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Course # 94393 • Diabetes Care and Patient Education

CASE STUDY: FACILITATING DIABETES SELF-CARE

Patient Y is an African American woman, 62 years of age, who was diagnosed with type 2 diabetes 16 years ago. Her history includes hypertension, which is currently well controlled on medication, body weight 30 lbs above ideal, clinical signs of early renal failure, cardiovascular disease, and early-stage retinopathy. She reports that, "My blood sugar never has been too good, and I don't think it ever will be. Lately it's gotten worse." In your assessment, you note that Patient Y's blood glucose has ranged from 43–383 mg/dL over the previous few months.

Patient Y tells you that she feels confident in her ability to monitor her blood glucose and administer her insulin. She demonstrates that she is able to do this. However, she is concerned about her widely fluctuating blood glucose levels. She says, "Sometimes my sugar's too high, and I don't know what I did to make it high. Other times, it's low, and I get really scared that I'll end up in a coma." She goes on to report that if her blood sugar is less than 100 mg/dL, she will routinely treat herself with a tablespoon of sugar added to 10–12 ounces of orange juice.

Patient Y indicates that she has a good understanding of basic principles of meal planning and that her family is generally supportive of her dietary needs. Her dietary recall reveals that she makes many appropriate food choices when she eats but that her eating pattern is inconsistent. She skips or delays meals in some cases and eats large amounts at other times. In apparent frustration, she states, "It doesn't seem to matter whether I eat right or not."

Discussion

Patient Y's statements reflect a low level of self-efficacy in some important areas of diabetes self-management. For example, she does not believe that she can achieve good glycemic control, and she lacks confidence in her ability to manage the dietary aspects of her own care. The basis for a therapeutic and empowering relationship with Patient Y will begin when these feelings of frustration and helplessness are acknowledged. You can do this by asking open-ended questions that focus on her feelings. For example, you can ask her, "What is the hardest thing for you right now about dealing with your diabetes?"

If you learn that Patient Y's greatest concern revolves around her fear of experiencing serious hypoglycemia, it will then be an important part of your teaching plan to include instruction on hypoglycemia prevention and management. As you probe further, you discover that the fear Patient Y has surrounding hypoglycemia drives her to take excessive amounts of sugar when she perceives that her blood glucose is too low. You find that, in many cases, she takes large amounts of sugar based upon subjective feelings of "being low," without checking her blood sugar first. You also realize that Patient Y's "comfort zone" for low blood glucose, anything less than 100 mg/dL, is actually quite a bit higher than standard values of 60–70 mg/dL for hypoglycemia. You can see that frequently taking large amounts of sugar seems to result in blood glucose values that rebound to very high levels. This is probably a major contributor to her overall pattern of blood glucose fluctuations. Furthermore, you can presume that Patient Y's irregular pattern of eating is another factor in her erratic glucose pattern, probably accounting for the episodes of true hypoglycemia that she has had.

It is important to teach Patient Y that she can safely prevent and manage hypoglycemia in a way that will help her achieve better overall blood glucose control. In order to gain her trust, the patient's fear of hypoglycemia should be validated by acknowledging that it can be a serious side effect of insulin. You want her to know that keeping her safe is your priority as well.

Once trust has been established, you will want to consider Patient Y's readiness to change the behaviors that seem to be causing poor glycemic control. Following is a scenario of how you might accomplish this:

Nurse: "It sounds like having a serious episode of low blood sugar really worries you."

Patient Y: "I've been to the ER with it before, and they told me you can die if the sugar goes too low."

Nurse: "I can understand why you are afraid of having a hypoglycemic reaction. It certainly can lead to serious problems if not treated. Fortunately, most people can either prevent it or treat it in the early stages. I would like to talk to you about some ways of preventing and treating low blood sugar. There are ways that you should be able to prevent low blood sugar without causing so many highs in between."

Patient Y: "That would be good."

Nurse: "It would involve some changes on your part, including what you do when your blood sugar is low. It would involve not taking quite so much sugar so often. Is this something you'd be interested in hearing about?"

Patient Y: "I can think about it. But I don't want to do anything that will let my blood sugar go too low."

By indicating that she will allow you to provide tentative information, Patient Y demonstrates that she is in the contemplation stage of behavioral change. Your role, therefore, is to offer information, provide empathic feedback, and listen reflectively.

