慢性疾病的家庭疗法 Home Care Chronic Disease Prevention Program.ppt

homecarechronicdiseasepreventionprogram,melanies.bunnrn,msacollaborationofdukeuniversity,divisionofcommunityhealthanduniversityofsouthcarolina,schoolofmedicine,homeworkreview,whatdidyoudo?whathappenedasyoudidthat?whydoyouthinkthathappened?hereswhatmighthavehappened.howdoesthisimpactthenexttimeyoutrythis?,chronicdiseasemanagement,module1:health/illness,vitalsigns,exercise,nutritionmodule2:motivationalinterviewingmodule3:endoflifemodule4:heartattackmodule5:copdmodule6:strokemodule7:hypertensionmodule8:diabetesmodule9:congestiveheartfailure,objectives,definediabetesandtheimpactofdiabetesonhealthdescribehealthylifestylechoicesforthepersonwithdiabetesdemonstrateuseofmotivationalinterviewingwiththepersonwithdiabetes,diabetes,diabetes:thenumbers,aboutsevenpercentofamericanshavediabetessixthleadingcauseofdeathintheus,diabetes:whatisit?,insulinisahormonethathelpsthebodytoprocess“sugars”intoenergydiabetesisadiseaseinwhichthebodydoesnotuseitsinsulinproperlyoritdoesnotproduceenoughinsulintheresultiselevatedbloodsugarlevels,symptomsandsigns,extremethirstextremehungerweightlossfrequenturinationvisionchangesrecurrentinfections,diagnosis,fastingbloodsugargreaterthan126tworandombloodsugarsgreaterthan200afterfastinganddrinking75gramsofsugar,twohourpost-prandialbloodsugargreaterthan200,typesofdiabetes,typei-thebodydoesnotproduceinsulin;presentfrombirth(geneticdefect)typeii-thebodydoesnotuseitsowninsulinproperly-called“insulinresistance”;mayleadtotypei;startswellafterbirth,usuallyinadultyearsgestationaldiabetes-occursduringpregnancy,somewomengoontodeveloptypeiidiabetes,typeiidiabetes,mostcommonformofdiabetesinsulinresistanceonsetoccursusuallyinadultyears,riskfactorsfortypeiidiabetes,overweightfamilyhistorypriorhistoryofgestationaldiabetesafricanamericanrace,treatment,injectableinsulinshortactingmediumactinglongactingoralmedicationsincreaseinsulinsecretionincreaseinsulinsensitivity,insulin,rapidacting(humalogandnovolog)shortacting(regular)intermediateacting(nph)longacting(lantus)24hoursmixes-combinationsoftheabove,insulin,keepunopenedbottlesintherefrigeratorinsulinwillstayfreshforonemonthwithoutrefrigeration(under86f)checkinsulinbeforeusingitshortactingandglargineareclearintermediateandlongactingarecloudyifclumpsarevisible,throwthebottleaway,testingbloodglucose,helpsassesshowwellbloodglucoselevelsarebeingcontrolledhelpsguidechangesinmedicationsveryimportantifinsulinisbeingusedshouldbetestedifhypoglycemia(lowbloodglucose)issuspectedtestingtimesvary,typicallytwotofourtimesaday,testingbloodglucose,beforemeals:90-130onetotwohoursaftermeals:lessthan180testasprescribedbythedoctor-usuallyfastingmorning,beforemealsandatbedtime,hypoglycemia“lowbloodsugar”,occurswhenbloodglucosedropstoolowformostpeoplethisislessthan70canbelifethreatening*symptomsmayincludenausea,dizziness,sweatingkeepasourceofglucosereadilyavailable-twoglucosetablets,onecupofmilk,halfcupofjuiceretestafter15minutescarryglucosetabletswhenexercising,hemoglobina1c,testedwithbloodsamplethreemonthaverageofbloodglucosereadingsguidesdecisionsabouttreatmentkeeptrackofyourvaluesnormalis4-6%forsomeonewhoisnon-diabeticgoalisascloseto6%aspossible,nonpharmacologicaltreatment,diet/nutritionexerciseweightloss,nutrition,whatapersonwithdiabeteseatsisveryimportantitsmorethanjustnoteatingsugar,glycemicindex,ratingsystembasedonhowfastthefoodraisesbloodglucosetwohoursaftereatingreferenceiswhitebread=100thehighertheglycemicindex,thefasterthefoodraisesthebloodglucose.thefasterthebloodglucoserises,themorequicklyinsulinisreleased.,glycemicindex,indiabetics,becauseoftheinsulinresistance,thebodydoesntrespondaswellsoglucoselevelsstayhighlongerthannormallowerisbetterwhenitcomestoglycemicindex,examples,highglycemicindexwhiterice,whitebread,potatomoderateglycemicindexryebread,macaroniandcheeselowglycemicindexbanana,milk,grapes,brownrice,diabeticdiet,keepingbloodglucosesinthenormalrangedecreasesthelikelihoodofcomplications,diabeticdiet,morethatjustnoteatingsugareatingtherightfoodsattherighttimesintherightamounts,diabeticdiet,1500-2000caloriedietformostmenandwomen40-60%ofcaloriesfromcarbohydrates20%ofcaloriesfromproteinlessthan30%ofcaloriesfromfat,diabeticdiet,eachmeal60gramsofcarbohydrates;fruits,vegetables,dairy,starchsugarsubstituteslowfat,lowcholesteroleatatthesametimeeachdayeatstructuredmeals,exercise,alwayswarmupandcooldownforabouttenminutescheckbloodsugarbeforeandimmediatelyafterexercisedonotexerciseifbloodsugarisgreaterthan250andeatasmallsnackiflessthan100drinktwocupsofwaterbeforeandafterexercise,controlweight,withgoodnutritionalchoicesandincreasingactivity,thissoundslikealotofworkisitworthit?,yes!,commoncomplications,blindnessduetobleedingbloodvesselsintheeyekidneyfailurewhichleadstodialysisstrokeheartattacknumbness(neuropathy),commoncomplications,gum/teethdiseasesfootproblemsinfectionspotentialamputation,treatment,healthydietexerciseweightlossmedicationstolowerbloodsugarmedicationstolowerbloodpressuremedicationstolowercholesterolmedicationstoprotectthekidneyscheckyourfeeteachday,followupwithyourdoctor,aspirinfordiabeticsovertheageof40badcholesterol(ldl)goallessthan100examinationbyophthalmologyyearlyhba1ceverythreemonthsurinecheckedforproteineachyearfootcheckeverythreemonthspneumococcalvaccinationbloodpressuregoallessthan130/80,whoshouldbescreened?,personswithhypertensionpersonswithhyperlipidemiaothersatdiscretionofphysician,warningsymptoms,historyofanillness/infectionnauseasweatingvomitingfootulcers,warningsigns*,bloodsugarlessthan70bloodsugargreaterthan300increasedheartrateincreasedrespiratoryratefootulcers*allvitalparametersaredeterminedbyrnsupervisorandarepatientspecific,otherwarnings,nottakingmedications,references,neal,lj.&guillett,se.careoftheadultwithachronicillnessordisability.mosby,st.louis,missouri,2004.pp286-294.kennedymalone,l.etal.managementguidelinesforgerontologicalnursepractitioners.f.a.daviscompany,philadelphia,pa,2000.pp369-376.lippincott,williamsandwilkins.managingchronicdisorders.lippincottwilliamsandwilkins,usa,2006.pp127-132.//home.jsp,casestudy,68yearoldobesemaletellsyouhehashaddiabetesfor15yearshetellsyouthathisdoctorisworriedabouthiseyesandhiskidneyshealsotellsyouthathisdoctorthinksthathedoesnoteatwellandeatstoomanysweets.,casestudy,hetellsyouthatheforgetstotakehismedicationsfordiabetesmostofthetimebutgoesontotellyouthathedoesnotreallythinkthattheyareimportanthetellsyou,“idontevenunderstandhowtheycantellifmybloodsugarsareundercontrolornot.”,casestudy,whileyouaretalkingwithhim,heopensupaboxandbeginstoeatthelargepieceofchocolatecakethatisinsidetheboxhetellsyouthathisfatherhaddiabetesandwentondialysisbecausehiskidneysfailed,casestudy,whatworriesyouabouthisbehavior?whatarehisriskfactorsfordiabetes?,casestudy,whatworriesyouabouthisbehavior?hisdiet-i.e.chocolatecakenottakinghismedicationsdoesntseemtobeconcernedwhatarehisriskfactorsfordiabetes?obesityfamilyhistoryeatinghabits,casestudy,whatarepossiblecomplicationsofdiabetes?,casestudy,whatarepossiblecomplicationsofdiabetes?kidneyfailureblindnessheartattackstrokeneuropathy(nervedamage),casestudy,whattypesoflifestylemeasureswouldbeappropriateforhim?,casestudy,whattypesoflifestylemeasureswouldbeappropriateforhim?diabeticdietlowinsugars,fats,cholesterol,sodiumexercisetakingmedicationsasprescribedbyhisphysician,casestudy,hewantstoknowhowhisbloodglucoseismonitored,canyouexplainthattohim?whattestisusedtofollowbloodglucose?whatisthenormalrangeforbloodglucoselevels?,motivationalinterviewing,howdoyouasthenurseaidemotivatehimtofollowdietaryguidelinesfordiabetics?nowthatyouvegainedhistrustyoucanstartaskingquestionsthatwillbeginthechangetalk.,startingthechangetalk,whatquestionscanweaskthatcouldstarthimthinkingaboutimprovinghisdiet?tellmeaboutyourdiet?whatdoyouthinkaboutyourdiet?,willing,able,ready,inthenextfewslides,putyourselfinthisclientsshoes.trytowritedownanswerstothequestionsfromhispointofview.,findouthowwillingheistochange,askopenendedquestionssohecan:statehisreasonsfornoteatinghealthystatethereasonshehasforeatinghealthyhavehimwritedownhisanswerstothefollowingquestions,whatarehisreasonsfornoteatinghealthy?2goodquestionstoask,explorehisreasonsfully,askhimhowkeepingunhealthyeatinghabitscouldbegoodforanyoftheseaspectsofhislife:healthlifestyleemotionsrelationshipscopingabilities(stress,forexample)worksociallifespirituallife,herearesomesamplereasonsforcontinuingtohaveanunhealthydiet,next,whatreasonsdoeshehaveforeatingahealthierdiet?,explorehisreasonsfully,askhimhoweatinghealthiercouldbegoodforanyoftheseaspectsofhislife:healthlifestyleemotionsrelationshipscopingabilities(stress,forexample)worksociallifespirituallife,herearesomesamplereasonsforeatinghealthier,next,howimportantisitforhimtochange?,askhimtocomparehisreasonsfornotchangingwithhisreasonsforchanginghavehimassignanumbertotherulerofchangeinthenextslide.thiswillshowhowimportantitisforhimtochange,howimportantisitforyoutochange?,onascaleof0to10,howimportantisittoyoutohavehealthyeatinghabits?the“rulerofchange”,willing,thisnumberontherulerofchangewillshowhowwillingheistochangeitwillshowhowwillingheistostarteatingahealthierdiet,willing(continued),ifhisrulerofchangenumberisbelow3or4:heisnotwillingtoconsiderchange.hehaslotsofresistancetochangehisreasonsforcontinuingtohaveunhealthyeatinghabitsarestongerthanhisreasonsforeatinghealthy.,samplequestiontohelpdecreaseresistance,whatwouldhavetochangetodecreasetheimportanceyougivetoyourreasonsforhavingpooreatinghabits?,questionstodecreaseresistance,alownumberontherulerofchangesayshedoesnotthinkthateatinghealthyisimportantandhedoesnotwanttochangebut,lookathisnumberontherulerofchangeifhesnotatzero,hemusthaveatleastasmallinterestinchange.,decreasingresistance,ifthisisthecase,ask:whyareyouat_andnotzero?whatwouldittakeforyoutogofrom_to_?hisanswersmightgethimtostartthinkingthatchangemightbeagoodthing,willing(continued),ifthenumbertheclientgivesfortheimportanceofchangingisaround5:heis“onthefence.”heissplitbetweenwantingtotakeactionandnotbeingabletotakethefirststep.inthiscondition,hecantchange.,samplequestiontohelpincreasemotivation,whatwouldhavetochangetoincreasetheimportanceofyourreasonsforhavinghealthiereatinghabits?,willing(continued),ifthenumberhegivesfortheimportanceofchangeisgreaterthan6or7:heisnotresistanttochangeheisnot“onthefence”heisreadytotakesomeaction,next,findoutifheisable,measurehisconfidenceandabilitytohaveahealthierdietusetheconfidenceandability“rulersofchange”inthenextslide,assessingconfidenceandabilitytomakeachange,scoreyourconfidencetohaveahealthierdiet.scoreyourabilitytohaveahealthierdiet.,forscoresofabout6andbelow,ask,“whatwouldittaketoincreaseyourconfidencetohaveahealthierdiet?”whatencouragesyoutobelievethatyoucanachieveyourgoalsforchange?ask,“whatwouldittaketoincreaseyourabilitytohaveahealthierdiet?”,increasingconfidenceandabilityaboutchange,otherquestionstoask”whatelsecouldhelpyouhavehealthiereatinghabits?whoelsecouldhelpyouhavehealthiereatinghabits?adaptedfrommillerandrollnick,motivationalinterviewing,2002,forlowconfidenceandabilityscores,maybethegoalisnotrealistic,itexceedshisconfidenceandability.ask:whatwouldhappenifyoureducedthesizeofyourgoal?whatwouldyoubewillingtotry?maybeifyoureducedyourgoalforchanging,youwouldbemorelikelytotry.,roleofthenurseaide,findoutwhatisimportanttotheclientandusethistomotivatehim/hertochangehelptheclientidentifyanactivitythathe/shehastheabilityandconfidencetoachieve,thenextstep:beingready,ifheswilling(importancescore5andabove)ifhesable(confidenceandabilityscoresare5andabove)thenhesready,beingreadymeans:,beingreadytosetagoalandmakeaplankeepingtrackofprogresstowardthegoalbeingpreparedforsetbackswiththerightattitudeandaplan“b”,classexercisegoalsetting,putyourselfintheshoesofthediabeticclientwhodoesnothavehealthyeatinghabitsusingyourcurrentgoalsettingskills,writeagoalforeatingahealthierdietonthenextslide,usingyourownwordswritedownagoalandplanforhealthyeatingthegoal/planshouldbefromtheviewpointofthecasestudysdiabeticclient,settingandplanningagoalsmartmethod,ausefulmethodforsettinggoals,smart.tobeeffective,goalsneedtobe:specificmeasurableactionorientedrealistictime,smartmethodsomeexamples,agoalthatisnotsmartwillprobablyfail.“iamgoingtostopeatingchocolatecake.”,setandplanagoalsmartmethodsomeexamples(continued),asmartgoalwouldbe,“iwillletmykitchensupplyofsnackswithaddedsugarrunoutandreplacethemwithfruitsovera4weekperiod.atthesametimeiwillreducethesugarysnacksieatatworkbyone-half.in4moreweeksiwillreplacesugarsnacksatworkwithfruitthatibringin.iwillsatisfymysweettoothonlyatmychurchsocialswhereiwillkeepmyportionsizesthesizeofafist.”,setandplanagoalsmartmethod,nowusethesmartmethodtorewritetheactivityyouchosetosupporttheclientsgoalforhavinghealthiereatinghabitswriteonthenextslidethissmartgoalfromtheviewpointofthediabeticclientinthecasestudy,whatisyoursmartgoal?,smart,ready,readyalsoincludestrackingprogressinawrittenlogoronacalendarseeingconcreteprogresshelpsbuildconfidenceaddingcommentscanalsoidentifywhathelped,whatwasdifficult,whatyoulearned,howyoucangetbetter,progresscheck(sample),mygoalwas_iwas_successfulinreachingmygoalwhathelped_wasdifficultilearnedthat_adaptedfromhipchatraining,2005,ready,readyalsoincludesbeingpreparedforsetbacksandrelapsesbacktooldhabitsplanforrecoveryfromsetbackshavea“planb”remember,setbacksarechancesforlearninghowtodothingsbetter,setbacksarenotfailures.,ready-stayingreadyandmotivated,whenyoumakeyourgoal,dontforgettorewardyourselfarewardprovidesanincentivetostaymotivated.“afteridothis,ill.”,finalword,diabetesisacomplicatedandconfusingdiseaseworkingwithandcommunicatingwiththeteamwillhelpeveryoneworkonthesameissuetogether,includingthepatient,whatdidyoulearn?,whatisdiabetesandhowdoesitimpacthealth?whatarehealthylifestylechoicesforthepersonwhohasdiabetes?howwouldyouusemotivationalinterviewingwiththepersonwhohasdiab