Diabetes is an acute metabolic disorder that is characterized by high levels of blood glucose. The disease is triggered by failure of the pancreas to secrete sufficient insulin or failure of the body to effectively utilize the insulin that is produced by the pancreas. Insulin is the hormone responsible for regulation of blood glucose in the body. The condition of high levels of blood glucose in the body which is typical of diabetes is called hyperglycemia. Hyperglycemia is toxic and if uncontrolled it ends up damaging the cardio-vascular system, the respiratory system and the nervous system (Mertig, 2007).
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Approximately 6.2% of the population in the United States suffers from diabetes. The percentage translates to 17 million people. People suffering from diabetes require extensive education in order to manage the disease effectively. They must learn how to control the level of glucose and other ways of preventing the disease from becoming complicated. The patients must therefore plan their menu and food, plan their exercise routines, take care of their skins, regulate occurrences of other diseases that are related to diabetes, learn about the cycles of the disease, and manage hyperglycemic/hypoglycemic incidents (Payrot, 2007).
Most of the patients diagnosed with diabetes annually have no idea about the drastic changes that they are bound to make in their lifestyle and nutrition. These lifestyle changes pose the greatest challenge to diabetes patients. The main objective of this teaching plan is to empower patients suffering from diabetes with information so that they could be able to take individual initiatives towards management of the diabetes and improve the general health of their bodies.
The assessment of the patients was based on their ability, willingness and limitations of learning, degree of knowledge about diabetes and lifestyle choices. Instead of making a standard generalized plan, the individual needs of every patient were analyzed. The metabolic needs of patients varied between newly diagnosed patients and patients in late stages of progression of the disease. Age was also taken into consideration since younger patients will be required to manage diabetes for a relatively longer time as opposed to older patients who may not have to maintain diabetes for a long time due to their advanced years. The management needs of a 40 year old patient will certainly differ from those of an 80 year old patient or those of a 60 year old patient. The younger patient has more time to develop complications, requires drastic lifestyle changes, is more likely to be depressed and therefore requires more rigorous therapy.
The lifestyles of the learners vary a lot. Some of them have daily schedules that vary widely and inconsistent patterns in their life due to the nature of their work and other social relationships. They might therefore have several combinations of medication or multiple insulin injections on a daily basis. On the other hand, patients with regular routines will require mono-therapy or regular insulin injections. The patients’ level of knowledge about diabetes will also affect the teaching program whereas more experienced patients will be called upon to share their skills with newly diagnosed patients since peer teaching is usually very effective.
The main objectives of the teaching plan are as listed below:
· The patient will be able to make descriptions of diabetic medicines that have been prescribed by the doctor or any other medical officer and the instructions given regarding how and when the medication should be taken.
· The patient will be able to use a blood glucose meter effectively to self-monitor his/her glucose levels after observing a nurse or any other medical officer doing so.
· The patient will be able to take proper care of the skin and feet and be in a position to demonstrate the process.
· The patient will also be able to give detailed benefits of regular exercising and its role in improving control of blood glucose levels.
Since the teaching plan’s main aim is to encourage individual changes in lifestyle and behavior, the plan is tailor-made for each patient with regard to the abilities, needs and the respective stage of the patient in the diabetes cycle (Raid et al, 2007). Each patient must therefore have an individual meal plan that is tailor-made for his or her lifestyle, long term and short term goals on lifestyle adjustment, and knowledge on importance of undergoing a dietary therapy. The importance of adhering to the treatment regimen will be emphasized to the patient in the teaching plan.
The teaching plan is designed in such a way as to help newly diagnosed patients and patients who need to evaluate their diabetes management practices. This cannot happen at once and there must be continuous therapy since management of diabetes requires regular evaluation and changes as the disease progresses. The regular continuous education will be carried out through regular meetings between me and the patient where we can talk face to face at a convenient time.
Since patients attending the class will be at different stages of the disease, the teaching plan will be designed to entail the learning capability, the stage of the disease, and the patient’s aptitude. The strategies to be used in the teaching process will include lectures, PowerPoint presentations, group discussions, videos and demonstrations by the health practitioner. The sessions will take from two to four hours whereby the first two/three hours will be used for teaching and the remaining one hour will be used to discuss issues affecting the group members. The topics will be given in the following order:
· Overall overview of the disease (2hours)
· The objectives and process of monitoring blood glucose levels (3 hours)
· Insulin and other medication (2 hours)
· Role of regular exercises in diabetes management (30 minutes)
· Feet and skin care (30 minutes)
· Complications that may arise from diabetes (1 hour)
· Role of dietary therapy in diabetes (2 hours)
· How to manage and cope with diabetes (2 hours)
· Review of patient’s questions and grey areas (2 hours)
· Questions and answer session (1 hour).
The topics will be covered within a time frame of six days.
Evidence of Implementation
Overall Overview of the Disease
A diabetes patient must understand the meaning of diabetes and the terms associated with the disease. Patients who comprehend the nature and effects of the disease are more likely to adhere to the prescribed medication and treatment therapy (Frier & Fisher, 2007). Diabetes is a serious long term disease that progresses with time and requires adjustments in lifestyle especially with regard to physical activities and nutrition. The overall objective of nutritional and medical therapy is to help the patient make self-motivated changes in his or her life in order to improve the general health of the body.
Blood glucose level should be checked before and after the meal to enable the patient to make informed choices about the food to consume at a particular time. The choice of food will be based on how the patient responds to a particular type of food. Patients are taught the specific procedure for retrieving an adequate sample of blood and the steps they should take to gett the results. Studies have shown that patients who have knowledge about using blood-glucose meters and interpreting the data read from the meter perform blood-glucose evaluation on a consistent basis (Williams et al, 2007).
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Several blood glucose monitors are available in the market. For best results, the patient must be advised on how to get a device that is convenient and easy to use. Before selection of the blood monitoring device, an assessment of the patient’s visual acuity and his/her hands dexterity must be taken into account. The process of selection of the device must take place at a health-care facility with guidelines from a diabetic specialist or educator. The patient requires to be told the importance of recording the results of the rests in a log sheet. In the sheet the patient must include the time and date, and the symptoms he or she is experiencing at the time of obtaining the specimen. Every time the patient visits a health-care facility he/she should bring the log sheet and share the information with the doctor in charge of the patient.
The process of doing the test should include a talk on glycosylated hemoglobin (HbA1c), the test performing and interpretation of the data by the health practitioner (Mertig, 2007). Laboratory tests on HbA1c serve the role of monitoring the patient and are ordered on a regular basis. The simplest way of describing HbA1 to a patient is to tell the patient that the test involves measurement of the level of sugar that is found within the proteins of the red blood cells (Corbin & Gettings, 2007). The test is able to capture the average level of sugar in the patient for the past three months. If the blood sugar is high, the level of the glycosylated hemoglobin will also be high. High levels of blood sugar over a long duration destroy small and large blood vessels putting the patient at a risk of experiencing complications that arise from diabetes.
Medication and Insulin
Diabetic patients are very conscious about the disease and must be informed that medicine is used for the purpose of the disease management and not due to their failure to manage the nutrition regime (Merck & Co, 2009). Depression sets in once the patient starts to take insulin and/or medicines for hyperglycemia. The different types of oral diabetic agents will therefore be reviewed in the session. The review will also extend to studying the different types of insulin available and how to mix the insulin to achieve the best results. The patients will be taught on how to self-administer the prescribed oral agents and the insulin. The importance of taking the right dose according to the prescribed instructions will also be discussed. The patients will also be informed about the symptoms and signs of both hyperglycemia and hypoglycemia and the exact measures to take when they are suffering from an attack (Peyrot, 2007).
