92% of participants will know how to educate a diabetic patient.
92% of participants will know how to educate a diabetic patient.
After completing this module, the learner will be able to:
Diabetes is a chronic, incurable disease, and managing diabetes requires careful attention to diet, exercise, blood glucose levels, and the proper use of medications. Managing diabetes requires patients to make significant and lifelong changes in lifestyle, and it has been established that the incidence and seriousness of diabetic complications can be decreased if the disease is effectively managed.
These changes require a lifelong commitment from the patient. Healthcare professionals can provide information and guidance, but much of the burden for the day-to-day management of the disease must be on the patient, and to successfully live with diabetes, patients need information. They must understand the disease of diabetes, they must understand the importance of therapeutic interventions, and they must follow treatment recommendations. If they do not have the proper information, and they do not adhere to the treatment plan, they will not control the disease; the disease will control them. The responsibility of nurses and other healthcare professionals is to ensure that patients who have diabetes receive the information they need to self-manage their disease and the support they need to apply this knowledge. The incidence of type 1 and type 2 diabetes is already very high, the incidence of both is rapidly increasing, and this trend is expected to continue. Nurses have traditionally taken a lead role in diabetes education, and as the number of people with diabetes increases, this responsibility is sure to grow.
The patient is a 56-year-old male who has type 2 diabetes; he was first diagnosed with the disease 12 years ago. He has come to see his primary care provider (PCP) because, for the past six weeks, he has had numbness and tingling in both feet, extending from the tips of the toes to just below the ankles. For the first four weeks, these sensations were intermittent, but now they are constant. He states that he also has occasional episodes of substernal chest pain; these are brief and occur both at rest and when he is active.
The patient is 5 feet 6 inches, weighs 267 pounds, and BMI of 43.1, placing him in the obese category. He is currently prescribed metformin, 800 mg twice a day, HCTZ, 25 mg twice a day, and lisinopril, 5 mg once a day. He had been prescribed post-prandial insulin but stopped taking it eight months ago because he "felt fine without it." His blood pressure today is 168/92 mm Hg. Aside from the subjective complaints of numbness and tingling in both feet and chest pain, the physical examination and health history are unremarkable. The patient smokes 10-15 cigarettes a day. He does not drink alcohol, and he has a desk job and a sedentary lifestyle.
When asked, the patient cannot identify any long-term complications of diabetes, and although he knows that high serum glucose is not good, he does not know why. He has not spoken in-depth about his disease with a healthcare professional for several years, and he last saw the PCP 14 months ago. The patient cannot remember when he last had an eye examination in the past several years. He confesses that he never examines his feet and does not take any special precautions to protect them. He occasionally skips his metformin doses and antihypertensives, he never exercises, and he measures his blood sugar two to three times a month. Although his primary care provider has offered the patient consultations with a dietician, a physical therapist for an exercise program, appointments with a smoking cessation program, and the name and address of a diabetes support group, the patient has not followed up with any of these as he considers them unnecessary and inconvenient.
The patient is married, and according to the patient his wife "thinks he looks fine," and she does not understand why he needs to “take all those medications” if the patient is relatively happy with his current state of health.
The primary care provider does a 12-lead ECG and obtains a blood sample for measurement of A1C, blood glucose, serum cholesterol, BUN, creatinine, and estimated GFR. The office has laboratory capabilities, and the results are:
Based on the patient's medical history, his somatic complaints, and the results of the laboratory tests and the ECG, the PCP informs the patient that he has atherosclerotic heart disease, kidney damage, and peripheral neuropathy. The PCP also informs the patient that he is at risk for diabetic retinopathy, an extension and worsening of heart disease and kidney disease, and foot ulcers, and only immediate changes in his lifestyle and health habits can prevent these complications.
In the United States, diabetes is an enormous and rapidly growing public health problem, and some key facts from The National Diabetes Statistics Report emphasize this point.1
There are many types of diabetes, and they can be usefully classified into four groups. The condition of pre-diabetes will also be discussed.
