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HEALTH AND WELLNESS 1/2013
HEALTH AND WELLNESS
CHAPTER IX
1
Chair of Nursing at the Faculty of Physiotherapy and Pedagogy
Higher School of Management and Administration in Zamosc
Katedra Pielęgniarstwa Wydziału Fizjoterapii i Pedagogiki
Wyższa Szkoła Zarządzania i Administracji w Zamościu
2
Independent Public Regional Hospital in Chelm
Department of Internal Medicine
Samodzielny Publiczny Szpital Wojewódzki w Chełmie
Oddział Chorób Wewnętrznych
3
Department of Obstetrics and Perinatology
Medical University of Lublin
Klinika Położnictwa i Perinatologii
Uniwersytet Medyczny w Lublinie
EWA KOSTRZEWA-ZABŁOCKA1, WOJCIECH KRAWCZYK2,
PIOTR RASZCZEPKIN2, MAGDALENA MICHALAK3
Educational role of the nurse in prevention
of late complications of type 2 diabetes as an example
of “Diabetes School” in Chelm
Rola edukacyjna pielęgniarki
w zapobieganiu późnym powikłaniom cukrzycy typu 2,
na przykładzie “Szkoły Cukrzycy” w Chełmie
INTRODUCTION
Diabetes mellitus is a disease that occurs among all human races, as well as
animals, on all continents and of every age. In latin - diabetes means "flow" and
mellitus means "sweet as honey". The term refers to people with untreated diabetes
who experienced excessive production of urine with high blood sugar content. In the
past diabetes was diagnosed by tasting whether the urine is sweet. The oldest
document of the diabetes existence where discovered in the Ebers papyrus from
1550 BC,
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found in Thebes in 1872. Before the invention of insulin, type 1 diabetes was a fatal
disease. In 1922 for the first time a patient was given insulin experimentally. Insulin
treatment was given in 1933 to 5 year-old boy from Sweden, who lived with the
disease the next 70 years. Since then, the insulin is a life-saving drug [7,10].
The essence of diabetes mellitus is the absolute or relative insulin deficiency
[10]. The disease is characterized by clinical signs such as glycosuria, high blood
glucose concentration, inadequate metabolism of carbohydrates, proteins and fats,
disturbed electrolyte hemostasis. Type 2 diabetes is also associated with obesity [3].
In Poland diabetes is a major cause of severe complications such as blindness,
kidney failure, limb amputation, as well as a significant risk factor for myocardial
infarction, ischemic heart disease, hypertension, stroke, diabetic foot syndrome and
congenital defects in newborns.
Diabetes is a major and growing problem of the modern world, affecting people
in every age in all countries around the world [12]. In recent years, the epidemic
increase in the prevalence and incidence of diabetes is emphasized, mainly due to
changes in the lifestyle, physical activity limitation, increased calories intake leading
to overweight and obesity.
Diabetes mellitus has been recognized by the United Nations as the XXI century
epidemic disease. The latest research shows, that in European countries diabetes
affects about 40% of people aged over 80 years.
Diabetes mellitus is a chronic, social disease, that can not be cured, however it is
possible to alleviate the symptoms and prevent late complications [6,7]. According
to the World Health Organization (WHO) and the International Diabetes Federation
(IDF), in 2010 around the world 285 million people suffer from diabetes, with an
increase of about 7 million diagnosed cases per year [11].
Diabetes is a major sociological problem because the treatment lasts a lifetime.
Appropriate treatment and discipline of the patient can maintain full efficiency and
quality of life. Due to chronic nature of the disease type 2 diabetes requires regular
medication, the use of proper diet, lifestyle changes by increasing physical activity,
maintaining blood glucose levels close to normal, treatment of hypertension and
cardiovascular disease. Proper treatment including also the maintenance of proper
weight and normal lipid levels [13.15]. Treatment of diabetes mellitus and
particularly its complications is very expensive, therefore education of the patient
and his family is very importatnt. In this case the nurse should play an important
role.
A patient who has knowledge about the disease, is more likely to take part in the
treatment. Educational activities are an important part of the nursing care. The nurse
should give the patients informations about diabetes, to prepare them to live with the
disease and to recommend how to prevent complications. These activities lead to a
return to an almost normal life [14].
The aim of the study was to demonstrate the role of the education carried out by
nurse and to present the impact of the "Diabetes School" on the prevention of the
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Ewa Kostrzewa-Zabłocka, Wojciech Krawczyk, Piotr Raszczepkin,
Magdalena Michalak
Educational role of the nurse in prevention of late complications
of type 2 diabetes as an example of “Diabetes School” in Chelm
diabetes mellitus late complications, based on example to determining the blood
concentration of glycated hemoglobin (HbA1c).
