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Diabetic Patient Education

2 Contact Hours including 2 Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Clinical Nurse Specialist (CNS), Dietitian/Nutritionalist (RDN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Thursday, September 8, 2022
FPTA Approval:CE20-540151. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

92% of participants will know how to educate a diabetic patient.

Objectives

After completing this module, the learner will be able to:

  1. Identify basic facts about the causes, pathological process, diagnosis, complications, and treatment of diabetes.
  2. Explain why glycemic control is important.
  3. Identify the four M’s for diabetes self-management.
  4. Identify two important concepts of diabetic complications.
  5. Identify common barriers that prevent adherence to and compliance with the diabetic treatment regimen.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Dana Bartlett (RN, BSN, MA, MA, CSPI)

Introduction

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.

Case Study #1

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:

  • A1C - 9.4%
  • Blood glucose - 219 mg/dL
  • Serum cholesterol - 199 mg/dL
  • BUN - 24 mg/dL
  • Creatinine - 1.9 mg/dL
  • Estimated GFR – 50-54 mL/min/1.73 m2
  • The 12-lead ECG shows evidence of a mild degree of left ventricular hypertrophy.

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.

An Overview Of Diabetes

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

  • More than 1 in 10 Americans — 34.2 million people — have diabetes.
  • Approximately 1 in 3 American adults — 88 million people — have pre-diabetes.
  • Most Americans who have pre-diabetes do not know they have the disease.
  • New cases of diabetes were higher in non-Hispanic blacks and people of Hispanic origin than in non-Hispanic Asians and non-Hispanic whites.
  • American Indians and Alaskan Natives have the highest percentage of existing cases of diabetes.
  • New cases of type 1 and type 2 diabetes have significantly increased in American youth.
  • Many American adults who have diabetes are overweight, they smoke, and they have serious diabetes-related co-morbidities.

Diabetes Classification and Pathophysiology

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:

  • A fasting plasma glucose of 100 to 120 mg/dL
  • or a two-hour plasma glucose during an oral glucose tolerance test of 140 to 199 mg/dL
  • or an A1C of 5.7-6.4%.4

Screening for Diabetes and Diagnosis of Diabetes

Screening

The information in this section is from the American Diabetes Association's (ADA) Standards in the Medical Care of Diabetes – 2020.4

  • All adults should be tested for diabetes beginning at age 45.
  • Adults of any age should be tested for diabetes or pre-diabetes if they are overweight or obese (BMI ≥ 25 kg/m2 or ≥ 23 kg/m2 in Asian Americans) or if they have one or more of the following additional risk factors for diabetes that are listed below.4 If the screening tests are normal, they should be repeated at three-year intervals, at a minimum.4
    • First-degree relative with diabetes.
    • HDL cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L).
    • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander).
    • History of cardiovascular disease (CVD).
    • Hypertension: ≥140/90 mmHg or on therapy for hypertension.
    • Other clinical conditions associated with insulin resistance, e.g., severe obesity, acanthosis nigricans (A skin condition that occurs in people who have diabetes or who are obese).
    • Sedentary lifestyle.
    • Women who have polycystic ovary syndrome.
  • For children and adolescents who are overweight (BMI ≥ 85th percentile) or obese (BMI ≥ 95th percentile, risk-based screening for pre-diabetes or type 2 diabetes should be considered after the onset of puberty or after ten years of age, whichever is first.4 Risk factors for diabetes in this population are:4
    • A first-degree or second-degree relative who has/had type 2 diabetes.
    • Gestational diabetes during the child's gestation.
    • Native American, African American, Latino, Asian American, Pacific Islander ethnicity.
    • Conditions associated with insulin resistance (Acanthosis nigricans, dyslipidemia, hypertension, polycystic ovary disease, or small for gestational age birth weight) or signs of insulin resistance.
  • Patients who have pre-diabetes should be tested every year.4
  • Women who have had gestational diabetes should be tested at least every three years for life.4

Diagnosis of Diabetes

A normal fasting glucose level is 70 to 100 mg/dL. Diagnostic criteria for diabetes mellitus are listed in Table 1.