Type 1 diabetes: Type 1 diabetes is an autoimmune disease caused by genetic susceptibility and environmental triggers.2 It is characterized by pancreatic β cell destruction and lack of insulin production.2 The onset typically occurs during childhood or adolescence,2 and type 1 diabetes accounts for ~ 5-10% of all cases of the disease in the United States.3,4 In a very small percentage of cases of type 1 diabetes the patients do not secrete insulin, but there is no evidence of autoimmunity; these patients have what is called idiopathic type 1 diabetes.2,4
Type 2 diabetes: Type 2 diabetes is characterized by insulin resistance and a relative lack of insulin production.2,3 Type 2 diabetes is also caused by an interplay of genetics and environment but in this form of the disease the environmental factors that increase the risk of developing type 2 diabetes have been identified, and many of them are modifiable, e.g., diet, obesity, and a sedentary lifestyle.2,4,5
Gestational diabetes: Gestational diabetes is defined as insulin resistance and abnormal glucose tolerance that occurs during pregnancy.6,7 Approximately 9% of all pregnancies are complicated by gestational diabetes.7 Many women who have gestational diabetes will develop the disorder in subsequent pregnancies,8 and approximately 50% will eventually develop type 2 diabetes.6
Diabetes due to other causes: Type 1 and type 2 diabetes account for approximately 95% of all cases of the disease. There are many other types of diabetes, including (but not limited to) drug or chemical-induced diabetes, monogenic diabetes syndromes, diabetes caused by an infection, and diabetes due to diseases such as cystic fibrosis, neonatal diabetes, and Wolfram syndrome, but these are uncommon.2,4
It should also be noted that the traditional separation of diabetes into type 1 and 2 is not absolute and some patients cannot be definitively characterized as having type 1 or type 2 diabetes.4
Pre-diabetes: Pre-diabetes is not a disease itself, but it refers to patients who have glucose levels that are below the criteria for diabetes mellitus but are above normal.4 A cluster of risk factors characterizes pre-diabetes, and an abnormal and progressive impairment of glucose homeostasis that precedes the development of type 1 or type 2 diabetes.2 The diagnostic criteria for pre-diabetes are:
The information in this section is from the American Diabetes Association's (ADA) Standards in the Medical Care of Diabetes – 2020.4
A normal fasting glucose level is 70 to 100 mg/dL. Diagnostic criteria for diabetes mellitus are listed in Table 1.
To diagnosis pre-diabetes, fasting plasma glucose, a two-hour plasma glucose done during an OGTT, or A1C can all be used.4 The diagnostic criteria for pre-diabetes are a fasting plasma glucose of 100 to 120 mg/dL (5.6 to 6.9 mmol/L, or a two-hour plasma glucose during an oral glucose tolerance test of 140 to 199 mg/dL (7.8 to 11.0 mmol/L), or an A1C of 5.7-6.4% (39 to 47 mmol/L).4
To diagnose gestational diabetes, a one-step or a two-step process can be used.4 With the one-step process, the diagnostic criteria for gestational diabetes are a fasting glucose of ≥ 90 mg/dL (5.1 mmol/L), or a one-hour OGTT result of ≥ 180 mg/dL (10.o mmol/L), or a two-hour OGTT result of ≥153 mg/dL (8.5 mmol/L).
For the two-step process, the diagnostic criteria are a fasting glucose of ≥95 mg/dL (5.3 mmol/L), or a one-hour OGTT result of ≥ 180 mg/dL (10.0 mmol/L), or a two-hour OGTT result of ≥ 155 mg/dL (8.6 mmol/L), or a three-hour OGTT result of ≥ 140 mg/dL (7.8 mmol).4
Chronic hyperglycemia initiates pathologic processes that cause inflammation and the free radical formation and initiate cellular damage to many organs and tissues. The complications of type 1 and type 2 diabetes include (but are not limited to) diabetic retinopathy, diabetic nephropathy, diabetic neuropathies, coronary heart disease, cerebrovascular disease, and peripheral arterial disease.9 Diabetes mellitus is a leading cause of blindness, lower limb amputation, chronic kidney disease (CKD), and renal failure.9
Diabetes and its attendant complications is a devastating disease, but there is strong evidence that with glycemic control, lifestyle modifications, the proper use of medications, and control of risk factors like hyperlipidemia and hypertension, pre-diabetes, type 2 diabetes, and diabetic complications can be prevented, delayed, or their progression slowed.9-17 There is also evidence that by using preventive interventions, remission of type 2 diabetes can be attained.17,18
Diabetes is a chronic disease, and although some patients who have type 2 diabetes can achieve remission, diabetes is essentially incurable, and lifelong self-management is necessary. As was mentioned above, preventive interventions can help patients control diabetes. However, many patients who have diabetes cannot or do not lose weight or stop smoking, and they do not have adequate control of their blood pressure, lipid levels, or blood sugar.19-21 Approximately one-third of US adult diabetics do not have the desired A1c levels19,20 and the number who have good glycemic control and have the optimal serum cholesterol level and blood pressure are far less.19 Despite the many advances in diabetic care, therapeutic goals are not being met.21
