Archive for the ‘Diabetic Patient Teaching’ Category
By Nancy Kimmel R.N., Ph.D., C.H.M.M.
The quality of life and health are greatly increased when those who are diabetic control their blood glucose levels consistently throughout the day. Tight glycemic control can prevent many of the illnesses associated with diabetes such as peripheral neuropathy, glaucoma, cardiovascular disease and hypertension. A good predictor of careful blood glucose monitoring is the Hemoglobin A1C test. This test can measure the amount of glucose that has bound to blood cells over ninety to a one hundred and twenty day period, which is the approximate life of a red blood cell. As it happens, glucose, once bound to a red blood cell, stays bound to it for the course of the blood cells life. The acceptable level that indicates good glycemic control is 7.0% or less. (1). Levels greater than this indicate that the diabetic individual needs to exert greater control over their blood sugar levels. Many times, diabetics will insist that they are doing a successful job at monitoring their blood glucose levels, until their hemoglobin A1C results come back with results greater than 7.0%.
It is not unusual for diabetics to become frustrated, or overwhelmed with the task of managing their blood glucose, administering insulin and eating a well balanced diet. Those diabetics, who have led a sedentary life style, are over weight, drink and or smoke, are placing their health in jeopardy by not adhering to their blood glucose monitoring regime. Finger sticks two to four times a day are not pleasant. Combine that with the insulin injections, and it is no wonder that many diabetics continue to ignore their medical problem. Also, many diabetics will say that they feel good, so there is no reason to monitor their blood glucose carefully. What the diabetic needs to understand is that although they may feel well, their blood glucose can still be at a level that is physiologically destructive. A blood glucose level of 160mg/dl may not make the diabetic notice any physical symptoms, but internally that extra sugar can break down muscle tissue, affect their kidneys and start plaque build up in their arteries by raising their LDL’s (low density lipoproteins). Family, friends and visiting nurses can help the diabetic manage their blood glucose consistently. Those members of the family who buy the groceries should keep healthy foods on hand for snack time such as yogurts, carrots, fruit, nuts, and whole grain cereals. Family members should try to eat the same foods as their diabetic member. Limiting carbonated beverages, cakes, cookies and processed sweets in the household will help the diabetic family member realize that they are important and help them to adhere to a well balanced diet. It is important for the diabetic family member to know that they are not alone.
Friends can help in a similar fashion by suggesting a healthy restaurant when dinning out, such as Mediterranean or sea food cuisine. The visiting nurse can help by meeting with the diabetic client and the rest of the family, offering praise, support and knowledge. Praise and encouragement from the nurse can help renew the clients hope and the family’s commitment to the health of their loved one. The visiting nurse can bring new knowledge about treatments and tests, verify that the client is using the equipment properly and assess the injection sites. They can also bring supplies to the home, such as syringes, alcohol wipes and brochures.
Diabetic support groups are also very helpful. Family members should encourage their loved one to attend and accompany them. The more knowledgeable a family is about their loved ones illness the better they will be at helping them manage their condition successfully.
Family members need to encourage their diabetic loved one to express their feelings. Let them weep, cry, yell and or scream. Give them the freedom to express their emotions in an accepting and loving environment. Whether the diabetic is six or sixty, diabetes can make one feel all alone, and this can lead to apathy towards their illness. Family and friends can play a crucial role in helping the diabetic manage their blood sugar so that they can live a long, healthy and happy life.
Below is a list of some of the diabetic support groups.
1. Lewis, Heiitkemper, Dirkesen, Medical Surgical Nursing 6th ed., Copyright 2006, Mosby, St. Louis., pages 1273 -1278.
Tags: diabetes, nursing
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By Nancy Lydia Kimmel R.N., Ph.D., C.H.M.M.
Proper foot care is very important for people who are diabetic. People spend a great amount of time on their feet. Knowledge of proper foot care can save the diabetic individual from many future complications that can arise from foot care neglect, such as open wounds, infection, and loss of toe nails, poor circulation, peripheral neuropathy, septicemia and gangrene. Diabetes causes poor circulation, which in turn causes the diabetic individual a loss of sensation. The feet are the farthest away from the heart and are therefore the most susceptible to complications from injury.
Using common sense and taking some simple precautions will go a long way to promoting healthy feet. Here is a list of some of some healthy tips for diabetics regarding their foot care.
- Water should be tested with the person’s hand, and should be tepid not hot. Due to peripheral neuropathy, it is possible to use water that is too hot and can cause injury to the tissue.
- Use soap that is gentle on the skin, such as Ivory. or Dove.. Antibacterial soaps can be harsh on the skin, cause allergic reactions in some people.
- Instead of clipping the toe nails, use an emery board. Clipping the toe nails can lead to breaking the skin or ingrown toe nails.
- See a podiatrist on a regular basis, at least monthly. The podiatrist can clip the toe nails and determine if there are any areas of concern.
- Wear foot coverings at all times. Going barefoot can lead to unexpected injury from foreign objects as well as bacterial infection. Sandals that are open toed should be avoided. Always try to cover the entire foot. Use slippers while in the home.
Be sure to have comfortable shoes. Choose shoes that are a half size bigger and wide enough to accommodate cotton socks. Leather shoes are better than vinyl man made materials. The type of activity that someone engages in usually dictates the type of shoes to be worn. Comfort should be their priority. A diabetic may choose not to wear socks with their tennis shoes while engaging in an activity. If they are wearing shoes made of vinyl or leather, their feet will sweat profusely. Sweat from feet, especially in a slightly anaerobic environment (without oxygen) can become acidic, rather than alkaline. The acid sweat can irritate the skin and excoriate areas where there are sores beginning to form.
- Always use cotton socks. Cotton absorbs sweat more than any other material. Avoid nylon socks if possible.
- Avoid shoes that have high heels. High heels will push the toes forward and can easily cause ingrown toe nails and loss of feeling.
- Try to elevate the feet during the day. Schedule daily rest periods. When elevating the feet, try to keep the feet higher than the heart. This position allows blood to flow easier and enhances circulation.
- Avoid perfumed lotions on the feet. If dryness is a problem, use alcohol and perfumed free lotions. Be sure to thoroughly massage all of lotion into the foot, or dry off excess lotion.
- Dry feet thoroughly after each washing and air out feet if possible during the day.
- Avoid standing for long periods of time. Blood has a tendency to pool in the foot and ankle area, making it harder to circulate back to the heart.
- Avoid activities that can cause injury to the foot, such as soccer and football. If those games cannot be avoided, then choose good foot protection.
Using proper foot care sense with good hygiene can make living with diabetes easier and prevent unnecessary complications that could affect the quality of ones life.
5. Dudek, Susan G., Nutrition Essentials for Nursing Practice, 5th ed., Publisher: Lippincott Williams & Wilkins, copyright 2006
Tags: diabetes, nursing
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By Nancy Kimmel R.N. Ph.D. C.H.M.M.
So, you are a diabetic. If you have just been recently diagnosed, then there is much to learn. Be careful where you get your information. The doctor should be your first source. Your doctor should prepare you with literature and other teaching material, as well as give you referrals to help groups. Being a diabetic doesn’t mean your life is going to change. It does mean that you will have to make important decisions about your health maintenance. If your diagnoses requires that you take oral hypoglycemics then you need to know how they work, when to take them, and the signs and symptoms of hypoglycemia and hyperglycemia. For those who are required to take injections of insulin, they must learn how to give themselves injections, and take their blood glucose level. The best idea is to take it slow. All of this information may seem overwhelming at the beginning. No one expects you to know everything. Most of all be patient with yourself.
