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Effectiveness of the modified "Diabetic teaching tool" in group instruction Burke, Matilda 1974

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THE EFFECTIVENESS OF THE MODIFIED "DIABETIC TEACHING TOOL" IN GROUP INSTRUCTION by MATILDA BURKE B.N. DALHOUSIE UNIVERSITY, 1969 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nursing Lde accept t h i s thes is as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1974 In presenting t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s t h e s i s f a r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed u i t h o u t my u r i t t e n permission. Department The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8, Canada 1/ i i ABSTRACT AN EXPERIMENTAL STUDY TD DETERMINE THE EFFECTIVENESS OF THE MODIFIED "DIABETIC TEACHING TOOL" IN GROUP INSTRUCTION This experimental study mas designed to determine i f the modified "Diabetic Teaching Tool" uas an effective tool for use in group instruction. The "Diabetic Teaching Tool" uas developed for individual instruction and tested in an earlier study by Skelton. This study uas conducted, aver a four-month period, at a large urban hospital during the regularly scheduled diabetic class. A l l patients who attended and who met the cr i t e r i a of the study uere asked to participate. A total of tuenty-four subjects agreed to participate and their written consent uas obtained. The f i r s t tuelve subjects uere assigned to the control group and received group instruction by means of the diabetic teaching program of the institution. The re-maining tuelve subjects uere assigned to the experimental group and received group instruction by means of the modified "Diabetic Teaching Tool". Each patient uas given a test of diabetic learning before commencement of the instruction and again tuo to seven days after completion of the instruction. A profile sheet uas completed at the time of the administration of the posttest. The tuo groups of subjects uere found to be highly similar uhen compared on the demographic and diabetic characteristics ob-tained from the profile sheet. The t-test uas used to analyze the test results. IMo s t a t i s t i c a l l y significant difference betueen the tuo groups uas found. Then the Pearson product-moment correlation i i i i v c o e f f i c i e n t uas used to compare the t e s t r e s u l t s and s e l e c t e d demo-graphic and d i a b e t i c c h a r a c t e r i s t i c s . The s e l e c t e d c h a r a c t e r i s t i c s uere age at t e s t i n g , education, age at onset of dia b e t e s , reason for current admission to h o s p i t a l or v i s i t to the doctor and the length of time since diagnosed. IMo s i g n i f i c a n t r e l a t i o n s h i p uas found betueen the t e s t r e s u l t s and these c h a r a c t e r i s t i c s f o r the c o n t r o l group. The only c h a r a c t e r i s t i c to be s i g n i f i c a n t l y r e l a t e d to t e s t r e s u l t s f o r the experimental subjects uas the length of time since diagnosed. The f i n a l comparison uas betueen the experimental subjects of t h i s study and those of the study conducted by S k e l t o n . The tuo groups of subje c t s uere h i g h l y s i m i l a r uhen compared on the demo-graphic and d i a b e t i c c h a r a c t e r i s t i c s . The mean score obtained on the subtests of the t e s t of d i a b e t i c l e a r n i n g uas s i m i l a r f o r both groups. The study concludes u i t h suggested i m p l i c a t i o n s , recommend-ations f o r changes i n the t e s t of d i a b e t i c l e a r n i n g and recommend-ations f o r f u r t h e r r e s e a r c h . TABLE OF CONTENTS Page LIST OF TABLES v i i i ACKNOWLEDGMENTS x l Chapter I INTRODUCTION TO THE STUDY 1 INTRODUCTION 1 THE PROBLEM.. ... 2 Statement of the Problem 2 Significance Df the Problem 2 SPECIFICS DF THE STUDY 5 Hypotheses 5 Variables G Assumptions o f the Study 6 Limitations o f the Study 6 Definition'of Terms 7 II REVIEW DF THE LITERATURE 9 GRDUP INSTRUCTION AS A TEACHING METHOD FDR PATIENTS 9 THE TEACHING FUNCTION DF THE NURSE 13 THE IMPORTANCE DF PATIENT TEACHING IN THE MANAGEMENT DF SELF-CARE IN DIABETICS 17 SUMMARY 21 III METHODOLOGY... 22 INTRODUCTION 22 THE SETTING 22 v vi Chapter Page CRITERIA FDR SUBJECT SELECTION 23 THE TOOL 23 THE PROCEDURE 25 DATA ANALYSIS 27 SUMMARY 27 IV ANALYSIS OF THE DATA 28 INTRODUCTION 28 DEMOGRAPHIC AND DIABETIC CHARACTERISTICS OF THE STUDY 29 Age 29 Sex 30 Marital Status 31 Education 32 Reason for Current Admission to Hospital or Visit to Doctor 32 Age at Onset of Diabetes 33 Length of Time Since Diagnosed... 3k Type of Control of Condition '. 35 Sources of Information 36 A COMPARISON OF DIFFERENCES IN PRETEST AND POSTTEST SCORES ON THE TEST OF DIABETIC LEARNING 38 CORRELATIONS BETWEEN DIFFERENCES IN TOTAL PER-CENTAGE SCORES ON PRETEST AND POSTTEST OF DIABETIC LEARNING AND SELECTED DEMOGRAPHIC AND DIABETIC CHARACTERISTICS OF SUBJECTS 50 A COMPARISON OF THE SCORES OF SUBJECTS USING THE MODIFIED "DIABETIC TEACHING TOOL" IN GROUP INSTRUCTION AND THE SCORES OF SUBJECTS USING THE "DIABETIC TEACHING TOOL" IN INDIVIDUAL INSTRUCTION 57 v i i Chapter Page V SUMMARY, DISCUSSION OF THE FINDINGS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 60 SUMMARY. 60 DISCUSSION OF THE FINDINGS 61 CONCLUSIONS . 65 IMPLICATIONS 66 RECOMMENDATIONS 66 BIBLIOGRAPHY 68 APPENDIXES . 72 A. Consent Forms 72 B. Record of D i a b e t i c Teaching 74 C. Patie n t P r o f i l e Sheet 76 D. M a t e r i a l P e r t a i n i n g to the Scares Obtained 79 E. Test of D i a b e t i c Learning 86 F. Modified D i a b e t i c Teaching Tool 100 G. Outline of D i a b e t i c Teaching Program 200 LIST OF TABLES Table Page I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY AGE 30 I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY SEX 31 I I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY MARITAL STATUS 31 IV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY EDUCATION ° 32 V A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY REASON FOR CURRENT ADMISSION TO HOSPITAL OR VISIT TO DOCTOR 33 VI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY AGE AT ONSET OF DIABETES 34 VII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY. LENGTH OF TIME SINCE DIAGNOSED 35 VI I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY TYPE OF CONTROL OF CONDITION 35 IX A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY SOURCES OF INFORMATION WHICH THEY HAVE USED 37 X A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING 39 XI A COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE TEST XII A COMPARISON OF CONTROL AND EXPERIMENTAL PILL-USERS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE TEST M X I I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON DIET-PLANNING SKILL TEST 42 v i i i ix Table Page XIV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON URINE-TESTING SKILL TEST 44 XV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON INSULIN-INJECTING SKILL TEST 45 XVI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE AND SKILL TESTS OF DIET-PLANNING 46 XVII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE AND SKILL TESTS OF URINE-TESTING 47 XVIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON INSULIN KNOWLEDGE AND SKILL TESTS 48 XIX THE CORRELATION BETWEEN AGE AT TESTING AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING 51 XX THE CORRELATION BETWEEN EDUCATION AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING 52 XXI THE CORRELATION BETWEEN AGE AT ONSET OF DIABETES AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING. 54 XXII THE CORRELATION BETWEEN LENGTH OF TIME SINCE DIAGNOSED AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING 55 XXIII A COMPARISON BETWEEN REASON FOR CURRENT ADMISSION TO HOSPITAL OR VISIT TO DOCTOR AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING 56 XXIV A COMPARISON OF THE MEAN SUBTEST SCORES OBTAINED BY SUBJECTS TAUGHT BY INDIVIDUAL INSTRUCTION AND SUBJECTS TAUGHT BY GROUP INSTRUCTION 59 X T a b l e X X V X X V I X X V I I X X V I I I X X I X S C O R E S O B T A I N E D B Y C O N T R O L A N D E X P E R I M E N T A L I N S U L I N - U S E R S ON K N O W L E D G E T E S T S C O R E S O B T A I N E D B Y C O N T R O L A N D E X P E R I M E N T A L P I L L - U S E R S ON K N O W L E D G E T E S T S C O R E S O B T A I N E D B Y C O N T R O L A N D E X P E R I M E N T A L S U B J E C T S ON D I E T - P L A N N I N G S K I L L T E S T S C O R E S O B T A I N E D B Y C O N T R O L A N D E X P E R I M E N T A L S U B J E C T S ON U R I N E - T E S T I N G S K I L L T E S T S C O R E S O B T A I N E D B Y C O N T R O L A N D E X P E R I M E N T A L I N S U L I N - U S E R S ON I N S U L I N I N J E C T I N G S K I L L T E S T . P a g e S O 81 82 83 ACKNOWLEDGMENTS My thanks are expressed to my Committee Chairman, Miss Mary Cruise and Committee member Mrs. Helen E l f e r t f o r t h e i r assistance during the completion of t h i s study; to Mrs. J u d i t h Skelton, f o r her assistance during the planning of t h i s study and f o r her continued advice; to Mi l e s Laboratories f a r per-mission to use the t o o l and f o r the p r o v i s i o n of the re q u i r e d m a t e r i a l s ; to Mrs. Helen Raine and Mrs. Kathleen Skinner f o r con-ducting the c l a s s e s ; to the s t a f f of the i n s t i t u t i o n f o r t h e i r cooperation; to Jack Yensen f o r h i s i n v a l u a b l e a s s i s t a n c e u i t h the data a n a l y s i s ; and f i n a l l y , to S i s t e r Maureen O'Loane f o r her h e l p f u l suggestions. x i CHAPTER I INTRODUCTION TO THE STUDY INTRODUCTION The teach ing of p a t i e n t s i s now cons idered to be an i m -por tant par t of the n u r s e ' s f u n c t i o n . The c o m p l e x i t i e s of h e a l t h care today and the n e c e s s i t y f o r p a t i e n t s to be able to f u n c t i o n independent ly over long pe r iods of t ime r e q u i r e an e d u c a t i o n a l f u n c t i o n i n nurs ing . ' ' ' Teach ing , as a nurs ing f u n c t i o n , can c o n -t r i b u t e to the promotion and maintenance of h e a l t h and to the p r e -vent ion of d i s e a s e . Th is teach ing c o n s i s t s of i n s t r u c t i o n to the p a t i e n t and h i s f a m i l y i n the management of h i s c o n d i t i o n . 2 The need f o r t e a c h i n g p a t i e n t s u i t h d iabetes m e l l i t u s i s u e l l documented. Thorough i n s t r u c t i o n to the p a t i e n t and h i s f a m i l y i s e s s e n t i a l to good management of d i a b e t e s . Th is i n s t r u c t i o n should cons ider the management of d iabetes under the c o n d i t i o n s of the p a t i e n t ' s home l i f e , h i s uork and h i s o ther a c t i v i t i e s . " ^ The i n c r e a s i n g i n c i d e n c e of d iabetes i n Canada n e c e s s i t a t e s the teach ing of la rge numbers of p e o p l e . Teaching groups of people "'"Barbara K. Redman, " P a t i e n t Educat ion as a Funct ion of Nurs ing P r a c t i c e , " Nurs ing C l i n i c s of North Amer ica , V I , No. k (December, 1971) , 573. 2 H e r e a f t e r , the uord " d i a b e t e s " u i l l r e f e r to d iabetes m e l l i t u s . ^"Teaching D i a b e t i c S e l f - C a r e , " The Neu England J o u r n a l of  Med ic ine , CCLXXVI ( January , 1967) , 182. 1 u i t h common concerns i n s t e a d of attempting to reach each i n d i v i d u a l i s i n d i c a t e d . The need f o r economy of time and resources r e s u l t s i n many nurses choosing the group method f o r t h e i r t eaching. The concern of t h i s study, then, i s uhether a "Diab e t i c Teaching T o o l " designed f o r and found to be e f f e c t i v e i n i n d i v i d u a l i n s t r u c t i o n can be e f f e c t i v e l y modified f o r use i n group i n s t r u c t i o n . THE PROBLEM Statement of the Problem Is the modified " D i a b e t i c Teaching T o o l " an e f f e c t i v e t o o l f o r use i n group i n s t r u c t i o n ? S i g n i f i c a n c e of the Problem The existence of diabetes has been knoun f o r c e n t u r i e s but 5 a treatment f o r i t uas not knoun u n t i l 1922. I t i s more prevalent today than ever before and a v a i l a b l e s t a t i s t i c s i n d i c a t e that the incidence of the disease, though not a c c u r a t e l y knoun, i s s t e a d i l y i n c r e a s i n g . ^ I t has been estimated that there are approximately 200,000 knoun d i a b e t i c s i n Canada and probably an equal number uho 7 have not yet been diagnosed. J u d i t h M. Sk e l t o n , "An Experimental Study to Determine the Ef f e c t i v e n e s s of a D i a b e t i c Teaching Tool" (unpublished Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973). 5 John Id. C a l d u e l l , Understand Your Diabetes (Toronto: Oxford U n i v e r s i t y Press, 1949), p. x i i . ^ G a r f i e l d G. Duncan, Diabetes M e l l i t u s : P r i n c i p l e s and Treat  ment (3d ed.; P h i l a d e l p h i a : Ld.B.Saunders Co., 1951), p. 106. 7 John A. Hunt (ed.0, Diabetes: A Manual f o r Canadians (5th ed Toronto: The Canadian D i a b e t i c A s s o c i a t i o n , 1973), p. 7. 3 Mast diabetics are, however, able to live normal and pro-ductive lives. This viewpoint is evident in much of the literature in such statements as: Given the benefits of modern treatment, the diabetic can live a normal l i f e in virtually every respect. He can work, play, even be a parent. He can do almost everything the non-diabetic can do. But f i r s t , he must learn to live with his disease.Q Diabetes mellitus can be successfully managed, and the opportunities for a f u l l l i f e in every respect are poten-tially as great as for those who da not have diabetes. This satisfactory outcome can be achieved most easily i f the different aspects of the management of diabetes are woven into the normal daily routine...... 9 These statements also suggest that the diabetic requires instruction about his condition i f he i s to manage i t successfully. It is a responsibility of the health professional to make this instruction available. Skelton stated, the onus on health professionals to make a comprehensive job of health teaching is ... profound."'^ The nurse, as a health professional, has begun to assume some responsibility for patient teaching. Krysan asked, "Haw are nurses to meet the increasing demand for the extensive teaching that diabetics require?""''"'' The development of a "Diabetic Teaching Tool" by Skelton was one response to this demand for teaching. This tool was designed Henry Dolger and Bernard Seeman, How to Live with Diabetes (3d ed.; New York: LJ.Ld. Norton and Co., 1972), p. 13. 9 Hunt (ed.), Diabetes, p. 62. ^Skelton, "Effectiveness of a Diabetic Teaching Tool," p. 2. "^Germaine S. Krysan, "How do Lde Teach Four Million Diabetics?" American Journal of Nursing, LXv", No. 11 (November, 1965), 105. f o r planned i n d i v i d u a l teaching to help the d i a b e t i c gain the know-ledge and s k i l l s r e quired f o r s e l f - c a r e . "The e f f e c t i v e n e s s of t h i s type of i n s t r u c t i o n was t e s t e d by comparing the s e l f - c a r e know-ledge and s k i l l s of two groups of adult d i a b e t i c s , one of which received the normal teaching of the i n s t i t u t i o n , and the other 12 planned i n s t r u c t i o n by means of the t o o l . " There were twenty sub-j e c t s i n each group. They were compared on a number of demographic and d i a b e t i c t r a i t s . Knowledge and s k i l l t e s t r e s u l t s of both groups were also compared. "Diabe t i c p a t i e n t s taught by means of the " D i a b e t i c Teaching Tool" demonstrated a s i g n i f i c a n t l y higher l e v e l of l e a r n i n g about s e l f - c a r e than d i d p a t i e n t s taught i n the unplanned manner ...."^ This appeared to be true r e g a r d l e s s of the duration of t h e i r diabetes age at time of teaching and t e s t i n g , previous education, and age at onset of diabetes. However, these f a c t o r s were s i g n i f i c a n t l y r e -l a t e d to the l e v e l of l e a r n i n g of p a t i e n t s r e c e i v i n g unplanned i n -s t r u c t i o n . I t i s recognized that i n d i v i d u a l p a t i e n t i n s t r u c t i o n has many advantages. An important one i s that i t can be at the i n d i v -i d u a l ' s l e v e l and pace. A l l content i s d i r e c t l y r e l a t e d to the i n -d i v i d u a l so that he does not have to s o r t out which f a c t s apply to him. However, i t also has some disadvantages. I t takes a consider-able amount of time and some p a t i e n t s s t i l l r e c e i v e only a minimum 12 S k e l t o n , "The E f f e c t i v e n e s s of a D i a b e t i c Teaching Tool," 40. 1 3 I b i d . , p. 89. 5 amount of instruction. J'" T l/alentine stated: Ideally, individual patient instruction has been pre-ferred, but uith the tremendous number of ... patients in clinics today and uith the limited number of professional people to render this teaching service, a more economical, yet adequate, method of teaching had to be found.^ The method to uhich she referred uas group instruction. What are the advantages of group instruction? Mezzanotte stated: Group instruction incorporates such advantages as more adequate instruction for more patients, a definite time and place for the instruction, a consistent presentation of the instructions and designation of one nurse to give the instruction. Moreover, i t offers the patient the poten-tially therapeutic value of participation in a group.16 Like the individual instruction, group instruction has disadvantages. It does not consider individual differences in learners or in mani-festation of diseases. In fact, individual concerns are frequently overlooked. The possibility of the group being controlled by one or more individuals is aluays a risk. Houever, nurses uith knou-ledge of group process and prepared in group teaching techniques can overcome many of these problems. SPECIFICS OF THE STUDY Hypotheses The hypotheses of this study uere: 1. there is no significant difference in the learning about Elizabeth Jane Mezzanotte, "Group Instruction in Preparation for Surgery," American Journal of IMursinq , LXX, IMo.l (January, 1970) ,89„ 15 Lois R. Valentine, "Self-Care Through Group Learning," American Journal of IMursing, LXX,l\lo. 10 (October, 1970), 2140. Mezzanotte, "Group Instruction," 89. 6 self care cf subjects receiving group instruction by means of the modified "Diabetic Teaching Tool" as compared to subjects receiving group instruction by means of the diabetic teaching program; 2. there is no significant difference in the scores on the test of diabetic learning of subjects receiving group instruction by means of the modified "Diabetic Teaching Tool" as compared to subjects receiving individual instruction by means of the "Diabetic Teaching Tool." Variables The independent variables in this study uere: 1. the modified "Diabetic Teaching Tool"; 2. the diabetic teaching program currently provided by the institution. The dependent variable uas the patient's learning about self-care as measured by a knowledge and s k i l l test. Assumptions of the Study This study uas based an tuo assumptions: 1. that diabetic patients require special learning to manage 17 their self-care at home; 2. that nurses have a role in the teaching of diabetic patients. Limitations of the Study The limitations of this study uere: Skelton, "The Effectiveness of a Diabetic Teaching Tool," 7. Ibid. i i 7 1. the small sample size; 2. the variability in the tuo groups of subjects. Definition of Terms Diabetic patient: "refers to any patient uho has a primary 19 or secondary diagnosis of diabetes mellitus." Diabetic Teaching Tool: refers to a teaching aid developed by Skelton. It consisted of an easel binder uhich contained pasters and nurses' instructions dealing uith eleven major content areas of diabetic learning and a carrying case uhich contained patient take-home folders, content corresponding to that presented in the easel binder, kardex slips, l i s t s of diabetic supplies, consent forms, meal-20 planning booklets and urine testing ki t s . Modified "Diabetic Teaching Tool": refers to a modification of the teaching aid developed by Skelton. The posters uere substit-uted by slides and minor deletions and additions uere made to the nurses' instructions to f a c i l i t a t e use of the tool in group in-struction. No changes uere made in the content. Each patient re-ceived a folder containing lesson material corresponding to that presented by the nurse, a meal-planning booklet and a urine testing k i t . This tool is contained in Appendix F of this study. Diabetic teaching program: refers to that program currently Skelton, "The Effectiveness of a Diabetic Teaching Tool," S. Judith M. Skelton, "A Diabetic Teaching Tool," Canadian  Nurse, LXIX, No. U (December, 1973), 36. a o f f e r e d at a large urban h o s p i t a l . The o u t l i n e of the program i s contained i n Appendix G of t h i s study. Group i n s t r u c t i o n : r e f e r s to teaching uhich i s planned and presented i n an inf o r m a l s e t t i n g to a group of tuo to eight p a t i e n t s S e l f - c a r e : " r e f e r s to the knouledge and s k i l l s uhich a d i a b e t i c person must have to manage h i s c o n d i t i o n e f f e c t i v e l y on a 21 day-to-day b a s i s . " P a t i e n t Learning: r e f e r s to the d i f f e r e n c e i n the scares obtained on the knouledge and s k i l l p r e t e s t and p o s t t e s t . S k e l t o n , "The E f f e c t i v e n e s s of a D i a b e t i c Teaching Tool," CHAPTER II REUIEU DF THE LITERATURE There is an abundance of literature cn the teaching af diabetic patients but only a limited amount is concerned uith the use of group instruction. Houever, there are articles and studies dealing uith group instruction for patients uith other conditions. These uere utilized in the preparation D f this study. The literature revieu is presented under the follouing headings: group instruction as a teaching method for patients; the teaching function of the nurse; and the importance of patient teaching in the management of self-care in, diabetics. GROUP INSTRUCTION AS A TEACHING METHOD FOR PATIENTS Group instruction has been utilized in the teaching of patients uith a variety of conditions. It has been uidely used for teaching prenatal care and to a lesser extent for instructing pre-operative patients. It is becoming a more popular method for teaching patients uith long term conditions such as rheumatoid a r t h r i t i s , chronic respiratory conditions and diabetes. Nickerson studied forty-one diabetic patients of uhom fifteen received group instruction, fifteen received individual in-struction, and eleven uere controls.''' The purpose of this study Donna Nickerson, "Teaching the Hospitalized Diabetic," American Journal of Nursing, LXXII, No. 5 (May, 1972), 937-938. 9 10 was-to determine i f d i a b e t i c s r e c e i v i n g group i n s t r u c t i o n uould demonstrate as much or more knouledge of diabetes and s k i l l i n urine t e s t i n g as d i a b e t i c s r e c e i v i n g i n d i v i d u a l i n s t r u c t i o n . The same questionnaire and check l i s t uere used f o r the p r e t e s t and p o s t t e s t fo r the three groups. The r e s u l t s uere: a gain of 0.73 points by the c o n t r o l group, a gain of 12.4 points by the p a t i e n t s uho re c e i v e d i n d i v i d u a l i n s t r u c t i o n and a gain of 16.5 pa i n t s by p a t i e n t s uho received group i n s t r u c t i o n . In continuing u i t h the group i n s t r u c t i o n to t h i r t y - s i x people Nickerson found, "better r e s u l t s and i n l e s s 2 time than i t took to i n s t r u c t f i f t e e n i n d i v i d u a l l y . " These f i n d i n g s uere supported by Bouen et a l . " ^ They i n -ve s t i g a t e d f i f t y - o n e p a t i e n t s to determine i f improvement i n p a t i e n t u e l l - b e i n g could be demonstrated i n a group of d i a b e t i c p a t i e n t s having a planned program of i n s t r u c t i o n . The c o n t r o l group c o n s i s t e d of tuenty-eight p a t i e n t s and the experimental group c o n s i s t e d of tuenty-three p a t i e n t s uho uere comparable i n age, ed u c a t i o n a l l e v e l and duration of disease. The c o n t r o l group r e c e i v e d an i n i t i a l assessment o n . f i v e s p e c i f i e d i n d i c e s , no i n s t r u c t i o n and a reassess-ment on the same f i v e i n d i c e s . The experimental group re c e i v e d the same assessments but betueen the tuo re c e i v e d f i v e i n s t r u c t i o n a l s e s s i o n s . The r e s u l t s shoued the experimental group to have made a s i g n i f i c a n t l y greater gain i n knouledge about t h e i r disease and s k i l l i n c a r r y i n g out t h e i r treatment than the c o n t r o l group made. There 2 I b i d . , p. 938. "^Rhoda G. Bouen, Rosemary Rich, and R o z e l l a M. S c h l o t f e l d t . " E f f e c t s of Organized I n s t r u c t i o n f o r P a t i e n t s u i t h the Diagnosis of Diabetes M e l l i t u s , " Nursing Research, No. 3 (Summer, 1961), 151-157. 11 uas no s i g n i f i c a n t d i f f e r e n c e betueen the tun groups i n r e l a t i o n to a t t i t u d e s or c l i n i c a l m a n i f e s t a t i o n of u e l l - b e i n g . The r e s u l t s of t h i s study suggest that group teaching i s e f f e c t i v e i n improving the p a t i e n t ' s knouledge about h i s c o n d i t i o n and h i s s e l f - c a r e s k i l l s but that t h i s does not n e c e s s a r i l y ensure a higher l e v e l of u e l l - b e i n g . Group teaching has been u t i l i z e d u i t h the p r e s u r g i c a l p a t i e n t u i t h some success. Lindeman s t u d i e d the e f f e c t of i n d i v i d u a l and group pre-operative teaching on a number of v a r i a b l e s i n 351 pre-5 s u r g i c a l p a t i e n t s . The r e s u l t s shoued group i n s t r u c t i o n to be as e f f e c t i v e as i n d i v i d u a l teaching f o r deep breathing, coughing and bed e x e r c i s e s as measured by postoperative v e n t i l a t o r y f u n c t i o n , length of h o s p i t a l stay, and number of ana l g e s i c s given postoper-6 a t i v e l y . Group teaching uas more e f f i c i e n t than i n d i v i d u a l teaching as measured by the mean length of time r e q u i r e d f o r p a t i e n t s to le a r n the bed. e x e r c i s e s . The mean length of l e a r n i n g time f o r sub-j e c t s uho rec e i v e d group i n s t r u c t i o n uas 1.8 minutes and f o r those 7 r e c e i v i n g i n d i v i d u a l i n s t r u c t i o n i t uas 4.1 minutes. In a d d i t i o n , i t uas more e f f i c i e n t i n terms of t o t a l time spent i n teaching. Mezzanotte als o s t u d i e d the use of group i n s t r u c t i o n i n 4 ' I b i d . , p. 156. 5 C a r o l A. Lindeman, "Nursing I n t e r v e n t i o n u i t h the Pre-s u r g i c a l P a t i e n t , " IMursing Research, XXI , No. 3 (May-June, 1972), 196. I b i d . , p. 206. I b i d . , p. 208. 12 a presurgical patients but did nut use a comparison group. She studied twenty-four patients having elective abdominal surgery. Instructions were given for thirty minutes to six groups of patients, averaging four patients per group. The planned instruction included four g major areas of information: 1. general instruction in preparation for surgery; 2. hospital policies concerning surgical patients; 3. suggestions about the control of pain; and k. activity that uould promote satisfactory recovery. The patients were intervieued by the investigator, five to seven days after surgery, using a printed guide to evaluate the in-struction. A l l patients agreed that the group instruction had been beneficial. Preference for group instruction was indicated by tuenty out of tuenty-four subjects uhen they uere asked to state a preference for jgroup or individual instruction. The investigator recognized that the study uas too limited to permit definite conclusions but ., she f e l t that i t supported the idea that a group technique uould be an effective method for instructing patients preoperatively Several nurses have uritten articles in support of group instruction but do not s t a t i s t i c a l l y support their claims. Robinson and Filkins report on the experiences of nurses uith group teaching Elizabeth Jane Mezzanotte, "Group Instruction in Preparation for Surgery," American Journal of Nursing, LXX, No. 1 (January, 1970), 89-91. 9Ibid., p. 90. 1 D I b i d . , p. 91. 13 i n an outpatient department.''""'" These c l a s s e s are organized so that there i s u t i l i z a t i o n of p a t i e n t w a i t i n g time. They measure t h e i r success by the increased p a t i e n t p a r t i c i p a t i o n and by the comments from the p a r t i c i p a n t s such as the one i n response to a d i a b e t i c foot care c l i n i c , " ' I f I'd had t h i s lesson on d i a b e t i c foot care ten years 12 ago, I might s t i l l have my l e g . ' " This does not n e c e s s a r i l y i n d i c -ate that group i n s t r u c t i o n i s superior to other forms of i n s t r u c t i o n but i t does i n d i c a t e that i t i s a v a l i d and u s e f u l teaching s t r a t e g y . THE TEACHING FUNCTION OF THE NURSE "The b a s i c purpose of nursing i s the promotion of h e a l t h ; teaching i s one of the nurse's a c t i v i t i e s that c o n t r i b u t e s to the attainment of that .aim.""^ A study by Pohl, of the teaching a c t i v -i t i e s of the nurse p r a c t i t i o n e r , revealed that there i s both'con-f u s i o n concerning the nurse's teaching r o l e and lack of preparation 14 f o r the r o l e . H o w e v e r i t i n d i c a t e d that the m a j o r i t y of nurses f e e l that teaching i s a nursing r e s p o n s i b i l i t y . One of the. con-c l u s i o n s drawn from the study was a d e f i n i t i o n of the teaching f u n c t i o n of the nursing p r a c t i o n e r . I t reads: "^Geraldine Robinson and M a r i l y n F i l k i n s , "Group Teaching with Outpatients," American Journal of Nursing, LXIV, No. 11 (Nov-ember, 1964), 110-112. 