Education and
delivery of diabetes care
Diabetes
is a chronic non-curable disease - management by self is important
A
large element of diabetes care is self management - knowledge is
needed for this to be done.
Guiding
Principles of Education:
- Must be tailored to the patients needs
- does not necessarily translate into action
- ongoing process that needs reinforcement
- should take form of a partnership
- needs to address patients agenda
- Diabetes Nurse Educators receive special training
-
Didactic lectures are generally not as effective at modifying behaviour
- individualised or group teaching is generally considered as being
more productive
- interactive computer programs may be effective
- overload of information is counterproductive
- prior to starting, initially assess knowledge, skills and attitudes
Ethnicity,
social background, financial circumstances, lifestyle, health beliefs
and educational background will influence educational message
- information needs to be delivered in small digestible chunks
- move from the simple to the complex
- scare tactics only have short term impact (unless results are
imminent)
- adults like to be involved in their education
Learning
is enhanced when the patient:
- Feels a need to know what is being taught
- can relate it to what they already know
- feel the material is personally relevant
- have confidence that they can do what they have been taught
- is actively, rather than passively involved
- has feedback on what they can do
Health
Belief Model (one model can can be used to explain behaviour)
A health protective behaviour is carried out based on the psychological
weighing up of the following:
- perceived susceptibility/vulnerability to the condition
- perceived severity of the condition
- perceived benefits of the health protective behaviour
- perceived barriers to carrying out the health protective behaviour
Monitoring
of glucose levels
Assessment and monitoring of glycaemic status is a cornerstone
of diabetes care and self-management.
Urine
testing:
- use of strips to measure pre-prandial glucose levels in urine
- has major limitations (due to raised renal threshold for glucose
- mostly in type 1)
- can be used by some with type 2 who have stable glucose levels
and are controlled by diet
- largely been replaced by self monitoring of blood glucose, but
has a role for detection of ketone levels, especially during pregnancy
or acute illness
Blood testing:
Capillary blood glucose levels/self monitoring of blood
glucose (SMBG):
- should be performed regularly at home so achievement of specific
glycaemic goals can be achieved and maintained
- blood glucose reagent strips are read visually or with a glucose
meter
- information is available immediately - well informed decisions
and helps motivation
- provide information for day to day management, but is not an indicator
of longer term glycaemic levels
Glycated
haemoglobin:
- measure of control over 120 days (average life span of red blood
cell)
- HbA1c - stable minor haemoglobin component that form slowly from
the non-enzymatic combination of haemoglobin and glucose. The rate
of formation is directly proportional to the glucose concentration
- blood is assayed by a number of different methods - some variability
between laboratories
has become the 'standard' for assessing glycaemic control - shown
to be predictive of many chronic complications
Organisation
of Diabetes Care
Need access to a multidisciplinary team
Best
delivery via concept of ‘Diabetes Centres’:
- diagnosis and assessment of new patients
- long term follow up
- continuing education of patients and staff
- screening for chronic complications
- specialist foot care
- specialist care for special groups (eg pregnancy)
- provision of telephone advice
Diabetes
Centre staff
- Diabetologist
- specialist nurse
- dietician
- podiatrist
Access to:
- nephrologist
- obstetrician
- vascular surgeon
- ophthalmic surgeon
- orthopaedic surgeon
-
cardiologist
- psychologist
A
comprehensive annual review is considered the key of structured
diabetes management:
1) Discussion
- physical and psychological health
- review of results of self monitoring
- enquiry into episodes of hypos and hypers
- knowledge of diabetes and self management
- smoking and alcohol use
- discussion of other diabetes related problems
2)
Physical examination
- BMI
- BP
- Visual acuity
- Detailed fundus examination
- Inspection of feet and footwear
- Injection sites
3)
Investigations
- Urinalysis (for proteins)
- HbA1c
- Serum creatinine and electrolyte concentrations
- Serum lipids
4)
Management
- Glycaemic control review
- Assessment of co-morbidity
- Review of all medications
- Attention to modifiable cardiovascular risk factors
- Management of long term complications
- Management plan for next 12 months
- Arrange review date
Online
resources:
Glycaemic
control in diabetes - full text article from the British Medical
Journal
Effective
diabetes care: a need for realistic targets - from the British Medical
Journal
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