Table 1: Criteria for the Diagnosis of Diabetes Mellitus4
  • Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least eight hoursOR
  • A two-hour plasma glucose ≥200 mg/dL (11.1mmol/L) during an oral glucose tolerance test (OGTT) OR
  • A1C ≥ 6.5% (48 mmol/mol) OR
  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L)

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

Diabetic Complications

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

Diabetic Patient Education: Basic Principles

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

  • Diabetes self-management education and support is an ongoing process.
  • Providers should inform all patients who have diabetes of the benefits and value of initial and ongoing DSMES. (Note: The benefits of DSMES are listed below in Table 2).
  • There are four times when DSMES is most needed and should be provided:
    • At the time of diagnosis.
    • Annually or when the patient is not meeting the treatment goals.
    • When complicating factors occur.
    • When transitions in care or the patient's life occur.
  • Diabetes self-management education and support should consider the clinical, educational, psychosocial, and behavioral aspects of self-management.
  • Each patient should be evaluated for possible access issues and barriers to effective self-care such as cultural, geographical, economic, language, and monetary barriers.
  • The medical nutrition plan should be coordinated with the overall DSMES plan, the patient's medication regimen, and her/his physical activity schedule.
  • Ensure coordination of the medical nutrition therapy plan with the overall management strategy, including the DSMES plan, medications, and physical activity on an ongoing basis.
  • Identify and address barriers affecting participation with DSMES services following referral.
  • Self-management by the patient is essential.

In brief, the core principles are Access, Coordination, Education, Individual, Ongoing, Self-Management, Support, and Timing.

Table 2: Benefits of DSMES21,23
  • A1C reduction
  • Decreases diabetes-related distress
  • Enhancement of self-efficacy and empowerment
  • Increased healthy coping
  • Improved quality of life
  • Promotes healthy lifestyle behaviors
  • Reduction in onset and worsening of diabetic complications
  • Reduction in all-cause mortality

Components of Diabetes Patient Education

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

  1. Assessment of the patient's knowledge of diabetes
  2. Basic information about the pathological process of diabetes
  3. Nutritional issues
  4. Exercise
  5. Smoking cessation
  6. Blood glucose monitoring
  7. Safe and effective use of medications
  8. Acute complications
  9. Chronic complications

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

  1. Being active
  2. Healthy coping
  3. Healthy eating
  4. Monitoring
  5. Problem-solving
  6. Reducing risks
  7. Taking medications

Assessing a Patient's Knowledge of Diabetes

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

Table 3: DKT Questions

The best way to take care of your feet is to:

  1. Look at and wash feet each day.
  2. Massage feet with alcohol each day.
  3. Soak them for 1 hour each day.
  4. Buy shoes a size larger than usual.

If you are beginning to have a low blood glucose reaction, you should:

  1. Exercise.
  2. Lie down and rest.
  3. Drink some juice.
  4. Take rapid-acting insulin.

Numbness and tingling in your feet may be symptoms of:

  1. Kidney disease.
  2. Nerve disease.
  3. Eye disease.
  4. Liver disease.

(Correct answers bolded)

The Pathological Process of Diabetes

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.

Nutritional Issues

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.

  1. A proper diet is the cornerstone of diabetic self-management.
  2. A typical diet prescription for a patient who has diabetes is not radically different than a "normal" diet.
  3. Weight loss/weight control is highly beneficial.
  4. Knowing what to eat, how much, and when is an ongoing process and a flexible approach is best.
  5. The ideal amount of carbohydrates for diabetic patients is not known, but as carbohydrates are quickly converted to glucose, monitoring carbohydrate intake is especially important.
  6. The ideal amount of fat for diabetic patients is not known. However, dyslipidemia is quite common in patients who have type 2 diabetes. Dyslipidemia is especially harmful to diabetics so a diet that emphasizes monounsaturated fats and avoiding trans-fats and saturated fats should be stressed, and frequent measurement of the lipid profile is desirable.
  7. The ideal amount of protein for diabetic patients is not known.
  8. Supplementation with vitamins or minerals is not needed if you are eating a balanced diet and there is no evidence for its benefits.
  9. Alcohol can cause delayed hypoglycemia, especially if the patient takes insulin or an insulin secretagogue. Also, the symptoms of alcohol intoxication and hypoglycemia are, in many ways, identical. You should drink alcohol in moderation, two drinks a day for men, one drink a day for women.
  10. Avoid sugar-sweetened beverages.

