1、Home Care Chronic Disease Prevention Program,Melanie S. Bunn RN,MSA collaboration of Duke University,Division of Community Health and University of South Carolina, School of Medicine,Homework review,What did you do?What happened as you did that?Why do you think that happened?Heres what might have ha
2、ppened.How does this impact the next time you try this?,Chronic Disease Management,Module 1:Health/Illness, Vital Signs, Exercise, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Modu
3、le 9: Congestive Heart Failure,Objectives,Define diabetes and the impact of diabetes on healthDescribe healthy lifestyle choices for the person with diabetesDemonstrate use of motivational interviewing with the person with diabetes,Diabetes,Diabetes: The numbers,About seven percent of Americans have
4、 diabetesSixth leading cause of death in the US,Diabetes: What is it?,Insulin is a hormone that helps the body to process “sugars” into energyDiabetes is a disease in which the body does not use its insulin properly or it does not produce enough insulinThe result is elevated blood sugar levels,Sympt
5、oms and signs,Extreme thirst Extreme hunger Weight loss Frequent urination Vision changes Recurrent infections,Diagnosis,Fasting blood sugar greater than 126 Two random blood sugars greater than 200 After fasting and drinking 75 grams of sugar, two hour post- prandial blood sugar greater than 200,Ty
6、pes of diabetes,Type I-The body does not produce insulin; present from birth (genetic defect) Type II-The body does not use its own insulin properly- called “insulin resistance”; may lead to type I; starts well after birth, usually in adult years Gestational diabetes-Occurs during pregnancy, some wo
7、men go on to develop type II diabetes,Type II diabetes,Most common form of diabetes Insulin resistance Onset occurs usually in adult years,Risk factors for type II diabetes,Overweight Family history Prior history of gestational diabetes African American race,Treatment,Injectable insulin Short acting
8、 Medium acting Long actingOral medications Increase insulin secretion Increase insulin sensitivity,Insulin,Rapid acting (Humalog and Novolog) Short acting (Regular) Intermediate acting (NPH) Long acting (Lantus) 24 hours Mixes-combinations of the above,Insulin,Keep unopened bottles in the refrigerat
9、or Insulin will stay fresh for one month without refrigeration (under 86 F) Check insulin before using it Short acting and glargine are clear Intermediate and long acting are cloudy If clumps are visible, throw the bottle away,Testing blood glucose,Helps assess how well blood glucose levels are bein
10、g controlled Helps guide changes in medications Very important if insulin is being used Should be tested if hypoglycemia (low blood glucose) is suspected Testing times vary, typically two to four times a day,Testing blood glucose,Before meals: 90-130 One to two hours after meals: less than 180 Test
11、as prescribed by the doctor- usually fasting morning, before meals and at bedtime,Hypoglycemia “low blood sugar”,Occurs when blood glucose drops too low For most people this is less than 70 Can be life threatening * Symptoms may include nausea, dizziness, sweating Keep a source of glucose readily av
12、ailable- two glucose tablets, one cup of milk, half cup of juice Retest after 15 minutes Carry glucose tablets when exercising,Hemoglobin A1C,Tested with blood sample Three month average of blood glucose readings Guides decisions about treatment Keep track of your values Normal is 4-6% for someone w
13、ho is non- diabetic Goal is as close to 6% as possible,Non pharmacological treatment,Diet/nutritionExerciseWeight loss,Nutrition,What a person with diabetes eats is very importantIts more than just not eating SUGAR,Glycemic index,Rating system based on how fast the food raises blood glucose two hour
14、s after eating Reference is white bread = 100 The higher the glycemic index, the faster the food raises the blood glucose. The faster the blood glucose rises, the more quickly insulin is released.,Glycemic index,In diabetics, because of the insulin resistance, the body doesnt respond as well so gluc
15、ose levels stay high longer than normal Lower is better when it comes to glycemic index,Examples,High glycemic indexWhite rice, white bread, potatoModerate glycemic indexRye bread, macaroni and cheeseLow glycemic indexBanana, milk, grapes, brown rice,Diabetic diet,Keeping blood glucoses in the norma
16、l range decreases the likelihood of complications,Diabetic diet,More that just not eating sugarEating the right foodsAt the right times In the right amounts,Diabetic diet,1500- 2000 calorie diet for most men and women 40-60% of calories from carbohydrates 20% of calories from protein Less than 30% o
17、f calories from fat,Diabetic diet,Each meal 60 grams of carbohydrates; Fruits, vegetables, dairy, starch Sugar substitutes Low fat, low cholesterol Eat at the same time each day Eat structured meals,Exercise,Always warm up and cool down for about ten minutes Check blood sugar before and immediately