12 I b i d . , p. 111.. •^Margaret L. Pohl, The Teaching Function of the Nursing  P r a c t i t i o n e r (2d.ed.; Dubuque, Iowa: Urn. C. Brown Co., P u b l i s h e r s , 1973), p. 1. ^ Margaret L. Pohl, "Teaching A c t i v i t i e s of the Nurse Prac-t i t i o n e r , " Nursing Research, XIV, No. 1 (Winter, 1965), 4-11. Ik The teaching f u n c t i o n of the nursing p r a c t i t i o n e r c o n s i s t s of a system of a c t i o n s , intended to induce l e a r n -i n g , which provides a c t i v i t i e s , m a t e r i a l s , and guidance i n informal s i t u a t i o n s ; i t includes both the a c t i v i t i e s of communication and the a c t i v i t i e s of s t r u c t u r e d teaching; i t i s d i r e c t e d toward a s s i s t i n g the le a r n e r to achieve h i s p o t e n t i a l ....15 In response to the question of how the nurse can car r y out the f u n c t i o n of teaching among such divergent groups of people as p a t i e n t s and i n so many s e t t i n g s Pohl s t a t e d that there i s one s i m i l a r i t y which has great s i g n i f i c a n c e : A l l these l e a r n e r s are human beings and the b a s i c processes of l e a r n i n g are the same f o r everyone, regard-l e s s of i n d i v i d u a l d i f f e r e n c e s or v a r i a t i o n s i n the teach i n g - l e a r n i n g s i t u a t i o n . 1 6 In s p i t e of i t s acceptance as a u s e f u l t o o l i n the p r a c t i c e 17 of nursing, teaching of p a t i e n t s has been performed i r r e g u l a r l y . One of the things to which Redman a t t r i b u t e s t h i s problem i s - the confusion about the teaching r o l e s of various health team members. She stated t h a t , "a c l e a r e r d e l i n e a t i o n of goals and the d i v i s i o n of labor would l i k e l y y i e l d more e f f e c t i v e care.""1'^ She emphasized that nursing must take some i n i t i a t i v e i n t h i s s i t u a t i o n . Palm.conducted a d e s c r i p t i v e survey to determine whether nurses give top p r i o r i t y to p a t i e n t teaching over other aspects 1 5 I b i d . , p. 11. •^Pohl, "Teaching Function of the IMursing P r a c t i t i o n e r , " p. k. 17 Barbara K. Redman, The Process of P a t i e n t Teaching i n  IMursing (2d ed.; Saint L o u i s : The C.\J.Mosby Co., 1972), p. Ik. " ^ I b i d . , p. 15. 15 of care uhen presented u i t h w r i t t e n d e s c r i p t i o n s of p a t i e n t s with 19 l e a r n i n g needs i n nonemergency s i t u a t i o n s of d i r e c t nursing care. F i f t y - n i n e percent of 151 m e d i c a l - s u r g i c a l nurses assigned top p r i o r i t y to teaching but tended to s t r e s s explanations of immediate care rather than preparation f o r discharge and s e l f - c a r e at home. The survey a l s o revealed that the nurses tended.to teach i n r e -sponse to expressed l e a r n i n g needs by p a t i e n t s uhich may i n d i c a t e that they have d i f f i c u l t y u i t h i d e n t i f y i n g these needs and are r e l u c t a n t to i n i t i a t e p a t i e n t teaching i f t h e i r oun assessment i s 20 the only b a s i s f o r the d e c i s i o n . One of the reasons suggested f o r the r e l u c t a n c e to i n i t i a t e p a t i e n t teaching i s the l a c k of knowledge concerning s p e c i f i c con-d i t i o n s . E t z w i l e r administered a t h i r t y - f i v e item m u l t i p l e choice t e s t on general knowledge of diabetes to 289 graduating senior 21 nursing students. The survey revealed a s i g n i f i c a n t lack of i n -formation concerning b a s i c concepts of diabetes as w e l l as knouledge 22 of fundamental nursing procedures r e l a t e d to the d i s e a s e . P a t i e n t teaching i s more than the g i v i n g of information i n response to a question, as uas painted out i n Pohl's d e f i n i t i o n of 19 Mary Lock Palm, "Recognizing Opportunities f o r Informal P a t i e n t Teaching," The Nursing C l i n i c s of North America, U l , No. k (December, 1971), 672-678. 2 D I b i d . , p. 676. 2 1 D o n n e l l D. E t z u i l e r , "Who's Teaching the D i a b e t i c ? " Diabetes, XVI, No. 2 (February, 1967), 111-116. 22 I b i d . , p. 116. 16 the teaching f u n c t i o n of the nurse p r a c t i t i o n e r . I t i n cludes planning the content, methods, techniques and devices that are to 23 be used and a means of e v a l u a t i n g whether l e a r n i n g has occurred. The nurse has a number of teaching methods from uhich to choose i n the process of executing her teaching f u n c t i o n . Monteiro s t a t e d , "The teaching can be very i n f o r m a l teaching done i n c i d e n t a l l y at" the p a t i e n t ' s bedside or, at the other end of the continuum, can be formal and h i g h l y s t r u c t u r e d , as teaching done i n the s t r u c t u r e d 2k formal l e c t u r e s of a d i a b e t i c teaching u n i t . " Palm shoued a p r e f -erence f o r i n f o r m a l teaching. She s t a t e d , "Informal teaching at the bedside has been i d e n t i f i e d as the most e f f e c t i v e , opportune, and 25 important teaching." Houever, more recent research has provided information uhich suggests that t h i s i s not n e c e s s a r i l y true i n a l l i n s t a n c e s . Redman expressed the need f o r evidence concerning the e f f e c t i v e n e s s of p a t i e n t teaching i n a v a r i e t y of circumstances. She urote, "Much i n s t r u c t i o n given by nurses i s done on a one-to-one basis i n s i t u a t i o n s uhere the b e n e f i t s of group i n s t r u c t i o n . . . 26 might be c o n s i d e r a b l e . " May Hornback, "Diabetes M e l l i t u s - The Nurse's Role," Nursing C l i n i c s of North America, U, No. 1 (March, 1970), 10. 2k L o i s A. Monteiro, "Notes on P a t i e n t Teaching - A Neglected Area," Nursing Forum, I I I , No. 1 ( W i n t e r , 1964), 26. 25 Palm, "Informal P a t i e n t Teaching," 678. Barbara K. Redman, "Patient Education as a Function of Nursing P r a c t i c e , " Nursing C l i n i c s of North America, U l , No. k (December, 1971), 579. 17 THE IMPORTANCE OF PATIENT TEACHING IN THE MANAGEMENT OF SELF-CARE IN DIABETICS The education of the p a t i e n t and h i s f a m i l y , about h i s con-d i t i o n , i s g e n e r a l l y accepted as one of the most important aspects 27 of the treatment of diabetes. Hamui o u t l i n e d some reasons f o r i t s importance. The more information the i n d i v i d u a l u i t h diabetes m e l l i t u s has about h i s disease, the greater the p o s s i b i l i t y that optimum c o n t r o l u i l l be achieved, and the incidence of acute complications u i l l be markedly reduced. There i s suggestive evidence that there uould also be an a s s o c i a t e d decrease i n the incidence of chronic c o m p l i c a t i o n s . In a d d i t i o n to these compelling medical reasons, the.educated p a t i e n t i s f a r more s e l f - s u f f i c i e n t and adaptable to a l l environmental s t r e s s e s , and i n general u i l l r e q u i r e feuer h o s p i t a l i z a t i o n s than the l e s s informed.28 A l l a n suggests that education of the d i a b e t i c may be the means df 29 saving h i s l i f e . Dolger and Seeman supported these v i e u s . They s t a t e d : The d i a b e t i c should knou everything that can be knoun about h i s ailment, i t s h i s t o r y , nature, hou i t develops, the problems i t c r e a t e s , hou i t i s t r e a t e d . He should be able to d i s t i n g u i s h medical f a c t from papular fancy, prejudice from sound p r a c t i c e . Knouing these t h i n g s , he u i l l be b e t t e r able to cape u i t h h i s disease every day of h i s l i f e . 3 0 27 George 0. Hamui, " S p e c i a l Announcement: Treatment of Diabetes," J o u r n a l of the American Medical A s s o c i a t i o n , CLXXXI (September 22, 1962), 1064. 28 T. . . I b i d . 29 Frank N. A l l a n , "Education of the D i a b e t i c P a t i e n t , " The  Neu England J o u r n a l of Medicine, CCLXUIII No. 2 (January 10,1963), 94. Henry Dolger and Bernard Seeman, Hou to L i v e u i t h Diabetes (3d ed.; Neu York: U.Ld. Norton and Co. Inc., 1972), p. 13. 18 U h i l e many agree w i th Hamwi t h a t , "the optimum time f o r the educat ion of the p a t i e n t i n r e l a t i o n to a c h r o n i c d i s e a s e , such as d i a b e t e s , i s when i t i s o r i g i n a l l y d iagnosed," 3 " ' ' they tend to s t r e s s the need f o r c o n t i n u i t y of e d u c a t i o n . Duncan s t a t e d , "Change i s i n e v i t a b l e . The understanding and the management of 32 d iabetes are no e x c e p t i o n . " Thus, the i n i t i a l educat ion i s r e a l l y an i n t r o d u c t i o n to a l i f e l o n g p r o c e s s . A l l a n a l s o gave support to t h i s idea when he s t a t e d : Adequate educat ion of the p a t i e n t at the beg inn ing of treatment can g ive him a s t a r t i n the r i g h t d i r e c t i o n and p ro tec t him from p i t f a l l s . N e v e r t h e l e s s , i t i s important f o r the p h y s i c i a n to see him at r e g u l a r i n t e r v a l s to rev iew and supplement h i s i n s t r u c t i o n . The w e l l informed and w e l l s u p e r v i s e d p a t i e n t i s best assured of the maintenance of good h e a l t h and a long l i f e . 3 3 E t z w i l e r , i n c o m p i l i n g h i s l i s t of aspects that should be taught to a l l p a t i e n t s and t h e i r f a m i l i e s , i n c l u d e d , "the importance of c o n -34 t i n u i n g care and e d u c a t i o n . " A study by Stone i n 1961 o f f e r e d support to those who b e -l i e v e d i n the importance of p a t i e n t e d u c a t i o n . He s t u d i e d 16D p a t i e n t s w i th d iabetes and found 126 p a t i e n t s to be poor l y r e g u l a t e d . A number of f a c t o r s were found to c o n t r i b u t e to t h i s i n c l u d i n g "^Hamwi, "Announcement," 1064. -in G a r f i e l d G. Duncan, A Modern P i l g r i m ' s Progress wi th Fur ther  R e v e l a t i o n s f o r D i a b e t i c s (2nd e d . ; P h i l a d e l p h i a : LU. B. Saunders C o . , 1967) p. i x . 3 3 A l l a n , " E d u c a t i o n , " 9 5 . Donne l l D. E t z w i l e r , " P a t i e n t E d u c a t i o n , " Diabetes M e l l i t u s : D iagnos is and Treatment, e d s . S te fan S . Fajans and K a r l E. Sussman, V o l . I l l (New York : American Diabetes A s s o c . , I n c . , 1 9 7 1 ) p . l 8 6 . 19 failure to adhere to diet, "because they did not know enough about 35 i t . " Fifty-one of the 126 poorly controlled patients responded to the appropriate instructions and treatment by achieving good control. 3^ Ldatkins et al studied sixty c l i n i c patients to determine the relationship between what people know, what they da and their 37 state of diabetic control. They found that those who knew more about diabetes managed better when rated on management of insulin, urine tests, diet and foot care. However, in rating disease control they found those who knew more to be in poorer control. This negative correlation between knowledge and control was also reported by Williams and Martin in, "The C l i n i c a l Picture of 38 Diabetic Control, Studied in Four Settings." Of 213 patients studied, 29 percent were in acceptable control and 71 percent in less than adequate control. However, other factors were found ta be re-lated to poor control such as early age at onset, large household size and presence of major social problems. Stone also identified emotional problems and refusal of the patient to attempt to regulate "^Daniel B. Stone, "A Study of the Incidence and Causes of Poor Control in Patients with Diabetes Mellitus," The American  Journal of the Medical Sciences, CCXLI (April, 1961), 441. Ibid. 37 Julia D. Watkins et a l , "A Study of Diabetic Patients at Home," American Journal of Public Health, LVII, l\lo. 3 (March, 1967), 452. 38 T. Franklin Williams and Dan A. Martin, "The C l i n i c a l Picture of Diabetic Control, Studied in Four Settings," Diabetes, XIV, via. 7 (July, 1965), 469. 2D the i l l n e s s as c o n t r i b u t i n g factors."'"' In view of these and other f i n d i n g s Skelton s t a t e d : Whether or not there i s a p o s i t i v e r e l a t i o n s h i p be-tween knowledge about diabetes and c l i n i c a l c o n t r o l of the disease i s s t i l l a matter D f debate. Whatever the ultimate t r u t h of t h i s d i s c u s s i o n , knowledge appears to ^ be relevant to e f f e c t i v e management of s e l f - c a r e at home. What i s the s i g n i f i c a n c e of t h i s information to p a t i e n t teaching? Skelton s t a t e d , "The problem, then, becomes l e s s one of 'should 41 we teach?' and more one of 'how can we b e t t e r our teaching?'" Stone, "Incidence and Cause of Poor C o n t r o l , " 441. I S k e l t o n , " E f f e c t i v e n e s s of a D i a b e t i c Teaching Tool," 13. I b i d . , p. 4. SUMMARY 2 1 The l i t e r a t u r e r e v i e u revealed an increase i n the use c f group i n s t r u c t i o n as a teaching method. Research i n v o l v i n g com-parison of group i n s t r u c t i o n and i n d i v i d u a l i n s t r u c t i o n has i n d i c -ated that group i n s t r u c t i o n i s as e f f e c t i v e as i n d i v i d u a l i n -s t r u c t i o n i n some instances and more e f f e c t i v e i n ot h e r s . Research i n uhich no comparison uas made i n d i c a t e d that group i n s t r u c t i o n i s an e f f e c t i v e means of p a t i e n t teaching. Houever, ue must be mindful of the other f a c t o r s uhich i n f l u e n c e l e a r n i n g , such as i n t e r e s t and exp e r t i s e of the teacher, number of people i n the group and readiness of the l e a r n e r . There i s an acceptance of teaching as a f u n c t i o n of the nurse. Houever, i t i s a f u n c t i o n that i s not u e l l performed. A number of reasons f o r t h i s inadequate performance uere i d e n t i f i e d . There uas much support f a r the b e l i e f that p a t i e n t teaching i s an important f a c t o r i n the management of s e l f - c a r e i n d i a b e t i c s . Unfortunately, the l i t e r a t u r e r e v i e u revealed that good management does not aluays lead to good c o n t r o l . Age at onset, household s i z e and the presence of emotional and s o c i a l problems uere f e l t to be c o n t r i b u t i n g f a c t o r s to lack of good c o n t r o l . CHAPTER I I I METHODOLOGY INTRODUCTION This study uas conducted to determine i f the modified "Diabetic Teaching Tool" i s an e f f e c t i v e t o o l f o r use i n group i n -s t r u c t i o n . The t o o l uas o r i g i n a l l y designed by Skelton f o r use i n i n d i v i d u a l i n s t r u c t i o n . No changes uere made i n the content of the t o o l but some m o d i f i c a t i o n s uere r e q u i r e d i n the format of present-a t i o n . The i n s t r u c t i o n uas given i n four and one-half hours. This in v o l v e d one-half hour of i n s t r u c t i o n on Monday and one hour of i n -s t r u c t i o n on each of the days Tuesday through F r i d a y . The e f f e c t -iveness of the modified, t o o l uas determined by comparing the l e a r n i n g about s e l f - c a r e by tuo groups of d i a b e t i c s , one of uhich r e c e i v e d planned group i n s t r u c t i o n by means of the i n s t i t u t i o n ' s d i a b e t i c teaching program, and.the other r e c e i v e d planned group i n s t r u c t i o n by means of the modified " D i a b e t i c Teaching Tool." A l l subjects uere pretested and po s t t e s t e d by the researcher. No attempt uas made to c o n t r o l other v a r i a b l e s uhich are l i k e l y to i n f l u e n c e the e f f e c t -iveness of any teaching program. I t uas hoped that these v a r i a b l e s uould be s i m i l a r f o r both groups of s u b j e c t s . THE SETTING .The subjects uere chosen from i n p a t i e n t s and ou t p a t i e n t s uho attended the d i a b e t i c c l a s s e s at a large urban h o s p i t a l betueen 22 23 November 5, 1973 and March h, 131k. A l l p a t i e n t s uho met the c r i t e r i a of the study uere asked to p a r t i c i p a t e . A l l p a t i e n t s uho agreed to p a r t i c i p a t e uere asked to give u r i t t e n consent. The consent forms are contained i n Appendix A of t h i s study. CRITERIA FOR SUBJECT SELECTION The c r i t e r i a f o r subject s e l e c t i o n uere s i m i l a r to those of the o r i g i n a l study f o r the purpose of comparison: 1. has a primary or secondary diagnosis of diabetes m e l l i t u s f 2. f a l l s i n t o one of the f o l l o u i n g c l a s s e s : a) neuly diagnosed d i a b e t i c s , b) diabetes out of c o n t r o l , c) diabetes u i t h cornplication(s ) , d) ante-partum p a t i e n t s , e) p a t i e n t s u i t h u nrelated medical c o n d i t i o n s , f ) p o s t - s u r g i c a l p a t i e n t s ; 3. i s IS years of age or over; h. speaks and u r i t e s E n g l i s h ; 5. i s si g h t e d ; 6. i s t a k i n g i n s u l i n or an o r a l hypoglycemic agent; 7. consents to p a r t i c i p a t e ; fl. l i v e s u i t h i n a f i f t y mile r a d i u s of Vancouver C i t y ; 9. has no current diagnosis of mental or emotional problems; 10. i s not a member of the hea l t h p r o f e s s i o n s ; and 11. has completed the f i v e sessions of the group i n s t r u c t i o n . THE TOOL The "Diab e t i c Teaching To o l " uas developed by Skelton f o r use i n i n d i v i d u a l i n s t r u c t i o n . The t o o l uas subjected to a c r i t i c a l 24 r e v i e u and r e v i s i o n by a panel of experts to e s t a b l i s h validity."'' No changes uere made i n the content of the t o o l but s l i d e s uere used i n s t e a d of a f l i p c h a r t . The content uas organized so that i t could be taught i n f i v e p a r t s : 1. i n t r o d u c t i o n 2. d i e t 3. medicine 4. e x e r c i s e , hygiene and urine t e s t i n g 5. problems. Changes uere r e q u i r e d i n the method of p r e s e n t a t i o n to f a c i l i t a t e use i n group i n s t r u c t i o n . In r e l a t i o n to d i e t , p a t i e n t s uere given a copy of t h e i r own d i e t but r e c e i v e d general i n f o r m a t i o n on d i e t planning. A l l p a t i e n t s uere exposed to information concerning a n t i -d i a b e t i c p i l l s and i n s u l i n . They uere expected to knau the type of medication they uere r e c e i v i n g so that they could choose the inform-a t i o n uhich a p p l i e d to them.- They uere a s s i s t e d by the nurse. The i n s u l i n - u s e r s uere given only one opportunity to prepare t h e i r i n s u l i n . Equipment uas provided so that they could p r a c t i c e at t h e i r bedside. The a d m i n i s t r a t i o n of i n s u l i n uas demonstrated by the nurse but the p a t i e n t s uere unable to give t h e i r oun i n s u l i n at that time. The uard s t a f f supervised the s e l f - a d m i n i s t r a t i o n of i n s u l i n uhen the p a t i e n t s uere ready to do i t . F i n a l l y , only one opportunity uas given to p r a c t i c e urine t e s t i n g during the i n s t r u c t i o n . Again t h i s uas f o l l o u e d up by uard s t a f f . U nfortunately, the o u t p a t i e n t s d i d J u d i t h M. S kelton, "An Experimental Study to Evaluate the E f f e c t i v e n e s s of a D i a b e t i c Teaching T D O I , " (unpublished Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973), 43. 25 not have t h i s o p p o r t u n i t y . The modified " D i a b e t i c Teaching T o o l " i s contained i n Appendix F of t h i s study. The modified t o o l uas pretested on a group of s i x d i a b e t i c s . The only changes req u i r e d r e l a t e d to the teacher's performance, e s p e c i a l l y i n d i r e c t i n g the p a t i e n t s ' a t t e n t i o n to the s l i d e s . The reader i s r e f e r r e d to Skelton's t h e s i s f o r a copy of the "Diabetic Teaching Tool" and the o b j e c t i v e s f o r i t s use. The knouledge and s k i l l t e s t developed by.Skelton uas pre-t e s t e d on approximately fourteen p a t i e n t s uho attended tuo l o c a l d i a b e t i c c l a s s e s and four p r o f e s s i o n a l people i n v o l v e d u i t h the teaching of these c l a s s e s . Question tuo caused same confusion f o r the p a t i e n t s as i t req u i r e d seven responses but only four spaces uere a v a i l a b l e on the ansuer sheet.. I t uas decided to move t h i s question to number one as i t uas a d i f f e r e n t form of question from the others and to leave an open space f o r the ansuer. Some of the p a t i e n t s found i t d i f f i c u l t to use a separate question and ansuer sheet. Thus, the tuo uere combined. F i n a l l y , the p r o f e s s i o n a l people questioned uhether you should consult a doctor uhenever you have a corn or a c a l l u s . This uas i n reference to question 23(E). The question uas then changed to read, "you have a f l u " r a t h e r than omit i t and change the t o t a l number of questions. THE PROCEDURE The steps f o l l D u e d i n the performance of t h i s study uere: 1. Permission uas obtained from the i n s t i t u t i o n ta conduct the study. 2. Discussion uas held u i t h Skelton concerning the p a s s i -26 b i l i t y of using the "D i a b e t i c Teaching Tool." 3. Permission uas obtained from M i l e s Laboratories to use the t o o l . L a t e r , permission uas obtained to modify i t . 4. P r e t e s t i n g of the knouledge t e s t developed by Skelton uas c a r r i e d out. The changes made are p r e v i o u s l y o u t l i n e d . The t e s t i s contained i n Appendix E of t h i s study. 5. The p a t i e n t p r o f i l e sheet uas designed f o r the purpose of o b t a i n i n g demographic and d i a b e t i c c h a r a c t e r i s t i c s of the s u b j e c t s . This p r o f i l e sheet i s contained, i n Appendix C of t h i s study. I t i s s i m i l a r to the one used by Skelton so that a comparison of the sub-j e c t s using the "Diabetic Teaching To o l " and modified " D i a b e t i c Teaching To o l " could be made. 6. The d i a b e t i c teaching program f o r the i n s t r u c t i o n of the c o n t r o l group of subjects uas conducted by a d i e t i c i a n and a nurse. An o u t l i n e of t h i s program i s contained i n Appendix G of t h i s study. 7. An explanation uas given to each p a t i e n t uho met the c r i t e r i a d e s c r i b i n g the purpose of the study and hou i t uould be con-ducted. A w r i t t e n consent uas obtained uhen- the p a t i e n t agreed to p a r t i c i p a t e . This was f o l l o u e d by the a d m i n i s t r a t i o n of the t e s t of d i a b e t i c l e a r n i n g which i s contained i n Appendix E of t h i s study. A l l subjects were pos t t e s t e d , using the same t e s t of d i a b e t i c l e a r n i n g , between two and seven days f o l l o w i n g completion of the i n s t r u c t i o n . The p r e t e s t s were administered at the p a t i e n t ' s bedside or i n the classroom before commencement of i n s t r u c t i o n . The p o s t t e s t s were administered at the p a t i e n t ' s bedside or i n h i s own home. The pa t i e n t p r o f i l e sheet uas completed at that time. A t o t a l of tuelve subjects uas obtained. 2 7 8. The "Diabetic Teaching Tool" uas modified for use in group instruction. This modified tool is contained in Appendix F of this study. 9. Instruction by the researcher uas provided for the nurse to familiarize her uith the modified "Diabetic Teaching Tool." ID. Pretesting of the modified tool uas. conducted on a group of six patients. The tool uas used for the instruction of the experi-mental group of subjects. The procedure followed uas identical to that outlined in item seven. A total of tuelve subjects uas obtained." DATA ANALYSIS The control and^experimental subjects uere compared on the demographic and diabetic characteristics obtained from the patients' profile sheet. The t-test uas used to analyze the test results. Then the Pearson product-moment correlation coefficient was used to compare the total percentage test scores with selected demographic and diabetic characteristics. A level of .05 was considered to be s t a t i s t i c a l l y significant for a l l tests. Finally, a descriptive comparison was made between the data obtained from the use of the modified "Diabetic Teaching Tool" and that obtained by Skelton from the use of the "Diabetic Teaching Tool" in individual instruction. SUMMARY This chapter has presented the methodology of the study. A description was given of the setting of the study, the cr i t e r i a far subject selection, the tool, the procedure followed in the preparation and execution of the study and a brief outline of the method of data analysis. CHAPTER IV ANALYSIS OF THE DATA INTRODUCTION A total of twenty subjects agreed to participate in the con-t r o l group of the study. Eight were later eliminated because of failure to attend the five classes. A total of eighteen subjects agreed to participate in the experimental group of the study. Six were later eliminated for a variety of reasons. Four of these six subjects failed to attend a l l five classes, one was found to have a diagnosis of a psychiatric nature and one was withdrawn by his doctor. No subjects withdrew from the study after completion of the five classes. The findings of this study were analyzed in the following manner: 1. A comparison was made of the demographic.and diabetic characteristics of the control and experimental subjects as obtained from the profile sheets. These characteristics were: age, sex, marital status, education, reason for current admission to hospital or v i s i t to the doctor, age at onset of diabetes, length of time since diagnosed, type of control of condition and sources of inform-ation used. 2. A comparison was made of the control and experimental subjects on the difference in their pretest and posttest scores on the test of diabetic learning by means of the t-test. 28 29 3. An examination of the c o r r e l a t i o n betueen the t o t a l percentage score and the demographic and d i a b e t i c c h a r a c t e r i s t i c s of the subjects using the Pearson product-moment c o r r e l a t i o n c o e f f i c -i e n t uas conducted. 4. A d e s c r i p t i v e comparison of the mean scores of the ex-perimental group of t h i s study on the t e s t of d i a b e t i c l e a r n i n g and the mean scores obtained by Skelton using the "D i a b e t i c Teaching T o o l " f o r i n d i v i d u a l p a t i e n t teaching uas presented. These tuo groups uere also compared on the demographic and d i a b e t i c c h a r a c t e r i s t i c s of the sub j e c t s . DEMOGRAPHIC AND DIABETIC CHARACTERISTICS OF THE SUBJECTS Age A comparison of the subjects by age i s contained i n Table I . One t h i r d of the subjects i n each group uere betueen f i f t y - f i v e and s i x t y - f o u r years of age. Houever, the experimental group had more subjects i n the younger age c a t e g o r i e s . This r e s u l t e d i n a median age of f o r t y - n i n e and one-half years f o r the experimental group u h i l e the median age f a r the c o n t r o l group uas f i f t y - f o u r and one-half years. 3D TABLE I A COMPARISON DF CONTROL AND SUBJECTS BY AGE EXPERIMENTAL Age (years) Control subjects Experimental subjects 15 - 2k 0 2 25 - 3k 1 2 35 - kk .3 1 k5 - 5k 2 2 55 - Sk k k 65 - Ik 2 1 75 - Bk 0 0 85 and aver a D Total 12 12 Sex . Table II indicates that the control and experimental group uere quite similar in relation to sex. The control group consisted of seven females and five males uhile the expe'rimental group had six females and six males. 31 TABLE II A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY SEX Sex Control Experimental subjects subjects Male 5 6 Female 7 6 Total 12 12 Marital Status . Table III shous a comparison of the control and experimental subjects by marital status. The majority of the subjects in each group uere married. Ten out of tuelve in the control group and seven out of tuelve in the experimental group uere married. The remainder of the control subjects uere uidoued uhile the remainder of the experimental subjects uere either single or separated. TABLE III A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY MARITAL STATUS Control Experimental Marital status subjects subjects Single 0 3 Married 10 7 LJidoued 2 0 Divorced/Separated 0 2 Total 12 . 12 32 Education The c o n t r o l and experimental subjects uere q u i t e s i m i l a r i n the l e v e l of education a t t a i n e d . Nine out of twelve subjects i n each group had achieved grade ten or higher. These data are contained i n Table IV. TABLE IV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY EDUCATION Level of C o n t r o l Experimental education subjects subjects completed Less than grade S 2 2 Grade 6 to 9 1 1 Grade 10 to 12 6 Beyond grade 12 ^ 5 3 T o t a l 12 12 Reason f o r Current Admission to H o s p i t a l or V i s i t to Doctor A comparison of the c o n t r o l and experimental subjects by reason f o r current admission to h o s p i t a l or v i s i t to the doctor i s contained i n Table V. The tuo groups of subjects uere very s i m i l a r . Each, group had ten subjects with diabetes r e l a t e d diagnoses and tuo subjects u i t h unrelated c o n d i t i o n s . In a d d i t i o n , each group had eight i n p a t i e n t s and four o u t p a t i e n t s . 33 TABLE V A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY REASON FOR CURRENT ADMISSION TO HOSPITAL OR VISIT TO DOCTOR Reason f a r current admission to h o s p i t a l or v i s i t to doctor C o n t r o l subjects Experimental subjects Neu d i a b e t i c k 3 Regulation of diabetes 5 7 Complication of diabetes 1 . 