The Nurse as Diabetic Educator, by Christopher Johnston

Due to the severity of complications related to diabetes, nurses need to educate their diabetic patients about risk factors for diabetes complications, the types of complications, and primary causes of complications. Therefore, three strategies nurses can use to help prevent or lessen the severity of complications include educating patients on the types of complication that can occur.

Nurses can also educate patients on the importance of controlling blood glucose levels through diet. Lastly, nurses need to educate patients about prevention and treatment of diabetic foot problems
Diabetes is a disease that is characterized by the inability of the body to either successfully produce or utilize insulin. A major problem associated with diabetes is the onset of complications that may affect the patient’s health status and may become life threatening (Lager, 2004). There are many chronic complications caused by diabetes, among them are peripheral vascular disease (PVD), neuropathy, retinopathy, and diabetic foot problems.
The nurse can spend some time during the intake assessment at the doctor’s office to educate the patient on the types of complications that can occur. For instance, PVD is a group of problems that affect the vascular system. PVD can lead to hypertension and possible stroke. Although there are many factors that may cause PVD, chief among them are hyperglycemia. Community health fairs are another good time for the nurse to educate patients on complications such as diabetic neuropathy. Bailes (2002) states that, “Fifty percent of all patients with diabetes will experience diabetic neuropathy when they have had the disorder for 25 years or more” (para 27). The neuropathy may present as a loss of temperature and pain sensation, or as severe pain in the feet and hands, as well as presenting in many other forms. Hyperglycemia is one of the major factors associated with the onset and severity of diabetic neuropathy. Retinopathy is the disease process of the retina and is, “Present in almost all people who have had diabetes for 20 years or more” (Bailes, 2002, para 37). The disease leads to varying stages of blindness from moderate to total loss of vision, and is “The leading cause of blindness in people younger than 75 years of age in the United States,” states Bailes (2002, para 37). As with PVD and neuropathy, the major cause of retinopathy is poorly managed blood glucose leading to hyperglycemia.
As the main cause of diabetic complications is uncontrolled blood glucose, the nurse needs to stress the importance of keeping glucose in tight control and as close to normal as possible, between 70-110. The nurse should use any available time to educate patients, including during health screenings, annual physical appointments, sick-visits at the doctor’s office and pre-opp education. This may include advising the patient to measure his or her blood glucose multiple times per day as well as following a strict diet. Vaughan (2005) shares many strategies, which nurses can use to help their diabetic patients with the complex job of maintaining healthy blood glucose levels. Among them are teaching the patient about glycemic index, which is the rating of food in regard to the effect the food has on immediate blood glucose levels (para 19). Nurses can suggest keeping a “food diary” so the patient can keep track of what he or she has eaten and the type of effects those foods had on his or her blood glucose level. As with the rest of the population, the diabetic patient needs to eat a diet low in saturated fats. Some simple tips which nurses can share with patients to achieve this include, “Draining fat off of cooked meats, trim visible fat from meat, remove skin from poultry, and grill, broil, bake, microwave or steam food and avoid frying it” (Vaughan, 2002, para 10).
Lastly, the nurse needs to educate the diabetic patient on ways to prevent the development of foot problems. Bailes (2002) notes that, “Approximately 20% of all hospital admissions of patients with diabetes are for diabetic foot conditions (eg, ulceration, infection, foot deformities, Charcot neuroarthropathy, osteoarthritis, amputation)” (para 48). As such, Gibbons and Locke (2006) have written several guidelines for nurses to follow and use in the prevention of diabetic foot problems. These include, “[Having the nurse teach] patients to wear well-fitting shoes, change shoes during the day to relive pressure areas, use orthotics to help accommodate the foot, and shaking shoes out and inspecting them before wear, for areas that might cause blisters or rubbing” (para 4). As diabetics may have neuropathy they may not feel small irritants like a pebble in the shoe or a tack in the foot. Furthermore, they may not notice the signs of infections such as pain or warmth in the foot. Nurses can use health fairs and office visits to suggest several foot hygiene techniques to help prevent foot complications: Such as, “Washing feet daily paying close attention to the area between the toes, trimming nails to a rounded edge, wearing socks appropriate for the shoes being worn, and never going barefoot” (Gibbons and Locke, 2006, para 5). Most importantly, the nurse should educate the patient to report foot problems to his or her doctor as soon as they are noticed. These problems include, “Cuts or breaks in the skin, ingrown nails, pain or loss of sensation, and changes in the color or discoloration of the foot” (Gibbons and Locke, 2006, para 5).
Although the nurse may only have the few short minutes during the patient intake at the doctor’s office or thirty minutes during preoperative education she or he needs to take advantage of every moment to educate the diabetic patient about the types of complications that can occur, the importance of controlling blood glucose levels through diet, and prevention and treatment of diabetic foot problems. But, as Shilling (2003) stated, “Patient education is not just an information giving exercise, and to make any of it effective it is important that the encounter is a two-way process. […] It is important to make any education and information given to patients appropriate to their day-to-day lives” (para, 25).
Intervention 1: Encourage Pt’s to eat a healthy diet low in saturated fat as well as foods with a low glycemic index and measure blood glucose several times per day.