MATERIAL AND METHODS
The study was conducted in the Family Doctor Clinic "Health" in Chelm in the
period from October 2011 to June 2012. The study was conducted among 71
patients with diabetes. Before the test, patients were given a questionnaire
containing 13 questions. All patients were informed about the nature of the study
and agreed to participate in the study. Surveys were developed by doctors working
in the " Diabetes School ". Before the education cycle, the level of HbA1c was
examined in each patient. Only 40 patients completed the whole cycle of education.
In these patients HbA1C concentration was re-examined and only those was
considered for further analysis.
RESULTS
The survey involved 40 women and 31 men, aged 43-78 yaers. The most
numerous group was 60-70 years. Survey participants was details of their education.
Almost half of them (33 patients) had secondary education, 17 people - higher 13 vocational, and 8 people - primary. The majority of survey participants (46 patients)
were pensioners. Eleven patients were economically active and 2 were unemployed.
Fourteen people suffered from overweight, 12 - obesity I degree, 7 - II grade
obesity, obesity of III degree was diagnosed in 1 patient. Normal weight limits
imposed in only 6 patients
The analysis of these data shows that the weight of the examined patients are
significantly different from the rates specified for the Polish population. To precisely
define how big this difference is, reminesis difficult, but there is no doubt that the
percentage of those with normal weight in the group surveyed is much lower than
the rate resulting from national statistics. Although there is no precise data for the
Polish BMI, because data from different centers varies, in the group of participants
of "Diabetes School” only 8.5% of respondents had normal body weight. The WHO
data published in 2002, based on the research of 1996, shows that this rate for Polish
population is 45.6%. In 2000 Polish Food and Nutrition Institute has estimated that
obesity applies to 15.7% of men and 19.9% women, and overweight were found in
41% of men and 28.7% of women. One year later, POL MONICA study showed
that obesity relates to 28% of men and 29% women. The data from the Central
Statistical Office in 2004 in Lublin region showed that 12.6% of men and 12.5% of
women are obese, and 34% of women and 34% of men are overweight.
Survey participants gave information on how they are treated. Most take only
oral medication (65%), 6% are treated with insulin, oral drug combination therapy
with insulin - 17% and 3 persons stated that they are treated with diet alone.
Another question concerned the location of treatment. Respondents could indicate
several places. A lot of people in addition to the category of "only the family doctor"
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also indicated for treatment a diabetologist, endocrinologist, hematologist,
neurologist, gynecologist, allergist, urologist, orthopedic surgeon, gastroenterologist
Survey participants were asked about whether their family (father, mother,
brother, sister, grandmother, grandfather, children) were diabetics. The results were
split almost evenly, with a slight predominance of negative responses (38 people).
Another question concerned the diabetes complications. Replies indicates for 4
complications: retinopathy, nephropathy, diabetic neuropathy and diabetic foot.
Another question related to the other diseases, concomitant in surveyed patients.
Replies indicated for 3 diseases: hypertension, ischemic heart disease and
cerebrovascular disease (stroke, TIA). The question of self-control fingerstick blood
sugar levels, 63 patients answered in the affirmative. Respondents who carry out
self-control declared a frequency of measurement. Most of those performed tests 3
times a day or more. Beginner school participants were asked about previous
diabetes education meetings. The 47 patients answered affirmative.
In all surveyed patients HbA1c levels were examined.
According to the criteria developed by the Polish Diabetes Association (PTD) in
2013, based on data contained in the questionnaires (patient age, type of diabetes,
date of diagnosis), it was found that HbA1c levels were normal in 22 patients, and in
49 patients it was incorrect. Comparing the information on the HbA1c level with the
information about early participation in diabetes education, it can be concluded that
among people with normal HbA1c, the percentage of people participating in
educational activities was slightly higher (76%) than the rate of those with abnormal
HbA1c (63%).
After 9 months from the first determination of the HbA1C level, in the
participants who regularly attended and finished “Diabetes School” course, HbA1c
level was re-examined. As it is written in the "material and methods" the study was
considered completed in only 40 patients: 22 women and 18 men.
The number of people with HbA1c level classified as normal and abnormal before starting the program "Diabetes School" are presented in Table I and Fig. 1.