0 Unrelated c o n d i t i o n 2 2 T o t a l 12 12 Age at Onset of Diabetes Table VI shous that the experimental subjects uere more evenly d i s t r i b u t e d throughout each of the age groups. The median age at onset f o r the c o n t r o l subjects uas f o r t y - f o u r and one-half years and f a r the experimental group i t uas t h i r t y - n i n e and one-half years. The experimental subjects uere s l i g h t l y younger at age of onset than the c o n t r o l s u b j e c t s . 34 TABLE UI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY AGE AT ONSET OF DIABETES Age at onset of diabetes (years) Control subjects Experimental subjects 0 - 14 1 2 15 - 24 0 1 25-34 . 1 2 35 - 44 • 4 2 45-54 1 2 . 55 - 64 4 2 65 - 74 1 1 75 and over 0 0 Total 12 12 Length of Time Since Diagnosed A comparison of the control and experimental subjects by length of time since diagnosed is contained in Table UII. Both groups had a similar number of newly diagnosed subjects. However, they differed in the number of subjects who were diagnosed for over five years. The control group had one-quarter of their subjects in this category while the experimental had one-half in this category. The median length of time since diagnosed was four and one-half years for the control subjects and five and one-half years for the experimental subjects. 35 TABLE VII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY LENGTH OF TIME SINCE DIAGNOSED Length of time Control Experimental since diagnosed subjects subjects 1 day to 6 days 0 0 1 week to 3 months 5 k months to 11 months 1 0 1 year to 5 years k 1. Over 5 years 3 6 Total 12 12 Type of Control of Condition The majority of the control subjects controlled their con-dition by diet and antidiabetic p i l l s while the majority of the experimental subjects were controlled by diet and insulin. Thus the two groups of subjects differed greatly when compared on this char-acteristic. Table VIII contains these data. TABLE VIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY TYPE OF CONTROL OF CONDITION Type of control Control Experimental of condition subjects subjects Diet and antidiabetic p i l l 7 3 Diet and insulin 5 9 Total 12 12 3 6 Sources of Information F i n a l l y , a comparison of the c o n t r o l and experimental sub-j e c t s by sources of information uhich they have used i s contained i n Table IX. Ten sources of information uere l i s t e d and most sub-j e c t s i n d i c a t e d they had used mare than one of these sources. The experimental subjects used more sources of i n f o r m a t i o n than the c o n t r o l s u b j e c t s . In the c o n t r o l group, ten subjects l i s t e d c l a s s e s as being most u s e f u l , one l i s t e d the nurse and one l i s t e d the doctor. In the experimental group, ten l i s t e d the c l a s s e s as most u s e f u l and tuo l i s t e d the doctor. The sources l i s t e d as most u s e f u l uere a l l used the ueek p r i o r to completion of the p r o f i l e sheet. In summary, the demographic and d i a b e t i c c h a r a c t e r i s t i c s of the c o n t r o l and experimental group uere h i g h l y s i m i l a r . The c h a r a c t e r i s t i c s uhich shoued the greatest d i f f e r e n c e uere length of time since diagnosed and type of c o n t r o l of c o n d i t i o n . 37 TABLE A COMPARISON OF CONTROL AND SOURCES OF INFORMATION IX EXPERIMENTAL SUBJECTS BY UHICH THEY HAVE USED Source of information C o n t r o l subjects Experimental subjects Classes Pamphlets Books Radio Newspaper T e l e v i s i o n Friend or r e l a t i v e Doctor Nurse D i e t i c i a n 12 9 1 1 1 5 1 5 2 1 12 5 5 0 2 3 k 8 7 6 A COMPARISON OF DIFFERENCES IN PRETEST AND POSTTEST SCORES ON THE TEST OF DIABETIC LEARNING 38 The test of diabetic learning consisted of a knowledge test for insulin-users, a knowledge test for antidiabetic pill-users, a diet-planning s k i l l test, a urine-testing s k i l l test, and an insulin-injecting s k i l l test. The scores obtained on each of the subtests are contained in Appendix D of this study. The differences in the total percentage score obtained on the pretest and posttest of diabetic learning were analyzed by means of the t-test. This was followed by the use of the t-test to analyze the differences in the pretest and posttest scores of the subjects on the subtests of the test of diabetic learning. The results D f these tests were related to the f i r s t hypothesis. Table X contains a comparison of control and experimental subjects by the differences in the total percentage score on the pre-test and posttest of diabetic learning. The mean for the experimental subjects was better than that of the control subjects. However, the difference was not s t a t i s t i c a l l y significant. Then the differences in pretest and posttest scores obtained on the knowledge test were analyzed for the insulin-users and anti-diabetic pill-users. Tables XI and XII contain these respective comparisons. Although in both instances the mean was better for the experimental group, the difference was not s t a t i s t i c a l l y significant. The differences in the pretest and posttest scores for con-tro l and experimental subjects on the diet-planning s k i l l test are contained in Table XIII. In this case the mean for the control subjects was better than the mean for experimental subjects but the 3 9 TABLE X A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING Control subjects Experimental subjects 11.• 6.5 12.9 6.9 13.3 9.0 14.2 13.0 14.3 16.0 20.5 17.2 24.0 27.5 26.5 41.8 28.0 48.5 34.0 55.1 48.5 56.5 51.7 75.4 C = 24.90 E = 31.11 t = 0.791 (not significant) TABLE XI A COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE TEST Control subjects Experimental subjects 3.0 0.5 6.5 1.0 10.0 4.0 15.5 7.5 35.0 16.5 32.5 37.0 40.0 56.5 C = 14.0 E = 21.72 t = 0.73 (not significant) TABLE XII A COMPARISON OF CONTROL AND EXPERIMENTAL PILL-USERS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE TEST Control subjects Experimental subjects 4.0 23.5 6.0 24.0 .9.0 15.0 9.0 20.0 25.5 33.0 C = 15.21 E = 20.S3 t = 0.822 (not significant) TABLE XIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON DIET-PLANNING SKILL TEST Control subjects Experimental subjects 0.0 1.0 0.5 1.0 -0.5 1.5 2.0 2.0 5.0 2.5 12.0 . 3.5 14.0 . 3.5 14.0 6.5 14.0 16.0 14.5 17.5 15.5 18.0 15.5 19.5 C = 8.875 E = 7.708 t = • 0.397 (not significant) 4 3 difference was not s t a t i s t i c a l l y significant. The mean for the experimental subjects uas considerably higher than the mean for the control subjects on the urine-testing s k i l l test. Once again i t uas not s t a t i s t i c a l l y significant. These data are contained in Table XIU. Table XV contains the comparison of the differences in pre-test and posttest scores for both groups on insulin-injecting tech-nique. The mean for both groups of subjects uas very similar and no st a t i s t i c a l l y significant difference uas found. The scores on the s k i l l tests uere then combined uith the related knowledge scores as extracted from the knouledge test. The total possible score that could be obtained on the knouledge and s k i l l tests for diet-planning uas thirty-six .points. A comparison of the pretest and posttest difference in this combined score for both groups is contained in Table XVI. The mean for the control group uas slightly better than that of the experimental group but the difference uas not s t a t i s t i c a l l y significant. The scores on the knouledge and s k i l l tests of urine-testing uere combined for a total of tuenty points. The differences in the pretest and posttest scores are compared in Table XVII. There uas considerable difference in the mean of bath groups in favor of the experimental subjects. The t-test analysis shoued a difference uhich uas significant at the .05 level. Table XVIII shous a similar comparison for both groups of subjects on the insulin knouledge and s k i l l tests. The total possible score uas tuenty-one points. The mean of the experimental subjects uas higher than that of the control subjects. Here again, the TABLE XIV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON URINE-TESTING SKILL TEST Control subjects Experimental subjects 0.0 0.0 0.0 1.0 -0.5 1.0 -0.5 1.5 -0.5 2.0 0.5 2.5 1.0 3.5 1.0 3.5 2.5 3.5 3.0 4.0 3.0 7.0 7.0 7.0 C = 1.375 E = 3.042 t = 1.844 (not significant) 45 TABLE XV A COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON INSULIN-INJECTING SKILL TEST Control subjects Experimental subjects 0.0 -0.5 0.5 0.0 1.0 0.5 6.0 1.5 9.0 1.5 2.5 a.o 9.0 10.0 C = 3.3 X = 3.6 t = 0.136 (not s i g n i f i c a n t ) 46 TABLE XVI A.COMPARISON OF THE CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE AND SKILL'TESTS OF DIET-PLANNING Control subjects Experimental subjects 6.0 2.0 7.0 3.5 7.0 3.5 7.5 4.5 S.5 6.5 10.0 8.0 16.0 9.0 16.0 11.5 17.0 18.0 20.5 24.0 25.5 24.5 25.5 32.5 C = 13.37 E = 12.29 t = 0.443 (not significant) TABLE X V I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON KNOWLEDGE AND SKILL TESTS OF URINE-TESTING Control subjects Experimental subjects -0.5 0.0 -0.5 1.0 1.5 2.5 2*5. 3.5 2.0 5.0 2.0 5.0 3.0 7.5 3.5 8.0 4.0 9.5 6.0 10.0 7.0 12.0 S.O 14.0 C = 3.2 E = 6.5 t = 2.210 (significant at the .05 level) 48 TABLE XVIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY DIFFERENCE IN PRETEST AND POSTTEST SCORES ON INSULIN KNOWLEDGE AND SKILL TESTS Control subjects Experimental subjects -1.0 -0.5 0.0 1.5 3.5 2.0 8.0 4.0 16.0 6.5 V.5 12.0 14.0 17.5 C = 5.3 E = 7.167 t = 0.520 (not significant) 4 9 d i f f e r e n c e uas not s t a t i s t i c a l l y s i g n i f i c a n t . The f i n d i n g s of the data a n a l y s i s r e s u l t e d i n acceptance of the f i r s t hypothesis uhich s t a t e d that there i s no s i g n i f i c a n t d i f f e r e n c e i n the l e a r n i n g about s e l f - c a r e of subjects r e c e i v i n g group i n s t r u c t i o n by means of the modified "Diabetic Teaching Tool" as compared to subjects r e c e i v i n g group i n s t r u c t i o n by means of the d i a b e t i c teaching program. 50 CORRELATIONS BETWEEN DIFFERENCES IN TOTAL PERCENTAGE SCORES ON PRETEST AND POSTTEST OF DIABETIC LEARNING AND SELECTED DEMOGRAPHIC AND DIABETIC CHARACTERISTICS OF SUBJECTS This s e c t i o n of the data a n a l y s i s contains an examination of the r e l a t i o n s h i p betueen p a t i e n t l e a r n i n g and s e l e c t e d demographic and d i a b e t i c c h a r a c t e r i s t i c s . The s e l e c t e d c h a r a c t e r i s t i c s are age at t e s t i n g , education, age at onset of diabetes, reason f o r current admission to h o s p i t a l or v i s i t to the doctor and the length of time since diagnosed. Skelton found a s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n - * ship betueen the t o t a l percentage t e s t scores of c o n t r o l p a t i e n t s and age at t e s t i n g , education and age at onset of diabetes but no such c o r r e l a t i o n s c h a r a c t e r i z e d the experimental subjects."'" This r a i s e d the p o s s i b i l i t y that these c h a r a c t e r i s t i c s might i n f l u e n c e the l e a r n i n g of subjects i n other groups. I t uas also decided to examine the remaining tuo c h a r a c t e r i s t i c s on the ba s i s that they might be s i g n i f i c a n t l y r e l a t e d to l e a r n i n g i n group i n s t r u c t i o n . The r e l a t i o n s h i p betueen age at t e s t i n g and d i f f e r e n c e i n t o t a l percentage score on the p r e t e s t and p o s t t e s t of d i a b e t i c l e a r n -ing i s contained i n Table XIX. No s i g n i f i c a n t c o r r e l a t i o n e x i s t e d f o r the c o n t r o l or experimental group. Table XX shous that no c o r r e l a t i o n e x i s t e d betueen the l e v e l of education and the d i f f e r e n c e i n t o t a l percentage score on the pre-t e s t and p o s t t e s t of d i a b e t i c l e a r n i n g . J u d i t h M. Skelton, "An Experimental Study to Determine the E f f e c t i v e n e s s of a D i a b e t i c Teaching Tool," (unpublished Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973), Bk. 51 TABLE XIX THE CORRELATION BETWEEN AGE AT TESTING AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING Diff e r e n c e i n t o t a l percentage score Age (Years) C o n t r o l subjects Experimental subject; 15-24 (1) (1) • • • • • • 6.5 17.2 25-34 (2) (2) 51.7 • • • 6.9 75.4 35-44 (3) (3) (3) 11.0 12.9 13.3 9.0 • • • • • • 45-54 (4) (4) 14.2 28.0 13.0 16.0 55-64 (5) (5) (5) (5) 20.5 26.5 34.0 48.5 27.5 41.8 55.1 •. 56.5 65-74 (6) (6) 14.3 24.0 48.5 • • • 75-84 (7) • •' • • • • 85 and over (8) • • • • • • r c = rE = -0.05 (not s i g n i f i c a n t ) 0.42 (not s i g n i f i c a n t ) 52 TABLE XX THE CORRELATION BETUEEN EDUCATION AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING Education Di f f e r e n c e i n t o t a l percentage score C o n t r o l subjects Experimental subjects Less than grade 6 (1) 12.9 9.0 (1) 24.0 56.5 Grade 6 to 9 (2) 34.0 55.1 Grades 10 to 12 (3) 13.3 6.5 (3) 14.2 27.5 (3) 20.5 48.5 (3) 48.5 • • • Beyond grade 12 (4) 11.0 6.9 (4) 14.3 13.0 (4) 26.5 16.0 (4) 28.0 17.2 (4) 51.7 41.8 ' (4) 75.4 Tp = 0.14 (not s i g n i f i c a n t rpr = -0.16 (not s i g n i f i c a n t ) 5 3 Again no c o r r e l a t i o n uas found betueen age at onset of diabetes and d i f f e r e n c e i n scores obtained by subjects i n both groups. Table XXI contains these data. Table XX I I i n d i c a t e s that no c o r r e l a t i o n uas found betueen length of time since diagnosed and d i f f e r e n c e i n the t o t a l percent-age score Dn both t e s t s f o r the c o n t r o l group. Houever a s i g n i f i c a n t ' c o r r e l a t i o n uas found to be present i n the experimental group. F i n a l l y , a t - t e s t uas used to determine the r e l a t i o n s h i p be-tueen the reason f o r current admission to h o s p i t a l or v i s i t to the doctor and the d i f f e r e n c e i n the t o t a l percentage score on the pre-t e s t and p o s t t e s t of d i a b e t i c l e a r n i n g . IMo s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p uas found f o r e i t h e r group of s u b j e c t s . These data are contained i n Table XXIII. In summary, no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p uas found betueen p a t i e n t l e a r n i n g and the s e l e c t e d c h a r a c t e r i s t i c s of age at t e s t i n g , education, age at onset of diabetes and the reason f o r current admission to h o s p i t a l or v i s i t to the doctor f o r e i t h e r the c o n t r o l or experimental group. Houever, there uas a s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p i n the experimental group betueen l e a r n i n g and the length of time since diagnosed. 54 TABLE XXI THE CORRELATION BETUEEN AGE AT ONSET OF DIABETES AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETTEST AND POSTTEST OF DIABETIC LEARNING Age at onset Dif f e r e n c e i n t o t a l percentage score (years) C o n t r o l subjects Experimental subjects 0-14 (1) (1) 12.9 • • • 6.5 17.2 15-24 (2) • • • 6.9 25-34 (3) (3) 51.7 • • • 9.0 75.4 35-44 (4) (4) (4) (4) 11.0 13.3 14.2 20.5 13.0 41.8 • • • • • • 45-54 (5) (5) 28.0 • • • 16.0 56.5 55-64 (6) (6) (6) (6) 14.3 26.5 34.0 48.5 27.5 55.1 • • • • • • 65-74 (7) 24.0 48.5 75 and over (8) • • • • • • r,-. = 0.22 (not s i g n i f i c a n t ) r£ = 0.48 (not s i g n i f i c a n t ) 55 TABLE XXII THE CORRELATION BETUEEN LENGTH OF TIME SINCE DIAGNOSED AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING Length of time Difference in total percentage score since diagnosed Control subjects Experimental subjects 1 day to 6 days • • • • • • 1 ueek to 3 months (1) 13.3 16.0 (1) 24.0 27.5 (1) 26.5 48.5 (1) 51.7 55.1 (1) ... 75.4 4 months to 11 months (2) 48.5 • • • 1 year to 5 years (3) 11.0 56.5 (3) 14.2 • • • (3) 14.3 • • • (3) 28.0 • • • over 5 years (4) 12.9 6.5 (4) 20.5 6.9 (4) 34.0 9.0 (4) • • • 13.0 (4) • • • 17.2 (4) • • • 41.8 r r = -0.33 (not significant) r r = -0.59 (significant at the .05 level) TABLE XXIII A COMPARISON BETUEEN REASON FOR CURRENT ADMISSION TO HOSPITAL OR VISIT TO DOCTOR AND DIFFERENCE IN TOTAL PERCENTAGE SCORE ON PRETEST AND POSTTEST OF DIABETIC LEARNING Difference in total percentage score Control subjects Experimental subjects Diabetes-related admissions Unrelated admissions Diabetes-related admissions Unrelated admissions 11.0 20.5 . 6.5 16.0 12.9 48.5 6.9 27.5 13.3 9.0 14.2 13.0 14.3 17.2 24.0 41.8 26.5 48.5 28.0 55.1 34.0 56.5 51.7 75.4 C = 22.99 C 1 = 34.5 E = 32.99 E 1 = 21 .75 t c = 1.087 (not significant) t F = 0.600 (not significant) 57 A COMPARISON OF THE SCORES OF SUBJECTS USING THE MODIFIED "DIABETIC TEACHING TOOL" IN GROUP INSTRUCTION AND THE SCORES OF SUBJECTS USING THE "DIABETIC TEACHING TOOL" IN INDIVIDUAL INSTRUCTION • Skelton s t u d i e d the e f f e c t i v e n e s s of the " D i a b e t i c Teaching Tool" on tuenty subjects uho r e c e i v e d i n d i v i d u a l i n s t r u c t i o n . This group of subjects uas compared u i t h the subjects taught by means of the modified " D i a b e t i c Teaching Tool" i n group i n s t r u c t i o n i n the f o l l o u i n g manner: 1. a comparison of demographic and d i a b e t i c c h a r a c t e r i s t i c s . of both groups of s u b j e c t s ; 2. a comparison of the mean score achieved by a l l subjects on the subtests of the t e s t of d i a b e t i c l e a r n i n g and of the mean t o t a l percentage score obtained. The median age of the subjects i n Skelton's study uas f i f t y years and i n the experimental subjects of t h i s study i t uas f o r t y - n i n e and one-half years. The s u b j e c t s uere als o s i m i l a r i n d i s t r i b u t i o n by sex. Skelton's study had 60 percent females u h i l e t h i s study had 50 percent females. The m a j o r i t y of subjects i n both groups uere married. Although a d i f f e r e n t method uas used to determine the educational l e v e l i t appears that both groups of subjects are h i g h l y s i m i l a r . A s i m i l a r i t y i s a l s o present i n the length of time since diagnosed. One-half of the subjects i n each group had been diagnosed f o r over f i v e years. Houever, there uere some areas of d i f f e r e n c e . This study had feuer subjects uho uere admitted to h o s p i t a l because of conditions unrelated to diabetes. Skelton had e i g h t out of tuenty u i t h unrelated c o n d i t i o n s u h i l e t h i s study had tuo out of t u e l v e . There uas a l s o some d i f f e r e n c e i n the age at onset of diabetes. The median age of the subjects obtained by Skelton uas i n the f o r t y - f i v e 58 to f i f t y - f o u r year range and the median age f o r subjects i n t h i s study uas i n the t h i r t y - f i v e to f o r t y - f o u r range. Thus the subjects i n t h i s study uere s l i g h t l y younger at onset of diabetes. F i n a l l y , the tuo groups of subjects d i f f e r e d on type of c o n t r o l of c o n d i t i o n . One-half of Skelton's subjects uere c o n t r o l l e d by d i e t and a n t i -d i a b e t i c p i l l s and one-half by d i e t and i n s u l i n . This study had one-quarter of i t s subjects being c o n t r o l l e d by d i e t and a n t i d i a b e t i c p i l l s and three-quarters being c o n t r o l l e d by d i e t and i n s u l i n . Thus there uas a great deal of s i m i l a r i t y betueen the group of subjects uho uere taught by the "Diab e t i c Teaching T o o l " i n i n d i v -i d u a l i n s t r u c t i o n and the group of subjects uho uere taught by the modified " D i a b e t i c Teaching T o o l " i n group i n s t r u c t i o n . The p o s t t e s t scores obtained by the tuo groups of subjects on the t e s t of d i a b e t i c l e a r n i n g uere al s o h i g h l y s i m i l a r . The tuo groups uere compared by means obtained but no s t a t i s t i c a l t e s t uas used. Table XXIV contains these data. F i n a l l y the mean of the t o t a l percentage score obtained by the tuo groups of subjects uas compared. The subjects taught by means of the "D i a b e t i c Teaching Tool" obtained a mean of 75.97 and the subjects taught by means of the modified " D i a b e t i c Teaching Tool" obtained a mean of 80.48. In summary, although no s t a t i s t i c a l t e s t uas used to compare the scores of the tuo groups of subjects the means obtained i n d i c a t e a high degree of s i m i l a r i t y . These f i n d i n g s r e s u l t e d i n acceptance of the second hypothesis uhich s t a t e d that there i s no s i g n i f i c a n t d i f f e r e n c e i n the scores on the t e s t of d i a b e t i c l e a r n i n g of subjects r e c e i v i n g group i n s t r u c t i o n by means of the modified " D i a b e t i c Teaching Tool" as compared to subjects r e c e i v i n g i n d i v i d u a l i n s t r u c t i o n by means of the "Diabetic Teaching Tool." 59 TABLE XXIV A COMPARISON OF THE MEAN SUBTEST SCORES OBTAINED BY SUBJECTS TAUGHT BY INDIVIDUAL INSTRUCTION AND SUBJECTS TAUGHT BY GROUP INSTRUCTION Mean Score Test Subjects taught by i n d i v i d u a l i ns t ruc t ion* Subjects taught by group i n s t r u c t i o n Knouledge test for p i l l - u s e r s 52.15 48.16 Knowledge tes t for i n s u l i n - u s e r s 56.95 59.61 D iet -p lanning s k i l l test 16.30 18.16 U r i n e - t e s t i n g s k i l l tes t 6.75 8.37 I n s u l i n - i n j e c t i n g s k i l l test 9.50 9.55 Knowledge and s k i l l tests of d i e t -planning 28.42 29.75 Knowledge and s k i l l t e s t s . o f u r i n e -tes t ing 14.90 16.95 Insu l in knowledge and s k i l l tests 17.60 17.66 •Permission to use these scores was given by Ske l ton . CHAPTER 1/ SUMMARY, DISCUSSION OF THE FINDINGS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS SUMMARY Th is exper imenta l study uas designed to determine i f the mod i f i ed " D i a b e t i c Teaching T o o l " uas an e f f e c t i v e t o o l f o r use i n group i n s t r u c t i o n . The hypotheses t e s t e d i n t h i s study u e r e : f i r s t , there i s no s i g n i f i c a n t d i f f e r e n c e i n the l e a r n i n g , about s e l f - c a r e , of s u b j e c t s r e c e i v i n g group i n s t r u c t i o n by means of the m o d i f i e d " D i a b e t i c Teaching T o o l " as compared to s u b j e c t s r e c e i v i n g group i n -s t r u c t i o n by means of the d i a b e t i c teach ing program; and second, there i s no s i g n i f i c a n t d i f f e r e n c e i n the scores on the t e s t of d i a b e t i c l e a r n i n g of s u b j e c t s r e c e i v i n g group i n s t r u c t i o n by means of the mod i f i ed " D i a b e t i c Teaching T o o l " as compared to s u b j e c t s r e -c e i v i n g i n d i v i d u a l i n s t r u c t i o n by means of the " D i a b e t i c Teaching T o o l . " The s tudy .uas conducted i n a l a r g e urban h o s p i t a l . I t i n -vo lved t u e n t y - f o u r s u b j e c t s uho attended the r e g u l a r l y scheduled d i a b e t i c c l a s s e s i n that i n s t i t u t i o n . These s u b j e c t s met. the c r i t e r i a of the study and gave u r i t t e n consent to p a r t i c i p a t e . The f i r s t t u e l v e s u b j e c t s uere ass igned to the c o n t r o l group and r e c e i v e d group i n s t r u c t i o n by means of the i n s t i t u t i o n ' s d i a b e t i c teach ing program. The l a s t t u e l v e s u b j e c t s uere ass igned to the exper imenta l group and r e c e i v e d group i n s t r u c t i o n by means of the m o d i f i e d " D i a b e t i c Teaching T o o l . " A d i e t i c i a n and a nurse p a r t i c i p a t e d i n the teach ing 60 61 of the c o n t r o l group; a nurse performed the teaching of the e x p e r i -mental group. A l l subjects uere t e s t e d before commencement of the i n s t r u c t i o n and t e s t e d again from tuo to seven days a f t e r completion of the i n s t r u c t i o n . A r e v i e u of the l i t e r a t u r e shoued that group i n s t r u c t i o n i s being used to teach p a t i e n t s u i t h a v a r i e t y of c o n d i t i o n s . The nurse i s t a k i n g a more a c t i v e r o l e i n teaching but i t i s a f u n c t i o n that i s not u e l l developed. F i n a l l y , there uas massive support f o r the need to teach d i a b e t i c s about s e l f - c a r e . The tuo groups of subjects uere compared on the demographic and d i a b e t i c c h a r a c t e r i s t i c s obtained from the p a t i e n t p r o f i l e sheet. The t - t e s t uas used to analyze the t e s t results.. The Pearson product-moment c o r r e l a t i o n c o e f f i c i e n t uas used to compare the t e s t r e s u l t s and s e l e c t e d demographic and d i a b e t i c c h a r a c t e r i s t i c s of the s u b j e c t s . F i n a l l y , a d e s c r i p t i v e comparison uas made betueen the experimental subjects of t h i s study and the subjects of Skelton's study uho uere taught by means of the " D i a b e t i c Teaching To o l " i n i n d i v i d u a l i n -s t r u c t i o n . A comparison of the mean scores of these tuo groups of subjects on the t e s t of d i a b e t i c l e a r n i n g uas also, undertaken. DISCUSSION OF THE FINDINGS The c o n t r o l and experimental subjects uere h i g h l y s i m i l a r uhen compared on the demographic and d i a b e t i c c h a r a c t e r i s t i c s obtained from the p r o f i l e sheet. The average age of the c o n t r o l s u b j e c t s uas f i f t y - f o u r and one-half years. The group c o n s i s t e d of f i v e males and seven females. Ten of the tuelve subjects uere married and tuo uere uidoued. The 62 educational level attained uas better than grade ten for nine out of tuelve subjects. Only tuo subjects uere admitted to hospital because of a condition unrelated to diabetes. The median age at onset of diabetes uas forty-four and one-half years uhile the median length of time since diagnosed uas four and one-half years. Control of condition uas maintained by diet and antidiabetic p i l l s far seven of the subjects and by diet and insulin for the remaining five sub-jects. They had used a variety of sources of information to learn about their condition but ten of the tuelve subjects listed the classes as the most useful, one listed the nurse and one listed the doctor. The average age of the experimental subjects uas forty-nine and one-half years. The group uas evenly divided into males and females. Seven of the tuelve subjects uere married, three uere single and tuo uere separated. The educational level attained uas better than grade ten for nine of the tuelve subjects. Only tuo uere ad-mitted to hospital because of a condition unrelated to diabetes. The median age at onset of diabetes uas thirty-nine and one-half years uhile the median length of time since diagnosed uas five and one-half years. Control of condition uas maintained by diet and antidiabetic p i l l s for three of the subjects and by diet and insulin for the re-maining subjects. They, too, had used a variety of sources of i n -formation to learn about their condition. Houever, ten listed the classes as most useful and tuo listed the doctor. The test of diabetic learning consisted of a knouledge test for insulin-users, a knouledge test for antidiabetic pill-users, a diet-planning s k i l l test, a urine-testing s k i l l test, and an insulin-injecting s k i l l test. The difference in the pretest and posttest 63 scores for a l l subjects on these subtests of the test uere subjected to t-test analysis. In addition the scores on the s k i l l test mere combined uith the related knouledge scores as extracted from the knouledge test. These uere also subjected to t-test analysis. A comparison of the tuo groups of subjects by the differences in total percentage score on the pretest and posttest of diabetic learning shoued no s t a t i s t i c a l l y significant difference. This uas probably due to the fact that the content presented to both groups of subjects uas highly similar. The main differences uere the use of slides accompanied by nurse's instructions for the experimental subjects and the distribution of a printed handout (uith material corresponding to that presented by the instructor) to each subject. The control subjects each received a copy of the Canadian Diabetic Association Handbook for. Diabetics and vieued a tuenty minute film. The control subjects did slightly better on the diet planning s k i l l test and on the combined knouledge and s k i l l diet-planning tests but the difference uas not s t a t i s t i c a l l y significant. A suggested reason for the difference in scores in this section uas that the con-t r o l subjects uere taught by a dietician uho also had contact uith the subjects outside the class. The experimental subjects uere taught by a nurse uho had no previous experience in this area and uho had no contact uith the subjects outside the class. No s t a t i s t i c a l l y significant difference betueen the tuo groups uas found in the urine-testing s k i l l test but there uas a significant difference in the combined scores on the knouledge and s k i l l tests of urine-testing. The experimental subjects may have done, better in this area as a result of having to practice the correct technique in the classroom and because they uere given precise printed information 64 about u r i n e - t e s t i n g . T h i s might have r e s u l t e d i n an i n c r e a s e d awareness o f the need t o be v e r y f a m i l i a r w i t h the t o p i c . A g a i n no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the two groups o f s u b j e c t s was found when compared on the i n s u l i n - i n j e c t i n g s k i l l t e s t and the combined i n s u l i n knowledge and s k i l l t e s t s . T h i s p r o b a b l y r e s u l t e d from t h e f a c t t h a t a l l i n p a t i e n t s who had not had e x p e r i e n c e w i t h s e l f - i n j e c t i o n s were a d e q u a t e l y s u p e r v i s e d by ward s t a f f . The m a j o r i t y o f o u t p a t i e n t s were not r e c e i v i n g i n s u l i n o r were a l r e a d y s k i l l e d i n the p r o c e d u r e . These f i n d i n g s r e s u l t e d i n ac c e p t a n c e o f the f i r s t h y p o t h e s i s . The f i n a l s t a t i s t i c a l a n a l y s i s was the c o r r e l a t i o n between t h e d i f f e r e n c e i n t h e p r e t e s t and p o s t t e s t s c o r e s on t h e t e s t o f d i a b e t i c l e a r n i n g by t o t a l p e r c e n t a g e s c a r e and the f o l l o w i n g demo-g r a p h i c and d i a b e t i c c h a r a c t e r i s t i c s : age at t e s t i n g , e d u c a t i o n , age at o n s e t o f d i a b e t e s , d u r a t i o n o f d i a b e t e s and r e a s o n f o r c u r r e n t a d m i s s i o n t o h o s p i t a l o r v i s i t t o the d o c t o r . There was no c o r r e l -a t i o n between any o f t h e s e c h a r a c t e r i s t i c s and t h e s c o r e d i f f e r e n c e f o r the c o n t r o l s u b j e c t s . The o n l y s i g n i f i c a n t r e l a t i o n s h i p f o r t h e e x p e r i m e n t a l group was between s c o r e d i f f e r e n c e and d u r a t i o n o f d i a b e t e s . A p o s s i b l e r e a s o n f o r t h i s f i n d i n g was the f a c t t h a t the e x p e r i m e n t a l group c o n t a i n e d more s u b j e c t s who had been d i a g n o s e d f o r o ver f i v e y e a r s . Some o f t h e s e s u b j e c t s had h i g h s c o r e s on the p r e t e s t which d i d not a l l o w f o r much change i n s c o r e s . Some su g g e s t e d r e a s o n s f a r the l a c k o f a s i g n i f i c a n t d i f f e r -ence i n the l e a r n i n g o f the two groups o f s u b j e c t s were: 1. A l l s u b j e c t s were aware t h a t they would be p a s t t e s t e d . 