62	 AJN t July 2010 t Vol. 110, No. 7	 ajnonline.com
atients with newly diagnosed or poorly
controlled diabetes will typ...
By Peggy A. Ulrich, MSN, RN, CDE,
and Nancy Abner, RN, CDE
ajn@wolterskluwer.com	 AJN t July 2010 t Vol. 110, No. 7	 63
64	 AJN t July 2010 t Vol. 110, No. 7	 ajnonline.com
When to
Do It
What to Ask How to Individualize It
ajn@wolterskluwer.com	 AJN t July 2010 t Vol. 110, No. 7	 65
hospital. Patients may feel overwhelmed by new
medical termin...
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Diabetes controlmetermedsmove

  1. 1. 62 AJN t July 2010 t Vol. 110, No. 7 ajnonline.com P atients with newly diagnosed or poorly controlled diabetes will typically leave the hospital with a diabetes education packet that the nurse hopes will be read. These packets are rarely individualized to the patient’s education level, age, financial situation, comorbidities, or other specific characteristics. While in the hospital, many patients won’t ask for help with their self- care. Some will rely on euphemisms like “touch of sugar” or “borderline diabetes” to downplay the importance of good control. If a nurse doesn’t offer them information, patients may think there’s nothing to know. If the nurse does teach them self- management skills, they’re often grateful to have help with this complex and chronic condition. The 5 M’s. The goal when teaching diabetes self- management in the hospital is to give the patient what the American Diabetes Association has called “survival skills.”1 The American Association of Diabetes Educators has identified seven core diabe- tes self-management skills2 that we’ve condensed, as shown below, into five clear, simple categories starting with the letter “m”: • Meter: monitoring blood glucose • Meds: taking medication • Meals: healthful eating • Move: being active • More: problem solving, such as sick-day man- agement or responding to hypo- or hyperglyce- mia; healthy coping, such as stress management; and reducing risks, such as foot care, blood pressure and lipid monitoring, eye examina- tions, and quitting smoking Even during a busy shift there are many “teacha­ ble moments” when an informed and well-­prepared nurse can make use of this simple self-care termi- nology to introduce inpatients to the skills they’ll need upon discharge. Knowledge deficit. A 2002 study by Uding and colleagues revealed that increasing nurses’ knowl- edge of diabetes is the first step toward effective patient education.3 However, the study also re- vealed that 53% of nurses failed to attend an in-­ service program on the subject of diabetes in the previous two years, while 26% said they’d never attended a diabetes in-service program. Many nurses feel uneasy recommending lifestyle changes to patients and believe that they lack ade­quate skills in lifestyle counseling. For example, they may be uncomfortable talking to a patient about topics like weight.4 Time crunch. The current health care environ- ment, with its short staffing, shorter patient stays, and cost containment, lends itself to nurses feeling time constraints for delivering patient care. One aspect of today’s nursing practice is that patient education can easily fall by the wayside, even though nurses know education is important to patients and families.5 The expectations of today’s staff nurses include caring for, educating, medicat- ing, and planning the discharge of their patients in a very short span of time. And shorter hospital stays decrease the quality time nurses can spend at the bedside with a patient, leaving many nurses feeling conflicted about the quality of care they can deliver. Competent, knowledgeable nurses are needed to achieve quality, cost-effective care and positive patient outcomes.3 Meter, Meds, Meals, Move, and More A simple bedside approach to teaching diabetes self-management.
  2. 2. By Peggy A. Ulrich, MSN, RN, CDE, and Nancy Abner, RN, CDE ajn@wolterskluwer.com AJN t July 2010 t Vol. 110, No. 7 63 The Five M’s1, 2, 6 Survival Skill When to Do It What to Ask How to Individualize It Meter When check- ing blood glucose levels Do you have a glucose meter at home? What meter do you use at home? How often do you check your blood glucose level at home? Do you use a logbook? Do you need a new logbook? What have your blood glucose val- ues been at home? Do you know what the numbers on the meter mean and what numbers should be your goals? How do you obtain your test strips? Demonstrate use of the glucose meter, including how to obtain a fingerstick sample from the side of the fingertip. Encourage the patient to practice using the glucose meter. Explain the use of the logbook; leave the log at the bedside and encourage the patient to record glucose values; show the patient how to check the glucose meter’s record for past readings. Inform the patient of the American Diabetes Association (ADA) target glucose ranges: fasting, 70–130 mg/dL; two hours after a meal, under 180 mg/dL (this value should be individualized for each patient); hypoglycemia, under 80 mg/dL; hyperglycemia, 200 mg/dL or higher. Explain the “rule of 15” for treating hypoglycemia: consume 15 g carbohydrates, wait 15 minutes, check glucose level, repeat steps if necessary. Explain when to seek help: for low (under 70 mg/dL) or high (over 300 mg/dL) glucose values that are persistent and unresponsive to treatment. Meds When giving daily medica- tions What medications do you take at home for your diabetes? Do you understand your medications and how they work? Is it difficult to afford your medica- tions? Do you ever forget your medica- tions? What do you do if you forget to take your medications? Ask patients to describe the name, action, dosage, timing, and any relevant adverse effects of their medications (provide handouts as needed). Teach patients about insulin preparation, injection, site selection, site rotation, proper storage, and drug action (peak, duration, when to look out for lows or highs). Teach how to handle skipped or forgotten medica- tions (never double the next dose; call provider with questions, if necessary). Suggest resources for obtaining free or reduced- price medications (such as pharmaceutical compa- nies or social workers).
  3. 3. 64 AJN t July 2010 t Vol. 110, No. 7 ajnonline.com Survival Skill When to Do It What to Ask How to Individualize It Meals When provid- ing or inquir- ing about ordering a meal Do you count carbohydrates at home? Do you measure your food? Do you read labels? Are you able to read labels? Would you like to see the dietitian? Would you like a copy of a meal plan? Do you eat out often? Who does the cooking in your home? Teach carbohydrate counting and portion control; help patients obtain individualized meal plans from a dietitian (the person who prepares food at home should be present for the dietitian consult, if pos- sible); give handouts on meal planning. Reinforce the principles of good nutrition; stress the importance of not skipping meals and avoiding excess snacking between meals. Explain the benefits of weight loss, if appropriate. Move When help- ing a patient with physical activity such as transfer- ring to a chair or walk- ing What kind of exercise or movement do you get at home? How regular is it? What barriers make it difficult for you to exercise? Do you have safety concerns about exercise or physical activity? What is your favorite physical activ- ity? Would your family exercise with you? Do you know that walking is a great exercise? Collaborate with patients to explore exercise options at home. Focus on realistic activity goals for each patient. Demonstrate chair exercises when necessary. Work closely with patient’s physician and other health care providers (physical therapist, diabetes educators). Emphasize the benefits of exercise: decreased insulin resistance; weight loss; greater well-being, mental focus, energy. Teaching tips. A nurse can save time and im- prove patient learning by seizing teachable mo- ments. These moments occur naturally in a nurse’s daily routine. Preparation and organization are ­cru­cial. One strategy is to keep handouts, videos, forms, and other information sources readily avail- able. All materials should be in plain language that can be understood even by those with little educa- tion. It’s also important to vary your approach. If you deliver the same talk over and over, you and your patient may both end up bored and disen- gaged. As often as possible move beyond merely having patients read pamphlets or listen to you describe strategies; it’s well established that learn- ing happens best when the learner must explain her or his understanding of a topic or actually per- form certain tasks while talking about them. Often nurses are too busy delivering care to stop and listen to patients. A nurse may be teach- ing healthful eating to a patient who’s worried about affording the next meal after leaving the
  4. 4. ajn@wolterskluwer.com AJN t July 2010 t Vol. 110, No. 7 65 hospital. Patients may feel overwhelmed by new medical terminology. Relying on the simple lan- guage of the five M’s will not only give the nurse a clear focus but will also help the patient better understand. This method includes asking pertinent questions and individualizing teaching for specific patients. t Peggy A. Ulrich is an assistant professor of nursing at Brevard Community College in Titusville, FL. She formerly worked at Parrish Medical Center as an inpatient diabetes educator and developed and implemented the 5M strategy she describes in this article. Nancy Abner is a certified diabetes educator at MIMA (Melbourne Internal Medicine Associates) in Melbourne, FL. Contact author: Peggy A. Ulrich, peggyulrich@cfl.rr.com. Diabetes Under Control is coordinated by Jane Jeffrie Seley, MPH, MSN, GNP, BC-ADN, CDE: diabetesnp@gmail.com. REFERENCES   1. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care 2009;32 Suppl 1:S13- S61.   2. American Association of Diabetes Educators. Professional resources. AADE7 self-care behaviors. n.d. http://www. diabeteseducator.org/ProfessionalResources/AADE7.   3. Uding J, et al. Efficacy of a teaching intervention on nurses’ knowledge regarding diabetes. J Nurses Staff Dev 2002; 18(6):297-303.   4. Jallinoja P, et al. The dilemma of patient responsibility for lifestyle change: perceptions among primary care physi- cians and nurses. Scand J Prim Health Care 2007;25(4): 244-9.   5. London F. No time to teach? A nurse’s guide to patient and family education. Philadelphia: Lippincott; 1999.   6. Funnell MM, et al. National standards for diabetes self- management education. Diabetes Care 2010;33 Suppl 1: S89-S96. Survival Skill When to Do It What to Ask How to Individualize It More When talking to a patient about dis- charge plan- ning; any time you are speaking to a patient about diabetes Do you understand the signs and symptoms of hypoglycemia? Do you know how to treat a hypo- glycemic episode? Do you get your feet checked regu- larly when you see the physician? Do you have regular checkups? Do you have family or social sup- port? Do you understand complications that can happen if you do not con- trol your blood sugar? Do you know what to do if you get sick? Have you been to outpatient diabe- tes education classes? Would you like me to make you an appointment for outpatient diabetes education classes? Will you need transportation to a diabetes education follow-up? Problem solving Teach recognition of the signs and symptoms and treatment of hypo- and hyperglycemia; what to do about missed medications and sick days; when to call for help. Healthy coping Explain that stress can raise blood glucose levels and that depression is common among those with diabetes; help the patient obtain a mental health consult if appropriate. Reducing risks Explain the importance of frequent foot inspec- tions; yearly eye examinations; flu vaccination; monitoring blood pressure and cholesterol levels; measuring the hemoglobin A1c level every three months until it’s less than 7% or within individual- ized target range, then every six months thereafter; quitting smoking. Provide resources, including connecting patients to outpatient diabetes programs (classes or indi- vidual appointments with a certified diabetes educator); helping patients find transportation to follow-up care and education; letting them know about other community resources such as clin- ics and smoking cessation programs; informing them about online resources such as the ADA (www.diabetes.org) and (for patients and fami- lies of those with type 1 diabetes) the Juvenile Diabetes Research Foundation International (www.jdrf.org).