Home Care Chronic Disease Prevention Program

1. Home Care Chronic DiseasePrevention Program Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine

2. Homework review • What did you do? • What happened as you did that? • Why do you think that happened? • Here’s what might have happened. • How does this impact the next time you try this?

3. Chronic Disease Management Module 1:Health/Illness, Vital Signs, Exercise, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Module 9: Congestive Heart Failure

4. Objectives • Define diabetes and the impact of diabetes on health • Describe healthy lifestyle choices for the person with diabetes • Demonstrate use of motivational interviewing with the person with diabetes

5. Diabetes

6. Diabetes: The numbers • About seven percent of Americans have diabetes • Sixth leading cause of death in the US

7. Diabetes: What is it? • Insulin is a hormone that helps the body to process “sugars” into energy • Diabetes is a disease in which the body does not use its insulin properly or it does not produce enough insulin • The result is elevated blood sugar levels

8. Symptoms and signs • Extreme thirst • Extreme hunger • Weight loss • Frequent urination • Vision changes • Recurrent infections

9. Diagnosis • Fasting blood sugar greater than 126 • Two random blood sugars greater than 200 • After fasting and drinking 75 grams of sugar, two hour post- prandial blood sugar greater than 200

10. Types of diabetes • Type I-The body does not produce insulin; present from birth (genetic defect) • Type II-The body does not use its own insulin properly- called “insulin resistance”; may lead to type I; starts well after birth, usually in adult years • Gestational diabetes-Occurs during pregnancy, some women go on to develop type II diabetes

11. Type II diabetes • Most common form of diabetes • Insulin resistance • Onset occurs usually in adult years

12. Risk factors for type II diabetes • Overweight • Family history • Prior history of gestational diabetes • African American race

13. Treatment • Injectable insulin • Short acting • Medium acting • Long acting • Oral medications • Increase insulin secretion • Increase insulin sensitivity

14. Insulin • Rapid acting (Humalog and Novolog) • Short acting (Regular) • Intermediate acting (NPH) • Long acting (Lantus) 24 hours • Mixes-combinations of the above

15. Insulin • Keep unopened bottles in the refrigerator • Insulin will stay fresh for one month without refrigeration (under 86º F) • Check insulin before using it • Short acting and glargine are clear • Intermediate and long acting are cloudy • If clumps are visible, throw the bottle away

16. Testing blood glucose • Helps assess how well blood glucose levels are being controlled • Helps guide changes in medications • Very important if insulin is being used • Should be tested if hypoglycemia (low blood glucose) is suspected • Testing times vary, typically two to four times a day

17. Testing blood glucose • Before meals: 90-130 • One to two hours after meals: less than 180 • Test as prescribed by the doctor- usually fasting morning, before meals and at bedtime

18. Hypoglycemia “low blood sugar” • Occurs when blood glucose drops too low • For most people this is less than 70 • Can be life threatening * • Symptoms may include nausea, dizziness, sweating • Keep a source of glucose readily available- two glucose tablets, one cup of milk, half cup of juice • Retest after 15 minutes • Carry glucose tablets when exercising

19. Hemoglobin A1C • Tested with blood sample • Three month average of blood glucose readings • Guides decisions about treatment • Keep track of your values • Normal is 4-6% for someone who is non- diabetic • Goal is as close to 6% as possible

20. Non pharmacological treatment • Diet/nutrition • Exercise • Weight loss

21. Nutrition • What a person with diabetes eats is very important • It’s more than just not eating SUGAR

22. Glycemic index • Rating system based on how fast the food raises blood glucose two hours after eating • Reference is white bread = 100 • The higher the glycemic index, the faster the food raises the blood glucose. • The faster the blood glucose rises, the more quickly insulin is released.

