慢性疾病的家庭疗法home care chronic disease prevention

Home Care Chronic Disease Prevention Program Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine Homework review What did you do? What happened as you did that? Why do you think that happened? Heres what might have happened. How does this impact the next time you try this? 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 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 Diabetes Diabetes: The numbers About seven percent of Americans have diabetes Sixth leading cause of death in the US 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 Symptoms and signs Extreme thirst Extreme hunger Weight loss Frequent urination Vision changes Recurrent infections 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 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 Type II diabetes Most common form of diabetes Insulin resistance Onset occurs usually in adult years Risk factors for type II diabetes Overweight Family history Prior history of gestational diabetes African American race Treatment Injectable insulin oShort acting oMedium acting oLong acting Oral medications oIncrease insulin secretion oIncrease insulin sensitivity Insulin Rapid acting (Humalog and Novolog) Short acting (Regular) Intermediate acting (NPH) Long acting (Lantus) 24 hours Mixes-combinations of the above Insulin Keep unopened bottles in the refrigerator Insulin will stay fresh for one month without refrigeration (under 86 F) Check insulin before using it oShort acting and glargine are clear oIntermediate and long acting are cloudy oIf clumps are visible, throw the bottle away 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 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 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 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 Non pharmacological treatment Diet/nutrition Exercise Weight loss Nutrition What a person with diabetes eats is very important Its more than just not eating SUGAR 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. Glycemic index In diabetics, because of the insulin resistance, the body doesnt respond as well so glucose levels stay high longer than normal Lower is better when it comes to glycemic index 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 Diabetic diet Keeping blood glucoses in the normal range decreases the likelihood of complications Diabetic diet More that just not eating sugar Eating the right foods At the right times In the right amounts 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 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 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 Control weight With good nutritional choices And increasing activity This sounds like a LOT of WORKis it worth it? YES! Common complications Blindness due to bleeding blood vessels in the eye Kidney failure which leads to dialysis Stroke Heart attack Numbness (neuropathy) Common complications Gum/teeth diseases Foot problems Infections Potential amputation 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 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 Who should be screened? Persons with hypertension Persons with hyperlipidemia Others at discretion of physician Warning symptoms History of an illness/ infection Nausea Sweating Vomiting Foot ulcers 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 Other warnings Not taking medications References Neal, LJ. dont want to fail again Healthy food costs more Next, What Reasons Does He Have for Eating a Healthier Diet? Reasons I have for Staying the Same (Not Eating Healthy) Reasons I have to Eat Healthy What benefits are you getting by not eating healthy (following diabetic dietary guidelines)? What are your fears, concerns about starting to eat healthier? What are the worst consequences you can imagine if you continued to eat in an unhealthy way ? (these are your fears, concerns about not eating healthy) What benefits could you get by eating healthy? Hint: Imagine what your life would be like if a miracle happened tomorrow and you could start eating a healthy diet. Explore His Reasons Fully Ask him how eating healthier could be good for any of these aspects of his life: Health Lifestyle Emotions Relationships Coping abilities (stress, for example) Work Social life Spiritual life Here are Some Sample Reasons for Eating Healthier Reasons I have for Eating Healthier Food What is the worst outcome you can imagine if you continued your unhealthy eating habits? Make my kidneys health worse Put me at risk for Stroke Heart attack Obesity means I cant enjoy doing physical activity with my children or grandchildren What would your life be like if a miracle happened and you were able to start eating healthier tomorrow? Control my blood sugar Lose weight Get my cholesterol down and reduce chance of stroke or heart disease Fit into better looking clothes Feel better physically and mentally Next, How Important is It for Him to Change? Ask him to compare his reasons for not changing with his reasons for changing Have him assign a number to the Ruler of Change in the next slide. This will show how important it is for him to change How Important is It for You to Change? On a scale of 0 to 10, how important is it to you to have healthy eating habits? The “Ruler of Change” 0 1 2 3 4 5 6 7 8 9 10 Not at all Very Important WILLING This number on the Ruler of Change will show how WILLING he is to change It will show how willing he is to start eating a healthier diet Willing (continued) If his Ruler of Change number is below 3 or 4: o He is not willing to consider change. o He has lots of resistance to change o His reasons for continuing to have unhealthy eating habits are STONGER THAN his reasons for eating healthy. Sample Question to Help Decrease Resistance What would have to change to decrease the importance you give to your reasons for having poor eating habits? Questions to Decrease Resistance A low number on the ruler of change says he does