Download rajiv gandhi university of health sciences

BANGALORE – KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
BELSIE J
1St year M.Sc (Nursing)
MASTER IN MEDICAL-SURGICAL NURSING
YEAR 2009-2010
CAUVERY COLLEGE OF NURSING
# 42/2B, 2C, TERESIAN CIRCLE
SIDDARTHA LAYOUT
MYSORE.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE
BANGALORE - KARNATAKA
ANNEXURE – I
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1
NAME OF THE
CANDIDATE AND
ADDRESS
Mrs. BELSIE
I st YEAR M.Sc. NURSING,
CAUVERY COLLEGE OF NURSING,
SUBASH NAGAR,
MYSORE – 570007.
2
NAME OF THE
INSTITUTION
CAUVERY COLLEGE OF NURSING,
MYSORE – 570007.
3
COURSE OF
STUDY AND
SUBJECT
DATE OF
ADMISSION TO
THE COURSE
TITLE OF THE
STUDY
MASTER IN NURSING
MEDICAL-SURGICAL NURSING
4
5.1
15-06-2009
“EFFECTIVENESS OF PLANNED TEACHING
PROGRAM ON DIABETIC MANAGEMENT IN
TERMS OF KNOWLEDGE AND PRACTICE”.
5.2
STATEMENT OF
THE PROBLEM
A STUDY TO ASSESS THE EFFECTIVENESS
OF
PLANNED
DIABETIC
TEACHING
MANAGEMENT
KNOWLEDGE
AND
PROGRAM
IN
TERMS
PRACTICE
ON
OF
AMONG
PATIENTS WITH DIABETES MELLITUS IN
SELECTED HOSPITAL AT MYSORE.
-2-
6. BRIEF RESUME OF THE INTENDED WORK
6.1 - INTRODUCTION
Diabetes mellitus poses a wide range of problems for patients and their family
members. These problems include pain, hospitalization, change in the lifestyle
and vocation, physical disability and threatened survival. Direct psychological
consequence can arise from any one of the factors, making it harder for patients
to treat their diabetes and live productive enjoyable lives (Joy M. Block, 1997).
Expert committee on the Diagnosis and classification of Diabetes Mellitus
(1998) Diabetes mellitus is the group of metabolic disorder characterized by
elevated blood level of glucose in blood (Hyperglycemia) resulting from defects in
insulin secretion, insulin action or both.
Patients with insulin dependent diabetes mellitus diagnosed before age five
and older patients with Non-insulin dependent diabetes mellitus may have
associated alteration in cognitive or intellectual functioning. The pathophysiology of those cognitive changes is not well understood in the young
patients those cognitive changes may be linked to recurring episodes of severe
hypoglycemia. In the older patients both micro vascular and atherosclerosis
disease are possible factors for complication.
The Centre for disease Control and Prevention (2003): There are
currently more than 194 million people with Diabetes Mellitus world wide. If
nothing is done to growth epidemic the number will exceed 300 million by the
year 2025.
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National Institute of Diabetes mellitus & Kidney disease (2003):
Diabetes Mellitus is the fifth leading cause of deaths in United State killing
150,000/Year. Prevalence of Diabetes Mellitus among the people aged 70 years
18 million, aged 60 years 8.6 million, men 8.7 million and women 4.3 million. In
2003 the five countries which the largest number of persons with Diabetes
Mellitus where India (35.5 Million), China (23.5), United State
(16 Million),
Russia (9.7 Million) and Japan (6.7 Million). 50% of peoples are unaware about
their conditions.
The World Health Organization (WHO) estimated that by the year 2025
India alone would have 60 Million people with Diabetes Mellitus. India is
alarming, every fifth individual with Diabetes Mellitus.
National Institute of Diabetes mellitus & Kidney disease (2003):
Diabetes Mellitus occurs in the age group most likely at 40 in India when
compared to the other countries where it develops only at 50 – 60 Years at age.
The most common form of Diabetes in Type – 2 about 90 – 93% of people Type 2
Diabetes Mellitus. Old age, Obesity, family history of Diabetes Mellitus, previous
history of gestational Diabetes mellitus, and Physical inactivity and hereditary
about 80% of people with type 2 Diabetes mellitus, one over weight.
6.2-NEED FOR THE STUDY
In 2000, according to the World Health Organization (WHO), at least
171 million people worldwide suffer from diabetes. Its incidence increasing
rapidly and it is estimated that by the year 2030 this number will be double.
Diabetes mellitus occurs throughout the world, but is more common
-4-
(Especially type 2) in the more developed countries. The greatest increase in
prevalence is, however expected to occur in Asia and Africa where most
patients likely be found by 2030. The increase in incidence of diabetes in
developing countries follows the trend of urbanization and lifestyle changes,
perhaps most importantly a “Western style” diet. This has suggested
environmental effects, but there is little understanding of the mechanism at
present through there is much speculation, some of it most compellingly
presented. It is well known that the prevalence of Diabetes mellitus is more in
India.
