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Dec.29.2020

Diabetes Education (Ambulatory) - CE

ALERT

Diabetes is a complex, chronic illness that requires continuous medical care with multiple risk-reduction strategies beyond glycemic control.

Ongoing self-management education and support are critical in preventing acute complications and reducing risks for long-term complications. Blood glucose (BG) monitoring is essential for positive patient outcomes.

Hypoglycemia (low BG) can be dangerous and should be treated as soon as possible.undefined#ref6">6

OVERVIEW

Diabetes mellitus (DM) is a chronic disorder caused by the inadequate production of insulin by the pancreas or the inadequate use of insulin by the cells. It is a condition of the inadequate metabolism of carbohydrates, fats, and proteins. The functioning pancreas secretes insulin and maintains glucose levels in a precise range. Insulin normally reduces BG levels by transporting glucose into the cells for use as energy and for storage as glycogen. When insulin is reduced, hyperglycemia occurs, depriving cells of fuel.

There are two primary forms of DM:

  • Type 1 diabetes, also called insulin-dependent DM, has an early, abrupt onset (usually before 30 years old),1 with little or no insulin secretion by the pancreas.
  • Type 2 diabetes, also called noninsulin-dependent diabetes mellitus (NIDDM), has a gradual onset (usually those older than 55 years old)1 with some pancreatic function remaining.

The principal symptoms of DM are polyuria, polyphagia, polydipsia, weight loss, and fatigue. Patients may experience pruritus, especially in the genital area, and a fruity odor to the breath may be noted when ketosis occurs. Diagnostic tests of blood and urine are used to point to the common signs and symptoms of DM.2

Untreated or poorly managed diabetes has multiple systemic complications. Even if the patient is compliant with treatment, retinopathy, which leads to blindness, can be a complication. Other systemic complications include neuropathy, atherosclerosis, renal failure, myocardial infarction, and stroke.1

A review of laboratory results, such as a hemoglobin A1C, provides a more accurate picture of the patient’s glycemic control over time than a fasting BG test, and it should be reviewed when discussing diet.3

The hemoglobin A1C is a stable glycoprotein formed when glucose binds to hemoglobin A in the blood. The A1C test is a diagnostic test and is defined as the estimated average glucose. It is usually performed twice a year and shows how well BG levels have been controlled over a 3-month period.3,6

The occurrence of diabetes is a growing problem in an aging population, as approximately one-quarter of people over 65 years old have diabetes and one-half have prediabetes.6 This proportion is expected to continue to rise in coming years and decades. Older adults with diabetes have higher rates of premature death, functional disability, accelerated muscle loss, and coexisting illnesses (e.g., hypertension, coronary heart disease, stroke).5 They are at greater risk for polypharmacy, cognitive impairment, urinary incontinence, and food insecurity, which may impact self-management abilities.5

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Teach the patient the signs and symptoms of diabetes (e.g., abnormal BG level, abnormal hemoglobin A1C level, frequent infections, urinary tract infections) and instruct him or her on when to seek additional care.3
  • Review with the patient food preferences, cultural norms or requirements regarding food, and socioeconomic status when discussing dietary recommendations.3
  • Review with the patient the need for daily monitoring of BG levels using a device for that purpose (glucose meter).
  • Review with the patient the need for keeping a BG diary.4
  • Review with the patient the need to keep a food diary to track the BG response to his or her diet.3
  • Teach the patient who takes multiple insulin injections or has an insulin pump, that carbohydrate intake can be altered and the insulin dose can then be altered to his or her food intake.4
  • Teach the patient that the balance between insulin and glucose can be easily upset by trauma and infection.
  • Teach the patient the signs and symptoms of hypoglycemia (e.g., sweating, shaking, confusion) and hyperglycemia (e.g., hyperurination, thirst, blurry vision) and instruct him or her on when to seek additional care.
  • Warn the patient that hypoglycemia can be dangerous and should be treated immediately.
  • Encourage questions and answer them as they arise.