Disadvantage 1: Socioeconomic barriers and the effect of high glycemic index foods.
There are several barriers to eating healthy; chief among them is the cost of fresh fruits and vegetables. (Mayoclinic, 2005) For many families it is it is less expensive to by bargain foods, which are usually processed foods such as frozen dinners, burritos, and fast food. Unfortunately, these foods are usually high in sodium, saturated fat, and refined carbohydrates. Refined carbohydrates are high on the glycemic index, which will cause a substantial rise in systemic blood sugar, with little nutritional value.

Disadvantage 2: Knowledge deficit due to the convenience and exposure of non-healthy food options.
Additional barriers to healthy eating are convince and exposure. We are constantly exposed and tempted by unhealthy foods (Gellar, 2007). We see ads on T.V., in magazines, on the radio, and signs from the freeway everyday. Further more there are soda and snack vending machines in most of our schools, and work places. Convince, is a major factor in unhealthy eating. With all the exposure to unhealthy foods, you can see that they are more convenient. With junk food that is ready to eat right out of the machine and fast food that is hot and ready with no preparation needed, it is easy to see why so many people are tempted.

Intervention 2: prevent foot complications through educating the pt on proper foot care, footwear, and appropriate medical care.

Disadvantage 1: Socioeconomic status/inadequate, insurance. There may be a lack of clinics in the patient’s immediate area. Many insurance programs will not cover the best treatment.
“In some geographical areas there are no health-care clinics at all.” (Van Houtum, para 2) This makes travel to distant towns or cities imperative, not only when a medical problem or emergency arises, but also to attend regularly scheduled appointments. As many people who live in rural areas are among the countries poorest and gas prices are steadily on the rise it many patients are unable to afford to travel two to three times per month to maintain adequate diabetic foot care. Further more, for the patients that can make regular appointments there is the cost of the visit it’s self. An additional problem is that some patient’s health insurance may to cover the treatments necessary in the beginning of foot complications, taking the position that the treatment is too costly. However, “problems that are neglected in the early stages may deteriorate and necessitate aggressive and expensive interventions.” (Van Houtum, para 5)

Disadvantage 2: Religious and cultural practices that may increase diabetic foot problems.
Cultural and religious beliefs can become barriers to prevention and treatment of diabetic foot problems. (Van Houtum, 2005) Some religious practices such as Catholicism require kneeling while praying. Kneeling puts pressure on the toes and decreases blood flow to the feet. Still other religions require patrons to go bare foot while visiting holy places, putting the diabetic patient at risk for injuring his or her already precarious feet. Other cultural beliefs such as seeing a healer or medicine man instead of seeking contemporary medical care can prolong the problem possibly leading to further complications.

References
Bailes, B. K. (2002). Diabetes mellitus and its chronic complications. Association of Operating Room Nurses Journal, 76, 265-284. Retrieved October 28, 2006, form Expanded Academic ASAP database.
Gellar, A. L., Schrader,K., Nansel, R. T. (2007) Healthy Eating Practices Perceptions, Facillitators, and Barriers Among youth with Diabetes. Retrieved October 26, 2007 from http://tde.sagepub.com/cgi/content/full/33/4/671
Gibbons, G., & Locke, C. (2006) Foot ulcerations and infections. In H. E. Lebovitz, (Ed.), Therapy for diabetes mellitus and related disorders (pp. 521-526). Alexandria, VA: American Diabetes Association.
Lager, J. (2004). Diabetes mellitus. Retrieved January 07, 2007 from http://www.faqs.org/nutrition/Diab-Em/Diabetes-Mellitus.html
Mayo clinic. (2005). Diabetes mellitus. Retrieved October 26, 2007 from
http://www.mayoclinic.com/health/diabetes-diet/DA00029
Shilling, F. (2003). Foot care in patients with diabetes. Nursing Standards 17 (23), 61-65. Retrieved October 28, 2006, from Expanded Academic ASAP database.
Van Houtum, W, H, (2005, November 12). Barriers to the delivery of diabetic foot care, Lancet 366 (9498), 1678-1679. Retrived October 26, 2007, from Expanded Academic ASAP database.
Vaughan, L. (2005, July 13). Dietary guidelines for the management of diabetes. Nursing Standard 19 (44), 56-64. Retrieved October 21, 2006, from Expanded Academic ASAP database.