Offer Information

Inform the patient of the standard treatment for hypoglycemia, which is to take 15 grams of fast-acting carbohydrate for blood glucose less than 70 mg/dL. In addition, help Patient Y understand the relationship that her irregular pattern of eating may be having on fluctuations in blood glucose. Instruct her that hypoglycemia can usually be avoided by eating a balance of food types every four to five hours throughout the day.

Provide Empathetic Feedback

First, acknowledge and validate the patient's fears. Then, in a nonjudgmental way, you can describe to Patient Y how her behavior seems to contribute to the wide fluctuations in blood glucose levels. You could say: "It would probably be better if you checked your blood sugar to see if it is truly low before eating sugar. Then you will not be causing your blood sugar to rise if it is not necessary. In addition, I don't think you need to take as much sugar as you have been for levels less than 100 mg/dL. It is recommended that you only need to treat for low blood sugar if it is less than 70 mg/dL. Even then, you can probably raise your blood sugar with a smaller amount of sugar, like just the orange juice without the added sugar."

Listen Reflectively

Serve as a mirror for her thoughts and beliefs. For example, you may respond to her ambivalence by saying, "Even though you haven't said you want to try these things right now, I get the feeling you might decide to try it at some point. I'll leave you some written information that you can keep on hand."

As you continue to work with Patient Y, you may discover other areas where she needs further diabetes education. You can continue to help her make appropriate decisions about her own care through an empowering approach. Just as you did with the issue of hypoglycemia, you should continue to acknowledge the patient's priorities, assess her levels of self-efficacy, and address her readiness to change behavior. Proper assessment of these areas will allow for the provision of appropriate and effective interventions.

Case Study: Self-Monitoring of Blood Glucose

Patient J is a man, 60 years of age, with a history of type 2 diabetes. He was brought to the emergency department after his neighbor found him at home with confusion, lethargy, right-side weakness, and slurred speech. Medical exam and work up in the emergency department revealed that Patient J was severely dehydrated and that his blood glucose was 860 mg/dL. He was diagnosed with HHS, an acute complication of type 2 diabetes. He was admitted to the medical unit on an insulin drip and for intravenous fluid and electrolyte replacement.

After Patient J's blood glucose and electrolytes returned to normal levels, his mental status cleared and he was free of any neurologic manifestations. While in the hospital, he was seen by the diabetes educator. He received instruction on diet, insulin administration, and blood glucose monitoring. His discharge plan was to return home on insulin injections with follow-up and teaching by a home healthcare nurse.

Discussion

Patient J's home healthcare nurse will play a crucial role in helping him prevent another episode of HHS and other serious problems associated with poorly controlled diabetes. One of the most important aspects of his care plan will be to teach and instruct him in SMBG. As an essential component of diabetes care, SMBG will enable Patient J and his healthcare team to monitor blood glucose levels and influential factors. Good glycemic control will not only help this patient avoid acute problems like HHS, it should also help him feel better on a daily basis. Good control can also help the patient avoid the devastating long-term complications of diabetes, such as blindness, renal failure, and cardiovascular disease.

Before developing a teaching plan for Patient J, a needs assessment to determine what he already knows about diabetes self-care should be performed. This should include areas of care such as nutrition, insulin administration, and blood glucose monitoring. The needs assessment in this case indicates that the patient is unable to correctly perform SMBG independently. He is assessed as being ready to learn this procedure because he clearly indicates that he is willing to incorporate this behavior into his daily life.

In order to most effectively teach Patient J this procedure, the principles of adult learning should be incorporated into the teaching strategy. Begin by finding out what he perceives as problems or barriers to successfully performing SMBG. This will empower Patient J by engaging him in the learning process. Furthermore, his interest may be stimulated by providing a brief rationale for what is being taught, including the benefits of SMBG. Continue applying principles of adult learning on an ongoing basis by keeping Patient J active in the learning process and providing him plenty of opportunity to interact and ask questions.

After teaching Patient J how and why to monitor his blood glucose, the nurse will ascertain his ability to perform this procedure by asking for a return demonstration using control solution. Once this is completed, finger sticking and bloodletting techniques may be covered, ensuring that he can perform these properly.

After the procedures have been reviewed, it is important to ensure that Patient J has a thorough understanding of how to interpret his blood glucose results. The patient should have an understanding of how to compare his food intake, activity pattern, medications, and daily stress level to blood glucose results using a diary. When he learns how these factors influence blood glucose, he will be better able to achieve and maintain glycemic control while avoiding problems associated with diabetes.