Table I. The number of pateints with normal and abnormal HbA1c level before
aducation
HbA1c level < 7% HbA1 level > 7%
11 people
29 people
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Ewa Kostrzewa-Zabłocka, Wojciech Krawczyk, Piotr Raszczepkin,
Magdalena Michalak
Educational role of the nurse in prevention of late complications
of type 2 diabetes as an example of “Diabetes School” in Chelm
30
25
20
HbA1c level < 7%
15
HbA1c level > 7%
10
5
0
Fig. 1
Table II and Fig. 2 shows the detailed distribution of the number of patients receiving different concentrations of HbA1c over 7%, before education
Table II. Number of patients in different groups of HbA1c level before
education
Number
of people
7,1% -8%
12
8,1% -9%
11
9,1% -10%
3
10,1% -11%
1
11,1% -12%
2
HbA1c level
12
10
HbA1C 7,1%-8%
8
HbA1C 8,1%-9%
6
HbA1C 9,1%-10%
4
HbA1C 10,1%-11%
2
HbA1C 11,1%-12%
0
Fig.2
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The results similar to those presented in Table I, after the education, shows Table
III and Fig. 3.
Table III. The number of pateints with normal and abnormal HbA1c level
after education
HbA1c < 7% HbA1c > 7%
15 people
25 people
30
25
20
HbA1c level < 7%
15
HbA1c level > 7%
10
5
0
Fig.3
Like Table II, Table IV and Fig. 4 shows the detailed distribution of the number
of patients receiving different concentrations of HbA1c over 7%, after education.
Table IV. Number of patients in different groups of HbA1c level after
education
Glycated
Number
hemoglobin level of people
7,1% -8%
13
8,1% 9%
10
9,1% -10%
2
10,1% -12%
0
11,1%-12%
0
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Ewa Kostrzewa-Zabłocka, Wojciech Krawczyk, Piotr Raszczepkin,
Magdalena Michalak
Educational role of the nurse in prevention of late complications
of type 2 diabetes as an example of “Diabetes School” in Chelm
14
12
10
HbA1C 7,1%-8%
8
HbA1C 8,1%-9%
6
HbA1C 9,1%-10%
HbA1C 10,1%-11%
4
HbA1C 11,1%-12%
2
0
Fig.4
The above data shows that the completing of full cycle of education lowers
HbA1c level. The results are not subjected to statistical verification, due to the small
size of the group.
DISCUSSION
The first "Diabetes School" was established in Sroda Wielkopolska in 2005 by
Doctor Andrzej Paciorkowski. The idea proved to be so good that the Polish
Diabetes Association with Zielona Gora Familly Doctors Agreement (organization
from 14 provinces - including Lublin) decided to spread the idea among the country.
The "School of Diabetes" was developed under the leadership of the Department of
Internal Medicine and Diabetology from Medical University of Poznań. The
program is coordinated by Doctor Andrzej Paciorkowski and President of the
Scientific Council Professor Bogna Wierusz - Wysocka. The motto of the program
is the idea formulated by Professor Elliot Proctor Joslin, american diabetologist:
"Patients with diabetes who know the most - live the longest."
The main objective of the program is to provide the patient with basic
information about diabetes, diabetes complications, methods of treatment,
informations about life style change, details of diet and the practical data about selfcontrol, insulin injections, pen handling etc [2]. Participants of the program are
patiens with diabetes, but also interested persons from the circle of relatives persons.
Activities carried out in the centers are charge free. The study will cover the
2500-3000 person from all the counrty and will last for three years. It is assumed to
repeat the next edition of "Diabetes School". Participants in the program at the
beginning and at the end of training fill an anonymous questionnaire. In people
surveyed weight, height, waist circumference, blood pressure were measured, and
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laboratory tests to check for metabolic control of diabetes and lipid profile were
performed. Lectures are conducted in cycles of 7-8 meetings. Topics of lectures
were determined centrally and include the following: general messages the of
diabetes, symptoms, treatment, prevention, acute and chronic complications.
Lectures are conducted by doctors, by oral and multimedia presentations.
Participants receive a printed summary of the lectures and take at the end of
course the test, for checking the acquired knowlege [4].
A very important role in education plays a nurse who is able to establish close
contact with the patient and his family. Patient diagnosed with diabetes is confused,
worried about his life and family. The disease causes a change of existing plans, and
sometimes a lifetime. The nurse who knows the patient can help him to lead an
almost normal life, and then, to alleviate the symptoms and the occurrence of
complications [1,5].
Nursing educational activities are dependent on the needs of the patient and
depend on the sex, age, the kind of job, the nature of treatment and complications.
