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

Home Care Chronic DiseasePrevention Program,Melanie S.Bunn RN,MSA 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,NutritionModule 2:Motivational InterviewingModule 3:End of LifeModule 4:Heart AttackModule 5:COPDModule 6:StrokeModule 7:HypertensionModule 8:DiabetesModule 9:Congestive Heart Failure,Objectives,Define diabetes and the impact of diabetes on healthDescribe healthy lifestyle choices for the person with diabetesDemonstrate use of motivational interviewing with the person with diabetes,Diabetes,Diabetes:The numbers,About seven percent of Americans have diabetesSixth leading cause of death in the US,Diabetes:What is it?,Insulin is a hormone that helps the body to process“sugars”into energyDiabetes is a disease in which the body does not use its insulin properly or it does not produce enough insulinThe result is elevated blood sugar levels,Symptoms and signs,Extreme thirstExtreme hungerWeight lossFrequent urinationVision changesRecurrent infections,Diagnosis,Fasting blood sugar greater than 126Two random blood sugars greater than 200After 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 yearsGestational diabetes-Occurs during pregnancy,some women go on to develop type II diabetes,Type II diabetes,Most common form of diabetesInsulin resistanceOnset occurs usually in adult years,Risk factors for type II diabetes,OverweightFamily historyPrior history of gestational diabetesAfrican American race,Treatment,Injectable insulinShort actingMedium actingLong actingOral medicationsIncrease insulin secretionIncrease insulin sensitivity,Insulin,Rapid acting(Humalog and Novolog)Short acting(Regular)Intermediate acting(NPH)Long acting(Lantus)24 hoursMixes-combinations of the above,Insulin,Keep unopened bottles in the refrigeratorInsulin will stay fresh for one month without refrigeration(under 86 F)Check insulin before using itShort acting and glargine are clearIntermediate and long acting are cloudyIf clumps are visible,throw the bottle away,Testing blood glucose,Helps assess how well blood glucose levels are being controlledHelps guide changes in medicationsVery important if insulin is being usedShould be tested if hypoglycemia(low blood glucose)is suspectedTesting times vary,typically two to four times a day,Testing blood glucose,Before meals:90-130One to two hours after meals:less than 180Test as prescribed by the doctor-usually fasting morning,before meals and at bedtime,Hypoglycemia“low blood sugar”,Occurs when blood glucose drops too lowFor most people this is less than 70Can be life threatening*Symptoms may include nausea,dizziness,sweatingKeep a source of glucose readily available-two glucose tablets,one cup of milk,half cup of juiceRetest after 15 minutesCarry glucose tablets when exercising,Hemoglobin A1C,Tested with blood sampleThree month average of blood glucose readingsGuides decisions about treatmentKeep track of your valuesNormal is 4-6%for someone who is non-diabeticGoal is as close to 6%as possible,Non pharmacological treatment,Diet/nutritionExerciseWeight loss,Nutrition,What a person with diabetes eats is very importantIts more than just not eating SUGAR,Glycemic index,Rating system based on how fast the food raises blood glucose two hours after eatingReference is white bread=100The 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,potatoModerate glycemic index Rye bread,macaroni and cheeseLow 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 sugarEating the right foodsAt the right times In the right amounts,Diabetic diet,1500-2000 calorie diet for most men and women40-60%of calories from carbohydrates20%of calories from proteinLess than 30%of calories from fat,Diabetic diet,Each meal 60 grams of carbohydrates;Fruits,vegetables,dairy,starchSugar substitutesLow fat,low cholesterolEat at the same time each dayEat structured meals,Exercise,Always warm up and cool down for about ten minutesCheck blood sugar before and immediately after exerciseDo not exercise if blood sugar is greater than 250 and eat a small snack if less than 100Drink two cups of water before and after exercise,Control weight,With good nutritional choicesAnd increasing activity,This sounds like a LOT of WORKis it worth it?,YES!,Common complications,Blindness due to bleeding blood vessels in the eyeKidney failure which leads to dialysisStroke Heart attackNumbness(neuropathy),Common complications,Gum/teeth diseasesFoot problemsInfectionsPotential amputation,Treatment,Healthy dietExerciseWeight lossMedications to lower blood sugarMedications to lower blood pressureMedications to lower cholesterolMedications to protect the kidneysCheck your feet each day,Follow up with your doctor,Aspirin for diabetics over the age of 40Bad cholesterol(LDL)goal less than 100Examination by ophthalmology yearlyHbA1c every three monthsUrine checked for protein each yearFoot check every three monthsPneumococcal vaccinationBlood pressure goal less than 130/80,Who should be screened?,Persons with hypertensionPersons with hyperlipidemiaOthers at discretion of physician,Warning symptoms,History of an illness/infectionNauseaSweatingVomitingFoot ulcers,Warning signs*,Blood sugar less than 70Blood sugar greater than 300Increased heart rateIncreased respiratory rateFoot ulcers*ALL vital parameters are determined by RN supervisor and are patient specific,Other warnings,Not taking medications,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.orghttp:/www.diabetes.org/home.jsp,Case study,68 year old obese maleTells you he has had diabetes for 15 yearsHe tells you that his doctor is worried about his eyes and his kidneysHe also tells you that his doctor thinks that he does not eat well and eats too many sweets.,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 importantHe tells you,“I dont even understand how they can tell if my blood sugars are under control or not.”,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 boxHe tells you that his father had diabetes and went on dialysis because his kidneys failed,Case study,What worries you about his behavior?What are his risk factors for diabetes?,Case study,What worries you about his behavior?His diet-i.e.chocolate cakeNot taking his medicationsDoesnt seem to be concernedWhat are his risk factors for diabetes?ObesityFamily historyEating habits,Case study,What are possible complications of diabetes?,Case study,What are possible complications of diabetes?Kidney failureBlindnessHeart attackStrokeNeuropathy(nerve damage),Case study,What types of lifestyle measures would be appropriate for him?,Case study,What types of lifestyle measures would be appropriate for him?Diabetic diet low in sugars,fats,cholesterol,sodiumExerciseTaking medications as prescribed by his physician,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?,Motivational interviewing,How do you as the Nurse Aide motivate him to follow dietary guidelines for diabetics?Now that youve gained his trust you can start asking questions that will begin the change talk.,Starting the Change Talk,What questions can we ask that could start him thinking about improving his diet?Tell me about your diet?What do you think about your diet?,WILLING,ABLE,READY,In the next few slides,put yourself in this clients shoes.Try to write down answers to the questions from his point of view.,Find Out How WILLING He is to Change,Ask open ended questions so he can:State his reasons for not eating healthy State the reasons he has for eating healthyHave him write down his answers to the following questions,What are His Reasons for Not Eating Healthy?2 Good Questions to Ask,Explore His Reasons Fully,Ask him how keeping unhealthy eating habits could be good for any of these aspects of his life:HealthLifestyleEmotionsRelationshipsCoping abilities(stress,for example)WorkSocial lifeSpiritual life,Here are Some Sample Reasons for Continuing to Have an Unhealthy Diet,Next,What Reasons Does He Have for Eating a Healthier Diet?,Explore His Reasons Fully,Ask him how eating healthier could be good for any of these aspects of his life:HealthLifestyleEmotionsRelationshipsCoping abilities(stress,for example)WorkSocial lifeSpiritual life,Here are Some Sample Reasons for Eating Healthier,Next,How Important is It for Him to Change?,Ask him to compare his reasons for not changing with his reasons for changingHave 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”,WILLING,This number on the Ruler of Change will show how WILLING he is to changeIt 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:He is not willing to consider change.He has lots of resistance to changeHis 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 changeBut,look at his number on the Ruler of ChangeIf hes not at zero,he must have at least a small interest in change.,Decreasing Resistance,If this is the case,Ask:Why are you at _ and not zero?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:He is“on the fence.”He is split between wanting to take action and not being able to take the first step.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:He is not resistant to changeHe is not“on the fence”He is ready to take some action,Next,Find out if He is ABLE,Measure his Confidence and Ability to have a healthier dietUse 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.,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:What would happen if you reduced the size of your goal?What would you be willing to try?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 changeHelp 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 planKeeping track of progress toward the goalBeing 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 habitsUsing 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 EatingThe 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:SpecificMeasurableAction orientedRealisticTime,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 habitsWrite 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 calendarSeeing concrete progress helps build confidenceAdding comments can also identify what helped,what was difficult,what you learne