival skills. Because of the
immediate need for multiple new skills, teaching is initiated as soon as
possible after diagnosis. Nurses whose patients are in the hospital rarely have
the luxury of waiting until the patient feels ready to learn; short hospital
stays necessitate initiation of survival skill education as early as possible.
This gives the patient the opportunity to practice skills with supervision by
the nurse before discharge. Follow-up by home health nurses is often necessary
for reinforcement of sur-vival skills.
major goal of patient teaching is an educated consumer, a patient who is
informed about the wide variations in the prices of medications and supplies
and about the importance of com-paring prices.
flexibility in teaching approaches is important. Teaching skills and
information in a logical sequence is not al-ways the most helpful for patients.
For example, many patients fear the injection. Before they learn how to draw
up, purchase, store, and mix insulins, they should be taught to insert the
needle and inject insulin (or practice with saline solution). Numerous
demonstrations by the nurse or practice injections before the pa-tient (or
family) gives the first injection may actually increase the patient’s anxiety
and fear of self-injection. Once patients have ac-tually performed the
injection, most are more prepared to hear and to comprehend other information.
(If they then want to practice further using a pillow or an orange, that would
be ap-propriate.) Thus, having patients self-inject first or having pa-tients
perform a fingerstick for glucose monitoring first may enhance learning to draw
up the insulin or to operate the glucose meter. Ample opportunity should be
provided for the patient and family to practice skills under supervision
(including self-injection, self-testing, meal selection, verbalization of
symptoms, and treatment of hypoglycemia). Once skills have been mastered,
participation in ongoing support groups may assist patients in incorporating
new habits and maintaining adherence to the treat-ment regimen.
tools can be used to complement teaching. Many of the companies that
manufacture products for diabetes self-care also provide booklets and
videotapes to assist in patient teaching. It is important to use a variety of
written handouts that match the patient’s learning needs (including different
languages, low-literacy information, large print). Patients can continue
learning about diabetes care by participating in activities sponsored by local
hospitals and diabetes organizations. In addition, magazines with information
on all aspects of diabetes management are avail-able for people with diabetes.