23. Glycemic index • In diabetics, because of the insulin resistance, the body doesn’t respond as well so glucose levels stay high longer than normal • Lower is better when it comes to glycemic index

24. Examples • High glycemic index White rice, white bread, potato • Moderate glycemic index Rye bread, macaroni and cheese • Low glycemic index Banana, milk, grapes, brown rice

25. Diabetic diet • Keeping blood glucoses in the normal range decreases the likelihood of complications

26. Diabetic diet • More that just not eating sugar • Eating the right foods • At the right times • In the right amounts

27. Diabetic diet • 1500- 2000 calorie diet for most men and women • 40-60% of calories from carbohydrates • 20% of calories from protein • Less than 30% of calories from fat

28. Diabetic diet • Each meal ~ 60 grams of carbohydrates; Fruits, vegetables, dairy, starch • Sugar substitutes • Low fat, low cholesterol • Eat at the same time each day • Eat structured meals

29. Exercise • Always warm up and cool down for about ten minutes • Check blood sugar before and immediately after exercise • Do not exercise if blood sugar is greater than 250 and eat a small snack if less than 100 • Drink two cups of water before and after exercise

30. Control weight • With good nutritional choices • And increasing activity

31. This sounds like a LOT of WORK…is it worth it? YES!!!

32. Common complications • Blindness due to bleeding blood vessels in the eye • Kidney failure which leads to dialysis • Stroke • Heart attack • Numbness (neuropathy)

33. Common complications • Gum/teeth diseases • Foot problems • Infections • Potential amputation

34. Treatment • Healthy diet • Exercise • Weight loss • Medications to lower blood sugar • Medications to lower blood pressure • Medications to lower cholesterol • Medications to protect the kidneys • Check your feet each day

35. Follow up with your doctor • Aspirin for diabetics over the age of 40 • Bad cholesterol (LDL) goal less than 100 • Examination by ophthalmology yearly • HbA1c every three months • Urine checked for protein each year • Foot check every three months • Pneumococcal vaccination • Blood pressure goal less than 130/80

36. Who should be screened? • Persons with hypertension • Persons with hyperlipidemia • Others at discretion of physician

37. Warning symptoms • History of an illness/ infection • Nausea • Sweating • Vomiting • Foot ulcers

38. Warning signs* • Blood sugar less than 70 • Blood sugar greater than 300 • Increased heart rate • Increased respiratory rate • Foot ulcers *ALL vital parameters are determined by RN supervisor and are patient specific

39. Other warnings • Not taking medications

40. References • Neal, LJ. & Guillett, SE .Care of the adult with a chronic illness or disability. Mosby, St. Louis, Missouri, 2004. pp 286-294. • Kennedy – Malone, L. et al. Management guidelines for gerontological nurse practitioners. F.A. Davis Company, Philadelphia, PA, 2000. pp 369-376. • Lippincott, Williams and Wilkins. Managing chronic disorders. Lippincott Williams and Wilkins, USA, 2006. pp 127-132. • http://diabetes.niddk.nih.gov/ • www.aafp.org • http://www.diabetes.org/home.jsp

41. Case study • 68 year old obese male • Tells you he has had diabetes for 15 years • He tells you that his doctor is worried about his eyes and his kidneys • He also tells you that his doctor thinks that he does not eat well and eats too many sweets.

42. Case study • He tells you that he forgets to take his medications for diabetes most of the time but goes on to tell you that he does not really think that they are important • He tells you, “I don’t even understand how they can tell if my blood sugars are under control or not.”

43. Case study • While you are talking with him, he opens up a box and begins to eat the large piece of chocolate cake that is inside the box • He tells you that his father had diabetes and went on dialysis because his kidneys failed

44. Case study • What worries you about his behavior? • What are his risk factors for diabetes?

45. Case study • What worries you about his behavior? • His diet- i.e. chocolate cake • Not taking his medications • Doesn’t seem to be concerned • What are his risk factors for diabetes? • Obesity • Family history • Eating habits

46. Case study • What are possible complications of diabetes?

47. Case study • What are possible complications of diabetes? • Kidney failure • Blindness • Heart attack • Stroke • Neuropathy (nerve damage)

48. Case study • What types of lifestyle measures would be appropriate for him?

49. Case study • What types of lifestyle measures would be appropriate for him? • Diabetic diet low in sugars, fats, cholesterol, sodium • Exercise • Taking medications as prescribed by his physician

50. Case study • He wants to know how his blood glucose is monitored, can you explain that to him? • What test is used to follow blood glucose? • What is the normal range for blood glucose levels?