CASE STUDY 3

Patient C is a moderately obese white female, 67 years of age, who has recently been diagnosed with type 2 diabetes. Her physician has recommended dietary modification and a walking program to manage her diabetes and promote weight loss. No diabetes medications have been prescribed at this time. As the nurse working in her physician's office, you are asked to provide Patient C with education on the dietary management of her diabetes. As part of your needs assessment, you ask the patient to provide a 24-hour dietary recall. The results and analysis of the dietary content are reported in Table 8.

Discussion

After reviewing Patient C's 24-hour dietary recall, you are able to identify areas where you can most appropriately focus teaching about nutrition. You do this by comparing the overall composition of her diet to the general nutritional recommendations. You can see by Patient C's 24-hour dietary recall that she tends to select foods that are high in both fat and sugar. She will need to know that these types of foods add unnecessary calories to her diet and contribute to her obesity. While you can calculate six servings of added fat in her diet (margarine), you also see that her intake contains several sources of "hidden fat," which greatly increase her overall fat intake. Examples of the high-fat foods she consumed are cheese, higher-fat hamburger, french fries, and chocolate-covered cookies. You should inform Patient C that for weight and cardiac-risk reduction, these foods should be consumed less frequently. You can suggest substituting lower-fat versions of these foods. These may include lean hamburger, low-fat or nonfat cheese, and a baked potato instead of fries. She can also reduce her saturated fat intake by choosing nonfat milk and nonfat yogurt. In place of margarine, she could consider using nonfat butter substitute or fat-free sour cream.

Assessment also reveals that Patient C's diet is low in fiber and vegetables and lacking fresh fruits of any kind for the particular day being examined. You can recommend that she begin substituting some of her higher-calorie food choices with fresh fruits or vegetables. This will help her lose weight while increasing her fiber intake. You can teach her about fruit serving sizes so that she does not increase her overall intake of sugar with the addition of fruit to her diet. The benefits of weight control should be emphasized, as some people with type 2 diabetes are able to control their diabetes with weight reduction alone.

Another point revealed by Patient C's dietary report is that most of her caloric intake is concentrated toward the end of the day. She should be advised that her glycemic control could improve if she distributes calorie and carbohydrate intake throughout the day. She can achieve this by eating smaller meals and snacks and spacing them evenly throughout the day. Eating breakfast can have a positive influence on appetite control, food choices, and metabolism, and thus help with weight management. A possible reason for this is that eating breakfast helps the person avoid becoming overly hungry, which can later lead to overeating and poor food choices. It is also believed that eating a healthy breakfast can set the psychologic and behavioral tone for the day, prompting better food choices overall [77].

After providing Patient C with these general guidelines for nutrition, you can begin teaching her about portion control using the plate method. An actual 9-inch dinner plate and food models can be used to help her visualize the amount of foods that she should be eating from each group. The recommended meal plan can be individualized by taking into account the types of foods that the patient is already eating. Then, you can suggest healthier substitutions for those foods so she is not faced with major changes in basic dietary content. To illustrate this concept, each food group will be discussed in turn.

Grains and Starchy Foods

Some of Patient C's starch choices were appropriate, and she can be encouraged to continue these foods in appropriate amounts. These included whole-wheat crackers (encourage lower-fat choices) and the baked potato, assuming appropriate portion size. Both of these starch sources add fiber and other nutrients to the diet. She should be instructed that she could significantly increase her intake of fiber from the potato by consuming its skin. The nurse should help Patient C explore potential substitutions for the less appropriate sources of starch in her diet. For example, a baked or boiled potato, with skin, could be substituted for the french fries, and whole-grain breads should be substituted for white. You can also explore ideas for increasing whole grain intake at breakfast. This can include eating oatmeal, high-fiber sugar-free cold cereals, or whole-grain breads.

Non-Starchy Vegetables

For patients with diabetes, vegetables provide a moderate source of carbohydrate with the benefit of being rich in fiber, vitamins, and minerals. They offer the added benefit of being naturally devoid of fat and very low in calories. Although canned and frozen vegetables may be an acceptable source, fresh produce is desirable.

Like many Americans, Patient C probably does not consume enough fresh vegetables on a daily basis. While one cup of canned green beans partially fulfills her daily serving allowance of vegetables, she could obtain more nutritional value from fresh sources, such as salads and raw produce. These are often higher in fiber and provide more variety of vitamins and minerals. They may also be more satisfying because the serving size for raw vegetables is larger than for cooked. Fresh vegetables also require more chewing and take longer to eat. The ADA recommends at least three to five servings of vegetables per day. This is a minimum requirement, and more is considered better. Non-starchy vegetables do not need to be counted when using the carbohydrate counting method. When following the plate method, half of the plate should be covered with non-starchy vegetables and salad can be added on the side [78].