2. Same s u b j e c t s i n each group mentioned the need t o s t u d y f o r t h e t e s t . 65 3. The same nurse taught both groups. Her group teaching techniques uere highly similar in both situations. k. A greater percentage of subjects in the experimental group had been diagnosed for over five years. Some of these subjects had very high pretest scores uhich did not allou for much change as a result of attendance at class. 5. The sample size uas too small. A comparison of the demographic and diabetic characteristics of the subjects receiving group instruction by means of the modified "Diabetic Teaching Tool" and those of the subjects receiving indiv-idual instruction by means of the "Diabetic Teaching Tool" shoued a high similarity betueen the tuo groups of subjects. The mean of both groups of subjects by total percentage scores on the test of diabetic learning and of the mean scores on the subtests of the.test uere also highly similar. On the basis of these findings the second hypothesis uas accepted. CONCLUSIONS The conclusions draun from the results of this study are: 1. The modified "Diabetic Teaching Tool" is equally as effective-as the established diabetic teaching program for the teach-ing of self-care to diabetics in small groups. 2. The modified "Diabetic Teaching Tool" is equally as effective as the "Diabetic Teaching Tool" for the teaching of self-care to diabetics. 3. The group instruction method is equally as effective as individual instruction in the teaching of diabetics about self-care. 66 4. Planned group teaching i s e f f e c t i v e f o r subj e c t s regard-l e s s of age at time D f teaching, e d u c a t i o n a l l e v e l a t t a i n e d , age at onset of diabetes, duration of diabetes and reason f o r current ad-mission to h o s p i t a l or v i s i t to doctor. Duration of diabetes uas a f a c t o r i n the l e a r n i n g of p a t i e n t s i n the experimental group. Hou-ever, many of these attended f o r a r e f r e s h e r and uere already knou-ledgeable about t h e i r c o n d i t i o n . 5. The low number of e l d e r l y people i n the study might i n d i c a t e that the nursing s t a f f are not sending them to c l a s s r a t h e r -than that they are not a v a i l a b l e . IMPLICATIONS Group i n s t r u c t i o n i s an e f f e c t i v e means of teaching s e l f - c a r e to d i a b e t i c s . This teaching should be u e l l planned and conducted by a teacher uho i s f a m i l i a r u i t h the group process. Nurses are becoming more i n v o l v e d i n teaching p a t i e n t s . To f a c i l i t a t e t h i s nursing a c t i v i t y , b a s i c nursing education should include i n s t r u c t i o n i n the dynamics of the group process. F i n a l l y , the r e s u l t s of t h i s study support the f a c t that group i n s t r u c t i o n can be as e f f e c t i v e as i n d i v i d u a l i n s t r u c t i o n i n the teaching of p a t i e n t s . RECOMMENDATIONS Recommendations f o r Use of the Test The f o l l o u i n g recommendations are made regarding the use of the t e s t of d i a b e t i c l e a r n i n g . 1. A r e v i s i o n of the t e s t so that i t c o n s i s t s of only one 67 form o f q u e s t i o n or a d i v i s i o n o f the t e s t so t h a t each d i v i s i o n c o n t a i n s o n l y one form o f q u e s t i o n . 2. A r e v i s i o n o f q u e s t i o n t w e n t y - t h r e e as some s u b j e c t s o b j e c t e d t o h a v i n g t o c o n s u l t a d o c t o r whenever some o f the s t a t e d e v e n t s o c c u r r e d . Recommendations f o r F u r t h e r R e s e a r c h The f a l l o w i n g recommendations are made f o r f u r t h e r i n v e s t i g -a t i o n : 1. A r e p l i c a t i o n o f t h i s s t u d y u s i n g a l a r g e r sample. 2. A r e p l i c a t i o n o f t h i s s t u d y u s i n g o n l y o u t p a t i e n t s . T h i s would e l i m i n a t e the i n c i d e n t a l t e a c h i n g which o c c u r s f o r i n p a t i e n t s , thus g i v i n g a more a c c u r a t e e s t i m a t e o f the l e a r n i n g as a r e s u l t o f exposure t o the t o o l . 3. A r e p l i c a t i o n o f t h i s s t u d y u s i n g a t h i r d group o f p a t i e n t s who do not a t t e n d any t e a c h i n g program. k. A s t u d y c o n d u c t e d t o compare the " D i a b e t i c T e a c h i n g T o o l " i n i n d i v i d u a l i n s t r u c t i o n and the m o d i f i e d " D i a b e t i c T e a c h i n g T o o l " i n group i n s t r u c t i o n . BIBLIOGRAPHY 68 69 A. BOOHS Calduell, John William. Understand Your Diabetes. Toronto: Oxford University Press, 1949. Dolger, Henry, and Bernard Seeman. HQUJ to Live uith Diabetes. 3d ed. New York: W.W. Norton and Company, Inc., 1972. Duncan, Garfield G. Diabetes Mellitus: Principles and Treatment. 3d ed. Philadelphia: W. B. Saunders Co., 1951. A Modern Pilgrim's Progress uith Further Revelations for Diabetics. 2d ed. Philadelphia: W. B. Saunders Co., 1967. Fazans, Stephen A., and Karl E. Sussman. (eds.). Diabetes Mellitus: Diagnosis and Treatment. Vol. III. IMeu York: American Diabetes Association, Inc., 1971. Houes, V i r g i l M. Individualization of Instruction: A Teaching Strategy. London: The MacMillan Co., Collier-MacMillan Ltd., 1970. Hunt, John A. (ed.). Diabetes: A Manual for Canadians. 5th ed. Toronto: The Canadian Diabetic Assoc., 1973. Olmstead, Joseph A. Theory and State of the Art of Small-Group Methods  of Instruction. Alexandria, Virginia: Human Resources Research. Org., March, 1970. Pohl, Margaret L. The Teaching Function of the IMursing Practitioner. 2d ed. Dubuque, Ioua: Wm. C. Broun Co., 1973. Redman, Barbara H. The Process of Patient Teaching in IMursing. 2d. ed. Saint Louis: C. V. Mosby Co., 1972. B. ARTICLES Allan, Frank N. "Education of the Diabetic Patient." Neu England  Journal of Medicine, CCLXVIII, No. 2 (January 10, 1973), 93-95. Bouen, Rhada G., Rosemary Rich and Rozella M. Schlotfeldt. "Effects of Organized Instruction for Patients uith the Diagnosis of Diabetes Mellitus," Nursing Research, X, No. 3 (Summer, 1961), 151-157. Etzuiler, Donald D. "Who's Teaching the Diabetic?," Diabetes, XVI, No. 2 (February, 1967), 111-117. Grim, Rosemary A. "Mr. Eduards' Triumph," American Journal of  Nursing, LXXII, No. 3 (March, 1972), 480-481. 70 Hallburg, Jeanne C. "Teaching Patients Self-Care," Nursing Clinics  • f North America, U, No. 2 (June, 1970), 223-231. Hamtdi, George J. "Special Announcement: Treatment of Diabetes," Journal of American Medical Association, CLXXXI, No. 12 (September 22, 1962), 1064. Hornback, May. "Diabetes Mellitus - The Nurse's Role," Nursing Clinics of North America, U, No. 1, (March, 1970), 3-12. Krysan, Germaine S. "How Do we Teach Four Million Diabetics?," American Journal of Nursing, LXV, No. 11 (November, 1965),105-107. Laugharne, Elizabeth and Fel i c i t y Duncan. "Gestational Diabetes -Uhen Teaching is Important," Canadian Nurse, LXIX, No. 3 (March, 1973), 34-36. Lindeman, Carol A. "Nursing Intervention with the Presurgical Patient," Nursing Research, XXI, No. 3 (May-June, 1972), 196-209. Martin, Marguerite M. "A Teaching Centre for Diabetics," American  Journal of Nursing, LVIII, No. 3 (March, 1958), 390-391. Mezzanotte, Elizabeth J. "Group Instruction in Preparation for Surgery," American Journal of Nursing, LXX, No. 1 (January, 1970) , 89-91. Monteiro, Lois A. "Notes on Patient Teaching - A Neglected Area," Nursing Forum, III, No. 1 (Uinter, 1964), 26-33. Nickerson, Donna. "Teaching the Hospitalized Diabetic," American  Journal of Nursing, LXXII, No. 5 (May, 1972), 935-938. Palm, Mary L.. "Recognizing Opportunities for Informal Patient Teach-ing," Nursing Clinics of North America, Ul, No. 4 (December, 1971) , 669-678. Pohl, Margaret L. "Teaching Activities of the Nursing Practitioner," Nursing Research, XIU, No. 1 (Uinter, 1965), 4-11. Power, Lawrence. "Commentary: New Approaches to the Old Problem of Diabetes Education," Journal of Nutrition Education, U, No. 4 (October-December, 1973), 230-232. Redman, Barbara K. "Patient Education as a Function of Nursing Practice," Nursing Clinics of North America, Ul, No. 4 (December, 1971), 573-580. Robinson, Geraldine, and Marilyn Filkins. "Group Teaching with Out-patients," American Journal of Nursing, LXIU, No. 11 (November, 1964), 110-112. I 71 Schueer, Jean E. "Teaching Students to Teach Health Care to Others," IMursing C l i n i c s of North America, VI, No. 4 (December, 1971), 679-690. Skelton, J u d i t h M. "A D i a b e t i c Teaching Tool," Canadian Nurse, LXIX, No. 12 (December, 1973), 35-3S. Stone, Daniel B. "A Study of the Incidence and Cause of Poor C o n t r o l i n P a t i e n t s u i t h Diabetes M e l l i t u s , " American J o u r n a l of the  Medical Sciences, CCXLI ( A p r i l , 1961), 436-441. S t o r l i e , Frances. "A Philosophy of P a t i e n t Teaching," Nursing  Outlook, XIX, No. 6 (June, 1971), 387-389. "Teaching D i a b e t i c S e l f - C a r e , " Neu England J o u r n a l of Medicine, CCLXXVI, No. 3 (January, 1967), 182. Trayser, L i s a M. "A Teaching Program f o r D i a b e t i c s , " American  Journal of Nursing, LXXIII, No. 1 (January, 1973), 92-93. Valentine, L o i s R. "Self-Care Through Group Learning," American  Journal of Nursing,LXX, No. 10 (October, 1970), 2140-2142. Itlatkins, J u l i a D. et a l . "A Study of D i a b e t i c P a t i e n t s at Home," American Journa l of P u b l i c Health, LVII, No. 3 (March, 1967), 452-459. . Ldatkins, J u l i a D., and Fay T. Moss. "Confusion i n the Management of Diabetes," American Journa l of Nursing, LXIX, No. 3 (March, 1969), 521-524. Williams, T. F r a n k l i n , and Dan A. M a r t i n . "The C l i n i c a l P i c t u r e of Dia b e t i c C o n t r o l , Studied i n Four S e t t i n g s , " Diabetes, XIV, No. 7 ( J u l y , 1965), 469. C. UNPUBLISHED MATERIALS Goodman, Gertrude UJarkentin. "An Experimental Study to Evaluate the E f f e c t of Planned Teaching on S e l f - M e d i c a t i o n P r a c t i c e s of Older Ambulatory Cardiac P a t i e n t s . " Unpublished Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1972. Pouer, Denise Mary. "The E f f e c t i v e n e s s of Planned Teaching of Mothers u i t h C h i l d r e n Treated i n Emergency Departments." Un-published Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1972. Skelton, J u d i t h Mary. "An Experimental Study to Evaluate the E f f e c t -iveness of a D i a b e t i c Teaching Tool." Unpublished Master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1973. APPENDIX A CONSENT FORMS CONSENT TO ACT AS SUBJECT FOR STUDY 73 S u b j e c t ' s Name: Date: I hereby consent t o p a r t i c i p a t e i n a d i a b e t i c t e a c h i n g program u s i n g the m o d i f i e d " D i a b e t i c T e aching T o o l " and t o be t e s t e d b e f o r e and a f t e r the i n f o r m a t i o n i s p r e s e n t e d . An e x p l a n a t i o n has been g i v e n t o me by M i s s M a t i l d a B u r k e . T h i s i s p a r t o f a stu d y on d i a b e t i c t e a c h i n g t o be performed by M i s s M a t i l d a Burke and an a s s i s t a n t . I u n d e r s t a n d t h a t t h e r e are no r i s k s i n v o l v e d and t h a t no i d e n t i f y i n g i n f o r m a t i o n u i l l appear i n the completed s t u d y . I f u r t h e r u n d e r s t a n d t h a t I am f r e e t o u i t h d r a u from the st u d y a t any t i m e . S u b j e c t ' s S i g n a t u r e CONSENT TO ACT AS SUBJECT FOR STUDY S u b j e c t ' s Name: ; Date: I hereby consent t o p a r t i c i p a t e i n a d i a b e t i c t e a c h i n g program u s i n g the Vancouver G e n e r a l H o s p i t a l d i a b e t i c t e a c h i n g program and to be t e s t e d b e f o r e and a f t e r the i n f o r m a t i o n i s p r e s e n t e d . An e x p l a n a t i o n has been g i v e n t o me by M i s s M a t i l d a B u r k e . T h i s i s p a r t o f a stu d y on d i a b e t i c t e a c h i n g t o be performed by M i s s M a t i l d a Burke and an a s s i s t a n t . I u n d e r s t a n d t h a t t h e r e are no r i s k s i n v o l v e d and t h a t no i d e n t i f y i n g i n f o r m a t i o n u i l l appear i n the completed s t u d y . I f u r t h e r u n d e r s t a n d t h a t I am f r e e t o u i t h d r a u from the s t u d y at any t i m e . S u b j e c t ' s S i g n a t u r e APPENDIX B RECORD OF DIABETIC TEACHING RECORD OF DIABETIC TEACHING Subject's Name: TOPIC DATE. COMPLETED 1. Film and Discussion 2. Dietary Control 3. Urine Testing k. Medicine 5. Insulin Reaction and Diabetic Coma RECORD OF DIABETIC TEACHING .uith Modified "Diabetic Teaching Tool", Subject's Name: TOPIC DATE COMPLETED 1. Introduction 2. Dietary Control 3. Medicine 4. Exercise, Personal Hygiene, and Urine Testing ' 5. Problems A P P E N D I X C P A T I E N T P R O F I L E S H E E T 77 Patient Number: PATIENT PROFILE SHEET AGE 1. 2. 3. 4. 15-24 25-34 35-44 45-54 5. 55-64 6. 65-74 7. 75-84 8. 85 and aver B. SEX 1. Male 2. Female MARITAL STATUS 1. Single 2. Married 3. klidoued 4. Divorced/separated REASON FOR CURRENT ADMISSION  TO HOSPITAL OR VISIT TO DOCTOR D. EDUCATION 1. Less than Grade 6 2. Grades 6 to 9 3. Grades 10 to 12 4. Beyond Grade 12 F. AGE AT ONSET OF DIABETES 1. Neu diabetic 2. Regulation of diabetes 3. Complication of diabetes 4. Unrelated condition 1. 2. 3. 4. 0-14 5. 45-54 15-24 6. 55-64 25-34 7. 65-74 35-44 8. 75 and over G. LENGTH OF TIME SINCE H. CONTROL OF CONDITION DIAGNOSED 1. 1 day to 6 days 2. 1 ueek to 3 months 3. 4 months to 11 months 4. 1 year to 5 years 5. Over 5 years 1. 2. Diet & antidiabetic p i l l Diet and Insulin I. ANTIDIABETIC PILL J. INSULIN Name 1. Name Dose (milligrams) Strength Time Dose (units) Time Name Strength Dose (units ) Time 7 8 URINE TESTING Reagents Time(s) L. CHECK ANY DF THE FOLLOWING SOURCES OF INFORMATION UHICH YOU  HAUE USED classes television pamphlets friend or relative books doctor radio nurse newspaper dietician M. OF THOSE WHICH YOU HAUE CHECK UHICH UAS THE MOST USEFUL? N. HOW RECENTLY HAUE YOU USED IT? 0. DIET PLAN (ATTACHED) 7 9 APPENDIX D MATERIAL PERTAINING TD THE SCORES OBTAINED Specification for the Test of Diabetic Learning Scores Obtained by Control and Experimental Group on Knowledge and S k i l l Test TABLE XXV SCORES OBTAINED BY CONTROL AND EXPERIMENTAL INSULIN-USERS ON KNOWLEDGE TEST Scores of control s ubjects Scores of experimental subjects (75 max.) (75 max.) Pretest Posttest Pretest Posttest 28.0 31.0 9.0 46.0 31.0 41.0 14.0 70.5 31.0 66.0 17.5 50.0 40.5 47.0 27.0 67.0 49.0 64.5 32.5 36.5 46.5 63.0 53.5 61.0 70.0 71.0 71.0 71.5 TABLE X X V I SCORES OBTAINED BY CONTROL AND EXPERIMENTAL PILL-USERS ON KNOWLEDGE TEST Scores of c o n t r o l s u b j e c t s (70 max.) Scores of experimental subjects (70 max.) Pretest P o s t t e s t P r e t e s t P o s t t e s t 16.0 36.0 S.O 31.5 17.5 26.5 29.0 53.0 1S.0 51.0 45.0 60.0 30.0 55.5 30.5 39.5 *f 1.5 45.5 46.5 52.5 82 TABLE XXVII SCORES OBTAINED BY CONTROL AND EXPERIMENTAL SUBJECTS ON DIET-PLANNING SKILL TEST Scores of control (20 max. subjects ) Scores of experimental subjects (20 max.) Pretest Posttest Pretest Posttest 0.0 0.0 0.0 16.0 0.0 12.0 0.0 17.5 0.0 14.0 0.0 18.0 0.0 14.0 0.0 19.5 0.0 14.0 13.0 16.5 0.0 14.5 13.5 20.0 0.0 15.5 15.0 17.5 0.0 15.5 16.5 17.5 10.5 15.5 16.5 18.0 15.0 14.5 16.5 20.0 17.0 19.0 17.0 18.0 19.0 19.5 17.5 19.5 83 TABLE XXVIII SCORES OBTAINED BY CONTROL AND EXPERIMENTAL SUBJECTS ON URINE-TESTING SKILL TEST Scares D f control subjects (10 max.) Scores of experimental subjects (10 max.) Pretest Posttest Pretest Posttest 0.0 1.0 0.0 7.0 0.0 7.0 0.0 7.0 3.0 3.0 4.0 7.5 5.0 4.5 5.0 8.5 5.0 6.0 5.5 9.0 5.0 8.0 6.0 6.0 5.0 8.0 6.0 8.0 5.5 5.0 6.0 10.0 7.0 6.5 7.5 8.5 7.0 9.5 7.5 10.0 8.0 8.0 8.0 9.0 9.0 10.0 8.5 10.0 84 TABLE XXIX SCORES OBTAINED BY CONTROL AND EXPERIMENTAL INSULIN-USERS ON INSULIN-INJECTING SKILL TEST Scores of control subjects (11 max.) Scores of experimental subjects (11 max.) Pretest Posttest Pretest Posttest 0.0 6.0 0.0 8.0 0.0 0.0 0.0 9.0 0.0 9.0 0.0 10.0 9.5 10.5 8.0 7.5 10.5 11.0 8.0 9.5 8.0 10.5 9.0 10.5 9.5 10.0 11.0 11.0 85 A BASIC COURSE IN DIABETIC SELF-MANAGEMENT SPECIFICATIONS FOR THE TEST OF DIABETIC LEARNING Insulin-Users Antidiabetic Pill-Users Topics Knou-ledge S k i l l Total Knou-ledge S k i l l Total 1 Diet 16 20 36 16 20 36 2 Medication 10 11 21 5 0 5 3 Urine tests 10 10 20 10 10 20 k Exercise k 0 k k 0 5 Foot care 5 0 5 5 0 5 6 Complications 18 0 18 18 0 18 7 Resources 12 0 12 12 0 12 Total 75 41 116 70 30 100 Judith M. Skelton "An Experimental Study to Determine the Effectiveness of a Diabetic Teaching Tool" (unpublished Master's thesis, University of British Columbia, 1973), p. 120. APPENDIX E TEST OF DIABETIC LEARNING2 Knowledge Test for Insulin Users Knowledge Test for Antidiabetic Pill-Users Diet-Planning S k i l l Test Urine-Testing S k i l l Test Insulin-Injection S k i l l Test The property of Miles Laboratories. 8 7 TEST OF DIABETIC LEARNING ( f o r I n s u l i n Users) Subject Number: Score: PART I: KNOULEDGE ( 7 5 p o i n t s ) Please place ALL your answers on t h i s t e s t paper. Far m u l t i p l e - c h o i c e or t r u e - f a l s e questions, c i r c l e the c o r r e c t response. For a l l other types of questions, w r i t e the c o r r e c t response i n the space provided. 1. Uhat are the names of the American/Canadian D i a b e t i c A s s o c i a t i o n Food Exchange Groups? 2. The f o l l o w i n g foods are allowed on a d i a b e t i c (A) b u t t e r m i l k (B) i c e cream (C) marmalade (D) mayonnaise (E) noodles 3. Foods i n one exchange group may be: (A) changed f o r foods i n another l i s t . (B) changed f o r foods i n the same l i s t . (C) changed f a r d i e t e t i c foods af any s o r t . (D) a l l eaten at the same meal. h. I n s u l i n causes the amount of sugar i n the blood to i n c r e a s e . 5. (A) Uhat i s the name of the i n s u l i n you are (B) Do you use U 4 0 or U 8 0 i n s u l i n ? (C) How many u n i t s of your i n s u l i n da yau take each time? (D) Uhat time of day da yau take your i n s u l i n ? (E ) Uhat time af day must you be most c a r e f u l of i n s u l i n r e a c t i o n s ? (F) How does your i n s u l i n act to help your diabetes? (G) May e x t r a i n s u l i n be stored i n the f r e e z e r ? Yes_ No (H) May you i n j e c t the same s i t e same month? twice i n the Yes No d i e t : True False True False True False True False True False True False True False True False True False True False taking? aa 5. ( I ) When should you avoid e x e r c i s i n g ? A. immediately a f t e r b r e a k f a s t . B. immediately before lunch. C. immediately before supper. D. immediately a f t e r supper. E. l a t e i n the evening. I f a d i a b e t i c person has had no complica t i o n s , he need not t e s t h i s u r i n e . True False 7. Routine urine t e s t s f o r sugar should be made (A) j u s t before meals. (B) on "double-voided" specimens. (C) one hour a f t e r meals. (D) each time a d i a b e t i c u r i n a t e s . True True True True False False False False 8. Your urine might t e s t p o s i t i v e f o r sugar i f (A) you had eaten too much. (B) you had taken too much i n s u l i n . (C) you had a f e v e r . (D) you uere emotionally upset. (E) you exerc i s e d too much. 9. Exercise tends to r a i s e the blood sugar l e v e l . 10. The amount of exerci s e a d i a b e t i c person does a f f e c t s the amount of i n s u l i n he r e q u i r e s . True True True True True False False False False False True False True . False 11. What uould you be a l e r t f o r i f you took more e x e r c i s e than normal? A. i n s u l i n r e a c t i o n . B. d i a b e t i c coma. C. muscle cramps. I D. an i n f e c t i o n . 12. What uould you do i f you had taken mare e x e r c i s e than normal? A. take only % the usual amount of i n s u l i n the next day. B. eat t u i c e as much bread at the next meal. C. take t u i c e the usual amount of i n s u l i n the next day. D. eat or drink something sueet immediately. 13. You should take e s p e c i a l l y good care of your f e e t because: (A) a number of years of i n j e c t i n g i n s u l i n , i n t o the legs may cause s u e l l i n g of the f e e t . True False (B) as d i a b e t i c p a t i e n t s became older they may have poor c i r c u l a t i o n i n t h e i r f e e t . True False (C) foot i n j u r i e s may be harder to heal i n d i a b e t i c s than i n other people. True False 89 14. I f you have a sore on your foot you should A. soak i t i n hot water and apply a s t e r i l e bandage. B. soak i t i n c o l d water and apply iodine. C. wash i t w e l l with warm water and apply a s t e r i l e bandage. D. wash i t w e l l with warm water and apply i o d i n e . 15. The BEST thing to da i f you have corns or c a l l o u s e s on your feet i s to A. t r i m them c a r e f u l l y with manicure s c i s s o r s . B. t r e a t them wit h a commercial corn and c a l l o u s remover. C. n o t i f y your doctor. D. soak them i n hot water and rub them D f f with an emery board. 16. A d i a b e t i c coma might be caused by (A) not enough i n s u l i n . (B) not enough food. (C) a fever . (D) too much ex e r c i s e . True True True True False False False False 17. An i n s u l i n r e a c t i o n might be caused by (A) too much i n s u l i n . (B) too much food. (C) a f e v e r . (D) too much e x e r c i s e . True True True True False False False False 18. Column A contains a l i s t of signs and symptoms of d i a b e t i c c o m p l i c a t i o n s . Column B contains a l i s t of d i a b e t i c complic-a t i o n s . On the l i n e to the l e f t af each s i g n and symptom, put the l e t t e r of the complication of which each i s c h a r a c t e r i s t i c . Each response i n Column B may be used once, more than once, or not at a l l . COLUMN A COLUMN B (1) dry s k i n and tongue A. i n f e c t i o n (2) hunger B. d i a b e t i c coma (3) fever C. i n s u l i n r e a c t i o n (4) f r u i t y breath (5) t h i r s t (6) f e e l i n g of f a i n t n e s s 19. I f yau were going i n t o a d i a b e t i c coma, how would your urine t e s t ? A. p o s i t i v e f o r sugar; negative f o r acetone. B. p o s i t i v e f o r sugar; p o s i t i v e f a r acetone. C. negative f a r sugar; negative f o r acetone. D. negative f o r sugar; p o s i t i v e f o r acetone. 9 0 20. When feeling the symptoms of a diabetic coma, you uould A. take your prescribed insulin . B. phone the doctor . C. eat some sugar . D. go for a ualk . E. both A and B . 21. When feeling the symptoms of an insulin reaction, you uould A. eat some sugar . B. take some extra insulin . C. go for a ualk . D. l i e doun and rest . E. bath B and D. 22. If nauseated and i l l uith the fl u , you uould A. skip your regular insulin and eat less . B. skip your urine tests . C. take your regular insulin and eat less . D. take your regular insulin and eat soft foods or fluids • You should consult your doctor uhenever: (A) you have an insulin reaction . True False (B) you have acetone in your urine . True False (C) you are planning an unusual amount of exercise . True False (D) you have a cut or scrape . True False (E) yau have a f l u . True False (F) yau have a fever . True False (G) yau have sugar in your urine . True False (H) yau uish to alter your diet . True False Column A contains a l i s t of services provided for diabetics. Column B contains a l i s t of people or organizations uho provide these services. On the line to the le f t af the service put the letter af the person or organization uhich provides each service. Each response in Column B may be used once, mare than once, or not at a l l . COLUMN A (1) adjust your diet prescription (2) provide free diet counselling (3) adjust your prescription for insulin (4) give insulin injections at home COLUMN B A. Victorian Order of Nurses B. Canadian Diabetic Association C. Doctor 91 TEST OF DIABETIC LEARNING (f o r A n t i d i a b e t i c P i l l - U s e r s ) Subject Number: Scare: PART I: KNOWLEDGE (70 p o i n t s ) Please place ALL your answers on t h i s t e s t paper. For m u l t i p l e - c h o i c e or t r u e - f a l s e questions, c i r c l e the c o r r e c t response. Far a l l other types of questions, w r i t e the c o r r e c t response i n the space provided. 1. What are the names of the American/Canadian D i a b e t i c A s s o c i a t i o n Food Exchange Groups? 2. 3. 5. The f o l l o w i n g foods are allowed on a d i a b e t i c d i e t : (A) b u t t e r m i l k True False (B) i c e cream True False (C) marmalade True False (D) mayonnaise True False (E) noodles True False Foods i n one exchange group may be: (A) changed f o r foods i n another l i s t . True False (B) changed f o r foods i n the same l i s t . True False (C) changed f o r d i e t e t i c foods of any s o r t . True False (D) a l l eaten at the same meal. True False I n s u l i n causes the amount of sugar i n the blood to i n c r e a s e . True False (A) What i s the name of the a n t i d i a b e t i c p i l l you are taking? (B) How many m i l l i g r a m s of your a n t i d i a b e t i c drug do you take each time? (C) What time of day do you take your a n t i d i a b e t i c drug? (D) How does your a n t i d i a b e t i c drug act ta help your diabetes? 6. I f a d i a b e t i c person does not take i n s u l i n , he need not t e s t h i s u r i n e . True False 92 7. Routine urine tests for sugar shuuld De made (A) just before meals. (B) on "double-voided" specimens. (C) one hour after meals. (D) each time a diabetic urinates. True True True True False False False False Your urine might test positive for sugar i f : (A) you had eaten too much. True False (B) you had not taken your antidiabetic p i l l . True False (C) you had a fever. True False (D) you uere emotionally upset. True False (E) you exercised too much. True False 9. Exercise tends to raise the blood sugar level. True False 10. The amount of exercise a diabetic person does affects the amount of antidiabetic drug he requires. True False 11. What would you be alert (A) insulin reaction. (B) diabetic coma. (C) muscle cramps. (D) an infection. for i f you took more exercise than normal? 12. What would you do i f you had taken more exercise than normal? (A) take only 3£ an antidiabetic p i l l the next day. (B) eat tuice as much bread at the next meal. (C) take tuice as many antidiabetic p i l l s the next day. (D) eat or drink something sweet immediately. 13. You should take especially good care of your feet because: (A) a number of years of taking antidiabetic. drugs may cause swelling of the feet. True False (B) as diabetic patients become older they may have poor circulation in their feet. True False (C) foot injuries may be harder to heal in diabetics than in other people. True False lk. If you have a sore on your foot you should (A) soak i t in hot water and apply a sterile bandage. (B) soak i t in cold water and apply iodine. (C) wash i t well with warm water and apply a sterile bandage. (D) wash i t well with warm water and apply iodine. 93 15. The BEST thing to da i f yau have cams or callouses on your feet is to / (A) trim them carefully uith manicure scissors. (B) treat them uith a commercial corn and callous remover. (C) notify your doctor. (D) soak them in hot water and rub them off with an emery board. 