18、after exercise Do not exercise if blood sugar is greater than 250 and eat a small snack if less than 100 Drink two cups of water before and after exercise,Control weight,With good nutritional choicesAnd increasing activity,This sounds like a LOT of WORKis it worth it?,YES!,Common complications,Blind
19、ness due to bleeding blood vessels in the eye Kidney failure which leads to dialysis Stroke Heart attack Numbness (neuropathy),Common complications,Gum/teeth diseases Foot problems Infections Potential amputation,Treatment,Healthy diet Exercise Weight loss Medications to lower blood sugar Medication
20、s to lower blood pressure Medications to lower cholesterol Medications to protect the kidneys Check your feet each day,Follow up with your doctor,Aspirin for diabetics over the age of 40 Bad cholesterol (LDL) goal less than 100 Examination by ophthalmology yearly HbA1c every three months Urine check
21、ed for protein each year Foot check every three months Pneumococcal vaccination Blood pressure goal less than 130/80,Who should be screened?,Persons with hypertension Persons with hyperlipidemia Others at discretion of physician,Warning symptoms,History of an illness/ infection Nausea Sweating Vomit
22、ing Foot ulcers,Warning signs*,Blood sugar less than 70 Blood sugar greater than 300 Increased heart rate Increased respiratory rate Foot ulcers*ALL vital parameters are determined by RN supervisor and are patient specific,Other warnings,Not taking medications,References,Neal, LJ. & Guillett, SE .Ca
23、re of the adult with a chronic illness or disability. Mosby, St. Louis, Missouri, 2004. pp 286-294. Kennedy Malone, L. et al. Management guidelines for gerontological nurse practitioners. F.A. Davis Company, Philadelphia, PA, 2000. pp 369-376. Lippincott, Williams and Wilkins. Managing chronic disor
24、ders. Lippincott Williams and Wilkins, USA, 2006. pp 127-132. http:/diabetes.niddk.nih.gov/ www.aafp.org http:/www.diabetes.org/home.jsp,Case study,68 year old obese male Tells you he has had diabetes for 15 years He tells you that his doctor is worried about his eyes and his kidneys He also tells y
25、ou that his doctor thinks that he does not eat well and eats too many sweets.,Case study,He tells you that he forgets to take his medications for diabetes most of the time but goes on to tell you that he does not really think that they are important He tells you, “I dont even understand how they can
26、 tell if my blood sugars are under control or not.”,Case study,While you are talking with him, he opens up a box and begins to eat the large piece of chocolate cake that is inside the box He tells you that his father had diabetes and went on dialysis because his kidneys failed,Case study,What worrie
27、s you about his behavior?What are his risk factors for diabetes?,Case study,What worries you about his behavior? His diet- i.e. chocolate cake Not taking his medications Doesnt seem to be concernedWhat are his risk factors for diabetes? Obesity Family history Eating habits,Case study,What are possib
28、le complications of diabetes?,Case study,What are possible complications of diabetes? Kidney failure Blindness Heart attack Stroke Neuropathy (nerve damage),Case study,What types of lifestyle measures would be appropriate for him?,Case study,What types of lifestyle measures would be appropriate for
29、him? Diabetic diet low in sugars, fats, cholesterol, sodium Exercise Taking medications as prescribed by his physician,Case study,He wants to know how his blood glucose is monitored, can you explain that to him?What test is used to follow blood glucose? What is the normal range for blood glucose lev
30、els?,Motivational interviewing,How do you as the Nurse Aide motivate him to follow dietary guidelines for diabetics?Now that youve gained his trust you can start asking questions that will begin the change talk.,Starting the Change Talk,What questions can we ask that could start him thinking about i
31、mproving his diet?Tell me about your diet? What do you think about your diet?,WILLING, ABLE, READY,In the next few slides, put yourself in this clients shoes. Try to write down answers to the questions from his point of view.,Find Out How WILLING He is to Change,Ask open ended questions so he can: S
32、tate his reasons for not eating healthy State the reasons he has for eating healthy Have him write down his answers to the following questions,What are His Reasons for Not Eating Healthy? 2 Good Questions to Ask,Explore His Reasons Fully,Ask him how keeping unhealthy eating habits could be good for
33、any of these aspects of his life: Health Lifestyle Emotions Relationships Coping abilities (stress, for example) Work Social life Spiritual life,Here are Some Sample Reasons for Continuing to Have an Unhealthy Diet,Next, What Reasons Does He Have for Eating a Healthier Diet?,Explore His Reasons Full
34、y,Ask him how eating healthier could be good for any of these aspects of his life: Health Lifestyle Emotions Relationships Coping abilities (stress, for example) Work Social life Spiritual life,Here are Some Sample Reasons for Eating Healthier,Next, How Important is It for Him to Change?,Ask him to