Complications Arising from Diabetes
Teaching on complications arising from the disease will emphasize the impact made by the control of blood sugar in the patient’s long-term health. The patient must be equipped with the requisite skills to manage diabetes when suffering from minor illnesses such as gastrointestinal virus, flu or cold. Similarly the patient must be taught how to look out for fatal effects of diabetes which may lead to peripheral vascular disease, heart attack and stroke. The patients must also be taught to be on the watch-out for signs and symptoms of renal disease, respiratory tract infections, and urinary tract infections (Frier & Fisher, 2007).
In the training session, the patient must be equipped with skills to detect the onset of diabetic neuropathy. Diabetes is a fatal condition since it is a leading cause of deaths in the United States. It contributes to 75% of the strokes, peripheral vascular diseases, renal failures and 50% of myocardial infections. It also causes blindness to patients. The patients must also be advised on the importance of quitting smoking, managing lipid and cholesterol intake, monitoring blood pressure, taking foot and skin care, and managing other diseases that arise as complications of the diabetes.
The patient must be taught to take effective feet care which involves daily washing, careful drying between the toes, and thorough checking for bruises, redness, blisters, corns, swellings and calluses. Any change noticed by the patient must be reported to a health practitioner immediately. The patient must avoid walking when barefoot and must wear shoes that do not constrict his legs (Lowenstein et al, 2009). Fungal infections on the feet are common in diabetes and the patients must use athlete’s foot medication that is available over the counter. If the athlete’s foot fails to improve after medication, the patient should consult the health practitioner. All cuts, blisters and assorted injuries on the feet or the legs must be treated with utmost care.
Foot problems are common to diabetic patients. While some are harmless and mild to the patient, others are fatal and toxic. Dangerous signs that the patient should look out for include: Warm feet that are red in color; Cold feet that are black or blue in color; Swellings in the feet; Pain in the feet when resting or during physical exercise; Lack of the pain when the foot is injured; Shiny skin on the lower legs and the feet; and very weak pulses in the feet (Corbin & Gettings, 2007).
Exercise and Diabetes
A sensible loss of weight of between ten to twenty pounds improves dyslipidemia, hypertension and hyperglycemia (Mertig, 2007). The target weight loss for diabetes patient must be reasonable one that culminates into healthy weight of the body. Suitable weight loss has been defined as the weight acknowledged by the health care practitioner and the patient and is maintainable and achievable within a set period. Modern perspectives on weight of diabetes patients have shifted from emphasis on the patient’s real weight to concentration on the circumference of the patient’s waist. In men, a circumference greater than 40 inches poses a danger that the individual will suffer from metabolic disease while for women the prohibited waist circumference is a circumference that is greater than 35 inches.
Weight circumferences beyond the standard ones are part and parcel of the metabolic syndrome suffered by diabetic patients (Frier & Fisher, 2007). Reducing the fat in the abdomen improves the patient’s lipid profile and sensitivity to insulin. Patients should engage in long-term regular aerobic exercises. Exercises that enhance the strength of the muscles are recommended since by preserving muscular strength they increase mobility and reduce falls especially among elderly diabetic patients (Frier&Fisher, 2007). The benefits of regular exercises for a diabetic patient cannot be exhausted. They help in decreasing weight, improving the self-esteem of the patient, quality of life, flexibility and strength, the functioning of the cardio-vascular system and blood sugar control. Exercises increase the number of cell receptors which in turn increases the uptake of glucose by the cells.
Various factors have to be taken into consideration before a patient can embark on an exercise program. Every exercise program must be designed to suit the patient’s needs according to the time that the patient has at his/her disposal. The exercise program must be build over a period of time to make sure that the patient adapts to the routine. It has been reported that absorption of insulin occurs rapidly in an exercised limb which is very dangerous as it can cause hypoglycemia (Lowenstein et al, 2009). Patients must therefore be informed that intense exercises may raise the level of blood glucose leading to hyperglycemia which can only be countered by regulatory hormones.
The patients should be encouraged to include breaks of five to ten minutes to cool-down and warm-up. Warm-up sessions serves the purpose of preventing muscle injury through increasing the body temperature while cool-down sessions prevent pooling of blood and facilitate elimination of by-products of the metabolic process. Shorter sessions (ten minutes each) are recommended as opposed to longer sessions (30 minutes each) because research has established that shorter sessions enhance performance of the cardio respiratory system. This point must be emphasized to patients who think that they don’t have time for exercises to show them that they can create time for ten minutes sessions.