It is important to understand why you have diabetes. Diabetes whether Type I or Type II has been determined to have certain genetic links. Genetically speaking, Type I Diabetes risk to offspring from the mother is 1%-3%, risk to offspring of diabetic fathers is 4 %-6%, with identical twin concordance between 30%-50%. (1) In regards to Type II Diabetes the genetic predisposition of risk to first degree relatives is 10%-15% and identical twin concordance can exceed 90%. (1)
In Type I Diabetes the autoimmune system of the individual gradually destroys the beta cells within the pancreas. Signs and symptoms of diabetes do not begin to manifest until 80%-90% of the beta cells are destroyed. Beta cells are important because they are responsible for the production of insulin. Insulin is a hormone that controls the amount of glucose in the blood stream at any particular time. For instance, when a person indulges in a meal that is high in sugar content, there will be large amounts ofo circulating glucose in the blood. To protect the body from excessive amounts of glucose, there is cascade of hormonal signals that stimulate the pancreas to produce insulin and put the unused glucose back into the cell where it will stay until the body requires it. High glucose levels can put the person in danger of diabetic ketoacidosis. Excessively low levels of blood glucose can be just as dangerous as in hypoglycemia. The acceptable range of blood glucose levels considered optimum range between 90-120 mg/dl. The diagnoses of diabetes require blood tests for confirmation. Usually one of the following blood tests are done;
1. Fasting Plasma glucose level exceeding 126 mg/dl
2. Random, or casual, plasma glucose exceeding 200mg/dl, with the inclusion of the signs and symptoms of Type I Diabetes.
3. Two hour Oral Glucose Tolerance Test level exceeding 200mg/dl using a glucose load of 75mg.
Type II Diabetes is by far the most prevalent in those people diagnosed with diabetes. Also, certain populations have a predisposition to diabetes more so than others. Native Americans, Hispanics and African Americans appear to have higher rates of Type II diabetes than their non-Hispanic white counterparts.
The signs and symptoms of diabetes can differ depending on whether the person is Type I or Type II. For Type I diabetics, the symptoms include, polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger) as well as weight loss, weakness and fatigue. The signs and symptoms of Type II Diabetes are not as obvious as Type I. In Type II Diabetics, the onset is later in life. Also, their pancreas is still producing some endogenous insulin. Therefore, their symptoms are not as detectable. Symptoms include, delayed wound healing, peripheral neuropathy (decreased sensation or pain in extremities), fatigue and visual changes. or Diabetes, just like hypertension is a disease that must be treated for life. Diabetics who take proper care of themselves can live long healthy lives into their nineties.
2. Lewis, Heitkemper, Dirksen, Medical surgical Nursing 6th ed., Mosby, copyright 2004, pg. 1270-1273.
Tags: diabetes, nursing
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Nancy Lydia Kimmel R.N., Ph.D., C.H.M.M.
Diabetes is an illness that the patient must live with the rest of their lives. The key to living with diabetes successfully is managing tight glycemic control, or controlling blood sugar levels. Blood sugar levels can vary from time to time depending on several factors such as stress levels, amount of food consumed, type of food consumed, amount of insulin used or insufficient insulin coverage and the time of day.
The human being responds to Circadian Rhythms. These are regular changes in mental and physical characteristics that occur in the course of a day. This term may be more familiar as the, “biological clock”. A good example is that of someone working midnights for the first time. They find it very difficult to sleep during the day and stay awake all through the night. It is as if their body has a mind of its own. In fact, there is some truth to that statement. Bears hibernate because of their biological clock.
Circadian Rhythms combined with the above mentioned factors can produce wide fluctuations in the blood glucose levels of diabetics while they sleep. A diabetic’s blood glucose level may be at 135 mg/dL prior to bedtime and at two A.M. may drop to 40 mg/dL, causing a severe state of hypoglycemia. The body responds to such a drop by producing glucose from alternate sources, since there is no source of ingested food. The only sources of glucose come from the liver via gluconeogenesis, lipolysis (break down of lipids) and glycogenolysis.
The body’s hormones stimulate this cascading response to dangerously low blood sugar. The results of such a response, is that of high blood sugar. This rebound hyperglycemia can in turn causes ketosis. Ketosis occurs because the body is fooled into thinking that there is not enough glucose, since the cells are starved, and the glucose is floating in the blood stream instead of being utilized within the cells. The body then begins to break down proteins which in turn cause the release of ketones. The release of ketones causes the pH of the system to drop. If the pH of the body drops below 7.35, a state of Diabetic Ketoacidosis occurs, which can cause a diabetic coma.
This rebound hyperglycemia known to occur in response to hypoglycemia in the early hours of the morning between two and four A.M., is called, the Somogyi Effect. A good way of detecting the Somogyi Effect is to have the diabetic test their blood sugar during those hours. If their blood sugar is low, then they can correct it by eating a snack, before going back to sleep.