35、compare his reasons for not changing with his reasons for changing Have him assign a number to the Ruler of Change in the next slide. This will show how important it is for him to change,How Important is It for You to Change?,On a scale of 0 to 10, how important is it to you to have healthy eating h
36、abits?The “Ruler of Change”,WILLING,This number on the Ruler of Change will show how WILLING he is to changeIt will show how willing he is to start eating a healthier diet,Willing (continued),If his Ruler of Change number is below 3 or 4: He is not willing to consider change. He has lots of resistan
37、ce to change His reasons for continuing to have unhealthy eating habits are STONGER THAN his reasons for eating healthy.,Sample Question to Help Decrease Resistance,What would have to change to decrease the importance you give to your reasons for having poor eating habits?,Questions to Decrease Resi
38、stance,A low number on the ruler of change says he does not think that eating healthy is important and he does not want to changeBut, look at his number on the Ruler of Change If hes not at zero, he must have at least a small interest in change.,Decreasing Resistance,If this is the case, Ask:Why are
39、 you at _ and not zero?What would it take for you to go from_ to_ ?His answers might get him to start thinking that change might be a good thing,Willing (continued),If the number the client gives for the importance of changing is around 5:He is “on the fence.” He is split between wanting to take act
40、ion and not being able to take the first step. In this condition, he cant change.,Sample Question to Help Increase Motivation,What would have to change to increase the importance of your reasons for having healthier eating habits?,Willing (continued),If the number he gives for the importance of chan
41、ge is greater than 6 or 7: He is not resistant to change He is not “on the fence” He is ready to take some action,Next, Find out if He is ABLE,Measure his Confidence and Ability to have a healthier diet Use the Confidence and Ability “Rulers of Change” in the next slide,Assessing Confidence and Abil
42、ity to Make a Change,Score your confidence to have a healthier diet.Score your ability to have a healthier diet.,For Scores of About 6 and Below,Ask, “What would it take to increase your confidence to have a healthier diet?” What encourages you to believe that you can achieve your goals for change?A
43、sk, “What would it take to increase your ability to have a healthier diet?”,Increasing Confidence and Ability About Change,Other questions to ask”What else could help you have healthier eating habits?Who else could help you have healthier eating habits?Adapted from Miller and Rollnick, Motivational
44、Interviewing, 2002,For Low Confidence and Ability Scores,Maybe the goal is not realistic, it exceeds his confidence and ability. Ask: What would happen if you reduced the size of your goal? What would you be willing to try? Maybe if you reduced your goal for changing, you would be more likely to try
45、.,Role of the Nurse Aide,Find out what is important to the client and use this to motivate him/her to changeHelp the client identify an activity that he/she has the ability and confidence to achieve,The Next Step: Being READY,If hes WILLING (Importance Score 5 and above)If hes ABLE (Confidence and A
46、bility Scores are 5 and above)Then hes READY,Being READY Means:,Being READY to set a goal and make a planKeeping track of progress toward the goalBeing prepared for setbacks with the right attitude and a Plan “B”,Class Exercise Goal Setting,Put yourself in the shoes of the diabetic client who does n
47、ot have healthy eating habitsUsing your current goal setting skills, write a goal for eating a healthier diet on the next slide,Using Your Own Words Write Down a Goal and Plan for Healthy Eating The Goal/Plan should be from the View Point of the Case Studys Diabetic Client,Setting and Planning a Goa
48、l SMART Method,A useful method for setting goals, SMART.To be effective, Goals need to be:Specific Measurable Action oriented Realistic Time,SMART method Some Examples,A goal that is not SMART will probably fail.“I am going to stop eating chocolate cake.”,Set and Plan a Goal SMART method Some Exampl
49、es (continued),A SMART goal would be,“I will let my kitchen supply of snacks with added sugar run out and replace them with fruits over a 4 week period. At the same time I will reduce the sugary snacks I eat at work by one-half. In 4 more weeks I will replace sugar snacks at work with fruit that I b
50、ring in. I will satisfy my sweet tooth only at my church socials where I will keep my portion sizes the size of a fist.”,Set and Plan a Goal SMART method,Now use the SMART method to rewrite the activity you chose to support the clients goal for having healthier eating habitsWrite on the next slide this SMART goal from the viewpoint of the diabetic client in the case study,