Dietary management is an essential component of management of both
Type 1 and 2 diabetes mellitus. Approximately 30% people with diabetes
(Type2) are treated with dietary measures only. Meal planning is intended to
ensure a reasonably consistent food intake and a nutritionally adequate diet.
(Joyce M. Block (1997).
Diabetes mellitus is a serious health problem throughout the world. In
the United States an estimated 17 million people, or 6.2% of the population,
have diabetes. About one third of the people with diabetes mellitus are not
diagnosed, and these individuals are unaware that they have the disease.
Diabetes mellitus is the fifth leading cause of death in the United States, with
210,000 deaths annually. Nearly 29% of people over age 65 years have
diabetes. The incidence of diabetes is expected to increase 165% in the next
years. (Lewis 2004)
The most important tool in the management of diabetes after diet and
medication is regular exercise. Exercise for diabetics should be light and
proportional to their fitness. Regular exercise also helps to prevent weight
-5-
gain and plays a part in increasing personal well by reducing stress, Anxiety
and depression. Dr. Neelam Makol, Dr. A.M. Elizabeth (2005)
By 2010 three million people could be living with diabetes, and the
majority of them, will have Type2. More than 10,000 people are diagnosed
with Type2 diabetes in UK annually. This is due to in part to the rising
number of obese and over weight people and on going population. (Gwan hall
2006)
6.3 - STATEMENT OF THE PROBLEM:
“A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED
TEACHING PROGRAM ON DIABETIC MANAGEMENT IN TERMS OF
KNOWLEDGE AND PRACTICE AMONG PATIENTS WITH DIABETES
MELLITUS IN SELECTED HOSPITAL AT MYSORE”.
6.4 - OBJECTIVES OF THE STUDY:
 To assess the knowledge and practice regarding diabetic management
among the patients with diabetes mellitus.
 To evaluate the effectiveness of planned teaching program on diabetic
management.
 To find out the relationship between knowledge and practice with their
selected
demographic
variables
such
as
age,
sex,
education,
occupation, income, duration of illness, type of treatment.
 To determine the association between knowledge and practice score
with the selected demographic variables such as age, sex, education,
occupation, income, duration of illness, type of treatment.
-6-
6.5 - HYPOTHESIS:
 There will be a significant difference between pre test and post test
knowledge and practice scores regarding diabetic management among
patients with Diabetes mellitus.
 There will be a significant relationship between knowledge and practice
of patients with diabetes mellitus on diabetic management
 There will be significant association between pre test knowledge and
practice scores on diabetic management
and selected demographic
variables such as age, sex, education, occupation, income, type of
diabetes mellitus, duration of illness, type of treatment.
 There will be significant association between post test knowledge and
practice scores on diabetic management
and selected demographic
variables such as age, sex, education, occupation, income, type of
diabetes mellitus, duration of illness, type of treatment.
6.6 - OPERATIONAL DEFINITIONS:
 Effectiveness
It is the outcome measures of an action through planned
teaching program regarding diabetic management gained by the
patients with diabetes mellitus.
-7-
 Knowledge
Knowledge is defined as a verbal response about management of
Diabetes Mellitus. It is measured by structured interview questionnaire.
 Practice
It is an action or behavior gained by training on follow up, dietary
management, self glucose monitoring, exercise and self insulin
administration. It is measured by structured practice questionnaire
 Planned Teaching Program
It is systematic information given to patients with type-II diabetes
mellitus
regarding
dietary
management,
exercise,
self
glucose
monitoring, insulin therapy and prevention of complications.
 Diabetes mellitus
Diabetes mellitus is the group of metabolic disorder characterized
by elevated blood glucose level (Hyperglycemia) resulting from defects
in insulin secretion, insulin action or both. Hereafter Diabetes mellitus
is referred as DM.
 Patient with Diabetes Mellitus
Patients who are diagnosed to have type-II diabetes mellitus by
the diabetologist
6.7 - ASSUMPTION:
● The diabetic patients may have some knowledge regarding diabetic
managements.
● Planned teaching program helps to improve knowledge and practice
on diabetic management.
-8-
 Nurses can play a major role in educating the diabetic patients
6.8 - DELIMITATIONS:
o The study is limited to conduct in selected hospital, Mysore.
o The study is limited to the patients with type II diabetes mellitus .
o The sample size is limited to 60 Sample.
6.9 –CONCEPTIONAL FRAMEWORK
“HEALTH PROMOTION MODEL”
6.10 - REVIEW OF LITERATURE
The review of literature is a broad, comprehensive, in depth systemic
and critical review of scholarly publication, unpublished scholarly print
materials, AV materials and personal communications.
A literature review is a written summary of the existing knowledge
on a research problem. The task of reviewing research literature involves the
identification, selection, critical analysis and written description of existing
information on a topic (Polit and Hungler 2003).
The review of literature in this study is organized under the following
headings.
1. Review literature related to diabetic management.
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2. Review literature related to exercise
3. Review literature related to diet
4. Review literature related to Glucose monitoring
5. Review literature related to Medications & Insulin
6. Review literature related to prevention of complications of diabetes mellitus.
LITERATURE RELATED TO DIABETIC MANAGEMENT
Diabetic management is a measure taken to control or maintain the blood glucose level
in the body. It includes maintaining proper weight, diet, exercise, monitoring blood glucose and
medication (insulin therapy) and prevention of complication.
Deakin TA, Cade JE, Williams R, Greenwood DC. Nutrition & Dietetic Department,
urnley, Pendle & Rossendale Primary Care Trust, East Lancashire, UK (2006) conducted a study
To develop a patient-centred, group-based self-management program (X-PERT), based on theories
of empowerment and discovery learning, and to assess the effectiveness of the programme on
clinical, lifestyle and psychosocial outcomes. METHODS: Adults with Type 2 diabetes (n = 314),
living in Burnley, Pendle or Rossendale, Lancashire, UK were randomized to either individual
appointments (control group) (n = 157) or the X-PERT Programme (n = 157). X-PERT patients
were invited to attend six 2-h group sessions of self-management education. Outcomes were
assessed at baseline, 4 and 14 months. RESULTS: One hundred and forty-nine participants (95%)
attended the X-PERT Programme, with 128 (82%) attending four or more sessions. By 14 months
the X-PERT group compared with the control group showed significant improvements in the mean
HbA1c (- 0.6% vs. + 0.1%, repeated measures anova, P < 0.001). The number needed to treat
(NNT) for preventing diabetes medication increase was 4 [95% confidence interval (CI) 3, 7] and
NNT for reducing diabetes medication was 7 (95% CI 5, 11). Statistically significant
improvements were also shown in the X-PERT patients compared with the control patients for
body weight, body mass index (BMI), waist circumference, total cholesterol, self-empowerment,
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diabetes knowledge, physical activity levels, foot care, fruit and vegetable intake, enjoyment of
food and treatment satisfaction. CONCLUSIONS: Participation in the X-PERT Program by adults
with Type 2 diabetes was shown at 14 months to have led to improved glycaemic control, reduced
total cholesterol level, body weight, BMI and waist circumference, reduced requirement for
diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge
of diabetes, self-empowerment, self-management skills and treatment satisfaction.
Chang HC, Chang YC, Lee SM, Chen MF, Huang MC, Peng CL, Yan CY. Division
Community Medicine Department, Li Shin Hospital. (2007) conducted a study to design,
implement and evaluate disease outcomes at a regional hospital- based case management program
of care for patients with type 2 diabetes. A medical team and practice guidelines were established
in line with the health insurance strategy of Taiwan's Bureau of National Health Insurance (BNHI)
and American Diabetes Association (ADA) Standards of Care for Diabetes (2003 edition). Also, a
set of self-care booklets was designed suitable for use by the subject group. The study was
prospective and followed the patients from enrollment to one year. Patient outcomes were
determined based on laboratory examinations and recorded self-care behavior. Data were collected
at enrollment and over 4 follow-up times within a one year period. Generalized Estimating
Equation (GEE) multiple linear regression and logistic regression were used for repeated
measurements and adjustments of the effects of specific prognostic factors. Sixty subjects
diagnosed with type 2 diabetes (mean duration 3.25 years) were recruited. All participants were
married with a mean age of 52.5 years. A majority (58.3%) was male and 65% were ethnic Hakka.
Self-care knowledge and behavior accomplishment rates were: taking medications by oneself,
91.3% (knowing medicines, 25.4%); hypoglycemia management, 23.3%; monitoring blood sugar,
46.7%; exercise, 35.8%; diet management, 51.7% and foot care, 92.8%. Significantly improved
ADA diabetes care standard items included HbA1C (p< .0001), fasting glucose (p< .01) and
triglycerides (p< .05). The study incorporated evidence-based guidelines, public health insurance
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strategies and self-care booklets into a protocol to provide comprehensive care. The implemented
diabetes program achieved diabetes care goals and improved patient self-care.
LITRETURE RELATED TO DIET
Lois Jovanovich and colleagues, (1998) conducted a study to find whether a decrease in
Carbohydrate and calorie restricted diet can help people with type 2 diabetes mellitus to get their
blood sugar under control. After eight weeks on a diet with 25% of calories from Carbohydrate,
type 2 diabetes mellitus had a significant improvement in blood sugar level compared to those seen
with a diet of 55% calories from carbohydrate.
Willimas (2000) conducted a study on two groups of patient’s in their homes, in order
to estimate the degree which prescribed, diet were being followed. In the first study, 60
populations gave a 24 hour recall of the food item. In the second of the pattern of food intake was
studied on 17 clients over a 7 days period. The studies indicate a high frequency of failure by these
diabetic patient’s in taking the prescribed diet.
Blouza, (2000) conducted a correlation study on the effect of nutritional education on
the food intake regulation among 10 young volunteer diabetes mellitus patients. Each meal
provided was quantified before and after consumption for three days. No significant association
was found between the total energy intake and the amount of Carbohydrate (P< 0.01) and proteins
(p< 0.01).
Manisha chandalia et al (2001): Conducted study among 13 patients with type 2
diabetes mellitus to assess the effects of increasing the intake of dietary fiber on glycemic control.
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They had to follow two diets each for 6 weeks, a diet containing moderate amount of fiber and
higher fiber diet. Results shows that high intakes of dietary fiber improve glycemic control,
decreases hyper insulinemia and lowers plasma lipid concentrations in patients with type 2
diabetes mellitus.
LITERATURE RELATED TO EXERCISE
Latorge (1999) conducted a study to examine stage of change for regular exercise and
self perceived quality of life. Data was collected from 1,387 participants through a survey and they
were classified with respects to intention and exercise behavior and it was found that stage of
exercise was associated with self perceived quality of life. Physical function and General health
perceived and vitality.
Lurreson (1999) studied 196 subjects with diabetes and poor metabolic control along
with their, socio-economic characteristics and quality of life. It revealed that these patients had a
lower educational level and reported more complications, nervous problem and a lower degree of
physical activity.
Koch (2000), he used participatory action research (PAR) groups with men and women
who have been diagnosed with diabetes mellitus. Men with diabetes mellitus expressed that the
disease had made a positive impact on their life style; they viewed it as part of and not as an
illness. Those men choose foods with confidence and they took responsibility for themselves and
being supported by their partners was found to be helpful in managing their diabetes mellitus.
They managed their life with diabetes by minimizing in intrusiveness of the disease. Having
adequate family support and building in social system also here an effect on quality of life.
Rigla, (2000) conducted a comparative study on effect of physical exercise on lipo
protein and low density lipo protein modification in 14 type 1, and 13 type 2 diabetic patients.
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Anthropometric parameters, insulin requirements, blood pressures, the lipid profile LDL
composition, size and susceptibility to oxidation and the proportion of electro negative LDL were
measured before and after 3 months of physical exercise. The findings shows that there was
significant increase in high density lipoprotein cholesterol (p>0.05), waist circumference (p<.05)
in type 1 diabetes mellitus. There was a significant decrease in LDL cholesterol. Subs capsular to
triceps skin fold ratio (p<.01) mid arm muscle circumference (p>.001) insulin requirements
(p<.05), diastolic blood pressure (p<.01) in type 2 diabetes mellitus patients after exercise.
Myoung (2001), from Korea studied the health related quality of life for patient with
diabetes mellitus and found that the physical impact of diabetes included decreased energy,
limitation and physical suffering while its psychological or spiritual impose extended to general
stress, helplessness, fear, depression and strengthened their relationship with god.
Shobhana (2001) from India conducted a study to assess the role of diabetes integration
and psychological factor in patient with type 2 diabetes. A sample of 227 type 2 diabetes patients
participated in the study. It was found that diabetic integration and the psychological well being
subscales did not significantly related with the metabolic other medical indices.
Indian Scenario of Diabetes Mellitus A comparison “between” 1990 – 2001 shows that
more deaths are recorded due to non communicable disease includes diabetes mellitus. In 1990
Diabetes mellitus stood at 29th place in terms of mortality and in 2001 it is ranked at 20th. As
mentioned above the diabetes is an also etiological factor of much disease liken Cardio Vascular
Accidents risk factor and amputation, this indirectly leading to many deaths.
Durstine, (2002) endurance exercise training consisting of 15-20 miles/ week of brisk
walking, jogging, which accounts for 1,200-2,200 kcal of energy expenditure/ week is associated
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with reduction in low- density lipoprotein (LDL-C) and increases in high density lipo protein
(HDL-C) however, exercise almost ever alters total cholesterol and LDL-C unless accompanied by
a reduction in dietary fat intake an loss of body weight.
Nelson K.M, (2002) conducted a study on diet and exercises among adult with type 2
diabetes mellitus. A finding shows 31% reported no regular physical activity and another 38%
reported less than recommended level of physical activity. 62% respondents ate fewer than five
servings of fruits and vegetables/ day, 2/3 rd respondents consume greater than 30% of their daily
calorie from fat and greater than 10% calorie from saturated fat. The Study suggested that people
suffering with type-2 diabetes mellitus are encouraged to do regular physical activity and
improved dietary habits.
Ramachandran (2002) conducted that, the prevalence of type 2 diabetes and impaired
glucose tolerance is increasing in urban area of developing countries especially in India. The
period between 1989 and 1995 showed a 40% rise in the prevalence of diabetes and further of
16.4% in the next 5 years. Thus the project figures for Indian 2025 would be 57.2million as against
300 million worldwide.
Watkins(2004) he
examined the relationship among cognitive representative of
diabetes, diabetes specific health behaviors and quality of life.
Yoo JS, Lee SJ. College of Nursing, Yonsei University, Korea (2005) conducted a
study to systematic review and meta-analysis of the effects of exercise programs in patients with
type II diabetes mellitus. METHOD: Two investigators systematically searched and reviewed
English articles from PUBMED from 1988 to 2004, selecting randomized controlled trials on
structured exercise programs for DM patients. Out of 87 studies identified, a meta analysis was
done for eleven studies which satisfied inclusion criteria and focused on glycemic indices, lipid
indices, and cardiac function indices. RESULTS: The means and standard deviations were
compared for experimental groups that received exercise-only or exercise and diet programs and
control groups that received no intervention or only diet education. The groups were considered
- 15 -
homogeneous as the p value of the Q score in each variable group was over 0.05. The experimental
groups demonstrated a moderate positive effect on HbA1c and VO2max (d=0.55 & 0.5), and a
small positive effect on fasting blood glucose and cholesterol (d=0.38 & 0.27) compared to the
control groups. HDL and LDL cholesterol levels, however, showed a very low positive effect
(d=0.11 & 0.12) in the experimental groups. Aerobic exercise was more beneficial than resistance
exercise on HbA1c (d=0.59 vs 0.28) in the groups. CONCLUSIONS: Regular exercise has a
positive effect on HbA1c, fasting blood glucose, total cholesterol, HDL cholesterol, LDL
cholesterol, and VO2max in Type 2 diabetic patients.
LITERATURE RELATED TO GLUCOSE MONITORING
Wong FK, et al (2005) conducted a study on nurse follow – up patients with diabetes.
This randomization controlled trail was conducted in the medical department of a regional hospital
in Hong Kong. A total of 101 patients who needed glycemic monitoring, but who were otherwise
fit for discharge, were recruited. The control group continued to receive routine hospital care. The
study group was discharged early and received a follow up programmed which included a weekly
or biweekly telephone call from a nurse. When compared with the control group had a shorter
hospital stay (2.2 Vs 5.9, p, <0.001). The treatment into the real life environments of patients with
diabetes mellitus and nurse led transitional care is a practical and cost effective model. Nurse
follow up is effective in maintaining optimal glycerin to health behavior.
LITERATURE RELATED TO MEDICATION
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Fornos Pérez JA, Guerra García MM, Andrés Rodríguez NF, Egea Ibernón B.
Farmacéutico Comunitario en Cangas, Pontevedra, Spain (2004) conducted a study to evaluate the
results of pharmaceutical intervention in a program to monitor the drug therapy of type-2 diabetics;
and to assess the improvement of the indicators, glycosylated haemoglobin, basal glycemia, lipid
profile, albumin/creatinine, blood pressure, BMI, medication-related problems and adherence.
DESIGN: Randomized clinical trial. SETTING: 14 local pharmacies in the province of Pontevedra
(Galicia), Spain. SUBJECTS: 126 type-2 diabetics, over 18 years old and who joined voluntarily a
monitoring program, distributed 50-50 into intervention and control groups. VARIABLES: The
main variable was HbA1c. Other variables were: clinical indicators of metabolic control (mean
basal glycemia, lipid profile), blood pressure, BMI, medication-related problems, understanding of
the illness and its complications, adherence to medical treatment and to changes in life-style, and
incidence of complications. METHODS: Introduction and randomization of patients. Recording of
the initial status of the research variables, study and assessment stage, pharmaceutical
interventions to detect and resolve any passing medication-related problems and educational
activities. Referral to family doctor if his/her intervention required. Follow-up lasted 12 months
with monthly scheduled visits and on-demand visits, after which the variables were assessed once
more. The stages of study, evaluation, intervention and education did not occur in the control
group. DISCUSSION: The study will enable the role of the chemist in achieving the objectives of
controlling type-2 diabetes patients to be achieved through educational intervention and assistance
in drug therapy monitoring.
Wu SJ, et al (2006) conducted a study on Diabetic patients need long-term treatment
and follow-up exams as well as appropriate self-care pharmaceutical education to get the disease
under control and to prevent possible complications. Pharmaceutical treatment plays an essential
role in diabetes. If patients don't understand the medicines and dosages they take, their blood
glucose control may be affected. In addition, the possibility of developing hypoglycemia may be
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increased. In this paper, we enhance the POEM system, previously developed for diabetic patient
education, by providing diabetic patients' pharmaceutical education. The new system integrates
both diabetic patients' pharmaceutical education information and medical care information to
provide them with more comprehensive personalized medication information so that they can
access the on-line system afterwards. It also strengthens patients' understanding of pharmaceutical
functions, side-effects and relevant knowledge thus increasing patients' adherence of medication
orders and having better control in their blood glucose levels.
Müller UA, et al (2006) Intensified insulin therapy is the therapy of choice for patients
with diabetes Type I. Intensified insulin therapy includes an basis-bolus insulin injection regimen
or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring,
self-adaptation of insulin dosages by the patients themselves and a far-reaching liberalization of
nutrition. The patients learn self management of diabetes therapy in a structured treatment and
teaching program. The effectivity of this program is evaluated in the routine care. PATIENTS
AND METHOD: A peer-review quality circle was formed as an official working group of the
German Diabetes Association based on the formation of a working group (Arbeitsgemeinschaft fur
Strukturierte Diabetestherapie [ASD]) of presently 135 general internal medicine departments
from city, country and university hospitals throughout the country. The group attempted to
document and to improve the quality of structure and process of Type-I diabetes care in its
participating institutions by a system of peer supervision. Systematic follow-up examinations of 50
consecutive Type-I diabetic patients 12 to 15 months after participation in the program confirm the
outcome quality. The working group meets every year to discuss the results non anonymously. A
PC-system (DIQUAL) was developed for collecting, checking and pooling of the outcome data.
RESULTS: From 1992 a representative sample of 6.555 patients with Type-I diabetes was
examined. At the first time in 1998 the outcome results of 1.789 patients were analyzed depending
on the therapeutic goals. In patients with a high initial HbA1c (> or = 8%) an improvement from
9.8 to 8.0% was reached going together with a reduction of severe hypoglycemia from 0.23 to
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0.13/patient/year. In patients with an acceptable initial HbA1c (< 8%) the frequency of severe
hypoglycemia could be reduced from 0.65 to 0.24/patient/year without any deterioration in
metabolic control. Furthermore the incidence of ketoacidosis with hospitalization and the inpatient
days were reduced significantly. CONCLUSION: A substantial improvement of HbA1c and
reduction of acute complications, especially of severe hypoglycemia in patients with Type-I
diabetes were reached by participation in a structured teaching and treatment program in clinical
routine care.
LITERATURE RELATED TO PREVENTION OF COMPLICATION
Department of Biomedical Engineering, Texas A&M University, College Station,
Texas, 77843-3120, USA (2005) Conducted a study to establish that careful diabetes selfmanagement is essential in avoiding chronic complications that compromise health. Disciplined
diet control and regular exercise are the keys for the type 2 diabetes self-management. An ability
to maintain one's blood glucose at a relatively flat level, not fluctuating wildly with meals and
hypoglycemic medical intervention, would be the goal for self-management. Hemoglobin A1c
(HbA1c or simply A1c) is a measure of a long-term blood plasma glucose average, a reliable index
to reflect one's diabetic condition. A simple regimen that could reduce the elevated A1C levels
without altering much of type 2 diabetic patients' daily routine denotes a successful selfmanagement strategy. METHODS: A relatively simple model that relates the food impact on blood
glucose excursions for type 2 diabetes was studied. Meal is treated as a bolus injection of glucose.
Medical intervention of hypoglycemic drug or injection, if any, is lumped with secreted insulin as
a damping factor. Lunch was used for test meals. The recovery period of a blood glucose excursion
returning to the pre-prandial level, the maximal reach, and the area under the excursion curve were
used to characterize one's ability to regulate glucose metabolism. A case study is presented here to
illustrate the possibility of devising an individual-based self-management regimen. RESULTS:
Results of the lunch study for a type 2 diabetic subject indicate that the recovery time of the post- 19 -
prandial blood glucose level can be adjusted to 4 hours, which is comparable to the typical time
interval for non-diabetics: 3 to 4 hours. A moderate lifestyle adjustment of light supper coupled
with morning swimming of 20 laps in a 25 m pool for 40 minutes enabled the subject to reduce his
A1c level from 6.7 to 6.0 in six months and to maintain this level for the subsequent six months.
CONCLUSIONS: The preliminary result of this case study is encouraging. An individual life-style
adjustment can be structured from the extracted characteristics of the post-prandial blood glucose
excursions. Additional studies are certainly required to draw general applicable guidelines for
lifestyle adjustments of type 2 diabetic patients.
Department of health (2006) the other major challenge is identifying people with undiagnosed
diabetes. This is important as about 50% already have one or more complication of diabetes on
diagnosis and earlier diagnosis and treatment may have prevented this. The UK national screening
committee has advised that screening certain subgroups of the population for type 2 diabetes
mellitus is feasible and should be taken forward. The report also highlights that people with
diabetes are still experiencing problems assessing psychological support and that many feel this is
a significant gap in diabetes services, particularly on children, young people and parents.
7 . Material and Methods of Study
7.1 - SIGNIFICANCE OF THE STUDY:
The purpose of the study is to assess the knowledge and practice of the
patients
with
diabetes
mellitus
and
provide
education
on
disease
management in order to enhance their ability in caring themselves at home
and clinical setting.
- 20 -
7.2 Source of data:
The data will be collected from patient with type-diabetes mellitus at
selected hospitals, Mysore.
7.3 Research Design:
A Quasi – experimental (One group Pretest Post test) design is adopted
for this study.
One group Pretest Post test design
O1
X
O2
O1
:
Pre test Knowledge & Practice assessment
X
:
Intervention through Planned Teaching Program.
O2
:
Post test Knowledge & Practice assessment
7.4 Method of data collection:
Section-A: Demographic data
Section-B: Self administered questionnaire are used for assessing the
knowledge & practice.