The Somogyi Effect can occur at anytime during the day, but is most often equated with the early hours of the morning. Symptoms include headache, nightmares and night sweats. The treatment of this phenomenon usually involves lowering insulin dosage prior to sleep.
Another disorder similar to the Somogyi Effect is known as the Dawn Phenomenon. Although most diabetics are affected by this disorder, it seems to occur more often in pubescent adolescents. Adolescents’ blood sugar is affected adversely by their body releasing counter regulatory hormones. These counter regulatory hormones produce precipitously high blood sugar levels. It is thought that the growth hormone has some impact in relation to the production of counter regulatory hormones. Usually upon waking, the diabetic’s blood sugar is excessively high. Correction of the Dawn Phenomenon requires an increase in insulin coverage prior to bedtime.
It is easy to see how both of these disorders can be mistakenly diagnosed for the other. That is why it is important for the diabetic to test their own sugar on several early morning intervals and present the results to their doctor. Correct determination of which disorder is occurring is crucial to continued health of the diabetic.
- Lewis, Sharon., Heiitkemper, Margaret., Dirkesen, Shannon., Medical Surgical Nursing 6th ed., Copyright 2006, Mosby, St. Louis., pages 1273 -1278.
Tags: diabetes, nursing
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Once a patient is diagnosed as having diabetes, their world suddenly changes. Now they must monitor their glucose before meals and at bedtime, they must watch the sugars that they consume and be aware of the signs and symptoms of hypoglycemia and hyperglycemia and know what actions to take. This is a lot of information to process for a diabetic of any age. Type 1 diabetics tend to develop diabetes during adolescence. Type 1 indicates that they are dependent upon insulin to control their blood sugar. Type II diabetics usually develop diabetes later on in life and they are prescribed oral hypoglycemic agents to control their blood sugar. A healthy diet can make a positive impact on the diabetic’s life expectancy. Knowing what foods to eat and what foods to avoid is the cornerstone of managing diabetes, as well as tight glycemic control. Therefore nutritional intervention is the responsibility of the nurse, to help promote the health and well being of the patient. Nutritional recommendations for diabetic’s is similar to that of the National Cholesterol Education Program.
In the diabetic patient, their production of insulin (a necessary enzyme produced by the beta cells on the Islets of Langerhan within the pancreas) is insufficient. In type I diabetes, insulin deficit occurs at an early age, whereas in type II diabetes this insulin deficiency takes years to deplete. Lack of insulin allows proliferation of large amounts of glucose to travel freely throughout the blood stream. Insulin administered subcutaneously or via pill form, helps to move glucose from the blood stream back into the cells. Levels of normal blood glucose levels range from 70 -120 mg/dl, although some literature suggests levels up to 145mg/dl as normal. Excessive amounts of glucose in the blood stream can cause numerous health problems. Diabetes has been directly related to some of the following illnesses; kidney disease, high blood pressure, peripheral neuropathy, glaucoma and heart disease. Therefore it is essential for the diabetic patient to have a good understanding of the foods that will benefit them. Recommendations include choosing carbohydrates from grains, fruit and vegetables. Consistency of carbohydrates eaten regularly for snack and at meal time is a crucial factor in glycemic control, more than the type of carbohydrate eaten. Diabetics who receive either insulin or Lantus® (a long lasting insulin) at night should be instructed to eat a snack in the middle of the night to prevent a dramatic drop in blood sugar in the dawn hours. Hypoglycemia can be just a dangerous as hyperglycemia. The signs and symptoms of each state mimic the other. The rule of thumb is to treat the onset of either with a source of fast acting glucose source, such as a hard candy or fruit juice, and then check the blood sugar. Hypoglycemia can cause a coma. The brain is the only organ in the body that utilizes pure glucose. Therefore, by depleting the brains only source of food, the brain will cease to function. So, it is better to treat with fast acting sugar first. This is not going to raise the blood sugar appreciably if the blood sugar is already high. However, if the persons blood sugar is very low, then the addition of a fast acting sugar can save their life immediately. Of course, in a hospital setting, the nurse would immediately check the client’s blood sugar with a glucometer. Sucrose can replace starch without effecting blood sugar levels dramatically. The client should make a list of the foods that they are used to eating on a regular basis and with the help of the nurse re-structure their diet with choices from the food pyramid. Allow the client to choose the foods that they want to substitute. This is going to be their life diet, and it is very important that they be the one to structure how and what they eat. The patient should verbalize the benefits of the foods and what type of sugar source the foods represent. Once the patient can express their dietary plan, and the type of foods that are beneficial as opposed to those foods that are merely empty calories, the patient will feel encouraged and become more involved in their blood glucose monitoring.
