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Teaching Plan for Newly Diagnosed Diabetes 1

Teaching Plan for Newly Diagnosed Diabetic Patient


The Identified Learning Need
Patients with Diabetes have very comprehensive learning needs. The learning needs are
focused on managing their glucose levels and preventing complications of diabetes. Learning
needs for managing diabetes are complex and include: monitoring blood glucose levels,
menu/food planning, exercise, medications, skin care, management of co-existing disease
processes, knowledge of medications, knowledge of the disease process and how to manage
hypo or hyperglycemic episodes. Many patients are diagnosed with diabetes every year and
many are unaware that it requires lifestyle changes, especially in the areas of nutrition and
physical activity. Making these lifestyle changes is one of the greatest challenges they will
encounter in managing their diabetes. The main goal of the teaching plan is to provide the patient
with the knowledge to be able to make self-directed behavioral changes to improve their overall
health and manage their diabetes.

The Behavioral Objectives for the Teaching Plan


1. The patient will be able to describe the diabetic medications that they are on and how to
properly take the medications
2. The patient will be able to demonstrate proper skin and foot care.
3. The patient will be able to perform self-monitoring of blood glucose using a blood
glucose meter as evidenced by demonstration of the technique to the nurse or nurse
practitioner.
4. The patient will be able to describe the benefits of regular exercise and how regular
exercise can improve blood glucose control.
Teaching Plan
The diabetes teaching plan is aimed at helping the patient make educated lifestyle choices
and changes that will promote health and promote a stable blood sugar. Each patient needs a
comprehensive treatment approach. This includes: (a) an individualized food/meal plan
appropriate for his/her lifestyle, (b) education related to diabetes and nutrition therapy, and (c)
mutually agreed-upon short term and long term goals for lifestyle changes.
The teaching plan should stress the importance of complying with the prescribed
treatment program. This teaching plan should be tailored to the patient’s needs, abilities, and
developmental stage. The teaching plan for a patient with diabetes should include: diet,
administration, possible adverse effects of medication, exercise, blood glucose monitoring,
hygiene, and the prevention and recognition of hypoglycemia and hyperglycemia. The teaching
plan is an education program designed to help patients with newly diagnosed diabetes or patients
who need a review of concepts for managing their diabetes. However, diabetes management
requires on-going education and nutritional advice with regular review and modification as the
disease process progresses and the needs of the patient changes.

Teaching Plan for Diabetes


Teaching Plan would include 6 evening or day classes consisting of 2-3 hour sessions
Teaching Plan for Newly Diagnosed Diabetes 2

of education and group discussion. The topics and discussions would be as follows.
Day 1
o General overview of Diabetes (2 hours)

Day 2
o Blood glucose monitoring and goals of blood glucose
monitoring (3 hours)
Day 3
o Medications and Insulin (2 – 3 hours)

Day 4
o Complications from Diabetes (1 hour)

o Skin and Foot Care (0.5 hour)

o Exercise and Diabetes (1.5 hour)

Day 5
o Diet and Diabetes (2 hours)

o Coping with Diabetes (1 hour)

Day 6
o Questions and Answers (1 hour)

o Review of any concepts requested by patients (1 hour)

General Overview of Diabetes


Patients with diabetes need to understand what diabetes is. Patients who understand what
diabetes is and the complicated process associated with the disease are more likely to comply
with the prescribed regimen. Diabetes Mellitus is a syndrome with disordered metabolism and
inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of
insulin resistance and inadequate insulin secretion to compensate. Diabetes is a chronic
progressive disease that requires lifestyle changes, especially in the areas of nutrition and
physical activity. The overall goal of medical and nutritional therapy is to assist persons with
diabetes in making self-directed behavioral changes that will improve their overall health.

Blood glucose monitoring and goals of blood glucose monitoring:


Testing blood glucose levels pre-meal and post-meal can help the patient with diabetes
make better food choices, based on how their bodies are responding to specific foods. Patients
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should be taught specific directions for obtaining an adequate blood sample and what to do with
the numbers that they receive. Research has found that patients who have had education on the
use of their meters and how to interpret the data are more likely to perform self-blood glucose
monitoring on a regular basis
There are many different glucose monitors available for patients. The patient needs to
have a device that is easy for them to use and convenient. A patient’s visual acuity and dexterity
skills should be assessed prior to selecting a blood glucose-monitoring device. The patient needs
to be reminded to record the blood glucose values on a log sheet with the date and time and any
associated signs and symptoms that he/she is experiencing at the time the specimen was
obtained. This log should be shared with his/her primary care practitioner.
A discussion of glycosylated hemoglobin (HbA1c) should include the reasons for doing
the test, how it is performed and how the health care practitioner will interpret the data. These
laboratory tests are ordered on a routine basis along with other laboratory tests that are being
monitored for the patient. A simple method to describe the HbA1c is to tell the patient that the
test measures the amount of sugar that attaches to the protein in the red blood cell. The test
shows the average blood sugar during the last three months. The higher the blood sugar the
higher the HbA1c. The high blood sugar over a long period of time causes damage to the large
and small blood vessels therefore increasing the risk of complications from diabetes.
Medications and Insulin
The patient with diabetes needs to be reminded that the addition of medications to help
manage his/her diabetes is not because they are failing at diet management. Many patients with
diabetes become depressed or despondent when they have to begin taking oral hyperglycemic
medications and/or insulin. The teaching session should include a review of the different types of
oral diabetic agents. A review of the different types of insulins and how to mix insulins should
also be discussed. Teach the patient about self-administration of insulin or oral agents as
prescribed, and the importance of taking medications exactly as prescribed, in the appropriate
dose. Patients should be provided with a list of signs and symptoms of hypoglycemia and
hyperglycemia and actions to take in each situation.
Complications from Diabetes
The patient should be taught how to manage their diabetes when he/she has a minor
illness, such as a cold, flu or gastrointestinal virus. The patient should also be taught how to
watch for diabetic effects on the cardiovascular system, such as cerebrovascular incidents/stroke,
coronary artery disease, and peripheral vascular disease. Assessment for signs of diabetic
neuropathy should also be included in the teaching plan. Patients with diabetes should also
receive education on the importance of smoking cessation, cholesterol and lipid management,
blood pressure monitoring and management and management of other disease processes.
Skin and Foot Care
Teach the patient to care for his feet by washing them daily, drying them carefully
particularly between the toes, and inspecting for corns, calluses, redness, swelling, bruises,
blisters, and breaks in the skin. The patient should be encouraged to report any changes to his/her
health care provider as soon as possible. Advise the patient to wear non-constricting shoes and to
Teaching Plan for Newly Diagnosed Diabetes 4

avoid walking barefoot. The patient may use over-the-counter athlete’s foot remedies to cure foot
fungal infections and should be encouraged to call their health care provider if the athlete’s foot
doesn’t improve. The patient should be reminded that he/she needs to treat all injuries, cuts and
blisters particularly on the legs or feet carefully.
Patients should be aware that foot problems are a common problem for patients with
diabetes. Informing them of what to look for is an important teaching concern. The signs and
symptoms of foot problems to emphasize are: feet that are cold, blue or black in color, feet that
are warm and red in color, foot swelling, foot pain when resting or with activity, weak pulses in
the feet, not feeling pain although there is a cut or sore on the foot, shiny smooth skin on the feet
and lower legs.
Exercise and Diabetes
A moderate weight loss of ten to twenty pounds has been known to improve
hyperglycemia, dyslipidemia, and hypertension. The target goal for body weight for patients with
diabetes is based on a reasonable or healthy body weight. More emphasis is now placed on waist
circumference, rather than on actual weight. A waist circumference greater than 40 inches in men
and greater than 35 inches in women indicates a risk for metabolic disease. This is now part of
what is referred to as metabolic syndrome. Reducing abdominal fat improves insulin sensitivity
as well as lipid profiles. The benefits from exercise result from regular, long term, and aerobic
exercise. Exercise used to increase muscle strength is an important means of preserving and
increasing muscular strength and endurance and is useful in helping to prevent falls and increase
mobility among the elderly.
Regular exercise can improve the functioning of the cardiovascular system, improve
strength and flexibility, improve lipid levels, improve glycemic control, help decrease weight,
and improve quality of life and self-esteem. Exercise increases the cellular glucose uptake by
increasing the number of cell receptors. The following points should be considered in educating
patients regarding beginning an exercise program. Exercise program must be individualized and
built up slowly. Insulin is more rapidly absorbed when injected into a limb that is exercised,
therefore can result in hypoglycemia.
The exercise program should include a five to ten minute warm-up and cool-down
session. The warm-up increases core body temperature and prevents muscle injury and the cool-
down session prevents blood pooling in the extremities and facilitates removal of metabolic by-
products. Research studies show there are similar cardiorespiratory benefits that occur when
activity is done in shorter sessions, (approximately 10 minutes) accumulated throughout the day
than in activity sessions of prolonged sessions (greater than 30 minutes). This is an important
factor to emphasize with patients who don’t think they have the time and energy for exercise.
Meal Planning and Diabetis
The American Diabetes Association (ADA) has established nutritional guidelines for
patients with diabetes. Their focus is on achieving optimal metabolic outcomes related to
glycemia, lipid profiles, and blood pressure levels. Patients with diabetes need to maintain a
healthy diet consisting of multiple servings of fruits, vegetables, whole grains, low-fat dairy
products, fish, lean meats, and poultry.
Teaching Plan for Newly Diagnosed Diabetes 5