Fortunately, patient education and targeted interventions can make a difference. The American Diabetes Association (ADA) and other professional organizations recommend diabetes self-management education and support (DSMES). Diabetes self-management education and support improve health outcomes, and quality of life,21 and the ADA and many other professional organizations consider DSMES ". . . as one of the essential elements of comprehensive diabetes medical care, along with medical nutrition therapy.”21
Diabetes self-management education and support is a process that considers the needs, goals, and life experiences of each diabetic patient,21 and it is an evidence-based approach.21 Diabetes self-management education and support is a general approach more than a set of specific recommendations, and its purpose is to provide diabetic patients with knowledge, skills, and support that can be used to self-manage their disease.22 The core principles of DSMES are:21
In brief, the core principles are Access, Coordination, Education, Individual, Ongoing, Self-Management, Support, and Timing.
The essential topics of diabetes patient education are listed below. A convenient way to remember the key points is to think of them as the four M’s-Meals, Motions, Medications, and Monitoring.24
The American Association of Diabetes Care & Education Specialists has established similar priorities for diabetes patient education; these are called the AADE7 Self-Care Behaviors®. 25
A patient who has just been diagnosed with diabetes will be unlikely to know much, if anything, about the disease. Also, many diabetic patients do not have the information they need to self-manage diabetes26-28 and nurses and physicians may not have an adequate knowledge base about diabetes.29-31 Research has shown that lack of knowledge negatively affects a patient’s self-management of diabetes.32
Assessing a patient's knowledge level of diabetes can be accomplished using written material, classroom work, etc. There are many ways to perform this assessment. A useful assessment tool that can be used is the Diabetes Knowledge Test (DKT). The DKT has been in use for many years and is valid and reliable. Several questions from the DKT are listed in Table 3.33
The best way to take care of your feet is to:
If you are beginning to have a low blood glucose reaction, you should:
Numbness and tingling in your feet may be symptoms of:
(Correct answers bolded)
Patients do not need in-depth knowledge of the pathological process of diabetes, but they should have the information that is essential for successful self-management of the disease. The following points should be covered; the level of detail that is provided will be situationally dependent.
What is diabetes: Diabetes is a chronic disease that affects the body's ability to control blood sugar level. If it is not properly treated, diabetes causes high blood sugar levels and chronic high blood sugar - hyperglycemia - can cause serious complications.
The causes of diabetes: Type 1 diabetes is caused by the destruction of the pancreatic cells that produce insulin. Type 2 diabetes is caused by insufficient insulin production and an inability to use the available insulin. Type 1 diabetes is essentially genetic and inherited. Type 2 diabetes is caused by susceptibility to the disease and lifestyle factors.
What is insulin: Insulin is a naturally produced hormone that is used to carry glucose from the blood to the cells and tissues. Without insulin, glucose cannot be used by the body, and it accumulates in the blood.
Glucose: Glucose, commonly called blood sugar, is one of the primary sources of energy for the body.
The consequences of high blood glucose: Without insulin, blood glucose levels will become abnormally high, and chronic hyperglycemia causes progressive damage to the eyes, the kidneys, and the peripheral nerves. Chronic hyperglycemia also increases the risk of developing cardiovascular diseases such as atherosclerosis, hypertension, and stroke.
A cure for diabetes: Type 1 diabetes cannot be cured, and someone who has this disease must be on life-long insulin therapy. Type 2 diabetes can be controlled but not cured, and someone who has type 2 diabetes must be on a life-long program of diabetes self-management.
Careful attention to diet is one of the cornerstones of diabetes self-management.34,35 A consultation with a dietician or education from a diabetes education professional is considered mandatory when someone is initially diagnosed with diabetes, and periodic follow-ups are especially important. The basic principles that patients should learn are listed below.
