In the last decades, one of the big problems of the scientific community is the increase in the incidence of chronic degenerative diseases, among which is Diabetes Mellitus (Shariful Islam, Purnat, Anh Phuong, Mwingira, Schacht, & Fröschl, 2014). Diabetes is a public health disease, high cost that afflicts everyone without distinguishing age or socioeconomic levels, there are millions of people who do not know they have the disease and many others who, despite having been diagnosed, do not receive the appropriate treatment; hence, many complications derived from the disease are the product of the lack of information that patients have about the disease and treatment at home; in regard to food, exercise, hygiene among others (Verchota, & Sawin, 2016).
Diabetes Mellitus is a universal disease in the sense that it affects all the peoples of the world; and to all the organs and systems of the human body. It is a disease caused by lower production of insulin, insulin resistance or both, that is why people with diabetes have high levels of glucose, because their pancreas does not produce enough insulin or their muscles, fat and liver cells do not respond normally to insulin, or both. It is a multiorganic disease because it can damage almost all organs and especially the eyes, kidneys, heart and limbs (Jameson, and Jameson, 2016).
Diabetes Mellitus is a disease that affects people worldwide, increasing its incidence more and more, in such magnitude that there are currently approximately 150 million people affected with this disease. In the United States, more than 30 million people suffer from the disease and 84.1 million suffer from prediabetes, a condition that unless treated can trigger diabetes in a period of 5 years (Ford, Narayan, & Mehta, 2016). Hispanics are one of the groups with the highest incidence of the disease, with 12.1% of the total, compared to Asians, with 8.0%, and non-Hispanic whites, with 7.4%. Native Americans (15.1%) and African Americans (12.7%) are the two ethnic groups with the highest incidence of the disease, which is diagnosed in a greater proportion in the south and the Appalachian region in the United States (Ford, Narayan, and Neil, 2016). Also, the disease is more common among men (36.6%) than in women (29.3%), a proportion that is similar among all ethnic groups and educational levels (Ford et al., 2016).
High levels of glucose in the blood can cause various problems such as frequent urination (polyuria), excessive thirst (polydipsia), excess appetite (polyphagia), fatigue, weight loss and blurred vision; however, because type 2 diabetes develops slowly, some people with high blood sugar levels are completely asymptomatic (Buttaro, Trybulski, Bailey, Sandberg-Cook, 2013). The typical symptoms of type 1 diabetes are: polydipsia, polyuria, weight loss despite polyphagia, fatigue, nausea, and vomiting. The typical symptoms of type 2 diabetes are: polydipsia, polyuria, polyphagia, fatigue, blurred vision, infections that heal slowly, and impotence in men. It is appropriate to remember that the diabetic patient is a complex patient who can have manifestations of his disease at the level of several organs, even without symptoms and may even be unaware that he suffers from the disease (Buttaro et al., 2013).
Hypoglycemia: It is the most frequent acute complication of diabetes. Clinically, hypoglycemia usually manifests when blood glucose is less than 50-60 mg / dl, although lower figures can be observed with absence of symptoms and higher figures can be found with clinical manifestations. It can manifest at any time of the day; those that appear during nighttime sleep are especially dangerous because they may not awaken the patient (Buttaro et al., 2013). The clinical manifestations of hypoglycemia are cold sweating, tremors, tachycardia, palpitations, feelings of hunger and nervousness. In severe hypoglycemia, the functioning of the central nervous system is so damaged that the patient needs the help of another person to treat hypoglycemia. In these cases, may be disorientation, seizure, loss of consciousness and even death (Buttaro et al., 2013).
Hyperglycemia: It does not cause symptoms until the glucose values are significantly elevated, that is, above 200 mg/dl. Symptoms of hyperglycemia develop slowly over several days or weeks. The longer the blood sugar levels stay high, the more severe the symptoms may be. Early symptoms of hyperglycemia are; polyuria, polydipsia, blurred vision, tiredness, and headaches (Buttaro et al., 2013).