STRATEGIES

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the strategies to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings and laboratory test results are communicated to the clinical team leader per the organization’s practice.
  6. Confirm the patient’s point-of-care BG and A1C test results, if available, and review the results with the patient.
    If signs of hypoglycemia are present, perform a point-of-care BG for confirmation. 1,6
  7. Review with the patient the benefits of lifestyle management plans that may include:2
    1. Nutrition (diet management)
    2. Weight loss, as appropriate
      Rationale: Weight loss of 5% to 10% of body weight for a patient who weighs 91 kg (200 lb) can increase the ability to manage BG levels safely. 6
    3. Physical activity (moderate intensity) of at least 150 minutes per week or 20 to 25 minutes per day6
    4. Smoking cessation
    5. Medications as directed
  8. Instruct the patient about the importance of skin care, foot care, and dental care.
    1. Keep skin clean and dry.
    2. Wear well-fitting shoes with soft socks to avoid friction on the feet.
    3. Perform good dental care daily and manage care with a dental professional, as appropriate.
  9. Instruct the patient to perform daily BG monitoring. Explain that the typical times to check BG are before a meal, 2 hours after a meal, and at bedtime.6
    All patients diagnosed with DM, whether insulin dependent or not, should perform frequent BG monitoring to avoid complications such as hypoglycemia or hyperglycemia. 6
    Taking oral antidiabetic medication and being diet compliant are not guarantees that hypoglycemia or hyperglycemia will not occur or that BG levels will remain within safe parameters.
  10. Instruct the patient about BG targets.
    1. Before a meal: 80 to 130 mg/dl6
    2. Two hours after the start of a meal: less than 180 mg/dl6
  11. Review with the patient the common symptoms of low BG, such as shaking, sweating, nervousness or anxiety, dizziness, confusion, and hunger.
    1. Instruct the patient to check his or her BG for confirmation if signs of hypoglycemia are present.1,6
    2. Explain that low BG can be dangerous and should be treated as soon as possible.
    3. Advise the patient to have supplies (e.g., glucose tablets, fruit juice, regular soda, hard candy) on hand to manage a BG lower than 70 mg/dl.6
  12. Instruct the patient to avoid complications, such as high blood pressure, high cholesterol, and high triglycerides, that complicate good diabetes control.
  13. Instruct the patient to be prepared for emergencies, natural disasters, and hazards such as injury or the isolation that is required when exposed to viral and bacterial infections.
    1. Review information about insulin storage, as appropriate.
    2. Ensure that medication is available and in sufficient quantity.
    3. Ensure that glucose testing equipment (i.e., devices and testing strips) is available, in good working order, and in sufficient quantity.
  14. Provide the patient with information regarding diabetic self-management and support services in the community.
  15. Evaluate the patient’s response to the strategies.
  16. Perform hand hygiene.
  17. Document the strategies in the patient’s record.

EXPECTED OUTCOMES

  • Patient understands education provided.
  • Patient understands strategies for optimal self-management of diabetes.
  • Patient understands the importance of frequent and accurate BG testing.
  • Patient understands all aspects of self-management of diabetes as provided.

UNEXPECTED OUTCOMES

  • Patient does not understand or accept education provided.
  • Patient does not understand strategies for optimal self-management of diabetes.
  • Patient does not understand the importance of frequent and accurate BG testing.
  • Patient does not understand or accept all teaching about self-management of diabetes.

DOCUMENTATION

  • Patient’s response to strategies
  • Unexpected outcomes and related interventions
  • Education
  • Evaluation findings and laboratory test results communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

  • The incidence of type 2 diabetes has increased in children and adolescents in recent years, requiring diabetes education for a younger population and the family.
  • Preadolescent and adolescent peer pressure may be a factor for noncompliance. Families should attempt to find food selections that are both acceptable with peers and compliant with diet restrictions for children with diabetes.
  • Pediatric patients should be taught to perform their own BG monitoring and insulin administration as soon as developmentally capable to promote the patient’s sense of independence and control.

OLDER ADULTS CONSIDERATIONS

  • Older adults who present as confused should be tested for BG levels; low BG in older adults can be misdiagnosed or misunderstood as being related to aging or dementia.5
  • Older adults with fragile skin may be at greater risk for pressure injury, especially on the lower extremities.
  • Older adults should be evaluated for risk factors, such as coexisting illness and polypharmacy, that may impact BG levels.5

REFERENCES

  1. American Diabetes Association. (2020). Standards of medical care in diabetes-2020. Chapter 3: Prevention or delay of type 2 diabetes. The Journal of Clinical and Applied Research and Education: Diabetes Care, 43(Suppl. 1), pp S32-S36. doi:10.2337/dc20-S003 (Level VII)
  2. American Diabetes Association. (2020). Standards of medical care in diabetes-2020. Chapter 5: Facilitating behavior change and well-being to improve health outcomes. The Journal of Clinical and Applied Research and Education: Diabetes Care, 43(Suppl. 1), S48-S65. doi:10.2337/dc20-S005 (Level VII)
  3. American Diabetes Association. (2020). Standards of medical care in diabetes-2020. Chapter 6: Glycemic targets. The Journal of Clinical and Applied Research and Education: Diabetes Care, 43(Suppl. 1), S66-S76. doi:10.2337/dc20-S006 (Level VII)
  4. American Diabetes Association. (2020). Standards of medical care in diabetes-2020. Chapter 7: Diabetes technology. The Journal of Clinical and Applied Research and Education: Diabetes Care, 43(Suppl. 1), S77-S88. doi:10.2337/dc20-S007 (Level VII)
  5. American Diabetes Association. (2020). Standards of medical care in diabetes-2020. Chapter 12: Older adults. The Journal of Clinical and Applied Research and Education: Diabetes Care, 43(Suppl. 1), S152-S162. doi:10.2337/dc20-S012 (Level VII)
  6. Centers for Disease Control and Prevention (CDC). (2019). Living with diabetes. Retrieved November 16, 2020, from https://www.cdc.gov/diabetes/managing/index.html (Level VII)

ADDITIONAL READINGS

Association of Diabetes Care & Education Specialists (ADCES). (n.d.). Resources on glucose monitoring. Retrieved November 16, 2020, from https://www.diabeteseducator.org/practice/practice-tools/diabetes-management-tools/glucose-monitoring-resources

Evert, A.B. and others. (2019). Nutrition therapy for adults with diabetes or prediabetes: A consensus report. Diabetes care, 42(5), 731-754. doi:10.2337/dci19-0014

Joint Commission, The. (2020). National patient safety goals for the ambulatory health care program. Retrieved November 16, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ahc_jul2020.pdf

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports