Study Points

Diabetes Care and Patient Education

Course #94393 - $60 • 15 Hours/Credits

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    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Healthcare costs for people with diabetes

    THE SIGNIFICANCE OF THE PROBLEM

    Diabetes places a substantial burden on the individual, society, and the economy. In the United States, 12 million (25.2%) people older than 65 years of age have diabetes, and the numbers are growing [10]. It is projected that one in three Americans born in 2000 will have diabetes over the course of their lives [11]. National statistics indicate that with 30.3 million cases in the United States, 9.4% of the total population has this disease [10]. Approximately 7.2 million individuals with diabetes have not been diagnosed [1,10]. Another 84.1 million people are estimated to have prediabetes, a condition that significantly increases the risk for developing diabetes [10]. Diabetes accounts for substantial loss in overall worker productivity, costing approximately $90 billion in lost productivity in 2017 [10]. Reductions in productivity were associated with absenteeism, decreased efficiency at work, disability, and early death [3]. In addition to economic loss, chronic complications of diabetes can significantly diminish quality of life for the individual, accounting for more new cases of blindness, end-stage renal disease, and lower extremity amputation than any other medical diagnosis [1].

    Healthcare utilization by people with diabetes is considerable. Researchers report that people with diagnosed type 1 diabetes incur an average of $14,856 in healthcare expenditures per year, while those with type 2 diabetes acquire approximately $9,677 in expenditures [3]. This equates to healthcare expenditures that are roughly 2.3 times higher than for people without diabetes [4]. Diabetes contributes to longer hospital length of stay and higher rates of physician office and emergency department visits. A substantial amount of healthcare utilization by people with diabetes is associated with the chronic complications of this condition, particularly cardiovascular disease, neurologic symptoms, and renal complications. As sobering as these statistics are, it is predicted that the toll of diabetes will increase, related to higher rates of obesity and increasing cases of type 2 diabetes in children [12].

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  2. The prevalence of diabetes is greatest in which of the following ethnic groups?

    THE SIGNIFICANCE OF THE PROBLEM

    The prevalence of diabetes is greater in some racial and ethnic populations. Estimated prevalence rates for diabetes among adults 20 years of age and older in the following racial/ethnic groups are [2,10]:

    • Non-Hispanic whites: 7.4%

    • Asian Americans: 8.0%

    • Hispanic/Latino Americans: 12.1%

    • Non-Hispanic blacks: 12.7%

    • Native Americans/Alaska Natives: 15.1%

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  3. The three organ systems involved in the regulation and utilization of glucose by the body are the

    DISEASE PROCESS

    Three organ systems are involved in the regulation and utilization of glucose by the body. They are the liver, the pancreas, and the skeletal muscle tissue. The liver plays two roles in the regulation of blood glucose. One is the storage and release of glucose that has been ingested from the diet; the other is the synthesis of its own glucose supply. (The process of glucose production by the liver is called gluconeogenesis.) Normally, when blood glucose levels are low, the liver releases some of its stored or synthesized glucose and blood levels rise. Conversely, when blood glucose levels are high, the liver stops producing and releasing glucose and blood levels fall.

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  4. Insulin resistance refers to

    DISEASE PROCESS

    Insulin resistance is the second major pathologic process in diabetes. This refers to impairment in the body's ability to utilize insulin. With insulin resistance, blood levels of insulin may be high, but receptor sites for it are not available.

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  5. Type 1 diabetes

    CLASSIFICATION OF DIABETES

    Formerly known as "juvenile-onset" diabetes, this type usually has its onset in people younger than 30 years of age. It is most often seen in people with a lean body type, although it can occur in people who are overweight. Type 1 diabetes results when the person's pancreas cannot produce any of its own insulin for use by the body. If the person with type 1 diabetes does not receive insulin from an outside source (e.g., injections), he or she is likely to develop a life-threatening condition known as ketoacidosis. Patients with type 1 diabetes will always require insulin from an outside source to stay alive.

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  6. Type 2 diabetes

    CLASSIFICATION OF DIABETES

    In the past, this type of diabetes was called "adult onset" diabetes. With increasing incidence among children and adolescents, classification based on age of onset is no longer accurate. Type 2 diabetes is by far the most common type of diabetes, accounting for 90% to 95% of cases [18]. This type of diabetes usually begins in people older than 30 years of age and most commonly occurs in people older than 55 years of age. However, as mentioned earlier, it can occur at younger ages as well. Regardless of age of onset, type 2 diabetes is more likely to occur in those who are overweight.

    In the person with type 2 diabetes, the pancreas is able to produce at least some of its own insulin for use by the body. However, the insulin that is produced is either insufficient for the needs of the body or poorly utilized by the tissues. When available insulin is not readily utilized by the tissues, the condition is called insulin resistance.

    The need for an outside insulin source is variable in people with type 2 diabetes. Individual cases of type 2 diabetes may be treated with diet therapy, oral medications, insulin, or any combination of these. A patient with type 2 diabetes usually has a pancreas that is able to produce enough of its own insulin to prevent ketoacidosis from occurring. However, these patients may require insulin injections to keep blood glucose levels under control for the prevention of other acute and chronic complications.

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  7. Women with gestational diabetes are more likely to

    CLASSIFICATION OF DIABETES

    Women with gestational diabetes are at higher risk for hypertensive disorders and cesarean delivery. Fetal complications of gestational diabetes may include neural tube defects, perinatal death, large body size (macrosomia), lower Apgar scores, and childhood obesity [25]. Although most women with gestational diabetes will have normal glucose levels within six weeks postpartum, 35% to 60% will have developed diabetes in the next 10 to 20 years [26,27]. Therefore, regular blood glucose testing is recommended for these women during and following pregnancy. Maintenance of a healthy body weight and regular physical activity may help prevent the onset of type 2 diabetes in this population [28].

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  8. One sign or symptom of hyperglycemia is

    DIABETES COMPLICATIONS

    The primary symptoms of hyperglycemia are sometimes referred to as the "three polys" of diabetes. They are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive hunger). Polydipsia is related to intracellular dehydration, initiated after high levels of glucose in the blood remove water from the cells. Polyuria results when large amounts of glucose in the urine are accompanied by large losses of water. Polyphagia, which is most likely to occur in type 1 diabetes, is due to cellular starvation as stores of carbohydrates, fats, and proteins become depleted. Other signs and symptoms of hyperglycemia in diabetes include blurred vision, weakness, lethargy, and malaise.

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  9. Which of the following is a sign of diabetic ketoacidosis (DKA)?

    DIABETES COMPLICATIONS

    Hyperpnea (deep breathing) is usually present as a sign of DKA, reflecting the pulmonary system's response to acidosis. Acetone breath may occur. Signs of dehydration related to DKA include orthostatic hypotension and poor skin turgor. Acute abdominal pain, tenderness, and diminished or absent bowel sounds are commonly associated with DKA and frequently cause the patient to seek emergent treatment. Changes in mental status occur as the ketosis progresses.

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  10. In the United States, chronic complications of diabetes are

    DIABETES COMPLICATIONS

    The chronic complications of diabetes have a profound effect on the healthcare system as well as the individual. In the United States, the treatment of these complications cost an estimated $55 billion in 2017 [32]. While the economic costs of diabetic complications are enormous, their effect on quality of life for the individual and family can be equally devastating. The CDC reports the impact of chronic complications on Americans with diabetes as [33]:

    • Leading cause of adult-onset blindness

    • Leading cause of end-stage renal disease

    • Significant morbidity and disability due to foot ulcer and lower extremity amputation

    • Increased risk for cardiovascular disease (two to four times greater in diabetic patient)

    • Significantly increased risk for nerve disease, periodontal disease, and a host of other health problems

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  11. The onset and progression of diabetic nephropathy can be delayed through which of the following interventions?

    DIABETES COMPLICATIONS

    Hypertension significantly accelerates the progression of diabetic nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Angiotensin-converting enzyme (ACE) inhibitor drugs are commonly prescribed to diabetic patients for hypertension because they are effective blood pressure-lowering drugs with few side effects. In addition, ACE inhibitors are often prescribed to patients with diabetes even when they are not hypertensive because the drugs in this class have an independently protective effect on the kidneys, which can prevent the onset or progression of diabetic nephropathy. This means that the renal benefits of ACE inhibitors are above and beyond an effect attributable to blood pressure control alone. In addition to renal benefits, ACE inhibitors have been shown to reduce the risk for heart attack, stroke, and cardiovascular-related death in people with diabetes. Examples of ACE inhibitors include enalapril, fosinopril, lisinopril, and captopril. Another similar class of medication, angiotensin receptor blockers (ARBs), may be used in place of ACE inhibitors for delaying the progression of diabetic nephropathy [6]. A commonly used ARB is losartan.

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  12. Individuals who actively manage their own diabetes

    FACILITATING DIABETES SELF-CARE

    Diabetes self-management education (DSME) is considered an essential element of diabetes care. Furthermore, individuals who actively manage their own diabetes care have better outcomes than those who do not. For these reasons, an educational approach that facilitates informed decision making on the part of the patient is widely advocated [5,6].

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  13. Which of the following is a barrier to effective diabetes self-management?

    FACILITATING DIABETES SELF-CARE

    Unfortunately, patients can encounter a variety of psychologic and emotional barriers when it comes to effectively managing their diabetes. These barriers include feelings of inadequacy about one's own abilities, unwillingness to make the necessary behavior changes, and ineffective coping strategies. The following sections of this course will discuss the empowerment approach to diabetes education and will cover methods for overcoming related barriers.

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  14. Patient empowerment

    FACILITATING DIABETES SELF-CARE

    Patient empowerment is a widely supported approach to diabetes education. This model assumes that the patient is the person who will experience the consequences of diabetes and, therefore, is the one with primary rights and responsibilities regarding its management. Because the empowerment approach emphasizes the patient's role in decision making, education is aimed at providing information that the patient will need in order to manage his or her own care effectively. Healthcare providers who use the empowerment approach recognize that the ultimate responsibility for making changes that will affect health outcomes is with the patient. Therefore, the role of the healthcare provider is to assess patients' willingness to make changes and to help them set realistic goals.

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  15. Which of the following interventions supports the empowerment approach to education?

    FACILITATING DIABETES SELF-CARE

    According to the empowerment model, educators are most effective when they are able to recognize that they cannot and should not try to solve patients' problems for them. Instead, the role of the educator is to facilitate the patients' problem-solving skills and to support a decision-making process that is likely to benefit patients' health status. These skills can be supported by exploring, with the individual, the range of self-care options available and the consequences of each. Educators will discover that some patients are resistant to this type of exploration and should be prepared to accept their own limitations in their ability to effect change [40].

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  16. Which of the following questions assesses self-efficacy?

    FACILITATING DIABETES SELF-CARE

    Assessment of diabetes self-efficacy can be useful in targeting areas where the patient lacks confidence in the ability to carry out a self-care behavior. Specific self-efficacy questionnaires are sometimes used to make this assessment. One such questionnaire asks respondents how sure they are that they can perform specific diabetes-related behaviors. Sample statements from this type of questionnaire are presented in Table 5. The use of a specific questionnaire for self-efficacy is not always feasible. In that case, asking a few related questions as part of the general assessment can still make an expedient self-efficacy assessment. For example, patients can be asked how confident they feel (on a scale of 1 to 10) about their ability to manage diabetes on a day-to-day basis [41].

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  17. The Stages of Change Model assumes that

    FACILITATING DIABETES SELF-CARE

    Readiness to change refers to the hypothesis that people move through a series of stages as they give up unhealthy behaviors and adopt health-enhancing behaviors. The Stages of Change Model has been widely used in smoking cessation as well as in DSME. The researchers identified six stages that people go through as they attempt lifestyle changes. These stages range from precontemplation, during which the patient does not intend to change within the next six months, to maintenance, when healthy behaviors have been practiced for greater than six months. For each stage of change, certain interventions on the part of the healthcare provider are recommended. By employing these interventions, the healthcare provider is able to "meet" the patient within his or her own particular stage of change at a given time [42].

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  18. Coping skills can be facilitated by

    FACILITATING DIABETES SELF-CARE

    Helping the patient identify his or her own beliefs about having diabetes is an important step toward facilitating the development of coping skills. Because beliefs are usually reflected in the thoughts that a person has, healthcare providers can help the patient identify the thoughts that motivate self-care behavior. For example, negative thoughts tend to trigger behavior that is not constructive. The patient may think, and therefore believe, that "Checking blood sugar is useless." This negative thought process can result in failure to monitor blood glucose levels adequately. On the other hand, a positive thought, such as "Checking my blood sugar helps me stay well," would be more likely to result in constructive health-enhancing behavior. Providing the patient with reflective feedback about his or her beliefs may help convert self-limiting thoughts into constructive thoughts. When the patient with diabetes is able to reflect upon his or her beliefs about having the disease, he or she may be able to identify how those thoughts affect health-related behaviors and, ultimately, health status.

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  19. Effective diabetes self-management education programs

    DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

    In general, the goal of diabetes self-management skills training programs is to enable the patient to become the most active participant in his or her own care.

    Several studies have demonstrated that self-management training improves self-care behavior, clinical outcomes, and the quality of life for patients with diabetes. Diabetes education and support is also associated with better use of primary and preventive services and lower rates of hospitalization [6]. Further, it has been found that patients who have diabetes education have lower average healthcare costs than those who do not [44]. Although experts and research findings agree that DSME is essential, the U.S. Department of Health and Human Services reported that only 56.8% of people with diabetes have ever received any formal education on how to manage their condition. The national goal is to increase this proportion to 62.5% by the year 2020 [45]. In 2010, it was indicated that progress had been made in the arena of diabetes education and disease monitoring [46]. As of 2016, more than 4,100 DSME and DSMS programs were offered across the United States, with approximately 1.1 million people participating in the programs [47]. One barrier to diabetes education is access. Providers of DSME can help address this issue by [5]:

    • Clarifying the specific population to be served by understanding the community, service area, or regional demographics

    • Determining that population's DSME needs and identifying resources outside the provider's practice that can assist in ongoing support

    • Identifying access issues (e.g., socioeconomic or cultural factors, lack of encouragement from other healthcare providers to seek education) and working to overcome them

    National standards have been developed for the establishment and maintenance of quality diabetes self-management programs [5,6]. This curriculum includes, but is not limited to, the following components (specific components to be delivered should be based upon an individual needs assessment):

    • Diabetes disease process and treatment options

    • Nutrition

    • Exercise and activity

    • Medications

    • Monitoring of blood glucose and use of results

    • Prevention and treatment of acute complications

    • Prevention and treatment of chronic complications

    • Psychosocial adjustment

    • Developing personal strategies to promote health and behavior change

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  20. Which of the following is a principle of adult learning?

    DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

    An effective approach to teaching diabetes self-care in adult settings is to employ various principles of adult learning theory. An important principle of adult learning theory is that adults tend to be self-directed learners who feel a need to learn. Asking the patient what he or she feels addresses this principle of adult learning and is the most important issue during the needs assessment.

    Focus Teaching on the Patient's Perceived Problems

    Determine what the patient feels he or she needs to know and what the perceived problems are. The adult learner will be more likely to acquire new knowledge and skills when teaching is directed toward specific problems rather than toward a comprehensive set of material.

    Find Out What the Patient Already Knows

    Adults tend to learn better when teaching incorporates prior knowledge and past experiences. When teaching a problem-solving process, for example, ask the patient how he or she has dealt with a similar situation in the past. Build upon this experience to teach new material.

    Keep the Patient Active in the Learning Process

    Provide opportunities for interaction, questions, and sharing. Teaching is apt to be more effective when the patient's own life experiences can be incorporated into the lesson.

    Allow for Self-Directed Learning

    Enhance the learner's sense of autonomy by letting him or her make choices about what is being taught. For example, you can allow the patient to choose the mode of learning or the amount of time spent on a particular topic.

    Give the Patient a Reason to Learn

    Adult learners generally must perceive the benefits of what is being taught. Address this by giving the patient a brief rationale for the content that you are presenting, focusing on the benefits that can result from learning.

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  21. Which of the following is a benefit of self-monitoring blood glucose (SMBG)?

    MANAGEMENT OF DIABETES

    A major benefit of SMBG is that it provides feedback about how well treatment goals are being met. By keeping blood glucose levels as near normal as possible over time, people with diabetes can reduce their risk for acute and chronic complications. SMBG can help prevent hypoglycemia and provide information relevant to adjusting food intake, activity level, and medication [6]. Several studies have shown that SMBG is associated with decreased morbidity and mortality in individuals with type 2 diabetes [49,50,51].

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  22. An appropriate intervention with the patient who perceives blood glucose monitoring as inconvenient is to

    MANAGEMENT OF DIABETES

    Individuals may not want to check their blood glucose on a regular basis because they perceive it to be an inconvenience that encroaches on their lifestyle. Healthcare providers might be able to help such patients overcome this barrier by providing information about how improved blood glucose control can result in feeling better on a day-to-day basis. Further information may be provided regarding how glycemic control reduces the risk for long-term complications, making patients more able to lead productive lives. The perception that SMBG is inconvenient may also be offset if patients are shown how this procedure can allow for greater flexibility in meal planning. By monitoring the effects of various foods and the timing of meals on blood glucose, patients can have more choices with regard to eating [48]. Patients who find regular blood glucose monitoring bothersome may be interested in meters that are smaller, faster, and require fewer steps during testing. Some meters allow for "alternate site" testing, in which the patient can collect a blood sample from the forearm or the thenar aspect of the palm, where fewer nerve endings make the procedure less painful. Additionally, the IDF/SMBG Working Group has suggested possible regimens that may be individualized to address the specific needs of each person with diabetes [48].

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  23. The HbA1c test

    MANAGEMENT OF DIABETES

    Although SMBG using a capillary blood sample is indispensable in the day-to-day management of diabetes, results from these tests have some limitations. One such limitation is that results of SMBG reflect the blood glucose for a specific moment in time without giving an indication of overall blood glucose control. The glycated hemoglobin test, more commonly known as the HbA1c, is a laboratory test that uses a venous blood sample to show the average blood glucose over the previous two to three months.

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  24. Carbohydrate counting

    MANAGEMENT OF DIABETES

    Carbohydrate counting is a method for keeping track of the amount of carbohydrate in each meal or snack. Emphasis is placed on the total amount of carbohydrate in a meal or snack rather than on the source. Limits are set for the maximum amount of carbohydrate that should be consumed for each meal or snack. Foods counted as carbohydrates are starches (including starchy vegetables), sugars, milk, and fruit. Nonstarchy vegetables are so low in carbohydrates that they are generally not included in carbohydrate counting. The ADA suggests beginning with 45–60 grams of carbohydrate per meal [70]. A food diary and blood glucose records are used to determine if this is the proper amount of carbohydrate for the individual.

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  25. Which of the following is NOT one of the tenets of the Create Your Plate Method?

    MANAGEMENT OF DIABETES

    The teaching tenets of the Plate Method are [68,76]:

    • Use a nine-inch dinner plate.

    • Fill approximately one-half of the plate with nonstarchy vegetables, such as leafy greens, onions, peppers, tomatoes, cucumbers, green beans, broccoli, carrots, cauliflower, and others.

    • Fill one-fourth of the plate with lower fat protein foods, such as lean cuts of meat, fish, poultry with skin removed, egg whites and egg substitutes, two ounces of reduced-fat cheese, plant-based proteins (e.g., beans, lentils, edamame, tofu, hummus, tempeh), nuts, or spreads (e.g., peanut or almond butter).

    • Fill one-fourth of the plate with grains and starchy food, such as whole grain breads, brown rice, whole grain pasta, potatoes, pumpkin, corn, or peas.

    • Add a small piece of fruit, one-half cup fresh frozen or canned fruit, or two tablespoons of dried fruit.

    • Add a low-calorie drink, such as water, unsweetened tea, or coffee.

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  26. Sulfonylureas act primarily by

    MANAGEMENT OF DIABETES

    Sulfonylureas act primarily by increasing insulin production from the pancreas. They can be further classified as first- or second-generation hypoglycemic agents. The first-generation agent used today is chlorpropamide; acetohexamide has been discontinued, and tolbutamide and tolazamide are no longer recommended treatment options for type 2 diabetes [17]. Although the only currently used first-generation sulfonylurea agent in the United States is chlorpropamide, it is important to have an understanding of all medications within this category in the rare case a patient presents with a history of having taken one of these agents. First-generation agents are associated with a greater potential for drug interactions and are less commonly used than the second-generation drugs. Second-generation sulfonylureas include glipizide, glyburide, and glimepiride, among others. They have largely supplanted the use of first-generation sulfonylureas because they have the convenience of once or twice a day dosing and the potential for fewer adverse effects.

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  27. Patients taking nonsulfonylurea secretagogues should be instructed to take their pills

    MANAGEMENT OF DIABETES

    Patients taking this agent should be instructed to take their pills 15 to 30 minutes prior to each meal. The number of doses taken is determined by the number of meals eaten. For example, if a meal is missed, the corresponding dose of medication is skipped. Conversely, a dose is added when an extra meal or large snack is taken.

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  28. A thiazolidinedione, such as pioglitazone or rosiglitazone, acts primarily by

    MANAGEMENT OF DIABETES

    Medications in this class improve the body's ability to use insulin. Insulin action is enhanced by "opening up" the insulin receptors in the liver and skeletal tissues. When this occurs, insulin resistance is reversed and the body is able to utilize circulating insulin more effectively. A secondary action of the insulin sensitizers is that they decrease the production and release of glucose from the liver. Because these agents are not hypoglycemic agents, they will not generally lower blood glucose to levels below normal. When used in combination with insulin or sulfonylureas, the potential for hypoglycemia exists.

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  29. Alpha-glucosidase inhibitors, such as acarbose and miglitol, act primarily by

    MANAGEMENT OF DIABETES

    Alpha-glucosidase inhibitors (AGIs) work by slowing the digestion of carbohydrate in the small intestine. This results in decreased postprandial blood glucose levels due to delayed absorption of sugars and starches into the bloodstream.

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  30. Injectable short-acting (regular) insulin

    MANAGEMENT OF DIABETES

    Also known as "regular" insulin, this is a clear insulin that is generally used to cover increases in blood glucose associated with the main meals. Onset of action is from 30 minutes to one hour after injection, with peak levels occurring in two to three hours. Persons using regular insulin are instructed to administer a dose between 30 to 45 minutes prior to the meal.

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  31. Reusing insulin syringes

    MANAGEMENT OF DIABETES

    The reuse of syringes is a controversial issue. Manufacturers of disposable syringes recommend single use only, while the ADA neither advocates nor prohibits this practice. Reusing needles may benefit some patients financially while helping to reduce medical waste. Recommendations for syringe reuse are intended for people who self-inject and who are capable of safely recapping a needle after each use. People who have poor personal hygiene, are acutely ill, have open wounds on the hands, or have decreased resistance to infection should not reuse their syringes. The ADA provides the following guidelines related to syringe reuse [106,107]:

    • Store the syringe at room temperature.

    • Recap the needle after each use.

    • Replace the syringe when the needle becomes dull or bent or has come into contact with anything other than the skin.

    • Inspect the skin around injection sites periodically for signs of infection.

    • Do not cleanse the needle with alcohol; this disrupts the silicone coating intended to make injection more comfortable.

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  32. The angle of the needle during insulin injection

    MANAGEMENT OF DIABETES

    Insulin injections are made into the subcutaneous tissue. Routine aspiration for blood prior to injecting the insulin is not necessary. The angle of the needle during injection should be individualized to avoid intramuscular injection. For most people, a subcutaneous injection can be achieved by grasping a fold of skin and injecting at a 90-degree angle. For those who are especially thin, the tissue should be lightly pinched and an injection angle of 45 degrees should be used [106].

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  33. Prefilled syringes

    MANAGEMENT OF DIABETES

    Prefilled syringes are stable for up to 30 days when stored in the refrigerator. This may be beneficial to those who are sight-impaired or do not have the manual dexterity to fill their own syringes. In these cases, family members, friends, and other caregivers may prefill the syringes on a periodic basis. If possible, syringes prefilled with a cloudy insulin should be stored in a vertical position with the needle pointed up to avoid clumping of suspended insulins in the needle. Prefilled syringes should be gently rolled between the palms prior to injection to warm the refrigerated insulin and to resuspend insulin particles [106].

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  34. The primary benefit of exercise to people with diabetes is that it

    MANAGEMENT OF DIABETES

    Physical activity is considered an important component of any diabetes management program. The primary benefit of exercise to people with diabetes is that it has been found to increase glucose utilization by the tissues, thereby lowering blood glucose concentration [6,111]. In some people with type 2 diabetes, a regular program of physical activity can increase insulin sensitivity to the degree that medications can be reduced or discontinued. Because people with diabetes are at increased risk for heart disease, exercise has the added benefit of its favorable effect on cardiovascular status. The benefits of regular exercise to people with diabetes can be summarized as [111]:

    • Improved insulin sensitivity

    • Reduction in body fat and weight

    • Reduction in incidence of cardiac disease

    • Improved lipid profile

    • Increase in high-density lipoproteins

    • Improved control of hypertension

    • Improved self-esteem

    • Reduced psychologic stress

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  35. The risk for exercise-related hypoglycemia is greatest for patients whose diabetes is controlled by

    MANAGEMENT OF DIABETES

    Patients who use insulin or sulfonylureas are at risk for hypoglycemia during or after exercise if proper adjustments are not made. This is due to the effect that exercise has on lowering blood glucose. People who use meal planning alone to control their diabetes are not generally at risk for experiencing exercise-induced hypoglycemia.