Exercise

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

Smoking Cessation

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

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.

  1. Blood glucose monitoring is done daily and periodically.
  2. Periodic glucose monitoring is done by measuring A1C, and the goal for most (but not all) patients is an A1C < 7%.41 Higher and lower A1C levels may be acceptable in certain situations, e.g., older adults.41 The A1C should be measured at least twice a year if the patient is following the prescribed treatment regimen, and the daily glucose levels are within the target range. More frequent testing may be necessary, e.g., four times a year.41
  3. The A1C level is used to predict the risk of long-term diabetic complications and to determine the effectiveness of the diabetic treatment regimen.
  4. Daily glucose monitoring is used to adjust food intake, adjust exercise intensity and frequency, and determine the proper use of diabetic medications.
  5. The blood glucose level that is desirable differs for each person, but low and high levels can cause acute and chronic complications.
  6. Each patient should be given clear, goal-oriented instructions about what to do if the blood glucose level is too high or too low.
  7. Blood glucose levels can be affected by infections, illness, and stress, and more frequent glucose monitoring will be needed during these situations.
  8. Accurate self-monitoring of blood glucose depends on the proper use of the equipment.
  9. For most people, a fasting blood glucose level should be between 80-130 mg/dL, and one-two hours after a meal, a blood glucose level should be < 180 mg/dL.41

Safe and Effective Use of Medications

Diabetic medications work by:

  • Providing exogenous insulin
  • Increasing the production or release of insulin
  • Decreasing the absorption of glucose
  • Increasing sensitivity to the effects of insulin, and
  • Decreasing/inhibiting the release/synthesis of glucagon

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

Acute Complications

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:

  • Hypoglycemia is more common in people who have type 1 diabetes, but many people who have type 2 diabetes have hypoglycemic episodes.45
  • Level 1 hypoglycemia is defined as a blood glucose level < 70 mg/dL.41
  • Level 2 hypoglycemia is defined as blood glucose level < 54 mg/dL, the patient is symptomatic, and treatment is needed.41
  • Level 3 hypoglycemia is blood glucose level so low that the patient has profound signs and symptoms of hypoglycemia and he/she cannot self-treat.41
  • Hypoglycemia can occur without signs and symptoms.41
  • The basic causes of hypoglycemia in a patient who has diabetes are too much insulin and a lack of blood sugar.
  • An individual hypoglycemic episode may not be dangerous, but over time frequent, multiple hypoglycemic events may negatively affect cognitive function, they can increase the risk of the development of a cardiovascular disease, a severe hypoglycemic event can cause death, and hypoglycemic events increase the risk of mortality.41,45,46
  • Typical signs and symptoms of hypoglycemia include (but are not limited to) agitation, confusion, dizziness, drowsiness, irritability, palpitations, sweating, and weakness.41,45,46
  • Some people can have significant hypoglycemia, but the body's response mechanisms fail to provide warning signs and symptoms, a condition called hypoglycemia unawareness.41
  • Hypoglycemia unawareness is not an unusual occurrence,41 and it is very common in type 1 diabetics, affecting as many of 35% of patients who have the disease.47

Treatment recommendations for hypoglycemia are listed in Table 4.

Table 4: Treatment of Hypoglycemia
  • Symptomatic hypoglycemia: Ingest carbohydrates - 15-20 grams of glucose is preferred - and repeat the blood glucose measurement in 15 minutes.
  • If the blood glucose is still low, ingesting more glucose until the glucose level is normal and then have a meal or a snack.
  • Fats can retard and prolong the glycemic response, and proteins can increase the insulin response without increasing the glucose level, so carbohydrates are preferred for treating hypoglycemia.41
  • Glucagon should be prescribed for anyone who has level 2 hypoglycemia.41
  • There is no proven benefit to trying to give an unconscious hypoglycemic patient glucose by way of the buccal mucosa.45

Chronic Complications

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:

  • Good glycemic control can prevent diabetic complications, and good glycemic control is a personal responsibility
  • Chronic diabetic complications develop very slowly, and they often do not cause obvious signs or symptoms until the pathologies are very advanced
  • In consideration of point number 2, it should be stressed that prevention of chronic diabetic complications also depends on periodic assessments by a physician or other health care provider
  • Patients should be given a schedule that clearly outlines when and how often they should have eye examinations, an assessment of their renal function and for the presence of peripheral neuropathy, and an examination for the presence of and risk of foot ulcers
  • Compliance with the preventive assessment schedule is crucial

Diabetic foot ulcers deserve special mention because:

  • They are quite common, and
  • There are many measures a patient can do to prevent diabetic foot ulcers.48
Table 5: Diabetic Foot Care
  • Early recognition of diabetic patients who are at risk for foot ulcers can delay and prevent bad outcomes.48
  • A foot examination by a physician or other healthcare professional should be done at least once a year.48
  • Poor glycemic control and cigarette smoking increase the risk of developing a diabetic foot ulcer, and these are issues that the patient can control.48,49
  • Check your feet every day, and do not forget to examine the bottom of your feet. Look for blisters, calluses, cuts, red spots, swelling, or any other abnormalities and call your physician or healthcare provider if there is a problem.49
  • Wash your feet every day. Dry them gently and then apply a moisturizing lotion or cream.49
  • Always wear comfortable shoes – they should not be tight – and wear clean, dry socks.49
  • Trim the toenails straight across. Do not cut them too short, and do not cut them down the sides.
  • Diabetes often causes peripheral nerve damage, so cold and heat sensation can be blunted. Do not expose your feet to very cold or hot conditions; you may suffer a thermal burn and not be aware of it. Do not go barefoot.49

Medication Administration

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

  • Choose a site.
  • Unless the skin is dirty, there is no need to clean the site.
  • Pull up and pinch a fold of skin.
  • Insert the needle at a 90° angle.
  • Push the plunger and hold the syringe and needle in place for 5-10 seconds.6 Remove the needle.
  • Do not rub the injection site.

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.

Adherence to a Diabetic Treatment Regimen and Follow-Up Care

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

  • Poor understanding of DSME specifics, e.g., self-monitoring of glucose, safe and effective use of medications
  • Financial constraints
  • Cultural barriers
  • Language barriers
  • Literacy and educational barriers
  • Family constraints or responsibilities
  • Poor availability of or inconvenient access to healthcare resources
  • Misconceptions and fears about the benefits and risks of diabetic treatments
  • Misconceptions about diabetes
  • Lack of family, social, or professional support
  • Psychological or emotional issues

Assessing and Encouraging Compliance

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

Summary

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:

  • Will address the issues of access and barriers.
  • Will have a high level of coordination between the healthcare professionals and the healthcare professionals and the patient.
  • Involve at least one instructor who has training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE (Certified Diabetes Educator) or BC-ADM (Board Certification in Advanced Diabetes Management.
  • Use the latest evidence-based information.
  • Have clear, behavior-oriented goals and frequent assessment of the patient's progress.
  • Be patient centered.
  • Involve the community, family, and professional support systems.
  • Be delivered at the time of diagnosis; annually, with an assessment of educational, nutritional, and emotional needs; when factors arise that complicate self-management, and when transitions in care occur.

The goals of a DSME should include:

  • Describing diabetes and diabetes treatments
  • Nutritional management as part of a lifestyle
  • Physical activity as a part of a lifestyle
  • Using medication(s) safely and for maximum therapeutic effectiveness
  • Monitoring blood glucose and other parameters and interpreting/using these values and for good self-management
  • Preventing, detecting, and treating acute complications
  • Preventing, detecting, and treating chronic complications
  • Personal ways to cope with psychosocial issues and concerns
  • Developing personal strategies to promote health and behavior change

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.

  1. Assessment of the patient's knowledge of diabetes
  2. Basic information about the pathological process of diabetes
  3. Nutritional issues
  4. Exercise
  5. Smoking cessation
  6. Blood glucose monitoring
  7. Safe and effective use of medications
  8. Acute complications
  9. Chronic complications

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

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