16. A diabetic coma might be caused by (A) not enough antidiabetic drug. (B) not enough food. ( C ) a fever. (D) too much exercise. True True True True False False False False 17. An insulin reaction might be caused by: (A) too much antidiabetic drug. (B) too much food. (C) a fever. (D) too much exercise. True True True True False False False False 18. Column A contains a l i s t of signs and symptoms of diabetic complic-ations. Column B contains a l i s t of diabetic complications. Dn the line to the le f t of each sign and symptom, put the letter af the complication of which each is characteristic. Each response in Column B may be used once, more than once, or not at a l l . COLUMN A (1) dry skin and tongue (2) hunger (3) fever (4) fruity breath (5) thirst (6) feeling of faintness COLUMN B A. infection B. diabetic coma C. insulin reaction 19. If you were going (A) positive for (B) positive for (C) negative for (D) negative for into a diabetic sugar; negative sugar; positive sugar; negative sugar; positive coma, haw.would for acetone . for acetone . for acetone . far acetone. your urine test? 20. Uhen feeling the symptoms of a diabetic coma, yau should (A) take your prescribed antidiabetic p i l l . (B) phone the doctor. (C) eat some sugar. (D) go for a walk. (E) both A and B. 3k Uhen f e e l i n g the symptoms of an i n s u l i n r e a c t i o n , you uould (A) eat some sugar. (B) take an e x t r a a n t i d i a b e t i c p i l l . (C) go f o r a ualk. (D) l i e doun and r e s t . (E) both B and D. I f nauseated and i l l u i t h the f l u , you uould (A) s k i p your r e g u l a r a n t i d i a b e t i c p i l l and eat l e s s . (B) s k i p your urine t e s t s . (C) take your r e g u l a r a n t i d i a b e t i c p i l l and eat l e s s . (D) take your r e g u l a r a n t i d i a b e t i c p i l l and eat s o f t foods or f l u i d s . You should consult your doctor whenever: (A) you have an i n s u l i n r e a c t i o n . (B) you have acetone i n your u r i n e . (C) you are planning an unusual amount of e x e r c i s e . (D) you have a cut or scrape • (E) you have the f l u . (F) you have a f e v e r . (G) you have sugar i n your urine • (H) you wish to a l t e r your d i e t . True False True False True False True False True False True False True False True False Column A contains a l i s t of s e r v i c e s provided f o r d i a b e t i c s . Column B contains a l i s t of people or o r g a n i z a t i o n s who provide these s e r v i c e s . On the l i n e to the l e f t of the s e r v i c e put the l e t t e r of the person or o r g a n i z a t i o n which provides each s e r v i c e . Each response i n Column B may be used once, more than once, or not at a l l . Column A Column B _(1) adjust your d i e t p r e s c r i p t i o n A. (2 ) provide free d i e t c o u n s e l l i n g _(3) adjust your p r e s c r i p t i o n f o r B. a n t i d i a b e t i c drug J.k) give i n s u l i n i n j e c t i o n s at C. home V i c t o r i a n Order of IMurses Canadian D i a b e t i c A s s o c i a t i o n Doctor 9 5 TEST OF DIABETIC LEARNING  PART I I : SKILLS  A. Diet Planning ( 2 0 p o i n t s ) Pati e n t Number: You have been given: ( 1 ) a copy of your own meal p l a n , and ( 2 ) a set of the American/Canadian D i a b e t i c A s s o c i a t i o n food exchange l i s t s . Using these, plan your meals f o r a t o t a l day. Be sure to w r i t e dawn bath the name and the amount of each food to be eaten at each meal. Indicate the amount i n terms of standard household measure-ments (e.g. teaspoons, tablespoons, cups, e t c . ) . 96 TEST OF DIABETIC LEARNING  PART I I : SKILLS Patie n t Number: B. Urine Testing ( i n p a i n t s ) 1. Testing f o r Sugar (a) u i t h C l i n i t e s t STEPS YES ND (1) Holds dropper i n upright p o s i t i o n . (2) Places 5 (or 2) drops of urine i n t e s t tube. (3) Places ID drops of uater i n t e s t tube. (4) Puts uater i n t e s t tube f i r s t or r i n s e s dropper a f t e r p u t t i n g urine i n . (5) P o s i t i o n s dropper so that drops da not s l i d e doun sides of t e s t tube. (6) Adds C l i n i t e s t t a b l e t u i t h o u t touching i t u i t h moist f i n g e r s . (7) Waits 15 seconds a f t e r b a i l i n g has stopped to read. (8) Shakes tube gently a f t e r r e a c t i o n has stopped. I (b) u i t h C l i n i s t i x 1 S T E P S YES i\in (1) Does not touch t e s t area of s t i c k u i t h f i n g e r s . (2) Dips t e s t - a r e a of s t i c k i n t o urine to moisten. (3) Waits ID seconds before reading r e s u l t s . (4) Does not set s t i c k doun u h i l e u a i t i n g to read r e s u l t s . (c) u i t h Testape STEPS YES ND (1) Does not touch test-end of tape u i t h f i n g e r s . (2) Moistens test-end of tape by dipping i n u r i n e . (3) Waits 1 minute before reading r e s u l t s . (4) Does not set tape doun u h i l e u a i t i n g to read r e s u l t s . Urine Testing (continued) (d) u i t h D i a s t i x STEPS  (1) Does not touch t e s t area of s t i c k u i t h f i n g e r s . (2) Dips t e s t area of s t i c k i n t o u r ine f o r 2 seconds. (3) Taps edge of s t r i p against s i d e of u r i n e container or sink to remove excess urine, (4) Waits 30 seconds before reading r e s u l t s . YES Reads oun sugar specimen c o r r e c t l y . 2* Testing f o r Acetone (a) u i t h Acetest Tablets STEPS YES IMO (1) Places Acetest t a b l e t on piece of clean uhite paper. (2) Places 1 drop of urine on t a b l e t . (3) Waits 30 seconds before reading. (b) u i t h Acetone Test Pouder STEPS YES wn (1) Pours small mound of pouder on clean uhite paper. (2) Adds enough urine to moisten completely (2-3 drops). (3) Waits 1 minute before reading. (c) u i t h H e t o s t i x i 'l-' " YFS i\in (1) Does not touch t e s t area of s t i c k u i t h f i n g e r s . (2) Waits 15 seconds a f t e r removing from urine before reading r e s u l t s . (3) Does not set s t i c k doun u h i l e u a i t i n g to read r e s u l t s . Reads acetone t e s t specimen c o r r e c t l y . Urine Testing (continued) 3* Testing f o r Sugar and Acetone together ( K e t o d i a s t i x ) Mark as f o r D i a s t i x and H e t o s t i x . SCORING URINE TESTS: TECHNIQUE: ACCURACY: Jh f o r ur i n e sugar t e s t _/3 f o r ur i n e acetone t e s t /2 f o r u r i n e sugar t e s t _ / l f o r urine acetone t e s t TOTAL: / I D gg TEST DF DIABETIC LEARNING PART I I : SKILLS C. I n s u l i n I n j e c t i o n (11 p o i n t s ) Pati e n t Number: Score: STEPS YES NO (1) Gathers equipment. (2) washes hands. (3) R a l l s b o t t l e of modified i n s u l i n between hands to mix. (4) Moistens cotton with a l c o h o l . (5) Cleans rubber stopper of i n s u l i n b a t t l e with a l c o h o l . (6) EITHER empties syringe and needle of a l l a l c o h o l (or H^O) l e f t from s t e r i l i z a t i o n procedure OR opens disposable needle and s y r i n g e packages without contaminating. (7) F i l l s s yringe w i t h a i r equal to amount of i n s u l i n . (8) Pushes needle through centre of rubber stopper. (g) I n j e c t s a i r i n t o b o t t l e of i n s u l i n . (10) F i l l s s yringe with i n s u l i n to c o r r e c t amount. (11) Removes any a i r bubbles. (12) Cleans i n j e c t i o n s i t e by rubbing s k i n g e n t l y with cotton soaked i n a l c o h o l . (13) Pinches up l a r g e amount of f l e s h . (14) I n s e r t s needle i n t o s k i n at 60-gO degree angle. (15) P u l l s plunger back g e n t l y . (16) Pushes plunger to i n j e c t i n s u l i n . (17) I n j e c t s p r e s c r i b e d amount af i n s u l i n . (18) P r o t e c t s s k i n with (alcahal-saaked) cotton while withdrawing needle. Number of times a s e p t i c technique v i o l a t e d (up to 4) SCORE = 22 - (#No + #Breaks i n Asepsis) 2 ( t o t a l p o s s i b l e = 11) APPENDIX F MODIFIED DIABETIC TEACHING TOOL3 Nurse's Instructions to Accompany Slides Patient's Instructions for Handout The property of Miles Laboratories. NURSE'S INSTRUCTIONS TO ACCOMPANY SLIDES 1 0 2 SLIDE 1 and diabetes 103 SLIDE 2 Introduction Diabetes i s not an i l l n e s s . Yau didn't "catch i t " , and uhen you care f o r i t pr o p e r l y , i t won't stop you from enjoying l i f e . Diabetes cannot be cared f o r by your doctor alone. Indeed, your doctor i s depending on you to lear n as much as yau can about diabetes, so that you w i l l be able to care f a r y o u r s e l f . There i s qu i t e a b i t to l e a r n , but i t i s n ' t very d i f f i c u l t i f you take i t one step at a time. To help you do t h i s , t h i s course on diabetes has been d i v i d e d i n t o f i v e c l a s s e s : 1. I n t r o d u c t i o n 2. Diet 3. Medicine k. E x e r c i s e , Hygiene and Urine T e s t i n g 5. Problems Most of the things the nurse w i l l teach you are thi n g s that you w i l l do y o u r s e l f every day at home. Ask her l o t s of questions to be sure you understand what she i s saying. Remember, i n the long your d i a b e t i c care i s up t D you! (Nurse's I n s t r u c t i o n s ) 10k SLIDE 3 Food-Energy Cycle EXPLAIN: "The human body i s made up of m i l l i o n s of t i n y c e l l s . There-f o r e , each t h i n g t h a t the body does (working, p l a y i n g and so on) i s r e a l l y done by a group of c e l l s working t o g e t h e r . C e l l s need energy i n order to work. Uhen everything i s working properly i n the body, they make that energy by burning f u e l which comes from the food one eats. The body's biggest sources of f u e l are sweet and starchy foods such as sugar, bread and c e r e a l s . However, other foods (such as meat, f r u i t and vegetables) can provide f u e l too. A f t e r these foods are swallowed, the body changes them a l l t o a simple form of sugar. I t i s t h i s sugar which the c e l l s use as f u e l . Sugar i s c a r r i e d to_ each c e l l i n the body by the blood stream. In order f o r the sugar to get i n s i d e the c e l l however, i n s u l i n must be present. I n s u l i n i s a chemical made by the pancreas (an organ near the stomach). You may th i n k of i n s u l i n as the key that opens the c e l l door to l e t the sugar i n . As long as one eats the proper foods ... and as long as the body i s provided with enough i n s u l i n ... the food-energy c y c l e w i l l work smoothly without any problems." RELATE the above explanation to the s l i d e provided - by p o i n t i n g out where organs or processes occur - wherever p o s s i b l e . GIVE each p a t i e n t the sheet t i t l e d "Food-Energy C y c l e " f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 105 SLIDE k D i a b e t i c Food-Energy Cycle EXPLAIN: "As we s a i d , i n s u l i n may be thought of as the key that opens the c e l l door to l e t sugar i n . I f your body i s short of i n s u l i n f o r some reason, sugar won't be able to get i n t o your c e l l s . When t h i s happens, the sugar keeps backing up i n your blood u n t i l i t overflows i n t o your u r i n e . I t i s when t h i s happens that you are found to have diabetes. Diabetes, then, i s a c o n d i t i o n i n which there i s n ' t enough i n s u l i n i n the blood to allow your food-energy c y c l e to work properly." RELATE the above explanation to the s l i d e provided - by p o i n t i n g out where organs or processes occur - wherever p a s s i b l e . GIVE each p a t i e n t the sheet t i t l e d " D i a b e t i c Food-Energy Cycle" f a r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 106 SLIDE 5 Symptoms EXPLAIN: Here are some of the things that you might have noticed because of your diabetes: 11 1. Because your body wasn't making enough insulin to allow your food-energy cycle to work properly — therefore the amount of sugar.in your blood rose and spilled over into your urine. Your kidneys had to work overtime to get r i d of this sugar — therefore you likely had to pass large amounts of urine quite often. 2. Because you were losing so much extra water this way, yau probably were also very thirsty. 3. Because your body wasn't able to use i t s sugar-fuel properly, you might have lost weight, no matter how much you ate. . h. Because much of what yau did eat was being lost as sugar in your urine, you were probably very hungry. 5. Because your blood sugar was not being changed into energy, you may have f e l t weak and tired. Uhen you are taking care of your diabetes properly, you won't have any of these symptoms. They are just your body's way of te l l i n g • yau that something needs to be done." GIVE each patient the sheet t i t l e d "Symptoms" far his Take-hame folder. (Nurse's Instructions) 1D7 SLIDE 6 One i n Every F i f t y Canadians EXPLAIN: "Knowing that you have diabetes may make you f e e l very l o n e l y or very d i f f e r e n t from your f r i e n d s and neighbours. I t shouldn't! Diabetes i s not an uncommon c o n d i t i o n . One out of every 50 Canadians has i t , and most of them are leading p e r f e c t l y normal l i v e s . Many s u c c e s s f u l and famous people (businessmen, p o l i t i c i a n s , a t h l e t e s , a r t i s t s and performers) are d i a b e t i c . Because they are able to care f o r t h e i r diabetes so e a s i l y and so w e l l , i t hardly i n t e r f e r e s with t h e i r l i v e s at a l l . The same can apply to you! Diabetes need not change your plans or your way of l i f e . I t w i l l mean adding some new h a b i t s ; but i t won't mean missing o l d pleasures." GIVE each p a t i e n t the sheet t i t l e d "One i n Every F i f t y Canadians" f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) loa SLIDE 7 General Questions DISCUSS the f o l l o u i n g m a t e r i a l uhich may be of concern to the p a t i e n t s : 1. Marriage and Family (a) " I f yau are s i n g l e , diabetes shouldn't change your plans to marry. Because diabetes i s so easy to care f o r , i t causes no problems i n r e l a t i o n to g e t t i n g or s t a y i n g married. (b) In a d d i t i o n , diabetes i n i t s e l f i s no reason f o r not having c h i l d r e n . D i a b e t i c people can and do have p e r f e c t l y healthy babies. Houever, the chance of having a d i a b e t i c c h i l d does increase i f one or both of the parents are d i a b e t i c . You uould be u i s e to t a l k to your doctor some mare about t h i s before s t a r t i n g a f a m i l y . (c) I f yau have c h i l d r e n houever, there i s a b e t t e r than average chance that they u i l l develop diabetes. You should advise them to have a doctor check t h e i r blood and urine f a r sugar r e g u l a r l y . " 2. L i f e Insurance "Any l i f e insurance p o l i c y yau had before you developed diabetes u i l l not be c a n c e l l e d . As f o r neu insurance, many companies today u i l l give l i f e insurance p o l i c i e s to d i a b e t i c people who are taking goad care af themselves." 3. work "Diabetes should not stop you from u o r k i n g . Indeed, i t probably uon't even have much e f f e c t on the kind af uork you can do. People u i t h diabetes are engaged i n almost every k i n d of uork you could name (from desk jobs to labour to hauseuork). Studies have shoun that they da as u e l l i n t h e i r uork — i n every uay -- as do non-diabetics." k. Sports and Other A c t i v i t i e s "Here again, there i s no need to give up or to change any-thi n g that you enjoy. As a matter of f a c t , e x e r c i s e i s e s p e c i a l l y good f o r the person u i t h diabetes. I t helps to burn up sugar. Houever, i f your e x e r c i s e pattern i s l i k e l y to change g r e a t l y from one day to the next, yau should discuss t h i s u i t h your doctor. He u i l l want to adjust yaur meals and medicine to take t h i s i n t o account." GIV/E each p a t i e n t one of the sheets t i t l e d "General Questions" fo r h i s Take-home f o l d e r . MOTE that there are two types af these sheets - one type f a r younger p a t i e n t s and one type f a r o l d e r p a t i e n t s . (Nurse's I n s t r u c t i o n s ) 109 SLIDE a Balance = Good Health EXPLAIN: "Yau and your doctor share s e v e r a l aims or goals i n the care of your diabetes. They are: 1. to get r i d of the symptoms of your diabetes (OR i f you have had no symptoms, to keep them from showing up); 2. to keep you from g e t t i n g any complications of diabetes; 3. to keep you healthy; and at the same time k. to i n t e r f e r e as l i t t l e as p a s s i b l e with your normal d a i l y l i f e . Reaching these goals depends upon keeping a c a r e f u l balance between 1. your food - which provides the sugar i n your blood stream; and 2. your i n s u l i n and exer c i s e - which help your body use t h i s sugar f o r energy. Tipping the balance to e i t h e r side w i l l r e s u l t i n problems. Keeping i t even w i l l r e s u l t i n goad h e a l t h . " BE SURE that the p a t i e n t has grasped the idea af "balance" i n r e l a t i o n to h i s diabetes, as t h i s concept i s b a s i c to s e v e r a l other explanations throughout the course. GIUE each p a t i e n t the sheet t i t l e d "Balance = Goad Health" f a r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 1 1 0 SLIDE 9 Diet EXPLAIN: "You may be asking y o u r s e l f uhy i t i s necessary f o r d i a b e t i c s tD f o l l o w a d i e t . By seeing tD i t that yDU eat the same kind and amount of food each day, you and your doctor are able to keep the sugar i n your blood at a safe l e v e l . Most foods can be changed intD sugar by the body. However, some foods make more sugar than others. I f you eat more food than your body needs, or too much of the wrong kinds of food, i t may cause the sugar i n your blood to b u i l d up. This w i l l t i p your good-health balance, and might cause some s e r i o u s problems. There-fo r e , i t i s e s p e c i a l l y important f a r you to watch both the kind and the amount of food that you eat. No tuo d i a b e t i c s are e x a c t l y a l i k e . So, each d i a b e t i c person's d i e t u i l l be d i f f e r e n t from that of other d i a b e t i c s . Only your doctor can work out the r i g h t d i e t f o r you. Nou there i s no need to be discouraged about the idea of d i e t . You uon't have to give up very many foods that you enjoy. You won't have to cook or eat meals d i f f e r e n t from your f a m i l y ' s . You won't have to buy s p e c i a l foods or shop i n s p e c i a l s t o r e s . You w i l l have to l e a r n a new uay of planning your meals -- but t h i s u i l l soon become second nature to you." G I V E each p a t i e n t the sheet t i t l e d " D i e t " f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) I l l SLIDE ID Kinds of Food EXPLAIN: "Your d i e t plan u i l l c a l l f o r foods such as m i l k , meat, vegetables, f r u i t , bread and c e r e a l s . These foods are necessary f a r good health and should be eaten every day by everyone -- non-d i a b e t i c s and d i a b e t i c s a l i k e ! Nearly a l l foods have some carbohydrate, p r o t e i n and f a t i n them. Houever, the amounts of each u i l l be d i f f e r e n t i n d i f f e r e n t kinds of foods. Foods that have more carbohydrate than p r o t e i n or f a t are c a l l e d carbohydrate foods. Carbohydrate foods are sugars, breads, c e r e a l s , f r u i t s and vegetables. Foods that have more p r o t e i n than carbohydrate or f a t are c a l l e d p r o t e i n foods. P r o t e i n foods are milk, cheeses, eggs, meats or f i s h . Foods that have more f a t than carbohydrate or p r o t e i n are c a l l e d f a t foods. Some f a t foods are b u t t e r , nuts and bacon. In planning your d i e t , your doctor u i l l make sure that you eat some carbohydrates, some p r o t e i n s and some f a t s at every meal. Each of these 3 types of food has a s p e c i a l job to perform: 1. Carbohydrate foods are used by the body i n the same uay that a car uses g a s o l i n e . They are burned by the c e l l s to provide energy. U h i l e other foods may also provide energy, carbohydrates dD so the f a s t e s t . Thus ue may say that they are l i k e "premium" gasoline. 2. P r o t e i n foods are used by the body f o r grouth, f o r b u i l d -ing muscles and f o r r e p a i r i n g any body damages, i . e . f o r "home b u i l d i n g and maintenance". 3. Fat foods are also f u e l foods. They, l i k e carbohydrates, provide energy f o r the body. Houever, they do not act as q u i c k l y as carbohydrates — so they are more l i k e " r e g u l a r " g a s o l i n e . Further-more, i f f a t s are not needed by the body at the time they are eaten, they may be s t o r e d -- s o r t of l i k e a "spare tank" — i n the form of body f a t . " GIVE each p a t i e n t the sheet t i t l e d "Kinds of Food" f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 112 SLIDE 11 Hou the Doctor Plans Your Diet EXPLAIN: "As ue s a i d before, as a d i a b e t i c , you w i l l need your own perso n a l i z e d d i e t . The doctor u i l l take many t h i n g s i n t o account i n planning t h i s d i e t f o r you. Here are some of them. 1. Your age C h i l d r e n , teenagers, pregnant uomen, and o l d e r a d u l t s a l l have s p e c i a l needs uhich determine the kind and amount of foods they should eat. Your doctor u i l l plan your d i e t to meet the s p e c i a l needs of your age group. 2. Your ueiqht I f you are overueight, your doctor u i l l give you a d i e t t h a t u i l l help you to lose ueight at f i r s t . Once you have reached the correct ueight f a r you, your d i e t u i l l be changed so that i t helps you keep that u e i g h t . 3. Sex Men and uomen have d i f f e r e n t food needs. Your doctor u i l l take these i n t o account. k. A c t i v i t y As ue s a i d before, e x e r c i s e causes the body to use up sugar. Therefore, more a c t i v e people u i l l need more food than l e s s a c t i v e ones. I f your a c t i v i t y u i l l change g r e a t l y from day to day, you may even need more than one d i e t p l a n . Talk t h i s over u i t h your doctor. 5. O v e r - a l l Health An i l l n e s s may cause your good-health balance of food, i n s u l i n and exercise to t i p . Therefore, uhen you are i l l , your doctor u i l l adjust your d i e t to meet the s p e c i a l needs your body has at that time. In a d d i t i o n , i f you have some other c o n d i t i o n besides diabetes, i t may have to be considered i n your d i e t plan as u e l l . " GIVE each p a t i e n t the sheet t i t l e d "Hou the Doctor Plans Your Di e t " f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 113 SLIDE 12 Things You Need to F o l l r j u i Your Diet EXPLAIN: "Following your d i e t on a day-to-day b a s i s i n v o l v e s the use of two t h i n g s : 1. The meal plan prepared by your doctor or d i e t i c i a n ; and 2. The food exchange l i s t s found i n the Canadian D i a b e t i c A s s o c i a t i o n booklet "Meal Planning f o r D i a b e t i c s i n Canada". Usually the meal plan i s given very simply -- f o r example, i n terms of f r u i t , meat, bread, f a t , milk and vegetables. U i t h the food exchange l i s t s these i n s t r u c t i o n s can be f a l l o w e d out with a v a r i e t y of t a s t y food choices." GIVE each p a t i e n t 1. a copy of h i s meal p l a n , and 2_. a Canadian D i a b e t i c A s s o c i a t i o n "Meal Planning" b o o k l e t . The meal plan may be obtained from the h o s p i t a l d i e t i c i a n . Suggest that the p a t i e n t may plan h i s meals f o r a day and b r i n g i t with him next day so that he may have i t checked. EXPLAIN: "You w i l l r e c a l l that both the kind and the amount of food that you eat are important. The Canadian D i a b e t i c A s s o c i a t i o n Exchange L i s t s take care of both these t h i n g s . F i r s t , they d i v i d e a l l of the foods you w i l l eat i n t o d i f f e r e n t k i n d s . Each of these makes up one Exchange L i s t . There i s a l i s t f o r milk products, a l i s t f o r meats, a l i s t f o r f r u i t s , a l i s t f o r breads, a l i s t f o r f a t s , and two l i s t s f o r vegetables. In a d d i t i o n , there are two l i s t s of "free foods". These l i s t s are found an pages 7 to 20 of your "Meal Planning" b o o k l e t . " (Nurse's I n s t r u c t i o n s ) 114 SLIDE 13 Exchange System EXPLAIN: "In a d d i t i o n to helping yau choose the c o r r e c t kinds of food f a r your d i e t , the Canadian D i a b e t i c Exchange L i s t s also t e l l you the amounts of food to eat. They do t h i s by the s i z e of the serving allowed. The idea behind t h i s i s that any measured se r v i n g of food on a given l i s t can be traded f a r any other measured se r v i n g on the same l i s t . For example, your meal plan may say that you can have a meat exchange f a r b r e a k f a s t . Uhen you look at the "Meat Exchange L i s t " you w i l l see that one egg i s the same as three s l i c e s of c r i s p bacon or one and one-half sausages. There are dozens of meats an the l i s t -- and you may have any one of them in the amount shown. Just remember: DIME EXCHANGE EQUALS ONE MEASURED SERVING. In most cases i t w i l l not be necessary to weigh your foods i n order to measure them. Most of the servings are given i n terms of standard household measures - cups, teaspoons, tablespoons and inches. I f you don't already have them, i t would be wise to get a standard S-ounce measuring cup, a set of measuring spaons and a small r u l e r . Measurements should be " l e v e l " - not heaped - and should u s u a l l y be made a f t e r the food i s cooked." GIVE each p a t i e n t the sheet t i t l e d "Things You Need to Fallow Your Diet" and "Exchange System" f o r h i s Take-home f o l d e r . BE SURE that each p a t i e n t also has 1. a copy of h i s own meal plan, and 2_. a "Meal" Planning" booklet. REVIEW each of the Canadian D i a b e t i c A s s o c i a t i o n exchange l i s t s with the p a t i e n t s by means of the f o l l o w i n g nine s l i d e s . (Nurse's I n s t r u c t i o n s ) 115 SLIDE 14 Mi l k Exchanges REVIEW the milk exchanges shown i n t h i s s l i d e with the pa t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" booklet. EMPHASIZE that any of these milk products i n the amount  shown i s equal to one milk exchange. 116 SLIDE 15 Vegetable A Exchanges REVIEU the vegetables shown i n t h i s s l i d e u i t h the p a t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" b o o k l e t . EXPLAIN that the "A" vegetables are the ones that have mare carbohydrate i n them. EMPHASIZE that any of these vegetables i n the amount shoun i s equal to one vegetable A exchange. 117 SLIDE 16 Vegetable B Exchanges REVIEW the vegetables shoun i n t h i s s l i d e u i t h the p a t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" b o o k l e t . EXPLAIN that the B vegetables are the ones that have l e s s carbo-hydrate i n them. EMPHASIZE that any of these vegetables i n the amount shoun i s equal to one vegetable B exchange. I f you f e e l that i t u i l l not confuse the p a t i e n t s , e x p l a i n to them that they may s u b s t i t u t e 2 measured se r v i n g s of "B" vegetables f D r o n e measured s e r v i n g of "A" vegetables any time "A" vegetables are c a l l e d f o r on t h e i r meal p l a n . 118 SLIDE 17 F r u i t Exchanges REUIEW the f r u i t s shown i n t h i s s l i d e with the p a t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" b o o k l e t . EMPHASIZE that any of these f r u i t s i n the amount shown i s equal to one f r u i t exchange. 1 cup raw st r a w b e r r i e s 119 SLIDE 18 Bread Exchanges REUIEIJJ the bread exchanges shoun i n t h i s s l i d e u i t h the p a t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" booklet. EMPHASIZE that any of these bread products i n the amount shoun i s equal to one bread exchange. 120 SLIDE 19 Meat Exchanges REVIEW the meats shewn i n t h i s s l i d e with the p a t i e n t s . HELP them to l o c a t e each i n t h e i r "Meal Planning" b o o k l e t . EMPHASIZE that any of these meat products i n the amount shown i s equal to one meat exchange. 1 2 1 SLIDE 20 Fat Exchanges H P . D ^ P V ^ / a t exchanges shoun i n t h i s s l i d e u i t h the p a t i e n t s , HLLH them t o l o c a t e each i n t h e i r "Meal P l a n n i n g " b o o k l e t . EMPHASIZE t h a t any o f t h e s e f a t p r o d u c t s i n the amount shoun i s e q u a l t o one f a t exchange. H 1 2 2 SLIDE 2 1 C a l o r i e Free Foods REVIEW the foods shoun i n t h i s s l i d e u i t h the p a t i e n t s . HELP them to lo c a t e each i n t h e i r "Meal Planning" booklet. EMPHASIZE that any of these foods may be used as d e s i r e d to add zest to the d i e t . 123 SLIDE 22 Calor ie Poor Foods U P , D + K R E U * E l l J t h B f D D d s s h o u j n i n t n i s s l i d B with the p a t i e n t s , ^ o u n c ^ r *° }°™te B a c h in the i r "Meal Planning" book le t . EMPHASIZE that they may choose tuo measured serv inos of these foods each day in addi t ion to the i r d i e t l ~ 12k SLIDE 23 There Aren' t Many Poods You Can't Have Exp la in ; When you have had a good look at a l l of the foods on the Canadian D iabet ic Exchange L i s t s , you u i l l r e a l i z e that there r e a l l y are not many foods uhich you may not have. These foods are not on the Exchange L i s t s because they have too much pure sugar in them. You should not eat any of the f o l l o u i n g foods, except on the advice of your doctor : sugar candy honey jam j e l l y preserves syrup marmalade pie sweetened condensed cake milk cookies cheuing gum regular so f t dr inks For exceptions to t h i s advice, plus seasonings and free foods uhich u i l l add zest to your d i e t , see pages 19 and 2D of your "Meal Planning" b o o k l e t . " GIVE each pat ient the sheet t i t l e d "There Aren ' t Many Foods That You Can' t Have" for h is Take-home f o l d e r . (Nurse's Inst ruct ions) 125 SLIDE 2k Questions re Diet DISCUSS the follouing information uhich may be of concern to the patients: 1. Food Shopping It is not necessary to buy special foods because you have diabetes. You can eat the same food as the rest of your family. Uhen buying canned or frozen foods (especially fruits and fr u i t juices), look for the uords "no sugar added" on the label. You may uish to buy some dietetic foods, such as non-caloric soft drinks or dietetic jam or j e l l y . Some of these are indeed allaued. But be careful, some a r t i f i c i a l sueeteners do_ contain carbohydrates. Check uith your "Meal Planning" booklet or the Canadian Diabetic Association Diet Counselling Service uhenever you are in doubt. . 2. Liquor Generally speaking, uine, beer and other alcoholic beverages are not permitted on a diabetic diet. Houever, i f you enjoy a drink, i t uould be uise to discuss the matter uith your doctor. He might shou you hou to include an occasional drink in your diet plan. 3. Eating Out There is no reason uhy having diabetes should stop you from eating out. Uhen you are in a restaurant, ask about the uay the food has been cooked. Try to eat plain foods (i.e. those uhich have not been breaded, fried or cooked in a sauce), since you can judge their exchange value more easily. If you take a lunch from home, you u i l l find that i t is quite easy to prepare. Just follou your meal plan, and choose exchanges uhich may be urapped and carried easily. k. Entertaining A diabetic diet is a healthy and tasty diet. • There is no reason uhy you shouldn't cook the same foods for your guests as you uould for yourself. If you uish to add extra fat or flour to a given dish, simply remove your oun portion before you do so. 5. Illness If you are nauseated or vomiting, or i f you have diarrhea or a poor appetite, you may not feel like eating your regular diet. If any of these things happen, you should phone your doctor. He may suggest that you convert your meal plan into f l u i d exchanges. If he does, turn to pages 20 and 21 of your "Meal Planning" booklet for directions. (Nurse's Instructions) 126 SLIDE 25 Medicine EXPLAIN: "Some d i a b e t i c s can keep t h e i r c o n d i t i o n i n balance by j u s t f o l l o u i n g t h e i r d i e t s . Other d i a b e t i c s r e q u i r e some s o r t of medicine i n a d d i t i o n to- t h e i r d i e t s to stay h e a l t h y . D i a b e t i c medicine comes i n tuo forms: - i n s u l i n and o r a l a n t i d i a b e t i c p i l l s . I f a d i a b e t i c person's pancreas i s making l i t t l e or no i n s u l i n , h i s doctor may u i s h him to take i n s u l i n . I n s u l i n must be i n j e c t e d beneath the s k i n because, i f i t i s su a l l o u e d , i t i s destroyed by the d i g e s t i v e j u i c e s of the stomach. I f a d i a b e t i c person's pancreas i s making some i n s u l i n , but not enough - or i f the i n s u l i n i t makes i s not able to do the job i t should - h i s doctor may u i s h him to take an o r a l a n t i d i a b e t i c  p i l l . I t i s c a l l e d an " o r a l " p i l l because i t can be su a l l o u e d , and i t i s c a l l e d an " a n t i d i a b e t i c " p i l l because i t f i g h t s against diabetes. Some d i a b e t i c persons can use the a n t i d i a b e t i c p i l l s ; . o t h e r s cannot. Don't t r y to compare your diabetes u i t h that of other people! Each d i a b e t i c p a t i e n t needs s p e c i a l study and care. A f t e r c a r e f u l study, your doctor has decided uhich medicine you need to care f o r your diabetes. F o l l o u h i s advice!" GIVE each p a t i e n t the sheet t i t l e d "Medicine" f o r h i s "Take-home f o l d e r " . (Nurse's I n s t r u c t i o n s ) 127 SLIDE 26 Antidiabetic P i l l s EXPLAIN: "Your doctor has decided that your diabetes u i l l be kept in its best balance i f you take an antidiabetic p i l l in addition to follouing your diet." HELP each patient to locate his antidiabetic p i l l among those illustrated on the slide. Then point out the information uhich applies to him from that given belou. NAME STRENGTH MODE OF ACTION Group I (Sulfonylureas) - Orinase (tolbutamide) - Mabenal (tolbutamide) - Genarex (tolbutamide) - Diabinese (chlorpropamide) - Chlaronase (chlorpropamide) - Dimelor Group II (Biguanides) - Dia Beta - DBI (phenformin) - DBI-TD 500 mg 500 mg 500 mg Helps the pancreas 250 mg to make more insulin. 100 or 250 mg 500 mg 5 mg Helps the body use 25 mg i t s insulin more 50 mg effectively. EXPLAIN: "It is most important that you take only this antidiabetic drug, and that you follou your doctor's instructions for taking i t exactly. If you do this, your good health balance u i l l stay even. If you don't, the balance u i l l tip, and you may run into serious problems. Although your diabetes is uell managed uith your antidiabetic p i l l , there may be some feu times uhen you u i l l have to take insulin as u e l l . When your body needs more insulin than i t can make (even uith the help of your p i l l ) - such as uhen you are sick, uhen you have a bad infection, or uhen you have an operation - this extra insulin may need to be supplied from outside your body by an i n -jection. Should you.need such an injection at home, your doctor u i l l be able to arrange for i t to be given by a visiting nurse. (NOTE: - As uith a l l kinds of medicine, antidiabetic p i l l s may cause unpleasant side effects in some people. These are very rare. Houever, should you have any nausea, vomiting, loss of appetite or any other such symptom, report i t to your doctor immediately.)" 128 SLIDE 26 (cont'd) GIVE each p a t i e n t the sheet t i t l e d " A n t i d i a b e t i c P i l l s " f o r h i s Take-home f o l d e r . BE SURE that each p a t i e n t knous the JL. name; 2_. str e n g t h ; J3. dose; k_. a d m i n i s t r a t i o n times, and 5_. mode of a c t i o n f o r h i s  oun drug. ASSIST him to f i l l i n t h i s information on the sheet provided. DO IMOT give t h i s information to i n s u l i n users. (IMurse's I n s t r u c t i o n s ) 129 SLIDE 27 Insulins EXPLAIN: "Your doctor has decided that your diabetes u i l l be kept in its best balance i f you take insulin as uell as follouing your diet. Insulin helps you manage your diabetes by making i t easier for sugar to get from your blood into the c e l l s , uhere i t can be burned for energy." HELP each patient to locate his insulin among those i l l u s -trated on the slide. Then point out the information uhich applies to him from that given belou. Time of Strongest Action Name Effect Rapid (fast - Regular (Toronto) just before acting) - Semilente lunch Medium - N.P.H. acting - Globin just before - Lente supper Prolonged (slou) - P.Z.I. during the acting. - Ultralente night ASSIST the patient to identify uhich strength of insulin he is to use (UHTJ or U80). EXPLAIN that this type of measurement of strength means that there are 40 or 80 l i t t l e bits of insulin in one c.c. (one syringeful). Point out that the strength of the insulin is aluays indicated by the colour of the print an the label - red far LIH-0 and green for U80. EXPLAIN: "It is most important that you take only this kind of insulin, and that you fallou your doctor's instructions for taking i t exactly. If you do this, your good health balance u i l l stay even. If yau don't the balance u i l l tip, and yau may run into serious problems." GIV/E each patient the sheet t i t l e d "Insulins" for his Take-home folder. BE SURE that each patient knous the 1. name, 2_. strength, 3_. dose, 4_. administration time(s), 5_. mode af action, and §_. time of strongest effect far his insulin. ASSIST them ta f i l l in their information on the sheet provided. DO NOT give this information to antidiabetic p i l l users. (Nurse's Instructions) 130 SLIDE 28 Equipment EXPLAIN: "There i s c e r t a i n equipment which you w i l l need to give your i n s u l i n i n j e c t i o n s . I t would probably be a good idea to keep a l l of t h i s equipment together i n one place (such as on a t r a y or i n a s p e c i a l cupboard). Here are the things you w i l l need: 1. Syringes: You should buy U s y r i n g e s . I t i s important f o r you to have t h i s s i z e , because that i s the strength of i n s u l i n you w i l l be using. Your _U syringes w i l l have coloured markings on them. You may wish to use e i t h e r g l a s s or p l a s t i c disposable (throw-away) s y r i n g e s . I f you choose g l a s s , you should buy at l e a s t 2 syringes (to allow f o r s t e r i l i z i n g and breakage). I f you choose disposables, buy them by the dozen, as they are l e s s expensive that way. Glass syringes are somewhat l e s s expensive than the disposable ones, but g l a s s must be b o i l e d or soaked i n a l c o h o l to make i t safe ( s t e r i l e ) f o r use. 2. Needles: You should buy gauge, inch long needles. This i s the s i z e that the doctor f e e l s i s best f a r you to use. Here again, you may choose from 2 types of needles: metal hub, reusable or p l a s t i c hub d i s p o s a b l e . I f you choose reusable needles, you should buy at l e a s t two. I f you choose disposables, buy them i n q u a n t i t y . Disposable needles have the advantages of being sharper and not needing s t e r i l i z a t i o n . 3. I n s u l i n : You should use the kind and strength of i n s u l i n which we discussed on the l a s t page. I t i s wise to always have at l e a s t 2 b o t t l e s of i n s u l i n on hand - the one you are using, and an e x t r a . Each i n s u l i n b o t t l e i s marked with an e x p i r y date. I t i s not safe to use that i n s u l i n a f t e r the date given. I f the b a t t l e expires before i t i s opened, r e t u r n i t t a your drug s t a r e . I f i t expires ance yau have s t a r t e d using i t , throw i t away. You may store the b a t t l e af i n s u l i n which you are using at room temperature. Extra b a t t l e s should be kept i n the r e f r i g e r a t o r . Don't store your i n s u l i n i n the f r e e z e r ! The extreme c o l d reduces i t s e f f e c t i v e n e s s . 131 SLIDE 28 (cont'd) k. A l c o h o l : You u i l l need a l c o h o l f a r cleaning your s k i n and some af your i n j e c t i n g equipment. Yau should buy 70% i s o p r o p y l a l c o h o l f o r t h i s purpose. Store your a l c o h o l i n a covered g l a s s container, as i t evaporates very q u i c k l y i f l e f t uncovered. 5. Cotton: Absorbent cotton u i l l be needed to apply the a l c o h o l to your s k i n . E i t h e r bulk cotton or cotton b a l l s u i l l serve t h i s purpose u e l l . Store your cotton i n a clean covered c o n t a i n e r . SHOLJ the p a t i e n t s as much of t h i s equipment ,as p o s s i b l e . Point out the names af the various parts of the syringe and needle. Discuss uhich parts they may and may not touch. Encourage them to handle the equipment and to ask questions about anything that puzzles them. GIV/E each p a t i e n t the sheet t i t l e d "Equipment" f a r h i s Take-home f o l d e r . ASSIST them by f i l l i n g i n the blanks provided. I f the doctor has not s p e c i f i e d a needle s i z e f o r the p a t i e n t , you could suggest 25 gauge 1/2" or 5/8". I f they do not knou the s i z e of syringe to use, suggest that they have i t completed by the uard s t a f f before they are discharged. (Nurse's I n s t r u c t i o n s ) 132 SLIDE 29 Preparing Your Insulin EXPLAIN: "Here are the nine steps to Follou in preparing your insulin injection: 1. Ldash your hands. 2. Mix your insulin, i f necessary, by ro l l i n g the bottle betueen your hands. 3. Moisten some cotton uith alcohol. k. Clean off the top of your insulin bottle uith the alcohol-soaked cotton. 5. Remove any alcohol or uater that may be in your syringe i f you are using a glass syringe. 6. Drau the right amount of air into the syringe. - 7. Push the needle through the rubber top of the insulin bottle. 8. Push the air into the insulin bottle. 9. Pull the plunger back to uithdrau the correct amount of insulin. Check for air bubbles in the syringe, and i f there are none, pull the needle out of the insulin bottle. Throughout the preparation and giving of your insulin i t is important to keep from touching the follouing: (a) the stem of the plunger, (b) the top of the syringe, (c) the point of the needle, (d) the top of the insulin bottle." DEMONSTRATE the above nine steps to the patients. HAUE THE PATIENTS RETURN THE DEMONSTRATION. Encourage them to identify each step as they do i t . LEAVE the injection equipment uith the patients so that they may continue to practice the procedure. This u i l l be checked by the ward staff. GIVE each patient the sheet t i t l e d "Preparing Your Insulin" for his Take-home folder. IF any patient w i l l be using a mixture of two insulins, follow the same steps as above, but use the sheet t i t l e d "Preparing Your Insulin Mixture" far the steps in preparation. GIVE the patient this sheet for his Take-home folder. (Nurse's Instructions) 133 SLIDE 30 Giving Your Insulin EXPLAIN: "Once you have prepared your insulin, most of the uork is done. There are only six steps l e f t to finish giving your insulin. 1. Clean the skin at the injection site uith alcohol-soaked cotton. 2. Pinch up a large area of skin. 3. Insert the needle quickly into the skin at 60 to 90 degree angle. k. Remove the hand that uas pinching the skin. Using that hand, pull back on the plunger to be sure that the needle is not in a blood vessel. (If blood should come back into your syringe, you must discard that insulin and begin a l l over again.) 5. Push the plunger in slouly to inject the insulin. 6. Remove the needle quickly at the same angle that i t uas inserted, bracing your skin uith a clean piece of cotton." POINT OUT the above six steps to the patients and DEMONSTRATE the procedure to them. Encourage the patients to identify each step as you are doing i t . EXPLAIN the follouing: "Insulin should aluays be injected to reach the loose space under your skin betueen your fat and your muscle. If you inject your insulin too close to the surface, i t may go into the fat or the skin and cause a painful stretching and suelling. In time, this may lead to shrinkage of the skin and fat, causing 1hollous'." "These lumps prevent your insulin from being absorbed by your body at the proper speed. Although i t may hurt less to give your injections in these places, you should not do so! Rotate the site of your injections through as many as possible of the areas shoun at l e f t . A chart may be helpful in doing this. You should never give tuo injections closer than one inch apart in the same month!" LEAVE the injection equipment and an orange uith each patient so that they may continue to practice the procedure. GIVE the sheet t i t l e d "Giving Your Insulin" for their Take-home folder. The uard staff u i l l observe them simulate the injection u n t i l they can perform the procedure safely and accurately. ENCOURAGE each patient to begin giving his oun injection as soon as passible. Once they have mastered this procedure, they should give their oun injection every day to REINFORCE this learning. (NOTE: i f any patient is. unable to overcame the psychological barrier of actually passing the needle through his skin, a Busher Automatic Injector may be recommended.) (Nurse's Instructions) 134 SLIDE 31 Care of Your Equipment - Daily Care uith Alcohol EXPLAIN: "It is important that you keep your injection equipment sterile (germ-free), in order that i t be safe for you to use. This may be done in tuo uays: 1. Daily Care uith Alcohol Alcohol is quite sufficient to keep your injection equipment sterile betueen ueekly bailings. Here's hou ta use i t : (a) Pour 70% isoprapyl alcohol into a clean covered container or a "steri-tube" (a special tube in a stand uhich you can buy at your drug store). (b) Drau enough alcohol into your syringe to f i l l i t . Squirt i t out. Repeat 2 or 3 times. (c) Put your syringe into the container. It should be covered uith alcohol. Place the l i d on the container. (d) Leave your syringe in the alcohol until you are ready to use i t again. (It must have been soaking in the alcohol at least 20 minutes to be sterile.) (e) You u i l l find that after many uses, the alcohol in your container u i l l have evaporated or become dis-coloured. If i t evaporates, just add some more (there should aluays be enough to caver your equipment). If i t becomes discoloured, throu i t auay and get some fresh alcohol." GIVE each patient the sheets t i t l e d "Care of your Equipment" for his Take-home folder. (Nurse's Instructions) 135 SLIDE 32 Weekly Care - Boil in Water EXPLAIN: "To be very sure that your injecting equipment is absolutely sterile, you should boil i t in water once a week. The steps for doing this are quite easy: (a) Take your syringe apart. Put the parts into a large strainer. (b) Put the strainer in a pot of boiling water. Be sure that the water covers.the equipment. (c) Boil 10 minutes. (d) Pick up the strainer, hold i t and pour the water out of the pan. Put the strainer back into the pan until everything has cooled. (e) To reassemble your syringe: i . " Pick up the outside part of the syringe (the 'barrel') with one hand. i i . With the other hand grasp the handle end of the plunger. i i i . Without touching any other part, slide the plunger into the barrel to put the syringe together. (f) Wrap your equipment in a freshly ironed piece of cloth, or return i t to the alcohol container - so i t stays sterile until you are ready to use i t . (g) You w i l l find that your syringe w i l l become cloudy after many bailings. Ta get r i d af this either soak i t in vinegar or boil i t in vinegar and water before s t e r i l i z i n g . (NOTE: If you have re-usable needles, they too must be st e r i l i z e d . Treat them exactly the same as your syringe, i.e. soak in alcohol every day and boil once a week. To put re-usable needles onto the syringe: - pick up the big part of the needle (the "hub"); put the needle onto the syringe and turn to tighten. Do not touch the point of the needle or the tip of the syringe!)" (Nurse's Instructions) 136 SLIDES 33 and 34 Exercise EXPLAIN: "Exercise i s goad f a r everyone. I t helps keep weight doun, muscles strong and blood flowing p r o p e r l y . In short - i t helps people stay healthy. This i s e s p e c i a l l y true f o r d i a b e t i c s . I f you w i l l t h i n k back to the goad-health balance you w i l l remember that e x e r c i s e , as w e l l as d i e t , has an e f f e c t on the balance of sugar and i n s u l i n i n the body. A l l the p h y s i c a l a c t i v i t i e s (such as walking, swimming, gardening) are kinds of e x e r c i s e . And a l l e x e r c i s e burns up sugar. Your doctor has planned your d i e t to give you the amount of food you need' to do the a c t i v i t i e s you u s u a l l y do. He has planned your medicine to see that you have j u s t enough i n s u l i n to use up the sugar i n your blood f o r energy. Therefore, to keep your good-health balance even, you should do about the same amount of e x e r c i s e  every day. The kind of e x e r c i s e i s not nearly as important as the amount. You can do j u s t about anything you please - provided that you do i t every day. I f you do more e x e r c i s e than u s u a l , i t may r e s u l t i n too l i t t l e sugar i n your blood. I f you do l e s s e x e r c i s e than u s u a l , i t may r e s u l t i n too much sugar i n your blood. Neither one of these c o n d i t i o n s i s good, because both of them upset your good-health balance. So, plan your a c t i v i t i e s so that*you do about the same amount of a c t i v i t y every day. (For example, i f you walk to work on week-days, take a walk on weekends too.) I f , f o r some reason, your a c t i v i t y has to be more or l e s s than normal (such as working overtime, planning an a c t i v e v a c a t i o n , or s t a y i n g i n bed with a c o l d ) , get i n touch with your doctor. He w i l l t e l l you how to change your d i e t and/or medicine to meet t h i s change." GIVE each p a t i e n t the s h e e t , t i t l e d " E x e r c i s e " f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 137 SLIDE 35 Personal Hygiene EXPLAIN: "In managing your diabetes, personal hygiene i s very important. The i l l u s t r a t i o n s on the s l i d e show f i v e aspects of hygiene that you should l e a r n . 1. About your teeth and gums: A l l of the things ue have t a l k e d about so f a r ( d i e t , medicine and e x e r c i s e ) are aimed at keeping the sugar and i n s u l i n i n your blood i n balance. I n f e c t i o n i s another t h i n g uhich can t i p t h i s good-health balance. Cuts and scratches are one source of i n f e c t i o n ; bad teeth and gums are another. So take good care of your teeth and gums, by brushing a f t e r meals and having r e g u l a r check-ups by your d e n t i s t . Be sure to t e l l your d e n t i s t that you are d i a b e t i c . 2. About smoking: In diabetes blood c i r c u l a t i o n may be lessened. The chemicals that get i n t o your system uhen you smoke tend to make your blood vessels contract (or t i g h t e n ) . This i n t e r f e r e s u i t h your blood c i r c u l a t i o n even more. Whether or not you may smoke (and i f so, hou much) i s something yau should t a l k to your doctor about. 3 and h. About your hands and f e e t : In diabetes, the blood supply i s often decreased (lessened) to the e x t r e m i t i e s , e s p e c i a l l y the legs and f e e t . This means that foot i n j u r i e s may s t a r t more e a s i l y , and be harder to h e a l . I t also means that you may not be able to f e e l heat, c o l d or sharp objects that may damage your f e e t . These simple r u l e s u i l l help yau avoid trouble u i t h yaur f e e t : (a) Wash your f e e t d a i l y u i t h a s o f t c l o t h and uarm soapy u a t e r . Dry them thoroughly. I f your s k i n tends to be rough or dry, apply a gentle s k i n cream (such as l a n a l i n ) . I f your s k i n tends t a be maist or sueaty, apply talcum pouder. Check u i t h your doctor before using s p e c i a l creams, salves or pauders on your s k i n . (b) Wear shoes that f i t and are comfortable. Break neu shoes i n s l o u l y by uearing them a feu hours each day at f i r s t . (c) Don't uear round g a r t e r s , sacks or stockings that are too t i g h t , or anything else that i n t e r f e r e s u i t h the blood supply t a your legs and f e e t . Put on clean socks or stockings every day. (d) Never go barefoot. 138 SLIDE 35 (cont'd) (e) Cut your t o e n a i l s (and f i n g e r n a i l s too, f o r that matter) a f t e r you bathe - uhen they are s o f t . Cut s t r a i g h t across the n a i l , ( n o t too short!) and don't dig i n t o the corners. ( f ) Don't t r y to cut corns and c a l l o u s e s by y o u r s e l f . Get them t r e a t e d by your doctor. (g) I f your feet are c o l d at n i g h t , wear clean socks to bed. Never use a heating pad or hot uater b o t t l e because these may cause burns on your f e e t . (h) Check your feet c a r e f u l l y every day, and report any s k i n changes uhich do not go auay to your doctor. 5. General C l e a n l i n e s s : Keep your s k i n and h a i r clean u i t h r e g u l a r bathing. Use l u k e -uarm (never hot!) uater and m i l d soaps and shampoos. Dry y o u r s e l f gently u i t h a s o f t t o u e l . Treat minor cuts and scrapes as f o l l o u s : - uash u i t h uarm, soapy uater and put on a clean bandage. Never put i o d i n e on c u t s , as i t could burn your s k i n . I f cuts, scrapes or b r u i s e s do not heal i n a reasonable time, t e l l your doctor. GIVE each p a t i e n t the sheet t i t l e d "Personal Hygiene" f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 139 SLIDE 36 Urine Testing EXPLAIN: "One of the most accurate ways of checking tha't your good-health balance is even -- rather than tipped to one side or the other — is by testing your urine. Your urine test results w i l l t e l l the doctor whether a l l the things you are doing to manage your diabetes are working O.K. Based on the results of your tests, he may make a change in your diet, medicine or exercise which w i l l help you feel better and keep a better balance. You should know how to' make two tests on your urine: One for sugar and one for acetone. Whichever urine test you are making, you should always use a "double-voided" specimen of urine. Here's how to get one: (a) About Vz hour before your time to test, urinate as much as you can. Don't save any of this urine. (b) Drink a glass of water and wait about Vz hour. (c) Urinate again and use this specimen for testing. (This second urine is called a "double-voided" specimen). You w i l l be given detailed instructions for one sugar and one acetone test. There are many other tests for urine sugar and acetone available. If you wish to use these, discuss the matter with your doctor. If he approves, be sure to read and follow the package directions carefully. This is essential i f your test i s to be accurate." (Nurse's Instructions) 140 SLIDE 37 Urine Testing - For Sugar EXPLAIN: "IF you eat more Food than is allaued, Forget ta take your medicine or da less exercise than usual, sugar u i l l build up in your blood. (The same thing may happen iF you are very upset about something or iF you have an inFection. As the amount oF sugar in the blood builds up, some oF i t u i l l overflau into your urine. An unusual amount oF sugar in the urine is a sure sign that your goad-health balance is tipped. One oF the most accurate means of testing your urine For sugar is uith Clinitest tablets. Here's hou: 1. Collect your urine in a clean container. Uith the dropper in an upright position place 5 drops oF urine in the test tube. 2. Rinse the dropper and add 10 drops oF uater. 3. Drop one Clinitest tablet into the test tube (be careFul not to touch i t uith damp Fingers). Uatch uhile the complete reaction takes place. 4. Do not shake the tube during the reaction nor for 15 seconds aFter the boiling has stopped. 5. AFter the 15-second uaiting period, shake the test tube gently and compare i t uith the colour chart. NOTE: CareFul observation af the solution in the test tube uhile reaction takes place and during the 15-second uaiting period is necessary to detect rapid "pass through" colour changes caused by amounts oF sugar aver 2%. Should the colour rapidly "pass through" green, tan and orange to a dark greenish-broun, record as over 2% sugar uithaut comparing Final colour development uith colour chart." DEMONSTRATE Clinitest procedure to the patients. Encourage them to participate in identiFying each step as you are doing i t . HAVE THE PATIENTS RETURN THE DEMONSTRATION, identifying the steps as they do so. (Nurse's Instructions) 141 SLIDE 38 Urine Testing - for Acetone EXPLAIN: "Generally speaking, your body uses sugar for energy. Houever, i t can also get energy from fat. When your cells are not getting enough sugar to provide the energy they need, your body breaks doun it s oun fat for energy. This process makes a substance called acetone, uhich u i l l s p i l l over into your urine in the same uay that sugar does uhen i t gets too high. Moderate amounts of acetone in your blood u i l l cause nausea, vomiting, flushed and dry skin, sleepiness and deep rapid breathing. Large amounts of acetone cause unconsciousness. So you can see that i t is important to knou uhen you are building up acetone. The uay to do this is by testing. One simple and accurate test for acetone can be done uith Acetest tablets. Just follou these steps: 1. Collect your urine in a clean container. Place one Acetest tablet on a clean piece of uhite paper. 2. Put one drop of urine on the tablet. 3. Lilait 30 seconds. 4. Compare the colour of the tablet uith the colour chart." DEMONSTRATE Acetest procedure to the patients. Encourage them to participate in identifying each step as you are doing i t . HAVE THE PATIENT RETURN THE DEMONSTRATION, identifying the steps as he does so. ENCOURAGE the patients to begin doing a l l of their oun urine tests as soon as passible. They may need supervision at f i r s t , but once they have mastered the procedure, they should be able to take the responsibility for testing and reporting the results on their oun. GIVE each patient the sheets t i t l e d "Urine Testing" for his Take-home folder. FILL IN the urine testing times on these sheets in the spaces provided. EXPLAIN: If your.urine tests greater than 1% for sugar on several tests in a rou OR i f you get a positive acetone test, notify your doctor. (Nurse's Instructions) SLIDE 39 Keep A Record EXPLAIN: "In order for your doctor to get an o v e r a l l p ic ture of how u e l l balanced your diabetes i s , he u i l l have to have an on-going record of your urine t e s t s . Such a record i s easy to keep." REUIEU the sample record u i th the p a t i e n t s . Be sure they understand uhat and hou to record in each column. (Nurse's Inst ruct ions) 143 SLIDE 40 Problems EXPLAIN: "As ue have s a i d , you u i l l u s u a l l y be able to keep the sugar and i n s u l i n i n your blood i n balance by f o l l o u i n g your doctor's orders about d i e t and medicine, and by g e t t i n g the same amount of exercise every day. There are, houever, some other things — things you can't help — uhich may t i p your good health balance. Some of these things are i l l n e s s , i n f e c t i o n , and severe emotional upset. Whenever one of these things happens to you, or uhenever you "cheat" on your d i e t , medicine or e x e r c i s e , you are i n danger of developing a problem u i t h your diabetes. I t i s important that you should be auare of these problems (uhat causes them and hou to knou you have them) so that you can t r e a t them uhen they occur and avoid them i n the f u t u r e . " (Nurse's I n s t r u c t i o n s ) SLIDE kl D i a b e t i c Coma EXPLAIN: "Di a b e t i c coma i s the problem uhich r e s u l t s uhen your sugar-i n s u l i n balance i s tipped to the sugar s i d e . As ue mentioned uhen ue uere d i s c u s s i n g u r i n e t e s t i n g , your body can make energy from f a t as u e l l as sugar. I t does t h i s uhen there's not enough i n s u l i n around to use your blood sugar i n the uay i t o r d i n a r i l y should. Uhen your body burns f a t f o r energy, i t produces f a t t y acids l i k e acetone.