Diabetic ketoacidosis or diabetic coma: This complication is characteristic of patients with type 1 diabetes. The most frequent causes of this clinical picture are the decrease or forgetfulness of insulin administration and intercurrent diseases (infections). It usually occurs when the glycemic exceeds 300 mg / dl. Ketone bodies are responsible for digestive symptoms such as the apple smell of breath, anorexia, nausea, vomiting and abdominal pain. In type 2 diabetes, there is usually no ketoacidosis, because although insulin secretion may be altered, there is enough to prevent it (Buttaro et al., 2013).
Hyperosmolar coma: This other complication is typical of type 2 diabetes. The signs of this complication are intense dehydration, such as dry skin and mucous membranes, hypotension, tachycardia and variable neurological signs (altered sensory, seizures, hemiparesis).
Problems of the lower extremities: Between 50 and 75% of lower limb amputations are performed in diabetics, and it is believed that more than 50% of these can be prevented with simple recommendations on daily foot care. Diabetic patients have to pay special attention to their feet, since they have a great tendency to develop some of the forms of the so-called diabetic foot (ulcers, infections, gangrene) after minimal injuries that often go unnoticed. These injuries can be of thermal origin (caution with the use of hot water bags), chemical (for example the use of caustic agents for calluses) or traumatic (injuries when cutting nails, foreign bodies in shoes, wearing shoes and excessively tight socks) (Buttaro et al., 2013).
The diabetic foot is favored by several other complications that arise in the diabetic patient:
Neuropathy: Sensory neuropathy causes a decrease in the perception of pain and the sensation of pressure and autonomic neuropathy alters skin hydration, favoring the formation of cracks.
Peripheral vascular disease: Extensive and early atherosclerosis contribute to poor healing and the development of possible gangrene (Buttaro et al., 2013).
Immuno-alteration: The hyperglycemia maintained alters the function of leukocytes, so it can affect the control of infections (Buttaro et al., 2013).
High-risk factors for the development of these complications are considered to be long-standing diabetes, age over 40 years, smoking and anatomical deformations of the feet (Buttaro et al., 2013).
The diagnosis is usually direct. The most appropriate initial method is to measure blood glucose after an overnight fast; it varies less from day to day and is more resistant to factors that alter non-specific metabolism of glucose. The diagnosis is corroborated if the blood glucose is 140mg / dl. (or more) on two separate occasions; being the normal values of 70-110 mg/dl. Usually, figures of fasting blood glucose less than 115mg / dl, do not justify the practice of new studies; figures between 115 and 140 mg /dl, although it is not diagnosed should arouse suspicion. Individuals with these values may show postprandial hyperglycemia, which is why some experts recommend other studies, such as the glucose tolerance test. This test has the advantage of detecting diabetes in its early stages, phase in which the treatment has its greatest effectiveness. The disadvantage is that this method can cause an excessive diagnosis. Among the factors that often cause impaired non-specific glucose tolerance are: carbohydrate restriction; absolute bed rest; medical or surgical stress; drugs; smoking during the administration of the test, or anguish from the needle stick. According to Buttaro, Trybulski, Bailey, & Sandberg-Cook, (2013) “In a patient exhibiting significant symptoms of hyperglycemia, a random blood sugar > 200mg/dl is diagnostic for diabetes” (p. 1064). Many patients with type II diabetes have the disease before the symptoms are appreciated, and that is why it is important to detect high-risk people in a primary way (Buttaro et al., 2013).
Conclusion with PICOT Question
Among chronic degenerative diseases, Diabetes Mellitus is one of the most frequent that results in multiple complications due, mostly, to ignorance, misinformation or little importance that patients pay to the disease. Consequently, health personnel play an important role in the education of these patients. However, this must be preceded by the prior information that patients have to be educated by health professionals that can correct and / or reinforce this prior knowledge, through the elaboration of strategies and / or educational plans or programs (Verchota, and Sawin, 2016). That is why I choose this topic to carry out the final Project for my Master in Family Nurse Practitioner.
How will patients between 20-60 years of age with the diagnosis of Diabetes Mellitus, (P), who attend a Diabetes education workshop (I), compared with patients who do not attend the workshop (C), perceive their level of knowledge about the disease (O) over a 1-year period (T)?