Diet and Diabetes
Diabetes organizations across various countries have established diet regimes for diabetic patients. The American Diabetes Association for instance has set guidelines which focus on optimal metabolism in relation to levels of blood pressure, lipid profiles and glycemia ( Merck&Co., 2009). Diabetic patients must keep to a health and balanced diet comprising of low-fat milk products, poultry, whole-grains, lean meats, vegetables, fish and various fruits. The standard diet can be exchanged with a diet consisting of milk, bread, protein, and vegetables containing low or intermediate carbohydrates.
The meal plan of the diabetic patient is based on the individual’s preferences, cultural beliefs, appetite and his or her food consumption schedule. Caloric needs of an individual are determined based on the amount of energy and the individual’s present weight. Adults engaging in normal daily activities require calories of about 40kcal/kg or 20kcal/lb daily.
Consistent daily intake of carbohydrates must be maintained since carbohydrates have the most profound impact on glycemia. The response of blood-sugar to food is affected by the type of starch, amount of carbohydrate, components of the monosaccharide, food processing and food cooking. Patients should be encouraged to maintain a food diary for better management of their menus. Fiber requirements for diabetic patients are similar to those of the general population.
As patients are advised about diet management they should receive similar advice about alcohol consumption. Diabetic patients should take precautions similar to those taken by the general population. However, patients suffering from diseases such as neuropathy and pancreatitis, pregnant patients and alcohol addicts must completely abstain from alcohol upon being diagnosed (Mertig, 2007). Consumption of alcohol on an empty stomach results in hypoglycemia. A patient planning to consume alcohol must include it in the food plan. Moderate consumption of alcohol when the patient has eaten properly does not affect blood sugar levels.
Coping with Diabetes
Diagnosis of diabetes just like diagnosis of other chronic diseases is usually shocking and devastating. Most patients are shocked, aggrieved and are in denial about the disease. Support by friends and families as the disease progresses assists the patient in accepting the syndrome. Patients must be informed that depression is common in diabetic cases and it should be treated since it interferes with the control of blood sugar leading to complications. The patient must also be made aware that diabetes is a life-time illness that will require long term commitment to life-style changes. The patient requires mental, physical, spiritual, personal and financial empowerment. Empowerment also comes from positive work and family relationships (Centers for Disease Control and Prevention, 2008).
Stress management is an integral aspect of coping with diabetes. The patient must be equipped with skills such as identifying the stress factors, the response of the body to stress, effect of stress on management of the disease, coping methods, and exercises to boost relaxations. Cardiovascular risk must be eliminated or minimized. The patients must learn how to deal with minor illnesses such as colds and flu since they impact heavily on glycemic levels. They must continue with insulin and other medications even when they are not sick.
Ensuring that one has a good level of hydration is important since dehydration accelerates hypovolemis (Peyrot, 2007). This can be curbed through hourly intake of liquids that are calorie-free. Monitoring of blood glucose sugar levels must take place more frequently when the patient is ill. The patient must self-administer insulin even when he or she is unable to eat during illness to avoid diabetic ketoacidosis (Peyrot, 2007). A list of foods to be consumed when experiencing hypoglycemia signs should be provided to the patient. Patients should undergo ophthalmologic inspections regularly so that diabetic retinopathy can be detected early. Consistent visits to the dentist are also advised so that areas susceptible to infections or oral lesions can be detected early.
Discussion of Teaching Materials used in the Presentation
The teaching materials used in the presentation include PowerPoint representations, diabetes conversation maps, Questions and answers cards, and live demonstrations. Diabetes conversation maps are highly colorful and they measure 3ft by 5ft .They contain simple facts about diabetes in general, exercises, nutrition therapy, self-monitoring of blood sugar levels, and complications arising from diabetes (Corbin & Gettings, 2007). The facilitator explains the issues to the patients by navigating the map from point to point. The other resources included newsletters, training manuals in hardcopy and electronic resources.