not think that eating healthy is important and he does not want to change But, look at his number on the Ruler of Change If hes not at zero, he must have at least a small interest in change. Decreasing Resistance If this is the case, Ask: o Why are you at _ and not zero? o What would it take for you to go from_ to_ ? His answers might get him to start thinking that change might be a good thing Willing (continued) If the number the client gives for the importance of changing is around 5: o He is “on the fence.” o He is split between wanting to take action and not being able to take the first step. o In this condition, he cant change. Sample Question to Help Increase Motivation What would have to change to increase the importance of your reasons for having healthier eating habits? Willing (continued) If the number he gives for the importance of change is greater than 6 or 7: o He is not resistant to change o He is not “on the fence” o He is ready to take some action Next, Find out if He is ABLE Measure his Confidence and Ability to have a healthier diet Use the Confidence and Ability “Rulers of Change” in the next slide Assessing Confidence and Ability to Make a Change Score your confidence to have a healthier diet. Score your ability to have a healthier diet. 0 1 2 3 4 5 6 7 8 9 10 None Low Medium Very High 0 1 2 3 4 5 6 7 8 9 10 None Low Medium Very High For Scores of About 6 and Below Ask, “What would it take to increase your confidence to have a healthier diet?” What encourages you to believe that you can achieve your goals for change? Ask, “What would it take to increase your ability to have a healthier diet?” Increasing Confidence and Ability About Change Other questions to ask” What else could help you have healthier eating habits? Who else could help you have healthier eating habits? Adapted from Miller and Rollnick, Motivational Interviewing, 2002 For Low Confidence and Ability Scores Maybe the goal is not realistic, it exceeds his confidence and ability. Ask: o What would happen if you reduced the size of your goal? o What would you be willing to try? o Maybe if you reduced your goal for changing, you would be more likely to try. Role of the Nurse Aide Find out what is important to the client and use this to motivate him/her to change Help the client identify an activity that he/she has the ability and confidence to achieve The Next Step: Being READY If hes WILLING (Importance Score 5 and above) If hes ABLE (Confidence and Ability Scores are 5 and above) Then hes READY Being READY Means: Being READY to set a goal and make a plan Keeping track of progress toward the goal Being prepared for setbacks with the right attitude and a Plan “B” Class Exercise Goal Setting Put yourself in the shoes of the diabetic client who does not have healthy eating habits Using your current goal setting skills, write a goal for eating a healthier diet on the next slide Using Your Own Words Write Down a Goal and Plan for Healthy Eating The Goal/Plan should be from the View Point of the Case Studys Diabetic Client Setting and Planning a Goal SMART Method A useful method for setting goals, SMART. To be effective, Goals need to be: o Specific o Measurable o Action oriented o Realistic o Time SMART method Some Examples A goal that is not SMART will probably fail. “I am going to stop eating chocolate cake.” Set and Plan a Goal SMART method Some Examples (continued) A SMART goal would be, “I will let my kitchen supply of snacks with added sugar run out and replace them with fruits over a 4 week period. At the same time I will reduce the sugary snacks I eat at work by one-half. In 4 more weeks I will replace sugar snacks at work with fruit that I bring in. I will satisfy my sweet tooth only at my church socials where I will keep my portion sizes the size of a fist.” Set and Plan a Goal SMART method Now use the SMART method to rewrite the activity you chose to support the clients goal for having healthier eating habits Write on the next slide this SMART goal from the viewpoint of the diabetic client in the case study What is Your Smart Goal? S M A R T READY READY also includes tracking progress in a written log or on a calendar Seeing concrete progress helps build confidence Adding comments can also identify what helped, what was difficult, what you learned, how you can get better Progress check (sample) My goal was_ I was_ successful in reaching my goal What helped_ _was difficult I learned that_ Adapted from HIP CHA training, 2005 READY READY also includes being prepared for setbacks and relapses back to old habits Plan for recovery from setbacks have a “Plan B” Remember, Setbacks are chances for learning how to do things better, Setbacks are not failures. READY - Staying Ready and Motivated When you make your goal, Dont Forget to Reward Yourself A reward provides an incentive to stay motivated. “After I do this, Ill.” Final word Diabetes is a complicated and confusing disease Working with and communicating with the team will help everyone work on the same issue together, including the patient What did you learn? What is diabetes and how does it impact health? What are healthy lifestyle choices for the person who has diabetes ? How would you use motivational interviewing with the person who has diabetes? How will what youve learned change the way you do your job? How will what youve learned change your life? References HIP CHA training, 2005 Miller, W.R. and Rollnick, S. Motivational Interviewing. New York: Guilford Press,2002 Botelho, R. 2002. Motivate Healthy Habits. Homework Assignment Think of another of your personal health improvement goals and fill out Handouts #1 to #5 and turn in next session: o Handout #1: Reasons for staying the same and changing o Handout #2: How important is change to me? Answer the question: How could I increase the strength of my reasons for changing and decrease those for staying the same? o Handout #3: How confident and able am I? o Handout #4: Answer the question: What could increase my confiden