You People Have No Idea - Care Scenario Notes PDF

lOMoARcPSD|36377953 YOU People HAVE NO IDEA - Care Scenario Notes Nursing Concepts in Health and Illness III (McMaster University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university...

lOMoARcPSD|36377953 YOU People HAVE NO IDEA - Care Scenario Notes Nursing Concepts in Health and Illness III (McMaster University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 N3SS3: PBL, HEALTH AND ILLNESS Fall 2021 YOU PEOPLE HAVE NO IDEA - HORMONES, DIABETES Textbook Reading: Diabetes Management DIABETES MELLITUS Etiology and Pathophysiology - Diabetes mellitus is a chronic multisystem disorder of glucose metabolism related to absent or insufficient insulin, impaired utilization of insulin, or bot - Current theories link the causes of diabetes to genetic, autoimmune, and environmental factor Type 1 Diabetes Mellitus - Type 1 diabetes mellitus typically occurs in people who are under 40 years of age, with 40% developing it before 20 years of age. It may occur at any age - Type 1 diabetes is the result of a long-standing process in which the body’s own T cells attack and destroy pancreatic cells, which are the source of the body’s insulin.Because the initial manifestation of type 1 diabetes is rapid, the symptoms are usually acute. - The classic symptoms—polyuria, polydipsia, and polyphagia—are caused by hyperglycemia. - The individual with type 1 diabetes requires insulin therapy to sustain life. Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis Type 2 Diabetes Mellitus - Type 2 diabetes mellitus accounts for over 90% of patients with diabetes. - In type 2 diabetes, the pancreas usually continues to produce some insulin. However, the insulin that is produced is either insufficient for the needs of the body and/or is poorly used by the tissues. - The most important risk factor for developing type 2 diabetes is believed to be obesity, specifically abdominal and visceral adiposity. - The manifestations of type 2 diabetes are more nonspecific and include fatigue, recurrent infections, recurrent vaginal yeast infections, prolonged wound healing, and visual changes Prediabetes - Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Those with prediabetes will usually develop type2 diabetes within 10 years if no preventive measures are taken Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Long-term damage to the body, especially the heart and blood vessels, may already be occurring in patients with prediabetes Gestational Diabetes - Gestational diabetes develops during pregnancy and is usually screened for and detected at 24 to 28 weeks of gestation by an oral glucose tolerance test. - Although most women with gestational diabetes will have normal glucose levels within 6weeks postpartum, their risk for developing type 2 diabetes in 5 to 10 years is increased. Diagnostic Studies - A diagnosis of diabetes is based on one of four methods: fasting plasma glucose, random plasma glucose measurement, 2-hour oral glucose tolerance test, and/or an A1C test. Collaborative Care - The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications of hyperglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible Drug Therapy: Insulin - Exogenous (injected) insulin is needed when a patient has inadequate insulin to meet specific metabolic needs. - Insulin is divided into two main categories: short-acting (bolus) and long-acting (basal) insulin. - Bolus insulin is used at mealtimes to combat postprandial hyperglycemia. - Basal insulin is used to maintain a background level of insulin throughout day. - A variety of insulin regimens are recommended for patients depending on the needs of the patient and his or her preference. - Insulin is most commonly given by subcutaneous injection. IV administration of regular insulin can be given when immediate onset of action is desired.T - The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen.An insulin pump can be used to administer continuous regular insulin. It is programmed to deliver a continuous infusion 24 hours a day with boluses at mealtime. - Hypoglycemia, allergic reactions, lipodystrophy, and the Somogyi effect are problems associated with insulin therapy. - Lipodystrophy may occur if the same injection sites are used frequently. The incidence has decreased with the use of human insulin. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Increased morning glucose levels may be due to the Somogyi effect. This is a rebound caused by hypoglycemia during the night that stimulates a counterregulatory response. - The Dawn phenomenon is characterized by hyperglycemia that is present on awakening in the morning, resulting from the release of counterregulatory hormones in the predawn hours Drug Therapy: Oral and Noninsulin Injectable Agents - These agents primarily work on three defects of T2DM: (1) insulin resistance,(2) decreased insulin production, and (3) increased hepatic glucose production - Oral agnets, non-insulin injectable agents > Oral Agents - Metformin (Glucophage) is a biguanide glucose-lowering agent. The primary action of metformin is to reduce glucose production by the liver. The ADA algorithm for the management of type 2 diabetes recommends the use of metformin combined with lifestyle interventions as the first-line therapy option. - Sulfonylureas increase insulin production from the pancreas. Since they can cause hypoglycemia, it is important to teach patients how to recognize and manage low blood glucose. Sulfonylureas are often added if metformin/ lifestyle interven. are not effective. - Meglitinides also increase insulin production from the pancreas. Because they are more rapidly absorbed and eliminated, they offer a reduced potential for hypoglycemia. They must be taken before meals, usually resulting in dosing three times a day. - α-Glucosidase inhibitors, also known as “starch blockers,” work by slowing down the absorption of carbohydrate in the small intestine. - Thiazolidinediones are most effective for people who have insulin resistance. Due to their severe adverse effects, the two drugs in this class are rarely used. - Dipeptidyl peptidase IV (DPP-4) inhibitors slow the degradation of the incretin hormone GLP-1, resulting in inhibited secretion of glucagon, increased insulin secretion, slowed gastric emptying, and decreased appetite. > Noninsulin Injectable Agents - Glucagon-like peptide (GLP)-1 receptor agonists target the incretin hormones. These medications improve glycemic control and additionals effect of reducing body weight. - Pramlintide (Symlin) is a synthetic analog of human amylin, a hormone secreted by the βcells of the pancreas. It is only taken concurrently with insulin and its use improves glycemic control Nutritional Therapy - The overall goal of nutritional therapy is to assist people with diabetes in making healthy nutritional choices, eating a varied diet, and maintaining exercise habits that will lead to improved metabolic control. - For those with type 1 diabetes, day-to-day consistency in timing and amount of food eaten is important for those individuals using conventional, fixed insulin regimens. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 Patients using rapid-acting insulin can make adjustments in dosage before meals based on the premeal blood glucose level and the carbohydrate content of the meal. - The emphasis of nutritional therapy in type 2 diabetes is placed on achieving glucose, lipid, and blood pressure goals as well as achieving weight loss if the patient is overweight or obese. - In a general diabetic meal plan, carbohydrates and monounsaturated fat should provide 45% - 65% of the total energy intake each day. Fats should compose no more than 25% to 30% of the meal plan’s total calories, with less than 7% of calories from saturated fats. - Protein should contribute 15% to 20% of the total energy consumed - Encourage patients to frankly discuss the use of alcohol with their health care providers because its use can make blood glucose more difficult to control. - Regular, consistent exercise is an essential part of diabetes and prediabetes management. Exercise increases insulin sensitivity and can have a direct effect on lowering the blood glucose levels Monitoring Blood Glucose - Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes management. By providing a current blood glucose reading, SMBG enables the patient to make self- management decisions regarding diet, exercise, and medication. - The frequency of monitoring depends on several factors, including the patient’s glycemic goals, the type of diabetes that the patient has, the patient’s ability to perform the test independently, and the patient’s willingness to perform SMBG. Bariatric Surgery - Bariatric surgery may be considered for patients with type 2 diabetes who have a BMI greater than 35 kg/m2, especially if the diabetes or associated co-morbidities are difficult to control with lifestyle and drug therapy. Pancreas Transplantation - Pancreas transplantation can be used as a treatment option for patients with type 1 diabetes mellitus. - Transplants are done for patients with end-stage kidney disease and who had or are having a kidney transplant NURSING MANAGEMENT: DIABETES MELLITUS - Nursing responsibilities for the patient receiving insulin include proper administration, assessment of the patient’s response to insulin therapy, and teaching of the patient regarding administration of, adjustment to, and side effects of insulin, particularly recognition and management of hypoglycemia. - Proper administration and assessment of the patient’s use of and response to oral and noninsulin injectable agents, as well as teaching of the patient and the family about these drugs are all part of the nurse’s function. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - The goals of diabetes self-management education are to enable the patient to become the most active participant in his or her care, while matching the level of self- management to the ability of the individual patient ACUTE COMPLICATIONS OF DIABETES MELLITUS - Diabetic ketoacidosis (DKA) is a life-threatening condition caused by a profound deficiency of insulin. It is characterized by hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in T1DM as compared to T2DM - Hyperosmolar hyperglycemic syndrome (HHS) is a life-threatening syndrome that can occur in the patient with DM who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and ECF depletion. - Hypoglycemia, low BG, occurs when there is too much insulin in proportion to available glucose in the blood. - Hypoglycemia is often related to a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. - A critical role of the nurse is the prompt recognition of hypoglycemia and the initiation of appropriate treatment dependent on the patient’s status. CHRONIC COMPLICATIONS OF DIABETES MELLITUS - Chronic complications of diabetes are primarily those of end-organ disease from damage to blood vessels from chronic hyperglycemia. These are divided into two categories: macrovascular complications and microvascular complications. - Macrovascular complications are diseases of the large and medium-sized blood vessels that occur with greater frequency and with an earlier onset in people with diabetes. - Microvascular complications result from thickening of the vessel membranes in the capillaries and arterioles, in response to conditions of chronic hyperglycemia. - Diabetic retinopathy refers to the process of microvascular damage in the retina because of chronic hyperglycemia. There are two types: proliferative and nonproliferative. Because the earliest and most treatable stages produce no vision changes, persons with diabetes should have an annual dilated eye examination. - Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidneys. Patients should be screened annually for albuminuria. A measurement of albumin-creatinine ratio from a urine specimen may also be done to assess renal function. - Diabetic neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. The two major categories of diabetic neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy - The most common form of sensory neuropathy is distal symmetric neuropathy, which affects the hands and/or feet bilaterally. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemic unawareness, delayed gastric emptying (gastroparesis), constipation, diarrhea, urinary retention, and sexual dysfunction. Complications of Foot and Lower Extremities - Foot complications are one of the most common causes of hospitalization in the person with diabetes. Sensory neuropathy is a major risk factor for lower extremity amputation. - Proper care of the diabetic foot ulcer is critical to prevent infections. - Because of the loss of protective sensations, proper care of the foot in a DM is critical Integumentary Complications - Up to two thirds of patients with type 1 and type 2 diabetes develop diabetes related skin problems - Common skin complications include acanthosis nigricans, diabetic dermopathy, necrobiosis lipoidica diabeticorum, and diabetic thick skin. - Because skin is prone to injury, special care must be taken to protect it from injury and ulceration. Infection - A patient with diabetes is more susceptible to infections due to a defect in the mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes. - Antibiotic therapy for infections, which must be prompt and vigorous, has prevented infection from being a major cause of death in diabetic patients. Psychosocial Considerations - Patients with diabetes have increased rates of mental health disorders, particularly depression. Assess patients for the signs and symptoms of depression at each visit. - Individuals with type 1 diabetes, particularly young women, have an increased risk of developing an eating disorder in comparison to people without diabetes. Open and collaborative communication is critical for identifying these behaviors early. Glycemic management in adults with T1DM Key Points - Basal-bolus insulin therapies (i.e., multiple daily injections or continuous SC insulin infusion) = preferred insulin management regimen for adults with T1DM - Insulin regimens should be tailored to individuals’ treatment goals, lifestyle, diet, age, general health, motivation, hypoglycemia awareness status, and ability for SM - All T1DM patients should be counselled on risk of hypoglycemia. Nocturnal hypoglycemia may be avoided by changes in insulin Tx. and increased monitoring - If glycemic targets are not met with optimized multiple daily injections, continuous SC infusion may be considered. Successful continuous SC insulin infusion therapy requires appropriate candidate selection, ongoing support, and frequent involvement with HCP Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Continuous glucose monitoring may be offered to those who are not