Dudek, Susan G., Nutrition Essentials for Nursing Practice 5th Ed., Lippincott Williams & Wilkins, copyright 2006
Tags: diabetes, nursing
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The diabetic patient can help control their blood glucose levels in conjunction with a healthy diet. Not only can they help to control their blood glucose levels with a healthy diet, but their lipids and blood pressure as well. Nutrition recommendations are developed from the following table:
Carbohydrates: /diabetics should choose from a selection of grains, fruits and vegetables. Fruits such as apricots, peaches, mangos, are high in vitamin C and have are a good source of roughage. Grains such as oats, wheat and barley are excellent choices. Having hot cereal like wheat and barley can be a real treat, especially when using Splenda® as a sugar substitute, and a small amount of butter. These carbohydrates are broken down gradually and stored in the liver. They are turned into glucose upon the bodies need at the moment.
Sweetners:/ It is best to avoid processed sweets, such as cakes, doughnuts, cookies and soda pop. Processed sweets and carbonated beverages contain large amounts of preservatives and sodium. The saying, “where sodium goes, water follows.”, is a good saying to keep in mind. What this means, is that the more sodium that is ingested, the more water the body will retain. Water retention leads to high blood pressure and increased pressure in the glomerular tubules within the kidney. As pressure builds up in this area, stage two of kidney disease can occur. It is difficult for those diabetics who are used to drinking sugar free soda. Try to break this habit. The main idea about dietary changes is that it is not a quick fix, but a life style change. The diabetic has to change their way of thinking about the foods that they normally eat. Use sweeteners judiciously. The best alternative is to become used to the taste of natural sugars, and to avoid sodium. Try not using salt for a few days. It is not hard to get accustomed to this. The diabetic will be able to taste the natural salt in their food without adding any extra salt.
Fats:/ Try to keep the fat content in the diet as low as possible. Trim the fat from meat prior to cooking. Braising the meat prior to adding water can eliminate extra fat left on the meat and add flavor to the broth. Read the labels of foods when purchasing groceries. Fat content will increase the diabetic’s blood glucose level, because ingested fat will stay in the system longer. Similar to fast digesting sugars, fat offers up lots of carbohydrates. These carbohydrates can be turned into sugars readily. Before the stored carbohydrates are broken down the body will use the undigested fat molecules. If the person is not active to burn calories, the fat will sit around and what ever portion is not used, the body will store. To explain this theory better, think about oil candles. The oil will burn for hours before being used up. Now imagine cotton candy. Cotton candy will flame and burn to a crisp with practically nothing left within seconds. This is how our body uses fats and sugars. When the body needs glucose, glycogen stored in the liver is enzymatically transformed into glucagon, which is transformed into glucose to feed our body from burning ATP (the body’s energy molecule). When all of the glucose is used up, the body begins to use up carbohydrates, and after the carbohydrates the body then burns fat. Once the fat is burned, the body begins to utilize protein. This protein can be found in the urine, and is a signal of malnutrition. Knowing what fats are good and which are bad can be very confusing. The best rule of thumb is to avoid processed foods and use meats that are not fatty or marbled with fat throughout. Bake, broil or boil foods. Braise meats in a pan after trimming the fat. Use seasonings without added salt. Using pure seasonings is a fantastic tasting experience. Fresh rosemary, thyme, oregano, and a host of other seasonings can add wonderful flavor to a meal. Use olive oil in place of the usual cooking oils. Some olive oils state that they are half corn oil and half olive. This is better than using 100% corn oil or canola oil. Try using fresh ground pepper and garlic cloves in place of salt additives. Keep in mind that you are what you eat, as the saying goes. Being healthy should be the most important goal of not only diabetics but for everyone.
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