- Too much acetone i s bad f o r your body. I t causes a c o n d i t i o n c a l l e d a c i d o s i s , uhich can lead to a d i a b e t i c  coma. Yau may hear d i a b e t i c coma c a l l e d other names, such a " d i a b e t i c a c i d o s i s " , " d i a b e t i c k e t o s i s " , or "hyperglycemia" (uhich means extra blood sugar). Whatever name you use, i t i s important to remember that d i a b e t i c coma i s a very s e r i o u s d i a b e t i c problem! There are s e v e r a l t h i n g s uhich might cause you to have a d i a b e t i c coma. Here are the most usual causes: (a) eat i n g too much food; (b) not taking,enough diabetes medicine (that i s , l e s s i n s u l i n or a n t i d i a b e t i c p i l l than yau are supposed t o ) ; (c) t a k i n g much l e s s than your usual amount of e x e r c i s e ; (d) a fever or an i n f e c t i o n ; (e) a severe emotional upset." (Nurse's I n s t r u c t i o n s ) SLIDE kZ Symptoms (of D i a b e t i c Coma) EXPLAIN: "Haw u i l l you know i f you are going i n t o a d i a b e t i c coma? Here are some of the most common symptoms: (a) dry s k i n and tongue; (b) severe t h i r s t ; (c) weakness, drowsiness or t i r e d n e s s ; (d) nausea, vomiting or l o s s of a p p e t i t e ; (e) deep r a p i d breathing and a " f r u i t y " s m e l l i n g breath." (Nurse's I n s t r u c t i o n s ) SLIDE 4 3 What To Da ( for Diabet ic Coma) EXPLAIN: "Here's what to do i f you f e e l you might be going into a •diabetic coma: (a) Test your u r ine : i t w i l l probably be 2% or greater for sugar and pos i t i ve for acetone. (b) Phone the doctor : t e l l him how you f e e l and what your urine tests s a i d . He w i l l t e l l yau what to do next . How can you keep from having a d iabet i c coma? Here are some usefu l suggest ions: (a) Follow your d iet c a r e f u l l y — never omit foods or meals and never take more than you should . (b) Never skip your d iabet i c medicine. Always measure i t ca re fu l l y and take i t r i gh t on t ime. (c) Do the same amount of exercise every day. (d) Avoid i n f e c t i o n s and emotionally upsett ing s i t u a t i o n s whenever you can. (e) Test your urine regu la r l y and report high sugars to your doctor . " GIV/E each pat ient the sheet t i t l e d "Diabet ic Coma" for h is Take-home f o l d e r . (Nurse's Inst ruct ions) 147 SLIDE 44 Insulin Shock EXPLAIN: "Insulin reaction is the problem uhich results uhen your sugar-insulin balance is tipped to the insulin side. That i s , you have either too much insulin or not enough sugar in your blood. Other names for insulin shock are "insulin reaction" and "hypo-glycemia" (meaning not enough blood sugar). Uhen your sugar-insulin balance is tipped to the insulin side, the result is that your blood has more insulin in i t than i t has sugar for the insulin tD uork an. This state of affairs is quite harmful for your body. Thus, insulin shack is a serious diabetic problem, and one uhich must be dealt uith at once! There are.several things uhich might cause you to go into insulin shack. Here are the most usual causes:. (a) not eating enough food (e.g. delaying or skipping meals, or leaving out foods you are supposed to eat); (b) taking more than the correct amount af diabetes medicine; (c) taking more than the usual amount of daily exercise." (Nurse's Instructions) SLIDE 45 Symptoms (of Insul in Shock) EXPLAIN: "How w i l l you know you are going into i n s u l i n shock? Here are some of the most common warning signs and symptoms: (a) f e e l i n g nervous, exc i ted , f a i n t or i r r i t a b l e ; (b) sweating; (c) hunger; (d) headache; (e) t rembl ing; ( f ) t rouble seeing c l e a r l y . " (Nurse's Inst ruct ions) 149 SLIDE 46 What To Do ( f o r I n s u l i n Shock) EXPLAIN: "Although i n s u l i n shock i s a s e r i o u s problem, i t i s a very easy one to t r e a t . Here's what to do i f you are f e e l i n g the symptoms of i n s u l i n shock: (a) Eat or drink something immediately. ( I f you have something sweet r i g h t on hand, take i t . I f not, don't waste time looking f o r sweets; j u s t eat something! (b) Wait 15 minutes. (c) THEN - i f you don't f e e l b e t t e r - eat or drink same more and phone the doctor. He w i l l t e l l you what to do next. How can you keep from having i n s u l i n r e a c t i o n s ? Follow these suggestions: (a) Never s k i p or delay your meals. Always eat e x a c t l y what your meal plan says, at the time i t says. (b) Always measure your d i a b e t i c medicine c a r e f u l l y and take i t on time. (c) Eat or drink something e x t r a beforehand i f yau know you are going to do more ex e r c i s e than u s u a l , UR i f there wasn't time f o r t h a t , eat or drink something immediately afterwards. (d) Always carry something sweet with you." GIVE each p a t i e n t the sheet t i t l e d " I n s u l i n Shock" f o r h i s Take-home f o l d e r . (Nurse's I n s t r u c t i o n s ) 1 5 0 SLIDE 47 Infect ion EXPLAIN: "As ue mentioned in our d iscuss ion of d i a b e t i c coma, an in fec t ion i s one of the things uhich may cause you to go into a d iabet ic coma. This i s because the fever that comes u i th many in fec t ions acts to t i p the s u g a r - i n s u l i n balance touard the sugar s i d e . Thus, i f you have an i n f e c t i o n (such as a severe cold or the f l u ) , you should be on the lookout for the symptoms of a d iabet ic coma. In addi t ion to those uarning s i g n s , i f you take your temperature you u i l l f i n d that i t i s above normal . " (Nurse's Ins t ruct ions) 151 SLIDE 48 What To Da ( f a r I n f e c t i o n ) EXPLAIN: "Because an i n f e c t i o n has much the same e f f e c t on your body as a d i a b e t i c coma, yau uould expect to t r e a t i t the same uay — and you do! (a) Test your urine (once again, i t u i l l probably be p o s i t i v e f o r both sugar and acetone). (b) Phone your doctor. T e l l him hou you f e e l , uhat your temperature i s , and uhat your urine t e s t s s a i d . He u i l l give you s p e c i f i c i n s t r u c t i o n s about your diabetes medicine and d i e t . (c) Go to bed — y o u ' l l need r e s t to a l l o u your body tD f i g h t that i n f e c t i o n . Nou that you knou that i n f e c t i o n s can be s e r i o u s problems for you, y o u ' l l uant to avoid them uhenever yau can. Here are same h i n t s f a r doing j u s t t h a t : (a) Stay auay from people uho yau knau already have i n -f e c t i o n s of one s o r t or another. (b) F o l l a u the r u l e s ue discussed under "Personal Hygiene". (c) Treat simple i n j u r i e s r i g h t auay so that they don't have a chance to became i n f e c t e d . " GIVE each p a t i e n t the sheet t i t l e d " I n f e c t i o n " f o r h i s Take-hame f o l d e r . (Nurse's I n s t r u c t i o n s ) 152 SLIDE 49 Protect Y o u r s e l f EXPLAIN: "There are tuo very simple things you should do to pr o t e c t y o u r s e l f : 1. Wear and/or Carry I d e n t i f i c a t i o n Both d i a b e t i c coma and i n s u l i n shock are s e r i o u s problems uhich c a l l f o r quick treatment. When they are severe, the d i a b e t i c person can f a i n t . That's uhy i t ' s very important to uear or carry d i a b e t i c i d e n t i f i c a t i o n . This i d e n t i f i c a t i o n u i l l help you get the treatment you need q u i c k l y . Medic A l e r t i s one very good source of d i a b e t i c i d e n t i f i c a t i o n . There are oth e r s . Talk to your doctor about uhich k i n d of i d e n t i f i c a t i o n you should use. 2. Carry Something Sueet I n s u l i n shock may come on very suddenly -- almost u i t h o u t uarning. When i t does, you uant to be able to t r e a t i t promptly. That i s uhy i t uould be u i s e f o r you to get i n t o the habit of aluays c a r r y i n g something sueet ( l i k e candy) i n your pocket or purse." (Nurse's I n s t r u c t i o n s ) 153 SLIDE 50 Where to Get Help EXPLAIN: "There are many people and o r g a n i z a t i o n s uho are ready to help you keep your good-health balance even. Here's a quick reference of uho they are and uhat they u i l l do f o r you. SOURCE WHAT THEY CAN DO FOR YOU 1. Doctor (phone number) 2. The Canadian D i a b e t i c A s s o c i a t i o n (branch phone number) 1. Get you s t a r t e d u i t h a good balance of D f d i e t , e x e r c i s e and diabetes medicine. 2. Change t h i s plan i f i t i s n ' t uorking f o r you. 3. Advise you uhat to da uhen your gaod-health balance i s i n danger of t i p p i n g . The Canadian D i a b e t i c A s s o c i a t i o n i s a non-p r o f i t o r g a n i z a t i o n dedicated to helping d i a b e t i c s l i v e a f u l l e r and h e a l t h i e r l i f e . You may j o i n the CD.A. through the n a t i o n a l o f f i c e or any one of i t s l o c a l branches. The b e n e f i t s of membership i n the CD.A. broadly i n c l u d e : 1. S e r v i c e s . Free d i e t c o u n s e l l i n g and operation of h o l i d a y camps uhich provide regulated d i e t s f o r c h i l d r e n and a d u l t s are some of the s e r v i c e s you can enjoy as a member of CD.A. 2. Education. At every l o c a l CD.A. meeting, part of the program i s devoted to e i t h e r demonstrations by doctors and d i e t i c i a n s , l e c t u r e s , open forums, or i n s t r u c t i v e f i l m s designed to help you and your f a m i l y l i v e a b e t t e r and more normal l i f e . .3. "The N e u s l e t t e r " . The CD.A. p u b l i c a t i o n "The N e u s l e t t e r " i s mailed to a l l members four times a year. Information and p r i c e s on other p u b l i c a t i o n s on diabetes are a v a i l a b l e from the n a t i o n a l o f f i c e . k. Encouragement. You and your f e l l o u members of the CD.A. have common problems and o b j e c t i v e s . In group meetings you have the opportunity of seeing hou others have overcome c e r t a i n d i f f i c u l t i e s . Then, too, yau may be able to help someone. Many have found encouragement and bene-f i t e d by p a r t i c i p a t i n g i n these meetings. SOURCE 154 SLIDE 50 (cont'd) WHAT THEY CAM DO FOR YOU 3. Public Health or 1. V/ictorian Order 2. of Nurses v i s i t - 3. ing nurses. Do home teaching. Give insulin injections at home. Help uith your food care i f you can't manage i t alone. (phone numbers) 4. Dial-a-Dietician Various provincial dietietic associations have organized Dial-a-Dietician programs to answer the questions about food and nutrition uhich arise in day-to-day (phone number) li v i n g . Information is available on such topics as: - everyday nutrition - foods and food values - budgeting and purchasing - meal planning and preparation - food additives - labelling - food fads and fallacies - therapeutic diet modifications If you have questions about any of these subjects, you should c a l l the Dial-a-Dietician number. Your questions u i l l be recorded, and a professional dietician u i l l c a l l you back - uithin 48 hours - uith the ansuers." GIVE each patient the sheet t i t l e d "Where to Get Help" for his Take-home folder. SLIDE 51 (Nurse's Instructions) PATIENT'S INSTRUCTIONS FOR HANDOUT and diabetes 157 Introduction Diabetes i s not an i l l n e s s . You d idn ' t "catch i t " , and uhen you care for i t p roper ly , i t uan' t stop you from enjoying l i f e . Diabetes cannot be cared for by your doctor a lone. Indeed, your doctor i s depending on you to learn as much as you can about d iabetes, so that you u i l l be able to care for y o u r s e l f . There i s quite a b i t to l e a r n , but i t i s n ' t very d i f f i c u l t i f you take i t one step at a t ime. To help you do t h i s , t h i s course on diabetes has been div ided into f i v e c l a s s e s : 1. Introduct ion 2. Diet 3. Medicine k. Exerc ise , Hygiene and Urine Test ing 5. Problems Most of the things the nurse u i l l teach you are things that you u i l l do yoursel f every day at home. Ask her l o t s of questions to be sure you understand uhat she i s say ing . Remember, in the long run, your d iabet ic care i s up to you! (Pat ien t ' s Copy) 158 Food-Energy Cycle The human body i s made up of m i l l i o n s of t iny c e l l s . There-fo re , each thing that the body does (working, p lay ing and so on) i s r e a l l y done by. a group of c e l l s working together . C e l l s need energy in order to work. Uhen everything i s working properly in the body, they make that energy by burning f u e l which comes from the food one e a t s . The body's biggest sources of f u e l are sweet and starchy foods such as sugar, bread and c e r e a l s . However, other foods , (such as meat, f r u i t and vegetables) can provide f u e l too . Af ter these foods are swallowed, the body changes them a l l to a simple form of sugar. It i s t h i s sugar which the c e l l s use as f u e l . Sugar i s ca r r i ed t £ each c e l l in the body by the blood stream. In order for the sugar to get ins ide the c e l l however, i n s u l i n must be present . Insu l in i s a chemical made by the pancreas (an organ near the stomach). You may think of i n s u l i n as the key that opens the c e l l door to l e t the sugar i n . As long as one eats the proper foods . . . and as long as the body i s provided with enough i n s u l i n . . . the food-energy cyc le w i l l work smoothly without any problems. (Pat ien t ' s Copy) 159 Diabet ic Food-Energy Cycle As ue s a i d , i n s u l i n may be thought of as the key that opens the c e l l door to l e t sugar i n . If your body i s short of i n s u l i n for same reason, sugar uon't be able to get into your c e l l s . Uhen t h i s happens, the sugar keeps backing up in your bload until., i t overf laus into your u r ine . It i s uhen t h i s happens that you are found to have d iabetes . Diabetes, then, i s a con-d i t i o n in uhich there i s n ' t enough i n s u l i n in the blood to a l l o u your food-energy cyc le to uork proper ly . Mrtr\ol (Pat ient ' s Copy) 160 Symptoms What are some of the things that you might have not iced because of your diabetes? 1. Because your body wasn't making enough i n s u l i n to allow your food-energy cycle to work properly - - therefore the amount of sugar in your blood rose and s p i l l e d over into your u r i n e . Your kidneys had to work overtime to get r i d of t h i s sugar — therefore you l i k e l y had to pass large amounts of urine quite o f t e n . 2. Because you were los ing so much extra water t h i s way, you probably were also very t h i r s t y . 3. Because your body wasn't able to use i t s s u g a r - f u e l proper ly , you might have los t weight, no matter how much you a t e . 4. Because much of what you did eat was being los t as sugar in your u r ine , you were probably very hungry. 5. Because your blood sugar was not being changed into energy, you may have f e l t weak and t i r e d . ,When you are taking care of your diabetes proper ly , you won't have any of these symptoms. They are just your body's way of t e l l i n g you that something needs to be done. (Pat ien t ' s Copy) 1 6 1 •ne i n Every F i f t y Canadians Knowing that you have diabetes may make you f e e l very l o n e l y or very d i f f e r e n t from your f r i e n d s and neighbours. I t shouldn't! Diabetes i s not an uncommon c o n d i t i o n . One out of every 5D Canadians has i t , and most of them are leading p e r f e c t l y normal l i v e s . Many s u c c e s s f u l and famous people (businessmen, p o l i t i c i a n s , a t h l e t e s , a r t i s t s and performers) are d i a b e t i c . Because they are able to care f o r t h e i r diabetes so e a s i l y and so u e l l , i t hardly i n t e r f e r e s u i t h t h e i r l i v e s at a l l . The same can apply to you! Diabetes need not change your plans or your uay of l i f e . I t u i l l mean adding some neu h a b i t s ; but i t uon't mean missing o l d pleasures. (Patient's Copy) General Questions There are probably a feu questions that are r e a l l y worry ing you about your diabetes. Let's answer them r i g h t now. 1. Uhat about marriage and c h i l d r e n ? I f you are s i n g l e , diabetes shouldn't change your plans to marry. Because diabetes i s so easy to care f o r , i t causes no problems i n r e l a t i o n to g e t t i n g or s t a y i n g married. In a d d i t i o n , diabetes i n i t s e l f i s no reason f o r not having c h i l d r e n . D i a b e t i c people can and do have p e r f e c t l y healthy babies. However, the chance of having a d i a b e t i c c h i l d does increase i f one or both of the parents are d i a b e t i c . You uould be u i s e to t a l k to your doctor some more about t h i s before s t a r t i n g a f a m i l y . 2. Uhat about l i f e insurance? Any l i f e insurance p o l i c y you had before you developed diabetes u i l l not be c a n c e l l e d . As f o r neu insurance, many companies today u i l l give l i f e insurance p o l i c i e s to d i a b e t i c people uho are taking good care of themselves. 3. Uhat about work? Diabetes should not stop you from working. Indeed, i t probably won't even have much e f f e c t on the kind of work you can do. People with diabetes are engaged i n almost every kind of work you could name (from desk jobs to labour'to housework). Studies have shown that they do as w e l l i n t h e i r work — i n every way •— as do n o n - d i a b e t i c s . k. Uhat about sports and other a c t i v i t i e s ? Here again, there i s no need to give up or to change anything that you enjoy. As a matter of f a c t , e x e r c i s e i s e s p e c i a l l y good f o r the person with diabetes. I t helps to burn up sugar. However, i f your e x e r c i s e pattern i s l i k e l y to change g r e a t l y from one day to the next, you should discuss t h i s with your doctor. He w i l l want to adjust your meals and medicine to take t h i s i n t o account. ( P a t i e n t ' s Copy - f o r younger p a t i e n t s ) General Questions There are probably a feu questions that are r e a l l y worry ing you about your diabetes. Let's answer them r i g h t now. 1. Uhat about marriage and c h i l d r e n ? Because diabetes i s so easy to care f o r , i t causes no problems i n r e l a t i o n to g e t t i n g or s t a y i n g married. So put your mind to r e s t about t h a t ! I f you have c h i l d r e n however, there i s a b e t t e r than average chance that they w i l l develop diabetes. You should advise them to have a doctor check t h e i r blood and urine, f o r sugar r e g u l a r l y . 2. What about l i f e insurance? Any l i f e insurance p o l i c y you had before yau developed diabetes w i l l not be c a n c e l l e d . As f o r new insurance, many companies today w i l l give l i f e insurance p o l i c i e s to d i a b e t i c people who are taking good care of themselves. 3. Uhat about work? Diabetes w i l l not stop you from working. Indeed, i t probably won't even have much e f f e c t on the kind of work you can do. People with diabetes are engaged i n almost every kind of work you could name (from desk jobs to labour to housework). Studies have shown that they do as w e l l i n t h e i r work i n every way -- as do no n - d i a b e t i c s . k. Uhat about sports and other a c t i v i t i e s ? Here again, there i s no need to give up or to change anything that you enjoy. As a matter of f a c t , e x e r c i s e i s e s p e c i a l l y good f o r the person with diabetes. I t helps to burn up sugar. ( P a t i e n t ' s Copy - f o r older p a t i e n t s ) 16k Balance = Good Health You and your doctor share s e v e r a l aims or goals i n the care of your diabetes. They are: 1. to get r i d of the symptoms of your diabetes (BR i f you have had no symptoms, to keep them from showing up); 2. to keep you from g e t t i n g any complications of diabetes; 3. to keep you healthy; and at the same time k. to i n t e r f e r e as l i t t l e as p a s s i b l e with your normal d a i l y l i f e . Reaching these goals depends upon keeping a c a r e f u l balance between 1. your food - which provides the sugar i n your blood stream; and 2. your i n s u l i n and e x e r c i s e - which help your body to use t h i s sugar f o r energy. Tipping the balance to e i t h e r side w i l l r e s u l t i n problems. Keeping i t even w i l l r e s u l t i n good h e a l t h . ( P a t i e n t ' s Copy) 165 Diet You may be asking y o u r s e l f uhy i t i s necessary f o r d i a b e t i c s to f o l l o u a d i e t . By seeing to i t that yau eat the same kind and amount af food each day, you and your doctor are able to keep the sugar i n your blood at a safe l e v e l . Most foods can be changed i n t o sugar by the body. Houever, some foods make more sugar than others. I f you eat more food than your body needs, or toD much of the urong kinds of food, i t may cause the sugar i n your blood to b u i l d up. This u i l l t i p your good-health balance, and might cause some serious problems. Therefore, i t i s e s p e c i a l l y important f o r you to uatch . both the kind and the amount of food that you eat. I\la tud d i a b e t i c s are e x a c t l y a l i k e . So, each d i a b e t i c person's d i e t u i l l be d i f f e r e n t from that of other d i a b e t i c s . Only your doctor can uork out the r i g h t d i e t f o r you. IMou there i s no need to be discouraged about the idea af d i e t . Yau uon't have to give up very many foods that you enjoy. Yau uon't have to cook or eat meals d i f f e r e n t from your f a m i l y ' s . You uon't have to buy s p e c i a l foods or shop i n s p e c i a l s t a r e s . You u i l l have ta lear n a ,neu uay of planning your meals — but t h i s u i l l soon become second nature to you. (P a t i e n t ' s copy) o 166 Kinds of Food Your d i e t plan u i l l c a l l f o r foods such as m i l k , meat, vegetables, f r u i t , bread and c e r e a l s . These foods are necessary fo r good health and should be eaten every day by everyone — non-d i a b e t i c s and d i a b e t i c s a l i k e ! Nearly a l l foods have some carbohydrate, p r o t e i n and f a t i n them. Houever, the amounts of each u i l l be d i f f e r e n t i n d i f f e r e n t kinds of foods. Foods that have more carbohydrate than p r o t e i n or f a t are c a l l e d carbohydrate foods. Carbohydrate foods are sugars, breads, c e r e a l s , f r u i t s and vegetables. Foods that have more p r o t e i n than carbohydrate or f a t are . c a l l e d p r o t e i n foods. P r o t e i n foods are milk, cheeses, eggs, meats or f i s h . Foods that have more f a t than carbohydrate or p r o t e i n are c a l l e d f a t foods. Some f a t foods are b u t t e r , nuts and bacon. In planning your diet,,your doctor u i l l make sure that you eat some carbohydrates, some pr o t e i n s and some f a t s at every meal. Each of these 3 types of food has a s p e c i a l job to perform: 1.. Carbohydrate foods are used by. the. body i n the same uay that a car uses g a s o l i n e . They are burned by the c e l l s to provide energy. "While other foods may also provide energy, carbohydrates do so the f a s t e s t . Thus ue may say that they are l i k e "premium" g a s o l i n e . -2. P r o t e i n foods are used by the body f o r grouth, f o r b u i l d i n g muscles and f o r r e p a i r i n g any body damages, i . e . f o r "home b u i l d i n g and maintenance". 3. Fat foods are also f u e l foods. They, l i k e carbohydrates, provide energy f o r the body. Houever, they do not act as q u i c k l y as carbohydrates — so they are more l i k e " r e g u l a r " g a s o l i n e . Furthermore, i f f a t s are not needed by the body at the time they are eaten, they may be stored — s o r t of l i k e a "spare tank" — i n the form of body f a t . ( P a t i e n t ' s Copy) 167 HQUJ the Doctor Plans Your Diet As ue s a i d before, as a d i a b e t i c , you u i l l need your oun personalized d i e t . The doctor u i l l take many things i n t o account i n planning t h i s d i e t f o r you. Here are some of them. 1. Your age C h i l d r e n , teenagers, pregnant uomen, and older a d u l t s a l l have s p e c i a l needs uhich determine the kind and amount of foods they should eat. Your doctor u i l l plan your d i e t to meet the s p e c i a l needs of your age group. 2. Your ueight . I f you are overueight, your doctor u i l l give you a d i e t that u i l l help you to lose ueight at f i r s t . Once you have reached the co r r e c t ueight f o r you, your d i e t u i l l be changed so that i t helps you keep that ueight. 3. Sex Men and uomen have d i f f e r e n t food needs. Your doctor u i l l take these i n t o account. k. A c t i v i t y As ue s a i d before, e x e r c i s e causes the body to use up sugar. Therefore, more a c t i v e people u i l l need more food than u i l l l e s s a c t i v e ones. I f your a c t i v i t y u i l l change g r e a t l y from day to day, you may even need more than one d i e t p l a n . Talk t h i s over u i t h your doctor. 5. O v e r - a l l h e a l t h An i l l n e s s may cause your good-health balance of food, i n s u l i n and exercise to t i p . Therefore, uhen you are i l l , your doctor u i l l adjust your d i e t to meet the s p e c i a l needs your body has at that time. In a d d i t i o n , i f you have some other c o n d i t i o n besides diabetes, i t may have to be considered i n your d i e t plan as u e l l . ( P a t i e n t ' s Copy) 168 Things You Need to Follow Your Diet Following your d i e t on a day-to-day b a s i s i n v o l v e s the use of two t h i n g s : 1. The meal plan prepared by your doctor or d i e t i c i a n ; and 2. The food exchange l i s t s found i n the Canadian D i a b e t i c A s s o c i a t i o n booklet "Meal Planning f o r D i a b e t i c s i n Canada". Usu a l l y the meal plan i s given very simply -- f o r example, i n terms of f r u i t , meat, bread, f a t , milk and vegetables. Your nurse or d i e t i c i a n w i l l give you a copy of your meal plan, which t e l l s you how much of each of these foods you may have at each meal. U i t h the food exchange l i s t s these i n s t r u c t i o n s can be followed out with a v a r i e t y of t a s t y food c h o i c e s . You w i l l r e c a l l - t h a t both the .kind and the amount of food that yau eat are important. The Canadian D i a b e t i c A s s o c i a t i o n Exchange L i s t s take care of both these t h i n g s . F i r s t , they d i v i d e a l l of the foods you w i l l eat i n t o d i f f e r e n t k i n d s . Each of these makes up one Exchange L i s t . There i s a l i s t f o r milk products, a l i s t f o r meats, a l i s t f a r f r u i t s , a l i s t f o r breads, a l i s t f o r f a t s , and.two l i s t s f a r vegetables. In a d d i t i o n , there are two l i s t s of "free foods". These l i s t s are found on pages 7 to 20 of your "Meal Planning" booklet. Exchange System In a d d i t i o n to h e l p i n g you choose the c o r r e c t kinds of food fo r your d i e t , the Canadian D i a b e t i c Exchange•Lists also t e l l you the amounts of food to eat. They do t h i s by the s i z e of the s e r v i n g allowed.. The idea behind t h i s i s that any measured serving of food on a given l i s t can be traded f a r any other measured se r v i n g on the same l i s t . For example, your meal plan may say that you can have a meat exchange f o r b r e a k f a s t . Uhen you look at the "Meat Exchange L i s t " you w i l l see that one egg i s the same as three s l i c e s of c r i s p bacon or one and one-half sausages. There are dozens of meats on the l i s t — and you may have any one of them i n the amount  shown. Just remember: OIME EXCHANGE EQUALS ONE MEASURED SERVING. In most cases i t w i l l not be necessary to weight your foods i n order to measure them. Most of the servings are given i n terms of standard household measures - cups, teaspoons, tablespoons and inches. I f you don't already have them, i t would be wise to get a standard 8-ounce measuring cup, a set of measuring spoons and a small r u l e r . Measurements should be " l e v e l " - not heaped - and should u s u a l l y be made a f t e r the food •is cooked. ( P a t i e n t ' s Copy) 169 There Aren't Many Foods That You Can't Have When you have had a good look at a l l of the foods on the Canadian D i a b e t i c Exchange L i s t s , you u i l l r e a l i z e that there r e a l l y are not many foods uhich yau may not have. These foods are not on the Exchange L i s t s because they have too much pure sugar i n them. You should not eat any of the f o l l o u i n g foods, except on the advice of your doctor: sugar candy honey jam j e l l y preserves syrup marmalade p i e cake cookies sueetened condensed milk cheuing gum re g u l a r s o f t d r i n k s For exceptions to t h i s advice, plus seasonings and fr e e foods uhich u i l l add zest to your d i e t , see pages 19 and 20 of your "Meal Planning" booklet. ( P a t i e n t ' s Copy) 170 Questions re Diet There may s t i l l he a number of small questions uhich uorry you about your d i e t . Let's c l e a r them up here and nou. 1. What about food shopping? I t i s not necessary to buy s p e c i a l foods because you have diabetes. You can eat the same food as the r e s t of your f a m i l y . When buying canned or frozen foods ( e s p e c i a l l y f r u i t s and f r u i t j u i c e s ) , look f o r the uords "no sugar added" on the l a b e l . You may ui s h to buy some d i e t e t i c foods, such as n o n - c a l o r i c s o f t drinks or d i e t e t i c jam and j e l l y . Some of these are indeed a l l o u e d . But be c a r e f u l . Some a r t i f i c i a l sueeteners do_ contain carbohydrates. Check u i t h your "Meal Planning" booklet or the Canadian D i a b e t i c A s s o c i a t i o n Diet Counselling Service whenever you are i n doubt. 2. What about l i q u o r ? Generally speaking, wine, beer and other a l c o h o l i c beverages are not permitted on a d i a b e t i c d i e t . However, i f you enjoy a drink, i t would be wise to discuss the matter with your doctor. He might show yau how to include an o c c a s i o n a l drink i n your d i e t plan. 3. What about eating out? There i s no reason why having diabetes should stop you from eating out. When you are i n a r e s t a u r a n t , ask about the way food has been cooked. Try to eat p l a i n foods ( i . e . those which have not been breaded, f r i e d or cooked i n a sauce), since you can judge t h e i r exchange value more e a s i l y . I f you take a lunch from home, you w i l l f i n d that i t i s quite easy to prepare. Oust f o l l o w your meal pl a n , and choose exchanges which may be wrapped and c a r r i e d e a s i l y . 