fully compliant with glycemic targets in order to improve glycemic control - Goal for DM patients is to achieve balance; achieve BG levels that are as close to target as possible while avoiding hypoglycemia Introduction - Insulin therapy is essential for those with T1DM - Human insulin and analogues preferred and used by most adults with T2DM - Insulin preparations are classified by their duration of action and further differentiated by their time of onset and peak of actions - Many adults with T1DM cannot have premixed preparations becuas frequent adjustments in their regimen is often warranted. Preferred options are basal-bolus injection therapy or continuous SC insulin infusion (CSII, aka. Insulin pump therapy) as basal and bolus regimens. - Avoiding hypoglycemia and achieving glycemic targets is optimal. Usually, patients use a step-up approach, starting with basal-bolus insulin therapy, then to CSII in some cases - Adjuvants of non-insulin injectables or oral antihyperglycemic agents is limited Insulin Therapy with Basal-Bolus Injection Therapy - Insulin therapy is required immediately upon Dx. of T1DM. Need to select the insulin regimen and comprehensive diabetes education - Insulin regimen with basal and bolus insulin needs to be tailored; age, general health, treatment goals, lifestyle, diet, hypoglycemia awareness, ability for SM, and adherence - Honeymoon period - after administering insulin initially, the requirements may be lower than normal but this period is usually transient; after some time, insulin requirements usually increase and stabilize with time - Intensive treatment of T1DM significantly delays the onset and slow the progression of microvascular and cardiovascular complications - Review: - Bolus insulin is used at mealtimes to combat postprandial hyperglycemia. - Basal insulin is used to maintain a background level of insulin throughout day Basal insulin and basal-bolus injection therapy - Basal insulin = long-acting or intermediate-acting insulin, provides glucose control in the background (i.e., in fasting state and between meals) - Basal insulin is given once or twice a day and includes- long-acting insulin analogues and intermediate-acting insulin NPH (neutral protamine Hagedorn) - U-100 long-acting analogues, insulin detemir, and insulin glargine (with rapid-acting insulin analogues for meals) when used as basal insulin in T1DM → lower FPG, less hypoglycemia, less severe nocturnal hypoglycemia (good clinical significance) - Biosimilar insulin glargine → has the same amino acid sequence as glargine, produced through the different manufacturing processes. Similar efficacy and Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 safety outcomes in adults with T1DM when maintained or switched from U- 100 glargine. - Insulin glargine U-300 → concentrated basal insulin that has a consistent, gradual, and extended flat release from SC tissues. Has a longer duration of action than U-100 glargine, similar or lower risk of hypoglycemia. However, may require a higher dose than insulin glargine U-100 but may cause less weight gain. - Insulin degludec → basal insulin with a long duration of action, ~42 hours. It is a once-daily injection that has a glucose-lowering effect with low day-to-day variability (i.e., it’s consistent). Provides similar glucose control but with less nocturnal hypoglycemia and reduced amounts necessary when compared to insulin glargine. Allows for more flexible timing of dosing without compromising metabolic control or safety Bolus insulin and basal-bolus injection therapy - Bolus insulin = rapid-acting or short-acting insulin is given to control the glycemic rise at meals and to correct hyperglycemia - The bolus insulin injection dose is decided based on: - The carbohydrate content of a meal - Carbohydrate-to-insulin ratio for each meal - Planned exercise - Time since last insulin dose - Blood glucose level - Bolus insulins include rapid-acting insulin analogues (insulin aspart, insulin faster-acting aspart, insulin glargine, insulin lispro) and shorter-acting insulin (regular insulin) - Pre-prandial (per-meal) injections of rapid-acting insulins result in lower postprandial glucose and improved overall glycemic control - Insulin aspart, glulisine, and lispro → should be administered 01-5 mins before the start of the meal. Can also be administered 0-15 minutes after start of the meal, but evidence shows better postprandial BG control with before admin. - Faster-acting insulin aspart → may be administered at the start of the meal or when necessary (Up to 20 minutes after start of the meal) - Insulin aspart and lispro → associated with reduced nocturnal hypoglycemia, slightly lower AQC, improves post-prandial glucose, and improved QoL when compared to short-acting insulin - Insulin glulisine → been shown to be equivalent to insulin lispro for glycemic control, with most effective A1C control when given pre-prandially - Faster-acting insulin aspart → earlier onset of action, but non-superior with respect to A1C reduction. However, better at postprandial glucose control vs. to insulin aspart Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 Hypoglycemia and Insulin Therapy - Hypoglycemia is the most common adverse effect of insulin therapy in people with T1DM - With adequate SME, appropriate glycemic targets, SM of BG and support, intensive therapy can result in less hypoglycemia - Rapid-acting insulin analogues (when compared to regular insulin) are associated with reduced frequency of hypoglycemic events. Long-acting insulin analogues reduces the incidence of hypoglycemia and nocturnal hypoglycemia when compared to intermediate- acting insulin as the basal insulin - 85% of hypoglycemic episodes can be attributed to → lifestyle factors and changes from SM behaviours (e.g., eating less food, taking more insulin, increased physical activity) - Adding bedtime snacks may be helpful in reducing nocturnal hypoglycemia, regardless of insulin type (especially when bedtime plasma glucose levels are 10 - Benefits with hypoglycemia → CSII does not appear to reduce the frequency of non-severe hypoglycemia - Several studies have shown improved QoL with CSII therapy Continuous Glucose Monitoring - Adults with T1DM benefit from CGM when compared to SMBG - In people with diabetes with a baseline A1C >7.0%, the use of CGM compared to SMBG results in an A1C reduction of approximately 0.4% to 0.6% - People with type 1 diabetes with an A1C 2.5) require confirmation with a first morning ACR OR timed overnight urine collection - Individuals with intermittent albuminuria may progress to overt nephropathy - Treatment is indicated only for those adolescents with persistent albuminuria. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Retinopathy - Retinopathy is rare in prepubertal children with type 1 diabetes and in postpubertal adolescents with good metabolic control - Earlier reductions in A1C during adolescence and attention to blood pressure (BP) control may stave off sight threatening diabetic retinopathy in adulthood - Neuropathy - When present, neuropathy is mostly subclinical in children - Dyslipidemia - Most children with type 1 diabetes should be considered at low risk for cardiovascular disease (CVD) associated with dyslipidemia. Exceptions are those w/ longer duration of disease, microvascular comp. or other CV risk factors (smoking, HTN,, obesity and/or family Hx. of premature CVD) - Dyslipidemia screening should be targeted at those greater than 12 years of age and younger children with specific risk factors for dyslipidemia - Hypertension - Up to 16% of adolescents with type 1 diabetes have hypertension - 24 HR ambulatory BP monitoring has been used to exclude white coat hypertension and to identify loss of diurnal systolic rhythm (nondippers) with nocturnal hypertension in some normotensive adolescents with type 1 diabetes; these abnormalities may be predictive of future albuminuria - Children with type 1 diabetes and confirmed hypertension should be treated according to the guidelines for children without diabetes Summary GLYCEMIC TARGETS - Children and adolescents 5 years of age should be treated with 1 mg glucagon subcutaneously or intramuscularly - In children ≤5 years of age, a dose of 0.5 mg glucagon should be given. The episode should be discussed with the DHC team as soon as possible and consideration given to reducing insulin doses for the next 24 hours to prevent further severe hypoglycemia - Dextrose 0.5 to 1 g/kg should be given intravenously over 1–3 minutes to treat severe hypoglycemia with unconsciousness when intravenous access is available DKA TX. - In children in DKA, rapid administration of hypotonic fluids should be avoided - Circulatory compromise should be treated with only enough isotonic fluids to correct circulatory inadequacy - Replacement of fluid deficit should be extended over a 48-hour period with regular reassessments of fluid status. The insulin infusion should not be started for at least 1- hour after starting fluid replacement therapy - In children in DKA, once blood glucose reaches ≤17.0 mmol/L, intravenous dextrose should be started to prevent hypoglycemia. The dextrose infusion should be increased, rather than reducing insulin, to prevent rapid decreases in glucose. The insulin infusion should be maintained until pH normalizes and ketones have mostly cleared - In children in DKA, either mannitol or hypertonic saline may be used in the treatment of cerebral edema Patients’ experiences of diabetes self-management education (SME) according to health literacy levels Abstract - The purpose of this study was to explore patients’ experiences with diabetes self- management education and how these experiences differed by health literacy levels - Patients with high health-literacy wanted systematic, in-depth, individualized counselling on lifestyle modifications and medications Introduction - DM SME is considered a critical element of the care of patients with diabetes who require adequate knowledge, motivation, and skills to manage their illness - Inadequate diabetes education hinders individuals’ ability to engage in self care - Health literacy - refers to the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Multidimensional; made up of components of knowledge; motivation; and competencies in accessing, understanding, appraising, and applying health- related information - Easy-to-read materials and the teach-back method were the most frequently used strategies for improving health-literacy - However, educational strategies aimed at improving health-literacy have been predominantly developed using the advice of healthcare professionals, and there is little empirical evidence showing the effectiveness of these educational interventions - Particularly, it is unclear whether patients with adequate or inadequate health-literacy would have different experiences with such education in terms of difficulty understanding the material and the support offered Results and discussion Category 1 - Depth and Breadth of Learning Acquiring health knowledge - IHL = inadequate health literacy; AHL = adequate health literacy - Patients with both AHL and IHL commonly obtained information about diabetes mellitus and its management, including blood glucose monitoring, nutritional management, exercise and physical activity, and medication usage from diabetes education - In addition, AHL patients added that, through diabetes education, they had learned how to adjust their personal lifestyle in order to manage diabetes. They realized that irregular life patterns had been a major barrier to regular diet and exercise, suggesting that AHL patients may require individualized plans for effective diabetes education. - IHL patients demonstrated insufficient knowledge of the basic tenets of diabetes management, even after participating in the diabetes education programme. Increased motivational outcomes - Patients commonly reported enhanced motivation for managing their illness after completing a diabetes education programme - Regardless of health-literacy level, most patients mentioned being ‘awakened’; reported being ignorant about the disease before the programme, but after the programme, they felt they had a better understanding of the seriousness of diabetes. - Some IHL patients reported having greater confidence in managing their diabetes after completing a diabetes education programme; this was not reported by AHL patients. Category 2: Navigation of Information Access to educational information - The most common reason for not having access to a diabetes education programme was having no opportunities provided at his or her medical institution. - Patients often said that they were asked to simply take their medication as ordered by their physician and that they had received no offer or referral for education - Some IHL patients also reported having no awareness of the seriousness of the disease Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 Approaches to gaining information - IHL patients demonstrated a more passive attitude towards seeking information than did AHL patients. However, AHL patients reported that they could clarify points that they did not understand by asking questions of nurse educators Alternative communication support - Patients exhibited different attitudes towards accessing information using online or social media resources according to their health-literacy levels - Most IHL patients showed more passivity or reluctance to use online services because they did not have sufficient skills in using these services. However, they did express a willingness to learn how to use online services if possible. - By contrast, AHL patients talked about their past experiences of searching for diabetes information online, although they had no actual experience of using online resources targeting diabetes management Category 3: Challenges and Strategies of Education Interpreting information - AHL and IHL patients both expressed some difficulty in understanding medical terminology; lack of familiarity with certain medical terms - In comparison with AHL patients, IHL patients experienced much more obvious difficulty in understanding basic information; IHL patients did not fully understand nutritional information including calories and nutrients, which frustrated them when attempting to follow a diet regimen - Poor retention of information, which acted as a barrier to understanding - Could not recall important points after long, comprehensive and detailed oral instructions from nurse educators. - The majority of AHL patients reported that the information provided in their diabetes education programme was easy to understand and even superficial – that is, they felt they were not given any concrete information Implementing practices - Regardless of health-literacy levels, the majority of patients expressed frustration in applying the information they obtained during their diabetes education programme - Participants asked for food menus beneficial to diabetes management that they could use when preparing a meal Category 4: Applying Knowledge to Daily Life - The implementation of diabetes information was the biggest problem for most patients - Most patients reported that a motivation to continue implementation was the most important factor for ensuring effective diabetes management. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - In comparison with AHL patients, IHL patients showed insufficient ability to appraise basic diabetes symptoms and to solve problems using their new knowledge - Furthermore, some patients with IHL misinterpreted hypoglycaemic symptoms – specifically, they believed that hypoglycemic symptoms involved only sudden blackouts or syncope, but not a feeling of dizziness. However, these problems were not mentioned by patients with AHL Discussion - Regardless of health-literacy levels, many patients reported improved knowledge and motivation for diabetes management after participating in a diabetes education programme; however, they expressed frustration in applying the information in their lives. - The difficulties experienced by many participants in understanding medical terms and ‘specific numbers’ (e.g., nutrients and lab values) indicate the need to better translate medical terms and concepts into simple, everyday language - Without a hands-on approach to diabetes management, IHL patients may experience a more trial-and-error process of managing their illness; result in more serious problems - Most patients understood the importance of continuing diabetes management in their everyday lives and wanted more support and encouragement from healthcare providers Key Differences Between IHL and AHL - IHL patients reported greater self-confidence in diabetes management after participating in a diabetes education programme. This finding suggests that although IHL patients initially have low confidence in illness management - IHL patients had limited access to health information and more passive attitudes towards using online sources or social media - IHL patients had difficulty processing large amounts of detailed information during education sessions Helping adolescents with T1DM “figure it out” Purpose and intro - The aim of this study was to gain an understanding of adolescent’s experiences living with diabetes and build a theoretical paradigm for future interventions in adolescents with type 1 diabetes mellitus (T1DM) - A theoretical model about the concept of “normalizing” was identified. Normalizing was defined as the ability to integrate diabetes into the background of one’s daily life to make diabetes ‘part of me’. The fifth phase of normalizing was “Figuring it out” which had 4 sub codes: (1) learning to accept diabetes, (2) believing it’s possible to manage their diabetes, (3) showing responsibility, and (4) staying on track, and the normalizing task was “accepting the new normal”. - Children with T1DM struggle to maintain their hemoglobin A1C in a safe range; only 10% of adolescents are still testing their BG the recommended four times daily Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - Studies have shown that a decrease in BG monitoring leads to higher A1C levels and an increased risk for diabetes-related hospitalizations like in DKA; hospital admissions are approximately 40% of the total overall cost of diabetes care - Less than one third of adolescents are able to maintain their A1C in target range for their age - Ongoing high BG levels, poor adherence to diet and exercise, and missing insulin doses persist into adulthood with only one third of adults able to maintain their A1C b7.5% and over 12% having very high A1C levels over 10% - About 208,000 children under 20 with T1DM; total cost for people diagnosed with diabetes in 2012 was $245 billion, and its estimated that $69 billion was due to decreased productivity - The theoretical paradigm of the concept of normalizing provides important information about strategies adolescents use as they ‘figure it out’ - This research builds on adolescent perceptions and strengths; it fosters understanding of the conditions present that allow adolescents success in DSM and helps move nursing science forward Results Accepting diabetes - Defined as understanding that diabetes is part of you and that having diabetes is normal. - They understand the consequences of not taking care of diabetes and believe that they are capable of dealing with diabetes and feeling normal. - Sub-themes include: (1) realizing diabetes is forever, (2) believing you are trapped, (3) understanding things need to change, (4) learning to cope, and (5) accepting new norm. - Adolescents have to first move out of denial of diabetes. - Believing you are trapped is defined as believing that there is no way out and you are stuck forever, therefore, you may as well adjust to having diabetes and accept it. - Understanding things need to change is defined as developing an awareness that it is the high blood sugars that cause illness - Conditions that related to understanding that things need to change included having multiple episodes of feeling sick leading to DKA and realizing that by taking insulin they were less likely to get sicK - Learning to cope is defined as the steps needed to emotionally handle having a chronic illness. Sub-codes include: (a) gaining a positive outlook, (b) seeing diabetes as not scary, (c) talking to a friend with diabetes, (d) finding solutions, and (e) realizing it’s not a big deal. “ - Seeing diabetes as not scary is important as parents’ reactions to BG sometimes make it hard for adolescents to not be scared. - Talking to a friend with diabetes is defined as being able to receive support and understanding from friends who have diabetes to help with coping. - The major goal in this phase of the journey, “Figuring it out” is accepting diabetes and understanding that diabetes is not going to go away, learning to deal with it, and making it part of your life. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 Believing its possible to manage diabetes - When the adolescent has the confidence to know how to manage diabetes in terms of decision making skills and in the desire to control diabetes successfully - Part of this process is when adolescents begin to make diabetes a priority in their life instead of trying to ignore it to ‘fit in’ with their friends. Sub-codes include: (1) changing the attitude, (2) knowing how to do everything, (3) realizing that diabetes is manageable, (4) making diabetes a priority, and (5) gaining confidence that you can do what you want - Changing the attitude is defined as a willing emotional state that allows you to believe in your ability to manage diabetes - Knowing how to do everything is defined as when you feel you have adequate knowledge and are capable of managing your diabetes Showing responsibility - Showing responsibility is defined as the mental ability to see the consequences of their actions and understand why being responsible is important. A sub-code is putting in an effort which is defined as taking the time to care for oneself. - The adolescents shared that they begin to put in an effort to take care of their diabetes as they take on additional responsibility for care, and that is seen in their ability to keep their blood sugar more level. - A condition when the adolescents are more likely to be able to show responsibility is when they understand there are consequences to their actions Staying on track - Defined as learning to manage diabetes in a way that is physically and emotionally healthy. Steps that help adolescents stay on track: (1) maintaining health, (2) setting goals, and (3) maintaining motivation. - A condition for setting goals was when adolescents became disappointed in results of A1C or blood sugars. A condition for not setting goals was not seeing the value in goal setting. - Maintaining motivation is defined as the ability to maintain the energy and focus and gather resources needed to consistently maintain a positive attitude. In phase 4 adolescents described not being motivated which is partly what led to their difficulties in their diabetes management. Discussion - It is critical to move adolescents into this stage of figuring their diabetes out as they transition to DSM - Helping adolescents find strategies to believe that they can manage their diabetes on their own through goal setting, and maintaining their motivation through positive feedback, is expected to be very beneficial for intervention design. - Recommendations - (a) Discuss current coping strategies with the adolescent to foster diabetes acceptance and provide positive feedback. Focus on positive habits that increase feelings of accomplishment. Downloaded by ANT Bo ([email protected])  lOMoARcPSD|36377953 - (b) Discuss with parents ways to support the adolescent with their self- management, focusing on providing positive feedback and fostering independent decision making while decreasing nagging, and address parental fears about diabetes. - (c) Strategize with parents if a ‘reward system’ for completing tasks that improve diabetes care such as BGM and keeping a BG log while providing positive feedback on their successes would be helpful in keeping on track. - (d) Engage school nurses and counselors in supporting adolescent self- management with positive comments that contribute to building self-esteem and examining their policies to determine if change is needed to better support adolescents with T1DM. - The major task in this phase of “figuring it out” was to figure out how to take control of balancing blood sugar and strive for a normal life. The key process in normalizing was ‘accepting the new normal’ Downloaded by ANT Bo ([email protected])