Diet and diabetes: Patients must be taught that food is converted to glucose, and diabetes is a disease characterized by an inability to regulate blood glucose, so attention to diet is the cornerstone of diabetic self-management. Medications, exercise, weight loss, and other lifestyle changes cannot change the course of diabetes if the patient does not eat a proper diet, and her/he has chronic hyperglycemia.
Weight management: Weight loss and weight control can slow down and prevent the progression of pre-diabetes to type 2 diabetes.34,35 If you have type 2 diabetes, weight loss and weight control can also help you attain control of blood sugar, reduce the need for medications, and prevent diabetic complications.
Diet specifics: Diet is perhaps the most challenging and confusing part of diabetic self-management, and patients will want to know what to eat, how much to eat when to eat, and what foods they should avoid. The dietician or the diabetic educator will provide each patient with dietary details specific to him/her. But it is reasonable for any healthcare professional to inform a patient of the following points.
Exercise is another vital part of diabetes self-management.34,35
Exercise helps patients lose weight, it improves glycemic control and insulin sensitivity, it helps decrease the risk for, and the severity of the cardiovascular disease,36 and it can help prevent or delay the onset of type 2 diabetes.10
Exercise prescriptions will be given to each patient, but every patient who has the disease should be informed that of its benefits. Aerobic exercise and resistance exercise can be included in the exercise program as both have been shown, alone or in combination, to be effective for patients who have pre-diabetes, type 1 diabetes, or type 2 diabetes.37,38
Unfortunately, many people who have diabetes smoke.39 Smoking increases the risk of developing type 2 diabetes and diabetic complications,10,39,40 it increases insulin needs, it increases insulin resistance, and it increases the risk of hypoglycemia.39 Smoking cessation is considered an essential part of diabetes care.10
Blood glucose monitoring is a complex topic. There are many ways to do it, and blood glucose monitoring is a lifelong concern for type 1 and type 2 diabetics. The following basic points should be covered with each diabetic patient.
Diabetic medications work by:
Teaching patients with diabetes about their medications is usually the responsibility of the diabetes educator, and it is beyond the scope of this module to discuss all the possible diabetic drug regimens. However, every nurse who is caring for patients who have diabetes should be able to provide patients with the basic information they need to use their medications safely and effectively.
A patient who has diabetes must know what medications she/he takes, e.g., the name and dose, when and how to take them, and the side effects of each drug. The patient should be advised that he/she should never stop taking diabetic medication, skip doses, or take more or less than what has been prescribed. It should be stressed to patients who have type 1 diabetes that they can never stop using insulin, and patients who have type 2 diabetes should be informed that as they age, lifestyle changes and oral medications may not be sufficient to attain glycemic control and they may need insulin. Finally, there are many commonly used prescription medications, over-the-counter drugs, and supplements that can affect the action of diabetic medications.42 Patients should be advised to ask a physician, pharmacist, or another healthcare provider before taking a prescription medication, over-the-counter medications, herbal product, or dietary supplement for the first time.
The previous points may seem very obvious, but it has been well documented that many patients do not have adequate knowledge of their medications, and patients who have diabetes often do not adhere to their medication regimen or do not use their diabetic medications properly.43,44
The acute complications of diabetes are hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar syndrome (HHS). Patients should be advised that the latter two are acute, but compared to hypoglycemia, they develop over a longer period, and they are characterized by extremely high serum glucose. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are primarily caused by poor compliance with the diabetic medication regimen or acute infection or illness. The signs and symptoms of these complications are non-specific, but mental status changes, polydipsia, polyuria, and weakness are often seen. Patients who have diabetes should be informed that if they develop any of these signs/symptoms and high serum glucose, they may have DKA or hyperglycemic hyperosmolar syndrome and that these are serious, life-threatening complications.
Hypoglycemia is much more common than DKA or hyperglycemic hyperosmolar syndrome, so patients should be educated about the causes, consequences, signs and symptoms, treatment of hypoglycemia, and hypoglycemia unawareness. Also, every time patients have contact with a healthcare professional, they should be asked when and how often they have hypoglycemia.
Patient teaching points about hypoglycemia should include the following:
Treatment recommendations for hypoglycemia are listed in Table 4.
