DEVELOPING A DIABETIC TEACHING PLAN
Changes 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 complications.
Many 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.
There 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 education.
This 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:
• Simple pathophysiology
a) Basic definition of diabetes (having a high blood glucose level)
b) Normal blood glucose ranges and target blood glucose levels
c) Effect of insulin and exercise (decrease glucose)
d) Effect of food and stress, including illness and infections (increase glucose)
e) Basic treatment approaches
• Treatment modalities
a) Administration of insulin and oral antidiabetes medica-tions
b) Diet information (food groups, timing of meals)
c) Monitoring of blood glucose and ketones
• Recognition, treatment, and prevention of acute compli-cations
• Pragmatic information
a) Where to buy and store insulin, syringes, and glucose monitoring supplies
b) When and how to reach the physician
For patients 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 stages.
Patients 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.
This 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 measures include:
• Foot care
• Eye care
• General hygiene (eg, skin care, oral hygiene)
• Risk factor management (eg, control of blood pressure and blood lipid levels, and normalizing blood glucose levels)
More 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.
Before 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.
Asking 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.
After 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.
A 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.
Maintaining 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.
Various 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.
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