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  36. Appropriate preventive foot care for people with diabetes

    MANAGEMENT OF DIABETES

    The value of preventive foot care cannot be overestimated. Preventive care includes daily self-foot exams, proper foot care, proper footwear, and regular foot exams by a healthcare professional.

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  37. The absence of protective sensation of the foot indicates

    MANAGEMENT OF DIABETES

    The annual clinical foot exam should include sensory testing with a monofilament to detect loss of protective sensation. This is a simple and noninvasive method for identifying feet that are at risk for problems that could lead to amputation. The test is done using a monofilament that resembles the bristle of a hairbrush. The monofilament is pressed onto specific areas on the plantar surface of the feet while the patient has his or her eyes closed. The patient then indicates whether or not the monofilament is felt, indicating the presence or absence of protective sensation. When protective sensation has been lost, there is an increased risk for amputation and the patient should be counseled on the importance of vigilant preventive measures. In some cases, custom-fit shoes are required for those who have lost protective sensation [6].

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  38. Hormones released during the sympathetic stress response

    MANAGEMENT OF DIABETES

    When asked what it feels like to experience stress, most people would respond with descriptions of feeling nervous, sweaty, or shaky, and perhaps experiencing dry mouth, a pounding heart, or "butterflies in the stomach." These common reactions to stress are known as the "fight or flight response," and they reflect the response of the sympathetic nervous system to stress. Hormones released during the sympathetic stress response make diabetes more difficult to control. These hormones include epinephrine, norepinephrine, glucagon, and growth hormone. Another stress hormone, cortisol, plays an important role in diabetes, as it stimulates glucose production by the liver in addition to increasing insulin resistance. In the person with diabetes, this will have the effect of raising blood glucose.

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  39. Which of the following conditions in patients with diabetes does NOT require immediate attention of a healthcare provider?

    MANAGEMENT OF DIABETES

    While minor illness can usually be managed safely at home through telephone contact with a physician, certain conditions will require the immediate attention of a healthcare provider [117]. These include:

    • Vomiting or diarrhea for more than six hours

    • Difficulty breathing

    • If on insulin: Blood glucose greater than 240 mg/dL that is unresponsive to insulin

    • If using oral diabetes medications: Blood glucose before meals greater than 240 mg/dL for 24 hours or more

    • Moderate or large ketones in the urine

    • Change in mental status

    • Fever for more than two days

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  40. Which of the following is a component of cultural competence in diabetes care?

    CULTURAL ASPECTS OF DIABETES CARE

    Cultural competence means being sensitive to differences in the values and beliefs that are shared by the members of an ethnic, cultural, racial, religious, or lifestyle preference of a group. Components of effective transcultural nursing include communication style, use of personal space, eye contact, and understanding of biologic variations. It is important to keep in mind, however, that there can be great variation among individuals within cultures. Therefore, stereotyping and making assumptions about an individual patient's beliefs based solely upon ethnic identification should be avoided.

    In most cases, it is not necessary to develop a thorough understanding of each and every culture encountered in diverse healthcare settings. However, a certain degree of cultural competence can and should be developed. The first step in doing this is to recognize that cultural differences do exist. How these variations impact diabetes self-management can be explored in the diabetes needs assessment. This may include a sensitive exploration of the person's healthcare practices and the role of family members. Other culturally impacted areas may include beliefs about illness, diet, the role of the patient in self-care, gender roles, religious rituals, and communication styles.

    Dietary preferences, meal preparation practices, and the symbolism of food represent an especially important area for the diabetes healthcare provider. When giving diet instructions, efforts should be made to consider the food preferences of the cultural group. Nutritional resources that are especially designed for members of different cultural groups are available from the ADA and the Academy of Nutrition and Dietetics.

    Cultural competence includes recognizing that cultural healthcare practices may differ from one's own beliefs about how an illness should be treated. Furthermore, cultural influences may not always be consistent with healthcare recommendations. This may be especially true with diabetes, as this disease requires significant behavioral adaptations. For example, an Hispanic American woman with diabetes may experience a conflict between her cultural gender role and dietary recommendations made by a healthcare provider. For many Hispanic Americans, a valued role for the woman is to prepare large traditional meals for the family. Americanized versions of many of these traditional foods, however, are high in fat and calories and are not recommended for people with diabetes. Therefore, the woman may experience a conflict between her cultural values and those of the mainstream healthcare system.

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