Part-A: Knowledge questionnaire consists of six parts, each part
consist of 6 questions except part VI , which consist of 5
questions, totally 35 questions as given in the following titles.
Part I: Diabetes Mellitus -6 items
Part II: Diet therapy -6 items
Part III: Exercise – 6 items
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Part IV: Self Blood Glucose monitoring – 6 items
Part V: Insulin therapy – 6 items and
Part VI: Prevention of complications – 5 items

Part-C: Practice questionnaire consists of 15 questions
7.5 SAMPLING PROCEDURE
7.5.1 SAMPLING CRITERIA
Inclusive criteria:
o Patients with type II diabetes mellitus
o The patients who can read kanada.
o Age group from31 – 70years will be included in this study.
Exclusive criteria:

The patients who are not willing to participate in the study.

The diabetic patients who are critically ill.

The patients who have type-I DM
7.5.2 Population:
Diabetic population
7.5.3 Sample:
Patients with type II Diabetes mellitus, who fulfills the inclusion
criteria.
7.5.4 Sample Size:
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60 Diabetic patients selected hospitals at Mysore.
7.5.5 Sampling Technique:
Convenient sampling technique is preferred for this study.
7.5.6 Setting:
The study setting is Cauvery Multi-specialty hospital at Mysore.
7.5.7 Pilot study:
Pilot study is planned with 10% of population.
7.5
VARIABLES
Independent variable
Planned teaching programme.
Dependent variables
Knowledge and practice
7.7 PLAN FOR DATA ANALYSIS
Descriptive and inferential statistical methods are used for this study.
Descriptive analysis are percentage,mean,standard deviation and
correlation.
Inferential statistics are t test and chi square test.
7.8 PROJECTED OUTCOME
The study result would reveals
1.the effectiveness of planned teaching programme in terms of gaining
knowledge and practice of diabetic patients.
2.nurses responsibility in providing patient education on health care
aspects.
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8
Ethical Considerations:
 Does study require any investigation or intervention to be conducted on
diabetic patients?
YES
 Has ethical clearance been obtained from hospital authorities in case
study requires investigation?
YES
 Informed consent will be taken from the participants and the concerned
authorities of the hospital.
9. - LIST OF REFERANCES
BOOK REFERENCE
1. Ahuja.MMS., Diabetes care in clinical practice.1st edition, Calcutta, Jaypeebrothers medical
publishers Pvt, 1996.
2. Brunner and suddarth’s., Text book of medical surgical nursing.10th edition, New York
wolters kluwer company, 2004
3. BasvanthappaB.T., Medical surgical nursing.1st edition, New Delhi, jaypee brothers’
medical publishers private Ltd, 2003.
4. Basvanthappa.B.T., Nursing research.2nd edition, New Delhi, jaypee brothers’ medical
publishers, 2007.
5. Cecil., Text book of medicine. 22nd edition, pennysylvania, Saunders, An imprint of
Elsevier, 2004.
6. Corinne H.Robinson, Marilyn. Normal and therapeutic nutrition, New Delhi, oxford and
IBH publishing co, 1982.
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7. Datta BN., Text book of pathology. 2nd edition, New delhi, Jaypee brothers medical
publishers (P) Ltd, 2004.
8. Denise F.polit, Cheryl tatano beck, Nursing research principles and methods, 7th edition,
Philadelpgia, A wolters kluwer company, 2004.
9. Davidson’s., principles and practice of medicine.20th edition, Churchill Livingstone
Elsevier, an imprint of Elsevier Ltd, 2006
10. Dhaar G.M, Irrobbani. Foundations of community medicine. 1st
edition, Elsevier India private limited, 2006
11. Harrison’s., principles of internal medicine.16th edition, New York
MC. Graw Hill medical publishing divisions, 2005.
12. Harsh Mohan. Text book of pathology. 5th edition, New Delhi ,Jaypee brother’s medical
publishers (P) LTD, 2005
13. Joyce.M.Black. Medical surgical nursing. 1st edition, Singapore, Harcourt brace and
company Asia pvt ltd, 1997
14. Kozier and Erb’s., Fundamentals of nursing. 8th edition, India, Dorling
education
publishers’ pvt ltd, 2008.
15. Kumar, cotran, Robbins. Basic pathology. 6th edition, Singapore, Harcourt Asia Pvt LTD,
1997.
16. Lippincott., Manual of nursing practice. 8th edition, London, Jaypee brother’s medical
publishers (P) Ltd, a wolters kluwer company, 2006.
17. Lewis. Medical surgical nursing. 6th edition, An Affiliate of Elsevier science, 2004
18. Mahajan.B.K., Methods in biostatistics. Banglore, jaypee brother’s medical publishers (p)
ltd, 1997.
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20. Shafer’s., Medical surgical nursing. 7th edition, Bombay, B.I publications pvt ltd, 1985.
21. Shyam ashtekar. Health and healing a manual of primary health care. 1st edition, orient
Longman limited, 2001
22. Signs and symptoms A2-in-1., Reference for nurses. Philadelphia, A wolters kluwer
company, 2005.