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Description of the Evaluation Strategies
The evaluation was geared towards assessing whether the goals and objectives of the training had been achieved. The purpose was to get the feedback of the learners with regard to the teaching program carried out so as to make improvements in future projects. The evaluation was based on four major approaches: the utilization-focused approach; the empowerment evaluation technique; the stake-holder evaluation approach; and while the goal-free evaluation approach.
The formative and summative types of evaluation were considered for the project. Formative evaluation involves assessing the project to make sure that the goals and aims of the teaching program are achieved. Summative evaluation concentrates on the overall effectiveness of the training being carried out (Centers for Disease Control and Prevention, 2008). Summative evaluation was found out to be the best mode of evaluation for this program.
The summative evaluation involved evaluation of whether the program had achieved the targeted outcome for the learners; impact evaluation was conducted to determine the effects of the teaching program whether intended or un-intended; a cost-benefit and cost-effectiveness analysis to determine effectiveness of the program in relation to the value obtained from each dollar spent; secondary analysis conducted by reviewing the impact of tools that were not employed in the study; and meta-analysis which integrated the outcome from all the types of evaluation carried out and types of evaluation techniques utilized to reach an eventual process outcome. Process indicators were used as a basis for providing the functioning and nature of the teaching program .The process indicators for the program included exposure to the program, involvement of the patient and the perceptions about the program.
Process and Outcome Evaluation
The class was surveyed immediately upon completion of the six training sessions. 97% of the patients reported that they found the sessions to have been very valuable for them. 96% of the patients said that they felt empowered to discuss issues related to their diabetes with their health practitioners. On the teaching format used, 92% rated PowerPoint presentations as the most effective format. They found it to be better than learning about diabetes from books and manuals. 86% of the participants rated group discussions as the best session of the training. The interaction with other patients made them realize that they were not alone in the battle against the disease and that they shared similar experiences with others.
The teacher was rated as effective and interactive though some of the patients felt that the teacher ought to have managed time effectively so as not to extend the sessions. The evaluation discloses that after the training session most of the patients were able to use their blood sugar meters appropriately, regulate the intake of carbohydrates in meals and snacks, read labels of foods more keenly to check for the calorie, fat and carbohydrate percentage, and discuss their health status with their families.
Strengths of the Training Program
· Improved knowledge and understanding about diabetes.
· Adoption of healthy exercise routines and techniques.
· Adoption of healthy nutritional regime, foot care, and skin care.
· Reduction of stress, anxiety and depression.
· Consistent correct self-administration of insulin and self-monitoring of blood glucose levels.
· Knowledge of how to handle diseases and complications arising from diabetes and how to cope with diabetes in general.
· The feeling of being in control of the disease and the overall health of the body.
Limitations of the Training Program
· Lack of sufficient resources to facilitate the training.
· Learners at different stages of the disease posed obstacles in integrating the teaching process.
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The program of teaching diabetic patients was designed to be held for six times, each session taking 3-4 hours. The duration was limited or extended depending on the needs and insights from the audience. The main objective of three to four hour sessions was to enable the patients to internalize the subject matter being taught and to be able to ask questions without undue haste or time pressure. The main focus of the teaching program was management of glycemic levels and prevention of complications that arise from diabetic condition. The patients were taught about the multiple diseases and syndromes that are associated with diabetes, and the factors responsible for occurrence of the diseases. Management of diabetes when the patient is suffering from other illnesses is crucial to survival of the diabetic patient.
The patients have been informed about how to respond to signs of hypoglycemia and hyperglycemia. In case of any doubts or ignorance of the recommended measures, the patients have been advised to contact their health practitioner immediately. The patients have been left with free handouts and brochures on management of diabetes. The handouts are also freely available at many health care agencies. At the end of the program, the patients are expected to fill in an evaluation sheet anonymously to estimate the effectiveness of the teaching program.