Fruit

Although fruit is a source of fructose, or fruit sugar, it is not forbidden to individuals with diabetes. There are many health benefits to eating fruit, including its provision of fiber, vitamins, and minerals to the diet. In the case of Patient C, she should be advised to begin reducing the amount of sucrose that she eats and replacing it with three servings of fruit each day. Whole fresh fruit is desired, although unsweetened canned fruit is acceptable. Whole fruits are strongly advised over juice because they offer the benefits of fiber, take longer to ingest, and may be more filling than juice. When instructing the patient about serving sizes of fruit, it should be emphasized that one serving is equal to a small piece of fruit, ½ banana, or 1¼ cup of strawberries.

Milk

Patient C should begin substituting nonfat milk and yogurt for the low-fat types she is currently using. When selecting yogurt, it should be plain or sweetened with a sugar substitute. Sugar-sweetened yogurt typically contains about 30 grams of carbohydrate, which is the same amount that she would get from two servings of milk.

Protein

Because cheese is categorized as a meat/protein, Patient C's 24-hour dietary recall reflects a surplus intake. She should be advised that large quantities of protein in the diet generally add to its fat content, especially if red meats, fried meats, or high-fat cheeses are selected. Although skinless baked chicken represents an appropriate meat choice for Patient C, she should be encouraged to make choices such as these more consistently. Strategies would include reducing portion sizes and consistently selecting poultry and fish over red meat. It should be reinforced that it is desirable to prepare meats by baking, broiling, and boiling. Meats that have been fried or have had fat added should be avoided. Processed meats, such as lunchmeat and hot dogs, should also be avoided due to their high fat and sodium contents. When selecting cheeses, the patient should be advised to choose lower-fat varieties, such as cottage cheese or reduced-fat hard cheeses.

Fat

As discussed, sources of hidden fat should be avoided in the diet. The number of recommended fat servings refers specifically to fat that has been added to food. An example of added fat included in Patient C's diet is the margarine that she used on her bread and potatoes. On a 1,500-calorie diet, four servings of added fat are recommended. Patient C should be instructed in strategies for reducing her overall fat intake, especially from hidden fat sources. She should be advised to read food labels when shopping to guide her in selecting foods lower in fat, especially the saturated and trans fat types. She can also be referred to a number of cookbooks published by the ADA and the American Heart Association that are readily available in bookstores, libraries, and on the Internet. Other suggestions for Patient C may include ideas for seasoning vegetables and potatoes without fat. Examples include using lemon juice, mustard, nonfat salad dressings, hot pepper sauce, garlic, ground pepper, nonfat sour cream, and other herbs and spices instead of fats and oils.

Sugar

Guidelines for the use of sugar by people with diabetes have been discussed. Patient C will need education and support in curtailing her high intake of sugar. She should be advised that although sugar is not absolutely forbidden to her now that she has been diagnosed with diabetes, she would need to learn how to make choices about sugar as part of an overall plan for healthy eating. As part of her meal plan for diabetes, Patient C can occasionally substitute a serving of sugar for a serving of fruit, starch, or milk. An example of an appropriate sugar substitution would be to have a 3-inch cookie in place of an orange. It should be recognized that the nutritional value of the cookie is inferior to that of the orange and therefore should only be an occasional substitution.

Case Study: Insulin Administration for the Visually Impaired Person with Diabetes

Patient R is a man, 49 years of age, with a 21-year history of type 1 diabetes. He is blind and lives alone without significant support from family or others. He also suffers from diabetic nephropathy and undergoes outpatient dialysis three times a week. He has been receiving home health nursing services for more than three years to assist with diabetes management.

Although Patient R has expressed appreciation for the support provided by the nurses, he is also resentful of their ongoing presence in his life. He longs for more privacy and more control over his own life and asks if there is any way that he can live more independently while maintaining his medical safety. The home health agency sends a nurse with strong diabetes management skills to Patient R's home to assess his potential for increased independence in the management of his diabetes.

Discussion

In her functional assessment, the nurse learns that, with adequate lighting, Patient R is able to see well enough to read a few words of large print with a magnifying glass. Other significant findings from a comprehensive needs assessment reveals that Patient R is able to:

  • Verbalize the correct dose and time of insulin injections

  • Inject insulin from a prefilled syringe safely and correctly

  • Perform the basic manual steps of blood glucose testing

  • Interpret blood glucose monitoring results as being high or low

  • Verbalize the correct action to take for hypoglycemia

  • Verbalize appropriate management of hyperglycemic emergencies

With these abilities in mind, the nurse is able to begin formulating a plan for Patient R. Although he demonstrates the cognitive and manual abilities needed for self-care, his severe visual limitations must be addressed before he is considered safe to manage these tasks on his own.