The most common chronic complications of diabetes that are specific to the disease and chronic hyperglycemia are diabetic nephropathy, diabetic neuropathy, diabetic retinopathy, and diabetic foot ulcers (Note: Diabetic neuropathy predisposes patients to the development of foot ulcers). Patients should not be expected to understand these complications in detail. However, diabetic patients should be educated so that they understand how serious these complications are and how they can be prevented. A periodic assessment of a patient's knowledge of the topic should be scheduled, as well.
A DSME program should include the following facts about diabetic complications:
Diabetic foot ulcers deserve special mention because:
Educating about the proper use of medications is an essential part of diabetic education.
Insulin injection: Insulin should be injected into the subcutaneous tissue, aka fat.50 Injection into muscle tissue can cause erratic and unpredictable absorption of insulin and can cause hypoglycemia.50 Intramuscular injection is more likely to happen if the patient is young, lean, or is using a long needle.50
The recommended injection sites are the abdomen, the buttocks, the thighs, and the upper arms, and these sites should be rotated.50 Constant use of the same site will cause fat to accumulate at the injection site, a condition called lipodystrophy, and this can cause erratic, unpredictable absorption of the drug and hypoglycemia.50
The basic insulin injection technique that should be taught is:51
It is not recommended that insulin be injected through clothing, but it does not appear that this will cause harm.51
Insulin needles and syringes should be considered infectious; they should be disposed of in a hazardous waste container, not into a simple wastebasket 51
Insulin needles and syringes are for one-time use only.51
Insulin bottles should be stored correctly, and directions for storage will be provided with each prescription. If the patient suspects or knows that insulin has not been stored correctly, she/he should contact the dispensing pharmacy.
Oral medications: Oral diabetic drugs must be taken according to schedule. Doses should not be skipped unless the patient has been advised to do so by a clinician, and extra doses should not be taken. Patients should be educated about adverse drug effects, particularly adverse effects that can affect glycemic control, e.g., hypoglycemia, diarrhea, nausea, and vomiting.
Complying with a diabetic treatment regimen is a lifelong commitment. Unfortunately, many people find the lifestyle changes, consistent and safe use of diabetic medications, and self-monitoring of blood glucose to be, at times, difficult. As mentioned earlier, many diabetic patients do not stop smoking, and they do not have adequate control of their blood pressure, lipid levels, or blood sugar.19-21 Approximately one-third of US adult diabetics do not have the desired A1c levels19,20 and the number who have good glycemic control and have the optimal serum cholesterol level and blood pressure are far less.19 Despite the many advances in diabetic care, therapeutic goals are not being met.21
There are many reasons why patients do not adhere or adhere inconsistently and incompletely with a diabetic treatment regimen, including, but not limited to:19,23,52-56
Barriers to compliance should be identified, and the patient's active participation should be used to address these barriers using specific treatments. The goals should be clear and behavior-oriented, and a follow-up schedule should be made. There is a considerable amount of information and activity that is required of diabetic patients for them to effectively self-manage the disease. The lifelong need to self-manage diabetes compounds this challenge, and patients may develop a syndrome called diabetic distress.23 Diabetic distress “refers to significant negative psychological reactions related to emotional burdens and worries specific to an individual's experience in having to manage a severe, complicated, and demanding chronic disease such as diabetes.23" Diabetic distress is a common problem, and it can harm many aspects of self-management, e.g., adherence to the medication regimen, higher A1C levels, and poor diet and exercise habits.23 All healthcare professionals that care for diabetic patients should be aware of this syndrome, and periodic evaluation for its presence is recommended.23
Managing diabetes requires patients to make significant and lifelong changes in lifestyle, and it has been established that the incidence and seriousness of diabetic complications and the incidence of type 2 diabetes can be decreased if the disease is effectively managed.
Day-to-day management of diabetes is the responsibility of the patient successful self-care of diabetes requires education. Nurses and other healthcare professionals are to ensure that patients who have diabetes receive the information they need to self-manage their disease and the support they need to apply this knowledge.
The American Diabetes Association and the American Association of Diabetes Educators strongly support the need for DSME. A successful DSME program:
The goals of a DSME should include:
The specifics of each program will vary depending on individual needs. However, the basic content should include the following topics, and every nurse who cares for diabetic patients would be able to discuss them with her/his patients.