23. Sundar rao. An introduction to biostatistics, second edition, department of biostatistics.
Christian medical college, Vellore, 1983
24. Sue rod well Williams. Nutrition and diet therapy. sThe .C.V .Mosby company 1969
25. Swaminathan, M., Hand book of food and nutrition.bangalore, The Bangalore printing and
publishing co.ltd, 1986.
26. The Washington manual of medical therapeutics, 32nd edition, Newdelhi, wolters kluwer /
Lippincott Williams and Wilkins, 2007.
27. Watson’s., Medical surgical nursing and related physiology.4th edition, londan, Balliere
Tindal, 1992
JOURNAL REFERENCE
1.
Abbott CA et al, “Incidence of and predictive risk factors for
diabetic naturopathic foot ulceration”,pubmed,1998,21(7).
2. Arvinda Fernandez, July 2006, “Journal of clinical nursing,”
vol.1, no 3,Bangalore
3. Ashok jain,”,”Nightingale nursing times,” January 2006 vol.1
4. Asrar et al, , “Retinopathy as a predictor of other diabetic complication”,pubmed,
2001,24(1).
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5. Bijiani RL, Diabetes is terrible-but preventable and treatable, “Health for millions”, 1998,
24 (2).
6. Bhatnagar p.c, diabetes mellitus, “Health for the millions”, 2005,volume 3.
7. Delorme s, chiasson JL, “Acarbose in the prevention of cardiovascular disease”,
pubmed, apr2005 5(2).
8. Estacio RO et al, , “The association between diabetic complications and exercise
capacity”, diabetes care,pubmed, 1998 21(2).
9.
Fuji motos, “Therapeutic utility of biguanides in the treatment of non insulin
dependent diabetes mellitus”,pubmed , 1999,57(3).
10. Gavril L,”New once daily intervention for type 2 diabetes
mellitus”,pubmed, 2004,42(2).
11. George Thayil, , Diabetes and heart disease, “Health action”. 2005
12.
Gwan hall, , managing diabetes in primary health care, “Nursing
times”, 2006 volume 102.
13. Health committee, lok vignyan, , diabetes mellitus, “Health action”, 2001,volume 14.
14. Hong YH et al, , “An ethnographic study on eating style of adult diabetes in
korea”,pubmed, 2005,35(2).
15. Jay Kumar R V et al, , prevention of diabetes mellitus, “Health action”. 2005
16. Jean tuecottee, ,”American journal of nursing,” “june 2002 vol.102,no.6.
17. Kale M.K, , diabetes neuropathy, “Health action”,
18. Molley.c.dougherty, Nursing Research, sep-oct, 2005 vol.54
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19. Neelam Makol et all, Diabetes the silent killer disease, “Health
action”, 2005
20. Nirmala.R.Ph.D,”What role in diabetes management, “Health
screen”, 2006,vol 2, no 23.
21. Paul zimmet, , diabetes, “Health dialogue”, 2004
22. Paulose K.Pcontrol of diabetes mellitus, “Health action”. , 2005,
23. Rachael crighton,”, “A American journal of nursing,” February 2002vol.102, no.2.
24.
Shanthi Johnson, Leah macaden, path physiology and management
of type 1 diabetes mellitus, “Indian journal of continuing nursing education”,
2005, part 1.
25.
Shanthi Johnson, Leah macaden, pathophysiology and management
of patient with type 2 diabetes mellitus, “Indian journal of
continuing nursing education”, 2005, part II.
26.
Smyth, T, Smyth D., diabetes mellitus, “Nursing times”. 2005
27.
Sue Roberts and the national diabetes support team, Progress on the diabetes NSF,
“NTclinical”, 2007, Volume 103,
28.
Susan L.T, Nutritional management of diabetes mellitus, “Nursing
clinic of north America”, 1993, 28(1).
29.
Tamil selvam, living with diabetes, “Health action”, 2007
Valume20.
30.
Tan A.S Yong XS, Wan.s and Wong, ML,”,Patient education in
management of diabetes mellitus” (online) “Singapore
medical journals” 1997,38(4).
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31.
Terry hainsworth, , progress and challenges in delivery of the
diabetes NSF, “NT clinical”, 2006,Volume 102.
32.
Thiagarajan T.R, diabetes and foot disease, “Health action”. 2005.
33.
Vijay
visvanathan,
the
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2006,
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34.
Wong FK,et al “Nurse follow up of patients with diabetes”,
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INTERNET
WWW.Google .com
www.yahoo.com
www.msn.com
www.diabetes.org/diabetes
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of
non
9. SIGNATURE OF THE CANDIDATE
10. REMARKS OF THE GUIDE
RECOMMENDED AND
FORWARDED
11. NAME AND DESIGNATION OF
(IN BLOCK LETTERS)
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE (IF ANY)
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNATURE
12.1 REMARKS OF THE CHAIRMAN
AND PRINCIPAL
RECOMMENDED AND
FORWARDED
12.2 SIGNATURE
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