The food/meal plan is based on the individual’s appetite, preferred foods, and usual
schedule of food intake and activities, and cultural preferences. Determination of caloric needs
varies considerably among individuals, and is based on present weight and current level of
energy. Required calories are about 40 kcal/kg or 20 kcal/lb per day for adults with normal
activity patterns. Emphasis should also be placed on maintaining a consistent day-to-day
carbohydrate intake at meals and snacks. It is the carbohydrates that have the greatest impact on
glycemia. Maintaining a food diary can help identify areas of weaknesses and how to prepare
better menu plans.
Recommendations for fiber intake are the same for patients with diabetes as for the
general population. It is recommended that they increase the amount of fiber to approximately 50
grams per day in their diet. Insoluble and soluble globular fiber delay glucose absorption and
attenuate the postprandial serum glucose peak, they also help to lower the elevated triglyceride
levels often present in uncontrolled diabetes. The discussion of diet management should also
include a discussion of alcohol intake. Precautions regarding the use of alcohol that apply to the
general public also apply to people with diabetes. Abstaining from alcohol should be advised for
people with a history of alcohol abuse, during pregnancy, and for people with other medical
conditions such as pancreatitis, advanced neuropathy, and elevated triglycerides. The effects of
alcohol on blood glucose levels is dependent on the amount of alcohol ingested as well as the
relationship to food intake. Because alcohol cannot be used as a source of glucose, hypoglycemia
can result when alcohol is ingested without food. The hypoglycemia can persist from eight to
twelve hours after the last drink of alcohol. When alcohol is ingested in moderation and with
food, blood glucose levels are not affected by the ingestion of moderate amounts of alcohol. If
the patient plans to consume alcoholic beverages they are to be included in the meal plan. The
patient should be reminded that no food should be omitted because of the possibility of alcohol-
induced hypoglycemia.
Coping with Diabetes
The patient needs to understand that the diagnosis of diabetes mellitus as with any
chronic illness can be unexpected and potentially devastating. Grief is the most common reaction
of an individual diagnosed with diabetes. Resolution of the grief is dependent on variables such
as education, economics, geography, and religious and cultural factors. The support of family
and friends affects the long-term acceptance of the disease progression. Patients need to be aware
that depression is common with chronic diseases such as diabetes. The depression should be
recognized and treated as soon as possible since depression can affect glycemic control and
complicate the management of the diabetes.
The patient needs to understand that diabetes is a lifelong disease process that requires a
lifetime commitment and lifestyle changes. The patient should be educated about empowerment
– having the resources and knowing how and when to use them. The skills of empowerment that
help the patient reflect on life satisfaction in the following areas: physical, mental, spiritual,
family related, social, work related, financial, personal. The patient should be encouraged to
establish goals which emphasize at least two of these areas in which he/she has control. In the
session of coping with diabetes the patient should be assisted to develop better problem solving
skills, which are necessary to manage a life-long disease such as diabetes. Coping with diabetes
should also include stress management concepts. Stress management concepts should include: a
definition of stress, the body’s reaction to stress, the effects of stress on diabetes management,
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identifying stressors, identifying methods of coping, relaxation exercises and identifying support
systems to tap into.
The patient should be instructed to continue taking his/her insulin and/or oral antidiabetic
agents while ill and even when unable to eat. The omission of insulin is a common cause of
ketosis and can result in a serious condition called diabetic ketoacidosis. The patient should be
given a list of foods that contain fast acting carbohydrates that they can consume when they
experience signs and symptoms of hypoglycemia. Patients should be encouraged to seek regular
ophthalmologic examinations to detect for diabetic retinopathy. Regular dental examinations
should also be encouraged to evaluate to potential areas that can become infected and possible
oral lesions.
Summary
The teaching program for the patients with diabetes is designed to be held for six
sessions. However, the sessions can be lengthened or shortened to meet the needs of the intended
audience. These two to three hour sessions allow the patient to absorb the material that is being
taught and to be able to ask questions. The learning needs are focused on managing their glucose
levels and preventing complications of diabetes. The patient needs to be educated on the multiple
disease processes associated with diabetes and the factors affecting each of these areas. The
patient also needs to have the knowledge of how to manage their diabetes when they are ill and
warning signs that they are hypo/hyperglycemic. Diabetic patients should be advised to contact
their health care provider any time they are unsure what to do or have questions on how to
manage their disease.
Reference:

• College of Nurses’ of Ontario (CNO). 2009. Teaching Plan for Diabetic Patient.
• Fenn P. (2007). Assessment and Management of Abdominal Obesity in Patients With
Type II Diabetes. Nursing Standard. 21 (25), 37-44.
• Huther S. E., Brashers V. L. (2008) Alterations of Hormonal Regulation in Huether,
McCance’s Understanding Pathophysiology , 4th edition, chapter 18, 447-480.
• Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2006). Medical-surgical nursing in
Canada: Assessment and management of clinical problems. 1st edition. St. Louis: Mosby.
• Registered Nurses’ Association of Ontario (RNAO). 2006. Diabetic Care.