One area of challenge for Patient R is related to measuring the insulin dose in the syringe. The nurse's initial approach is to observe the patient while he draws an insulin dose using syringes with the largest increment markings available. Because Patient R is on insulin doses of less than 30 units, he is able to practice using a 0.3-cc syringe. Not surprisingly, he is unable to see these syringe markings well enough to draw an accurate dose. Next, the nurse has Patient R try the same syringe using a magnifier. Even with this adaptive aid, he is still unable to consistently draw an accurate dose. The nurse concludes that it will be necessary to make arrangements for the patient's syringes to be prefilled by a sighted person and stored in the refrigerator for later use.

The nurse then considers the type and amount of insulin that Patient R is using. As a matter of convenience, he is using premixed 70/30 insulin, receiving 14 units in the morning and 7 units in the evening. Because he would be injecting different doses of insulin in the morning and evening, it is necessary to ensure that Patient R is able to distinguish between the two differently dosed prefilled syringes. This is accomplished using two glass jars, dissimilar in size and shape, to store the prefilled syringes. Each jar is then labeled in large letters using a bold black marking pen as "MORN" and "EVE." The nurse avoids using the abbreviations "am" and "pm" because of their similarity. She then works with Patient R on a plan to place a predetermined number of prefilled syringes in each jar, with the capped needles facing upward. The patient shows her where and how the syringes should be stored in the refrigerator to maximize his ease of use and minimize potential error.

Patient R's needs assessment has already determined that he is well versed in insulin administration practices. Therefore, the nurse has only to review those techniques with him and verify his competence by having him give a return demonstration. Part of her review includes reminding him to roll the prefilled insulin syringe gently between his palms prior to injection. She also verifies his ability to select the appropriate dose from the jars in the refrigerator and to select an appropriate injection site. She suggests an injection technique of gently placing the needle on the skin before inserting it, rather than using the conventional dart-like approach. This allows him better control over the site of injection.

The next challenge for Patient R is related to blood glucose monitoring. Although he has a meter that he is comfortable using, he is unable to read the results display accurately. The nurse discusses with him the possibility of trying a talking meter. The patient expresses that, because he is already familiar with his current meter, he would prefer to continue using it with a display magnifier if possible. The problem he perceives, however, is that the magnifying glass he is currently using is not sufficient for this procedure. To address this challenge, the nurse refers Patient R to the local chapter of the Braille Institute. Here, specialists are available to supply him with a prescription magnifier that is adaptable for use with his current meter. After receiving this device, the nurse works with the patient to ensure that he is able to accurately read the results displayed on his meter.

Although Patient R initiated these changes in his care because he desired more independence, the transition period is a time of anxiety on his part. After three years of having the security of a nursing visit twice a day, Patient R begins to question his ability to manage safely with less frequent nursing contacts. His concern is validated by the fact that he lives alone and does not have a significant other. It is important at this point to work with the patient and his physician on a plan for future nursing service that would ensure his safety while affording him the independence that he desires. Because he is socially isolated, it is agreed that Patient R should have face-to-face contact with medical personnel once a day. It is determined that outpatient dialysis appointments would meet this need for three days of each week. For the remaining four days of the week, a nurse would visit him at home. The purpose of these visits would be to perform a skilled assessment of the patient's current status and to ensure his medical safety on a daily basis. These nursing visits would include a review of Patient R's blood glucose results using the memory function of his meter. Syringes would be prefilled as needed. Periodically, the nurse would observe the patient performing his self-care procedures to ensure that changes in his functional ability had not occurred. The nursing service would continue to be available to Patient R 24 hours a day by telephone, with additional nursing visits made as needed. A medical social worker is involved in providing the patient with community resources and helping him obtain a diabetes identification bracelet.

This case demonstrates a problem-solving approach to diabetes self-management that promotes the independence of a visually impaired person with diabetes. While issues of medical safety are always paramount, other factors should be considered when developing a plan of care for the visually impaired patient. These factors include the patient's willingness and ability to become more independent, his baseline knowledge, and experience of diabetes self-care and resources available. In the case of Patient R, a safe and viable plan was developed that resulted in greater independence and promoted his sense of well-being.

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