The implantation plan outlines at least three steps to be taken to address the PICOT question. This include choice of an appropriate design and sample size, enrollment of the participants, and the intervention
This study will be conducted in a clinical setting with a sample of 52 patients. This will be a randomized controlled design, where from a sample of 52 patients, 26 patients will be randomly be allocated the intervention group (attending the workshop) and the 26 remaining patients will be randomly assigned to the control group (no-attending the workshop). Those in the control group will be on the wait list to attend the workshop latter. This procedure will address the ethical implication of barring patients from educational intervention and allowing data collection over short and long period. The study will be implemented to respond to the following concerns: would attendance to the workshop:
Impact on patients’ perception of illness?
Contribute to modifications in self-care behavior?
Impact on blood-glucose control?
Consent will be sought from the participants before enrollment and permission from the hospital ethical review board will also be sought.
This study will largely focus on patients diagnosed with diabetes mellitus
Only patients with diabetes mellitus, who are neither deaf nor dumb will be included in the study.
Non consenting patients with type 1 diabetes and those who are either deaf or dumb will be excluded from the study.
Both the intervention group and the control group will be tested for their knowledge about diabetes mellitus and about self-care behavior before the start of the workshop (Kalcza-Janosi & Pordea, 2015; Stark Casagrande et al., 2012). This will form the baseline knowledge. The questionnaire will comprise of patients’ general understanding of diabetes mellitus, its complications and management/self-care options.
The workshop will offer an educational intervention where the above-mentioned concerns will be used to test patients’ knowledge about the disease. The intervention will mainly focus on empowerment approach where participants will be motivated and endowed with skills for personal care. The workshop will be moderated by diabetes specialist who will provide training diabetes self-management for 4 weekly sessions. Each session will take roughly 2 hours. The workshop will be mainly problem-based learning and interactive, though the participants will be allowed to have relaxation moments to ease tension and have some refreshments. The participants will also be divided in small groups to allow for discussions and assessment.
To determine the effectiveness of the diabetes education workshop, the research will utilize both formative and impact evaluation. Through formative evaluation, it will be possible to gather data about the characteristics of the educational workshop and whether it met the program goals and was appropriate for the enrolled patients.
Impact evaluation will be conducted to ascertain the extent to which the workshop addressed the previously mentioned concerns: patients’ perception of diabetes mellitus, modifications in self-care behavior, and impact on blood-glucose control. Impact evaluation will therefore entail administration of questionnaire to both intervention and control groups at the end of the workshop period to assess knowledge.
Both pre and post workshop data will be analyzed using SPSS version 20. This will include descriptive and inferential analysis. Descriptive data will comprise of patients’ socio-demographic characteristics such as age, gender, residence, income, marital status, etc. Difference-in-difference and regression analysis will be used to analyze the variability in knowledge between those who attended the workshop (intervention group) and those who did not (control group). Results will be presented in graphs and tables.
- Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J. (2013). Primary Care, 4th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/
- Ford, N. D., Narayan, K. V., and Mehta, N. K. (2016). Diabetes among US- and foreign-born blacks in the USA. Ethnicity and Health, 21(1), 71-84. doi:10.1080/13557858.2015.1010490
- Jameson, J. L., and Jameson, J. L. (2016). Endocrinology: adult and pediatric. Philadelphia, PA: Elsevier/Saunders, 2016. Retrieved from http://eds.a.ebscohost.com.southuniversity.libproxy.edmc.edu/
- Kalcza-Janosi, k., and Pordea, A. (2015). Paper #44 – The evaluation of knowledge level and motivational components in patients with diabetes and their relationship to glycemic control. Romanian Journal of Experimental Applied Psychology, 643. Retrieved from http://eds.a.ebscohost.com.southuniversity.libproxy.edmc.edu
- Shariful Islam, S. M., Purnat, T. D., Anh Phuong, N. T., Mwingira, U., Schacht, K., and Fröschl, G. (2014). Non-Communicable Diseases (NCDs) in developing countries: a symposium report. Globalization and Health, 10(1), 1-12. doi:10.1186/s12992-014-0081-9
- Stark Casagrande, S., Ríos Burrows, N., Geiss, L., Bainbridge, K., Fradkin, J., Cowie, C., and … Cowie, C. C. (2012). Diabetes knowledge and its relationship with achieving treatment recommendations in a national sample of people with type 2 diabetes. Diabetes Care, 35(7), 1556-1565. doi:10.2337/dc11-1943