Diabetes Type 1: A Case Study and Teaching Plan
Patients need sometimes to be educated in their disease, especially if their disease is chronic and progressive. When patients lack basic knowledge on their disease, further complications may arise due to improper self-care and bad lifestyle choices. Nursing theories such as the Roy Adaptation Model, allow for better understanding of the specific needs of the patient and how to carry that out into an effective teaching plan. Case studies also help in determining proper treatment for specific situations.
A 16-year-old female with a history of type 1 diabetes was brought to the emergency section of her local hospital by her mother. Her name is Elsa. Her mother witnesses an episode of syncope. The symptoms present in the patient were flu-like accompanied by a productive cough that lasted 6 days prior to her arrival to the hospital. Furthermore, patient has been drinking and eating her normal daily dietetic amount intake.
Today she stated she became dizzy, diaphoretic, and also mentioned frequent urination every hour or so. Her mother was aware of her daughter’s diabetic condition as well as her recent feelings of dizziness and bout of frequent urination. Her mother assumed it was the flu and dismissed her symptoms. Her serum glucose was 391 mg/dL, her serum pH was 7.21, her serum ketone level was 7.2 mEq/L, and her anion gap was 20. The patient’s diagnosis was diabetic ketoacidosis and bronchial pneumonia.
Additional patient history revealed several things. Elsa does not appear to know how to manage her diabetes properly. She shows inconsistent eating habits and eats food that may contribute to the worsening of her condition. She also does not exercise enough as she stated she leads a mainly sedentary lifestyle. Patient is also 20 pounds overweight. In order to properly educate patient Elsa in better managing her disease, a teaching will be devised to help her cope with the complications related to diabetes type 1.
Assessment and Suggestions:
Assessment of patient’s history and condition reveals need for patient to participate in a diabetes self-management program that will specifically include proper instruction in fitness regimens, food journals, meal planning, daily glucose monitoring, and weight loss. She also needs to learn how to set goals and objectives in order to effectively succeed in the program. These suggestions will help Elsa learn how to eat, when to eat, and how much she is eating throughout the day along with setting fitness goals and monitoring her daily glucose levels to ensure good health while having diabetes type 1.
The National Standards For Diabetes Self-Management Education identify the basic principles patients should follow in order to effectively manage diabetes. One of the reasons Elsa appears with current complications is because she is unaware of what she should do to prevent complications. The National Standards identifies and covers all aspects of proper diabetes management and will be an important factor in determining proper patient education. In a journal article by Mensing et al. (2000), the authors describe the guiding principles of diabetes management:
1. Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term
2. DSME has evolved from primarily didactic presentations to more theoretically-based empowerment models
3. There is no one “best” education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes. Additional studies show that culturally and age-appropriate programs improve outcomes and that group education is effective.
4. Ongoing support is critical to sustain progress made by participants during the DSME program.
5. Behavioral goal-setting is an effective strategy to support self-management behaviors (Mensing et al., 2000, p. S89).
The Standards also indicate Self-Management Education should administered through an instructor who has prior experience related to education and diabetes management. The other option is a certified diabetes educator. The instructor must be a dietician, registered nurse, or a pharmacist. Following protocol as it relates to patient instruction is important in being able to properly educate and assist a patient with disease and illness management.
After implantation of comprised teaching plan, patient should be more knowledgeable of diabetes type 1 and its management. Elsa will also be expected to know how to maintain a healthy weight and BMI in order to further decrease possible complications from Diabetes type 1. Although patient education is important in successful program implementation, constant reinforcement along with periodic evaluation should also be carried out in order to observe and identify progress or setbacks. Within 6 months to a year, a final evaluation will take place to see if patient lost excess weight, is eating properly, and is maintaining a food journal.
In an article by IANNOTTI et al. (2006), DSM (Diabetes Self-Management) outcome expectations should not be defined by the effect of DSM on diabetes symptoms. Outcome expectation may offer beneficial or adverse physical effects, social reactions, or self-evaluative reactions. This especially applies to teenagers dealing with diabetes type 1. Accordingly, it is important to include reflect their family, social, and personal reality into their instruction. With that in mind, if Elsa follows the DSM, she could have a variety of positive outcomes. As the article explains: “DSM adherence can have varied positive outcomes: personal (e.g., improved performance in school and sports, increase in self-confidence), social (e.g., less conflict with parents), and physical (e.g., reduced symptoms and health problems) (IANNOTTI et al., 2006, p. 99).
Teaching Strategies: are appropriate to meet the individual’s needs, age & culture?
When instructing a teenager about proper diabetes self-management, it is important to consider their situation in life and tailor the program to their specific and personal circumstances. Along with basic education of the disease process of diabetes, tailor made treatment options and nutritional management should be considered as well as assessment of physical health and emotional well-being. Exercise, safe and effective use of medications, proper monitoring of blood glucose, prevention and detection of acute complications and chronic complications, and lastly, development of personal strategies to help cope with diabetes-related psychosocial issues should be reflected in the teaching strategies. Taking all of these factors into consideration will generate an effective DSM program.
Since teenagers are more and more used to socializing and learning online via websites such as facebook, google, and so forth, it is important to carry implementation of teaching plan online and also communicate with patient Elsa through phone and email. Providing options of communication for teenagers will make them feel more open to express any concerns, questions, or progress while learning. Elsa is overweight so a teaching strategy that could help concerning that issue is giving her access to an online site that helps people track their calories eaten and calories burned. Teens use cellphones and apps installed in their phone.