The nurse must gain the trust of the patient in order to help to solve the current
problems, should present the arguments motivating him to self-care. The nurse
should pay attention to the psychological state of the patient, workplace and
conditions, social conditions, the degree of involvement of the family in the
treatment process [8]. The role of the nurse-educator is also to prepare the patient for
optimal treatment of diabetes and prevent metabolic complitacions [9].
A number of randomized trials indicates the effect of diabetes education in the
reduction of HbA1c leves in patients participating in training, compared with
patients who only were given advice during routine medical visits to a specialist.
Our observations confirm this thesis.
CONCLUSION
1. There is a strong need of the management of diabetes education.
2. The “Diabetes School” is a good example of an efficient organization of the
education.
3. Good diabetes education improves metabolic diabetes control, as exemplified by
HbA1c concentration.
4. A nurse plays a very important role in the diabetes education.
5. There is a necessity for professional training of nurses in diabetes education.
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Ewa Kostrzewa-Zabłocka, Wojciech Krawczyk, Piotr Raszczepkin,
Magdalena Michalak
Educational role of the nurse in prevention of late complications
of type 2 diabetes as an example of “Diabetes School” in Chelm
LITERATURE
1. Czech A.: Diabetes independent of insulin (type 2). What does this mean for
you?, Wyd. Servier, Warsaw 1994.
2. Day J.L.: How to live with diabetes?, Wyd. Via Medica, Gdańsk 1999.
3. DeWitt D.E., Hirsch I.B.: Outpatient insulin therapy In type1 and type 2 diabetes
mellitus scientific review. JAMA 2003.
4. Dodson P.M. i wsp.: Combined care in the treatment of diabetes, Wyd. Via
Medica, Gdańsk 1999.
5. Otto-Buczkowska E.: Type 1 diabetes, Wyd. Cornetis, Wrocław 2006.
6. Shaw K.M.: Complications of diabetes, Wyd. Via Medica, Gdańsk 1998.
7. Sieradzki J. : Practical Diabetology, Wyd. Via Medica 2010.
8. Ślusarska B. I wsp.: Basic Nursing, Volume 1, Wyd. Czelej, Lublin 2004.
9. Talarska D., Zozulińska-Ziółkiewicz D.: Nursing internist, Wyd. PZWL,
Warsaw 2009.
10. Tatoń J., Czech A.: Diabetology, vol 1-2, Wyd. PZWL, Warsaw 2001.
11. Tatoń J.: Clinical Diabetology, Wyd. PZWL, Warsaw 1986.
12. Tatoń J., Czech A., Berna M.:, Clinical Diabetology, Wyd. PZWL, Warsaw
2008.
13. Tatoń J., Czech A.: Diabetes self-management guide, Wyd. PZWL, Warsaw
2008.
14. Uchmanowicz I., Kubera-Jaroszewicz K.: Diabetes Education. Standards of
nursing care for patients with diabetes. Wyd. Continuo, Wrocław 2012.
15. Wright A., Burden A.C. i wsp.: Sulfonylurea inadequacy: efficacy of insulin
over 6 years in patients with type 2 diabetes in the UK Prospective Diabetes
Study (UKPDS 57). Diabetes Care 2002.
ABSTRACT
An importatnt role in the modern treatment of diabetes plays patients education,
including giving the information about diabetes and the development of appropriate
behaviors and skills. The educational program "School of diabetes" is a good
example of efficient organization of educational activities. An educated nurse plays
a very important role in the efficient proceeding of education. Professionally
conducted education not only improves the psycho-emotional condition of patients,
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the degree of independence, effectiveness of treatment, but also improves the
metabolic control of diabetes, as exemplified by the improvement of HbA1c level.
STRESZCZENIE
We współczesnym leczeniu cukrzycy olbrzymią rolę ogrywa edukacja chorych,
obejmująca przekazywanie wiadomości o cukrzycy oraz kształtowanie
odpowiednich zachowań i umiejętności. Program edukacyjny „Szkoła cukrzycy”
jest dobrym przykładem sprawnej organizacji działań edukacyjnych. Bardzo ważną
rolę w sprawnym prowadzeniu edukacji odgrywa wykształcona pielęgniarka.
Profesjonalnie prowadzona edukacja nie tylko poprawia psychoemocjonalny stan
chorych, stopień samodzielności, skuteczność leczenia, ale również poprawia
stopień metabolicznego wyrównania cukrzycy, czego przykładem może być
poprawa stężenia HbA1c.
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