An instructor can offer suggestions of free apps such as “myfitnesspal,” to make keeping track of calories and exercises even easier and more convenient. There are also apps that suggest exercises like “workout trainer.” Ongoing support from loved ones is also significant in increasing the success rates of DSM. Discussing concerns and goals with the patient’s family will help them keep Elsa on track while also educating themselves in her condition.
Assessment of possible barriers and patient knowledge on diabetes is crucial in comprising an adequate teaching plan. Continual reassessment is also important in maintaining accurate information on patient progress. A teaching strategy that can be implemented along with providing adequate assessment is weekly quizzes. The weekly quizzes can be administered online via email with the instructor sending questions and the patient answering them.
The questions can consist of basic knowledge of diabetes, importance of glucose monitoring along with emotional well-being questions such as:
“How was your day?”
“Did you feel like you made any progress this week?”
“How many times do you feel hungry?”
“How many times do you feel tired?”
Seeing the responses and then offering alternatives or inspirational success stories and providing patient with additional reading resources will allow for greater absorption of information and proper and current evaluation of patient. Along with a weekly quiz, an additional monthly project where the patient devises a sample eating plan and exercise routine would be a great way to help the patient learn. Offering to be the student in Elsa’s sample eating plan and exercise routine will help Elsa identify from a different perspective the proper way to eat and stay active.
The standard information for DSM should include the following information:
What is diabetes? Diabetes is a chronic and progressive disease that affects the body’s ability to produce insulin or handle blood sugar.
Why is diabetes a chronic and progressive disease? There is no known cure for type 1 diabetes. Type 2 diabetes however has a better outcome with cases of prolonged remission in some. Type 1 diabetes however is progressive, meaning it will only get worse in time.
How common is diabetes? As a diabetes fact sheet states: “347 million people worldwide have diabetes” (WHO, 2013, p. xx-xx).
Causes of diabetes: Type 1 diabetes is caused by an infection in genetically susceptible people whereas type 2 diabetes can be caused by particular lifestyle factors or inherent biological issues. Overall diabetes comes from the body’s inability to make and use insulin.
Lifestyle factors that may contribute to diabetes are obesity, a sedentary lifestyle, alcohol use, and cigarette smoking.
Along with several other key points of information, instruction should also include daily foot care. Monitoring and assessing conditions of the feet can help a patient notice if there are any circulatory or nervous system issues. Patients especially with type 1 diabetes are prone to poor blood circulation and peripheral neuropathy. Prevention is key to eliminating risk of greater complications. Including preventative measures such as daily foot care and monitoring will better the chances of successful DSM.
The Roy Adaptation Model was used in constructing the teaching plan. The theory teaches that the person is “a bio-psycho-social being who is in constant interaction with a changing environment; coping with a changing world, through the use of both innate and acquired mechanisms which are biological, psychological and social in origin” (AIPPG, 2012, p. 1) The psychological and social aspects of this nursing theory offer insight into the possible methods and approaches involved in successful DSM instruction. As mentioned in a previous section, awareness of the complex reality the patient lives in, is beneficial in not only understand potential patient difficulties, but also implementing effective instruction. Other aspects of the nursing theory also helped in understanding the inevitabilities of certain outcomes and how to positively adapt to those anticipated outcomes.
The RAM (Roy Adaptation Model) states health and illness are inevitable dimensions of the person’s life and promotes positive response to environmental changes through adaptation. As AIPPG (2012), state: “The person’s adaptation is a function of the stimulus he/she is exposed to and his/her adaptation level and the person’s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response” (AIPPG, 2012, p. 1) RAM explains the need for adaptation in order handle inevitabilities. With diabetes type 1 being a progressive, chronic disease with no cure, it is important to know the known complications that will occur regardless of health and know how to adapt to at least prolong prevention of inevitable complications.
RAM states the person has four modes of adaptation which are: “physiologic needs, self-concept, role function and inter-dependence” (AIPPG, 2012, p. 1). That being said, RAM also sees interpersonal relations as being an integral part of nursing. This means inclusion of people as individuals or in groups such as: families, organizations, communities, and society as a whole in order to carry out nursing techniques and teaching strategies. To conclude, patients like Elsa who lack basic knowledge on their condition and is of teenage age, must have their DSM formed and established in a way that suits their needs and can keep them interested. Utilizing modern day phone applications, websites, and email to carry out DSM instruction will not only benefit patients like Elsa, but also enable better absorption, ease, and convenience.
AIPPG (2012). Roy’s Adaptation Model. Retrieved from http://currentnursing.com/nursing_theory/Roy_adaptation_model.html
IANNOTTI, R.J., SCHNEIDER, S., NANSEL, T.R., HAYNIE, D.L., PLOTNICK, L.P., CLARK, L.M. . . . SIMONS-MORTON, B. (2006). Self-Efficacy, Outcome Expectations, and Diabetes Self-Management in Adolescents with Type 1 Diabetes. Journal of Developmental and Behavioral Pediatrics, 27(2), 98-105. doi:10.1097/00004703-200604000-00003
Mensing, C., Boucher, J., Cypress, M., Weinger, K., Mulcahy, K., Barta, P. . . . Adams, C. (2000). National standards for diabetes self-management education. Task Force to Review and Revise the National Standards for Diabetes Self-Management Education Programs. Diabetes Care, 34(1), S89-S96. doi:10.2337/diacare.23.5.682
WHO (2013). WHO | Diabetes. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en/
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