4. What about e n t e r t a i n i n g ? As we s a i d before, a d i a b e t i c d i e t i s a healthy and t a s t y d i e t . There i s no reason why you shouldn't cook the same foods f o r your guests as you would f o r y o u r s e l f . I f you wish tD add e x t r a f a t or f l o u r to a given d i s h , simply remove your own p o r t i o n before you do so. 5. What about i l l n e s s ? I f you are nauseated or vomiting, or i f you have diarrhea or a poor a p p e t i t e , you may not f e e l l i k e e a t i n g your re g u l a r d i e t . I f any of these things happen, you should phone your doctor. He may suggest that you convert your meal plan i n t o f l u i d exchanges. I f he does, turn to pages 20 and 21 of your "Meal Planning" booklet for d i r e c t i o n s . 171 6. Canadian D i a b e t i c A s s o c i a t i o n Diet Counselling Service I f you have any questions or problems regarding your d i e t , the CD.A. Diet C o u n s e l l i n g Service i s a good place to t u r n . This s e r v i c e i s o f f e r e d free of charge to a l l d i a b e t i c p a t i e n t s . Contact your l o c a l CD.A. branch f o r d e t a i l s . ( P a t i e n t ' s Copy) 172 Medicine Same d i a b e t i c s can keep t h e i r c o n d i t i o n i n balance by j u s t f o l l o w i n g t h e i r d i e t s . Other d i a b e t i c s r e q u i r e some s o r t of medicine i n a d d i t i o n to t h e i r d i e t s to stay healthy. D i a b e t i c medicine comes i n two forms: - i n s u l i n and o r a l a n t i d i a b e t i c p i l l s . I f a d i a b e t i c person's pancreas i s making l i t t l e or no i n s u l i n , h i s doctor may wish him to take i n s u l i n . I n s u l i n must be i n j e c t e d beneath the s k i n because, i f i t i s swallowed, i t i s destroyed by the d i g e s t i v e j u i c e s of the stomach. I f a d i a b e t i c person's pancreas i s making same i n s u l i n , but nat enough - ar i f the i n s u l i n i t makes i s not able to do the job i t should - h i s doctor may wish him to take an o r a l a n t i d i a b e t i c  p i l l . I t i s c a l l e d an " o r a l " p i l l because i t can be swallowed, and i t i s c a l l e d an " a n t i d i a b e t i c " p i l l because i t f i g h t s against diabetes. Same d i a b e t i c persons can use the a n t i d i a b e t i c p i l l s ; others cannot. Don't t r y to compare your diabetes with that of other people! Each d i a b e t i c p a t i e n t needs s p e c i a l study and care. Aft e r c a r e f u l study, your doctor has decided which medicine you need to care f o r your d i a b e t e s . Follow h i s advice! ( P a t i e n t ' s Copy) 173 A n t i d i a b e t i c P i l l s Your doctor has decided that your diabetes u i l l be kept i n i t s best balance i f you take an a n t i d i a b e t i c p i l l i n a d d i t i o n to f o l l o u i n g your d i e t . This p i l l u i l l help you manage your diabetes by . The name of the p i l l he uishes you to take i s ] . Each of these p i l l s contains m i l l i g r a m s of drug. You are to take m i l l i g r a m s or p i l l ( s ) at the f o l l o u i n g time(s) every day: - . I t i s most important that you take only t h i s a n t i d i a b e t i c drug, and that you f o l l o u your doctor's i n s t r u c t i o n s f o r ta k i n g i t e x a c t l y . I f you do t h i s , your good health balance u i l l stay even. I f you don't, the balance u i l l t i p , and you may run i n t o s e r i o u s problems. Although your diabetes i s u e l l managed u i t h your a n t i d i a b e t i c p i l l , there may be some feu times uhen you u i l l have to take i n s u l i n as u e l l . When your body needs more i n s u l i n than i t can make (even u i t h the help of your p i l l ) . - such as uhen you are s i c k , uhen you have a bad i n f e c t i o n , or uhen you have an operation - t h i s e x tra i n s u l i n may need to be s u p p l i e d from outside your body by an i n j e c t i o n . Should you need such an i n j e c t i o n at home, your doctor u i l l be able to arrange f o r i t to be given by a v i s i t i n g nurse. (NOTE: -As u i t h a l l kinds of medicine, a n t i d i a b e t i c p i l l s may cause unpleasant side e f f e c t s i n some people. These are very r a r e . Houever, should you have any nausea, vomiting, l o s s of ap p e t i t e or any other such symptom, report i t to your doctor immediately.) ( P a t i e n t ' s Copy) 174 I n s u l i n s Your doctor has decided that your diabetes m i l l be kept i n i t s best balance i f you take i n s u l i n as u e l l as f o l l o u i n g your d i e t . I n s u l i n helps you manage your diabetes by making i t e a s i e r f o r sugar to get from your blood i n t o the c e l l s , uhere i t can be burned f o r energy. The name of the i n s u l i n your doctor uishes you to take i s . I t i s a ( r a p i d , medium, prolonged) a c t i n g i n s u l i n , uhich u i l l have i t s strongest e f f e c t on your body at the f o l l o u i n g time: . Because of t h i s , i t i s e s p e c i a l l y important that you avoid e x e r c i s i n g at that time, and that you eat your r i g h t on time. The strength of the i n s u l i n uhich you u i l l use i s U uhich means that there are l i t t l e b i t s of i n s u l i n i n one c.c. (one s y r i n g e f u l ) . You are to take UNITS of t h i s i n s u l i n each time you i n j e c t , i . e . at the f o l l o u i n g time(s) every day: I t i s most important that you take only t h i s kind of i n s u l i n , and that you f o l l o w your doctor's i n s t r u c t i o n s f o r t a k i n g i t e x a c t l y . I f you do t h i s , your good he a l t h balance w i l l stay even. I f you don't the balance w i l l t i p , and you may run i n t o serious problems. Two quick and sure ways of checking that you have the c o r r e c t i n s u l i n f o r you are the f o l l o w i n g : 1. Name on the l a b e l : yours should be . 2". Colour of the p r i n t on the l a b e l : yours should be , which i n d i c a t e s U . ( P a t i e n t ' s Copy) 175 Equipment There i s c e r t a i n equipment uhich you u i l l need to give your i n s u l i n i n j e c t i o n s . I t uould probably be a good idea to keep a l l of t h i s equipment together i n one place (such as on a t r a y or i n a s p e c i a l cupboard). Here are the things you u i l l need: 1. Syringes: You should buy __U s y r i n g e s . I t i s important for you to have t h i s s i z e , because that i s the strength of i n s u l i n you u i l l be u s i n g . Your _U syringes u i l l have coloured markings on them. You may u i s h to use e i t h e r glass or p l a s t i c disposable (throu-auay) s y r i n g e s . I f you choose g l a s s , you should buy at l e a s t 2 syringes (to a l l o u f o r s t e r i l i z i n g and breakage). I f you choose disposables, buy them by the dozen, as they are l e s s expensive that uay. Glass syringes are someuhat l e s s expensive than the disposable ones, but g l a s s must be b a i l e d or soaked i n a l c o h o l to make i t safe ( s t e r i l e ) f o r use. 2. Needles: You should buy gauge, inch long needles. This i s the s i z e that the doctor f e e l s i s best f o r yau to use. Here again, you may choose from 2 types af needles: metal hub, reusable DR p l a s t i c hub disposable. I f you choose reusable needles, you should buy at l e a s t tuo. I f you choose disposables, buy them i n q u a n t i t y . Disposable needles have the advantages of being sharper and not needing s t e r i l i z a t i o n . 3. I n s u l i n : You should use the kind and strength of i n s u l i n uhich ue discussed on the l a s t page. I t i s u i s e to aluays have at l e a s t 2 b o t t l e s of i n s u l i n on hand - the one you are using, and an e x t r a . Each i n s u l i n b a t t l e i s marked u i t h an e x p i r y date. I t i s not safe to use that i n s u l i n a f t e r the date given. I f the b o t t l e expires before i t i s opened, r e t u r n i t to your drug s t o r e . I f i t expires once you have s t a r t e d using i t , throu i t auay. You may store the b a t t l e of i n s u l i n uhich yau are using at room temperature. Extra b a t t l e s should be kept i n the r e f r i g e r -a t o r . Don't store your i n s u l i n i n the f r e e z e r ! The extreme c o l d reduces i t s e f f e c t i v e n e s s . ( P a t i e n t ' s Copy) 176 k. A l c o h o l : You w i l l need a l c o h o l f o r cleaning your s k i n and some of your i n j e c t i n g equipment. You should buy 70% i s o p r o p y l a l c o h o l f o r t h i s purpose. Store your a l c o h o l i n a covered glass container, as i t evaporates very q u i c k l y i f l e f t uncovered. 5. Cotton: Absorbent cotton u i l l be needed to apply the a l c o h o l to your s k i n . E i t h e r bulk cotton or cotton b a l l s u i l l serve t h i s purpose u e l l . Store your cotton i n a clean covered c o n t a i n e r . ( P a t i e n t ' s Copy) 177 Preparing Your I n s u l i n Here are the nine steps to f o l l o u i n preparing your i n s u l i n i n j e c t i o n : 1. Wash your hands. 2. Mix your i n s u l i n , i f necessary, by r o l l i n g the b o t t l e betueen your hands. 3. Moisten some cotton u i t h a l c o h o l . 4. Clean o f f the top of your i n s u l i n b o t t l e u i t h the alcohol-soaked c o t t o n . 5. Remove any a l c o h o l or uater that may be i n your syringe i f you use a glass s y r i n g e . 6. Drau the r i g h t amount of a i r i n t o the s y r i n g e . 7. Push the needle through the rubber top of the i n s u l i n b o t t l e . 8. Push the a i r i n t o the i n s u l i n b a t t l e . 9. P u l l the plunger back to ui t h d r a u the c o r r e c t amount of i n s u l i n . Check f o r a i r bubbles i n the s y r i n g e , and i f there are none, p u l l the needle out of the i n s u l i n b o t t l e . Throughout the preparation and g i v i n g of your i n s u l i n i t i s important to keep from touching the f o l l o u i n g : (a) the stem of the plunger, (b) the top of the s y r i n g e , (c) the point of the needle, (d) the tap of the i n s u l i n b o t t l e . ( P a t i e n t ' s Copy - f o r p a t i e n t s using only one kind of i n s u l i n ) 178 Preparing Your I n s u l i n Mixture Here are the steps to f o l l o u i n preparing your i n s u l i n i n j e c t i o n : 1. Wash your hands. 2. Mix your cloudy i n s u l i n by r o l l i n g the b o t t l e betueen your hands. 3. Moisten some cotton u i t h a l c o h o l . k. Clean o f f the tops of both i n s u l i n b a t t l e s u i t h the alcohol-soaked cotton.-5. Remove any a l c o h o l or uater that may be i n your s y r i n g e . 6. Drau a i r equal to the amount of cloudy i n s u l i n i n t o your s y r i n g e . Push the needle through the rubber stopper of the cloudy i n s u l i n b a t t l e . Push the plunger, f o r c i n g the a i r i n t o the b o t t l e . P u l l the needle out of the stopper u i t h o u t drauing any i n s u l i n . 7. Drau a i r equal ta the amount of re g u l a r (Toronto) i n s u l i n i n t o your s y r i n g e . Push the needle through the rubber stopper of the re g u l a r (Toronto) i n s u l i n b a t t l e . Push the plunger, f a r c i n g the a i r i n t o the b o t t l e . Leave the needle i n pl a c e . 8. Turn the b o t t l e of re g u l a r (Toronto) i n s u l i n upside • doun. P u l l the plunger back to u i t h d r a u the c o r r e c t amount of regular (Toronto) i n s u l i n . Check f a r a i r bubbles i n the s y r i n g e , and i f there are none, p u l l the needle out of the re g u l a r (Toronto) i n s u l i n b o t t l e . 9. Tip the b a t t l e af claudy i n s u l i n upside doun. Holding the plunger of the syringe f i r m l y i n p o s i t i o n - at the dose of Toronto i n s u l i n - push the needle through the rubber stopper of the cloudy i n s u l i n . P u l l the plunger back to u i t h d r a u the c o r r e c t amount of claudy i n s u l i n on top af the Toronto i n s u l i n already i n the s y r i n g e . P u l l the needle out of the b a t t l e . Throughout the preparation and g i v i n g of your i n s u l i n i t - i s important to keep from touching the f o l l q u i n g : (a) the stem of the plunger, (b) the top of the s y r i n g e , (c) the poi n t of the needle, (d) the top of the i n s u l i n b o t t l e . ( P a t i e n t ' s Copy - f o r p a t i e n t s using a mixture af tua i n s u l i n s ) 179 Giving Your I n s u l i n Once v D U have prepared your i n s u l i n , most of the mark i s done. There are only s i x steps l e f t to f i n i s h g i v i n g your i n s u l i n . 1. Clean the s k i n at the i n j e c t i o n s i t e u i t h a l c o h o l -soaked c o t t o n . 2. Pinch up a large area of s k i n . 3. Insert the needle g u i c k l y i n t o the s k i n at 60 to 90 degree angle. k. Remove the hand that uas pinching the s k i n . Using that hand, p u l l hack on the plunger to be sure that the needle i s not i n a blood v e s s e l . ( I f blood should come back i n t o your s y r i n g e , you must d i s c a r d that i n s u l i n and begin a l l over again.) 5. Push the plunger i n slowly to i n j e c t the i n s u l i n . 6. Remove the needle q u i c k l y at the same angle that i t was i n s e r t e d , bracing your s k i n with a clean piece of c o t t o n . I n s u l i n should always be i n j e c t e d to reach the loose space under your s k i n between your f a t and your muscle. I f you i n j e c t your i n s u l i n too close to the s u r f a c e , i t may go i n t o the f a t or the s k i n and cause a p a i n f u l s t r e t c h i n g and s w e l l i n g . In time, t h i s may lead to shrinkage of the s k i n and f a t , causing " h o l l o u s " . Too f r e q u e n t l y i n j e c t i o n s of i n s u l i n i n the same s i t e lead to t h i c k e n i n g of the s k i n , causing "lumps". These lumps prevent your i n s u l i n from being absorbed by your body at the proper speed. Although i t may hurt l e s s to give your i n j e c t i o n s i n these p l a c e s , you should not do so! Rotate the s i t e of your i n j e c t i o n s through as many as p a s s i b l e of the areas shoun at l e f t . A chart may be h e l p f u l i n doing t h i s . You should never give tuo i n j e c t i o n s c l o s e r than one inch apart i n the same month! ( P a t i e n t ' s Copy) 180 Care of Your Equipment I t i s important that you keep your i n j e c t i o n equipment s t e r i l e (germ-free), i n order that i t be safe f o r you to use. This may be done i n tuo uays: A l c o h o l i s quite s u f f i c i e n t to keep your i n j e c t i o n equip-ment s t e r i l e betueen ueekly b a i l i n g s . Here's hou to use i t : (a) Pour 70% i s o p r o p y l a l c o h o l i n t o a clean covered container or a " s t e r i - t u b e " (a s p e c i a l tube i n a stand uhich you can buy at your drug s t o r e ) . (b) Drau enough a l c o h o l i n t o your syringe to f i l l i t . S q u i r t i t out. Repeat 2 or 3 times. (c) Put your syringe i n t o the c o n t a i n e r . I t should be covered u i t h a l c o h o l . Place the l i d on the c o n t a i n e r . (d) Leave your syringe i n the a l c o h o l u n t i l you are ready to use i t again. ( I t must have been soaking i n the a l c o h o l at l e a s t 20 minutes to be s t e r i l e . ) (e) Yau u i l l f i n d that a f t e r many uses, the a l c o h o l i n your container u i l l have evaporated or became d i s c o l o u r e d . I f i t evaporates, j u s t add some more (there should aluays be enough to cover your equipment). I f i t becomes d i s -coloured, throu i t auay and get some f r e s h a l c o h o l . 2. Weekly Care - B o i l i n Water To be very sure that your i n j e c t i n g equipment i s a b s o l u t e l y s t e r i l e , you should b o i l : i t i n uater once a ueek. The steps f o r doing t h i s are quite easy: 1. D a i l y Care u i t h A l c o h o l (a) Take your syringe apart. Put the parts i n t o a large s t r a i n e r . (b) Put the s t r a i n e r i n a pot of b a i l i n g u a t e r . Be sure that the uater covers the equipment. (c) B o i l 10 minutes. ( P a t i e n t ' s Cbpy) 181 (d) Pick up the s t r a i n e r , hold i t and pour the uater out of the pan. Put the s t r a i n e r back i n t o the pan u n t i l everything has cooled. (e) To reassemble your s y r i n g e : i . P ick up the outside part of the syringe (the " b a r r e l " ) u i t h one hand. i i . U i t h the other hand grasp the handle end of the plunger. i i i . Uithout touching any other p a r t , s l i d e the plunger i n t o the b a r r e l to put the syringe together. ( f ) Urap your equipment i n a f r e s h l y ironed piece of c l o t h , or r e t u r n i t to the a l c o h o l container - so i t stays s t e r i l e u n t i l you are ready to use i t . (g) You u i l l f i n d that your syringe u i l l become cloudy a f t e r many b o i l i n g s . To get r i d of t h i s e i t h e r soak i t i n vinegar or b o i l i t i n vinegar and uater before s t e r i l -i z i n g . (NOTE: I f you have re-usable needles, they too must be s t e r i l i z e d . Treat them e x a c t l y the same as your s y r i n g e , i . e . soak i n a l c o h o l every day and b o i l once a ueek. To put r e -usable needles onto the s y r i n g e : pick up the b i g part of the needle (the "hub"), put the needle onto the syringe and turn to t i g h t e n . Do not touch the point o f the needle or the t i p of the s y r i n g e ! ) ( P a t i e n t ' s Copy) 182 Exercise Exercise i s good f o r every one. I t helps keep weight doun, muscles strong and blood f l o u i n g p r o p e r l y . In s h o r t , i t helps people stay healthy. This i s e s p e c i a l l y true f o r d i a b e t i c s . I f you u i l l t h i n k back to the good-health balance you u i l l remember that e x e r c i s e , as u e l l as d i e t , has an e f f e c t on the balance of sugar and i n s u l i n i n the body. A l l p h y s i c a l a c t i v i t i e s (such as u a l k i n g , suimming, gardening) are kinds of e x e r c i s e . And a l l e x e r c i s e burns up sugar. Your doctor has planned your d i e t to give you the amount of food you need to do the a c t i v i t i e s you u s u a l l y do. He has planned your medicine to see that you have j u s t enough i n s u l i n to use up the sugar i n your blood f o r energy. Therefore, to keep your goad-health balance even, you should do about the same  amount of exer c i s e every day. The kind of e x e r c i s e i s not nearly as important as the amount. I f you do more ex e r c i s e than u s u a l , i t may r e s u l t ^ e s s exercise i n too l i t t l e sugar i n your blood. I f — — - - ^ r - ^ ^ ^ - f - - - <^a-~ n-suql you do l e s s exercise than u s u a l , i t may _—-—' r e s u l t i n too much sugar i n your blood. ^ Neither one of these c o n d i t i o n s i s goad, ~^~~~~~~"BS>5^_~ ~ 4r* m e > f e e*erc-'.se-because both of them upset your goad- ' 1rV'"> u w " l health balance. So plan your a c t i v i t i e s so that you da about the same amount of a c t i v i t y every day. (For example, i f yau ualk ta uork on week-days, take a ualk on ueekends too.) I f , f o r some reason, your a c t i v i t y has to.be mare or l e s s than normal (such as uorking over-time, planning an a c t i v e v a c a t i o n , or s t a y i n g i n bed u i t h a c o l d ) , get i n touch u i t h your doctor. He u i l l t e l l you hou to change your d i e t and/ar medicine ta meet t h i s change. ( P a t i e n t ' s Copy) 183 Personal Hygiene 1. General Care In managing your d iabetes , personal hygiene i s very important. A l l of the things uie have ta lked about so far ( d i e t , medicine and exercise) are aimed at keeping the sugar and i n s u l i n in your blood in balance. Infect ion i s another thing uhich can t i p th i s good-health balance. Cuts and scratches are one source of i n f e c t i o n : there are many others as u e l l . To avoid i n f e c t i o n , f o l l o u these simple r u l e s : (a) Be c a r e f u l u i th anything sharp or hot . (b) Keep your skin and hai r clean u i th regular bath ing . Use lukeuarm (never hot ! ) uater and mild soaps and shampoos. Dry yoursel f gently u i th a so f t t o u e l . (c) Take goad care of your teeth and gums, by brushing a f te r meals and having regular check-ups by your d e n t i s t . Be sure to t e l l your dent is t that you are d i a b e t i c . (d) Treat minor cuts and scrapes as f o l l o u s : uash u i th uarm, soapy uater and put on a clean bandage. Never put iodine on cuts , as i t could burn your s k i n . If cuts , scrapes or bru ises do not heal in a reasonable t ime, t e l l your doctor . 2. S p e c i a l Foot Care In d iabetes , the blood supply i s often decreased ( lessened) to the extremeties, e s p e c i a l l y the legs and f e e t . This means that foot i n j u r i e s may s t a r t more e a s i l y , and be harder, to h e a l . It also means that you may not be able to f e e l heat , co ld or sharp objects that may damage your f e e t . These simple ru les u i l l help you avoid t rouble u i th your f e e t : (a) Uash your feet da i l y u i th a sof t c lo th and uarm soapy uater . Dry them thoroughly. I f your sk in tends to be rough or dry, apply a gentle sk in cream (such as l a n o l i n ) . I f your sk in tends to be moist or sueaty, apply talcum pouder. Check u i th your doctor before using s p e c i a l creams, salves or pouders on your s k i n . (b) Uear shoes that f i t and are comfortable. Break neu shoes in s lou l y by uearing them a feu hours each day at f i r s t . (c) Don't uear round gar te rs , socks or stockings that are too t i g h t , or anything e lse that i n t e r f e r e s u i th the blood supply to your legs and f e e t . Put on clean socks or stockings every day. (d) Never go barefoot . (Pat ient 's Copy) 184 (e) Cut your t o e n a i l s (and f i n g e r n a i l s too, f o r that matter) a f t e r yau bathe when they are s o f t . Cut s t r a i g h t across the n a i l (not too s h o r t ! ) and don't dig i n t o the corners. ( f ) Don't t r y to cut corns and c a l l o u s e s by y o u r s e l f . Get them t r e a t e d by your doctor. (g) I f your feet are c o l d at n i g h t , uear clean socks to bed. Never use a heating pad or hot uater b a t t l e because these may cause burns on your f e e t . (h) Check your f e e t c a r e f u l l y every day, and report any s k i n changes uhich do not go auay to your doctor. 3. Smoking As ue s a i d , i n diabetes blood c i r c u l a t i o n may be lessened. The chemicals that get i n t o your system uhen you smoke tend to make your blood v e s s e l s contract (or t i g h t e n ) . This i n t e r f e r e s u i t h your blood c i r c u l a t i o n even more. Whether or not you may smoke (and i f so, hou much) i s something you should t a l k to your doctor about. 4. Eye Care Changes i n v i s i o n may take place i n diabetes. Therefore, you should have a y e a r l y check-up by an eye s p e c i a l i s t . ( P a t i e n t ' s Copy) ! 185 Urine Testing One of the most accurate ways of checking that your good-health balance i s even — r a t h e r than tippe d to one side or the other -- i s by t e s t i n g your u r i n e . Your urine t e s t r e s u l t s u i l l t e l l the doctor uhether a l l the things you are doing to manage your diabetes are uorking O.K. Based on the r e s u l t s of your t e s t s , he may make a change i n your d i e t , medicine or exer-c i s e uhich u i l l help you f e e l b e t t e r and keep a be t t e r balance. You should knou hou to make tuo t e s t s on your u r i n e : one for sugar and one f o r acetone. Whichever urine t e s t you are making you should aluays use a "double-voided" specimen of u r i n e . Here's hou to get one: (a) About Vz-bauT before your time to t e s t , , u r i n a t e as much as you can. Don't save any of t h i s u r i n e . (b) Drink a glas s of uater and u a i t about 1/2-hour. (c) Urinate again and use t h i s specimen f o r t e s t i n g ( t h i s second urine i s c a l l e d a "double-voided specimen"). 1. Testing f o r Sugar I f you eat more food than i s a l l o u e d , f o r g e t to take your medicine or do l e s s e x e r c i s e than u s u a l , sugar u i l l b u i l d up i n your blood. (The same t h i n g may happen i f you are very upset about something or i f you have an i n f e c t i o n . ) As the amount of sugar i n the blood b u i l d s up, some of i t u i l l o v e r f l o u i n t o your u r i n e . An unusual amount of sugar i n the urine i s a sure s i g n that your good-health balance i s t i p p e d . One of the most accurate means of t e s t i n g your urine f o r sugar i s u i t h the C l i n i t e s t t a b l e t s . Here's hou: (a) C o l l e c t your urine i n a clean c o n t a i n e r . With the dropper i n an upright p o s i t i o n place 5 drops of urine i n the t e s t tube. Rinse the dropper and add 10 drops of u a t e r . (b) Drop 1 C l i n i t e s t t a b l e t i n t o the t e s t tube (be c a r e f u l not to touch i t u i t h damp f i n g e r s ) . Watch u h i l e the com-pl e t e r e a c t i o n takes p l a c e . Do not shake the tube during the r e a c t i o n nor f o r 15 seconds a f t e r the b a i l i n g has stopped. (c) A f t e r the 15-second u a i t i n g p e r i o d , shake the t e s t tube gently and compare i t u i t h the colour c h a r t . Note: C a r e f u l observation of the s o l u t i o n i n the t e s t tube u h i l e r e a c t i o n takes place and during the 15-second u a i t i n g p e r i o d i s necessary to detect r a p i d "pass through" colour changes caused by f=7 186 amounts af sugar aver 2%. Should the colour rap id l y "pass-through" green, tan and orange to a dark greenish-brown, record as aver 2% sugar without comparing f i n a l colour development with colour char t . Your doctor wishes you to test your urine for sugar at the fo l lowing t ime: 2. Test ing for Acetone General ly speaking, your body uses sugar for energy. How-ever, i t can also get energy from f a t . Uhen your c e l l s are not gett ing enough sugar to provide the energy they need, your body breaks down i t s own fat for energy. This process makes a substance c a l l e d acetone, which w i l l s p i l l aver into your urine in the same way that sugar does when i t gets too h igh . Moderate amounts of acetone in your blood w i l l cause nausea, vomiting, f lushed and dry s k i n , s leep iness , and deep rap id breath ing . Large amounts of acetone cause unconsciousness. So you can see that i t i s important to know when you are bu i ld ing up acetone. The way to do t h i s i s by t e s t i n g . One simple and accurate tes t for acetone can be done with Acetest t a b l e t s . Just fo l low these s teps : (a) C o l l e c t your urine in a clean conta iner . Place one Acetest tab le t on a clean piece of white paper. (b) Put one drop of urine on the t a b l e t . (c) Uait 30 seconds and compare the colour of the tab le t with the colour char t . • Your doctor wishes ydu to tes t your urine for acetone at the fo l lowing t imes: IMOTES: 1. I f your urine tes ts greater than 1% for sugar on severa l tes ts in a row, or i f you get a p o s i t i v e acetone t e s t , no t i f y your doctor . 2. There are many other tes ts for urine sugar and acetone a v a i l a b l e . If you wish to use these, d iscuss the matter with your doctor . If he approves, be sure to read and fol low the package d i rec t ions c a r e f u l l y . This i s e s s e n t i a l i f your tes t i s to be accurate . 187 3. Keeping a Record In order f o r your doctor to get an o v e r a l l p i c t u r e of hou u e l l balanced your diabetes i s , he u i l l have to have an on-going record of your urine t e s t s . Such a record i s easy to keep. Here's a sample. Date Times 7:30 a.m. S A 11:30 a.m. S A 4:30 p.m. S A 8:30 p.m. S A A p r i l 10 neg neg +1 neg +2 t r +2 t r 188 Problems As ue have s a i d , you u i l l usual ly be able to keep the sugar and i n s u l i n in your blood in balance by f o l l o u i n g your doctor 's orders about d iet and medicine, and by get t ing the same amount of exercise every day. There are , houever, some other things - - things you can ' t help - - uhich may t i p your good-health balance. Some of these things are i l l n e s s , i n f e c t i o n , and severe emotional upset . Uhenever one of these things happens to you, or uhenever you 'cheat ' on your d i e t , medicine or exerc i se , you are in danger of developing a problem u i th your d iabetes . It i s important that you should be auare of these problems (uhat causes them and hou to knou you have them) SQ that you can t reat them uhen they occur and avoid them in the fu tu re . (Pat ien t ' s Copy) 189 Diabet ic Coma Diabet ic coma i s the problem uhich r e s u l t s uhen your sugar -i n s u l i n balance i s t ipped to the sugar s i d e . As ue mentioned uhen ue uere d iscuss ing urine t e s t i n g , your body can make energy from fat as u e l l as from sugar. It does t h i s uhen t h e r e ' s not enough i n s u l i n around to use your blood sugar in the uay i t o r d i n a r i l y should . Uhen your body burns fat for energy, i t produces fa t ty acids l i k e acetone. Too much acetone i s bad for your body. It causes a condi t ion c a l l e d a c i d o s i s , uhich can lead to a d iabet ic coma. You may hear d iabet i c coma c a l l e d other names, such as "d iabet ic a c i d o s i s " , "d iabet i c k e t o s i s " or "hyperglycemia" (uhich means extra blood sugar ) . Uhatever name you use, i t i s important to remember that d iabet i c coma i s a very ser ious d iabet i c problem! There are severa l things uhich might cause you to have a d iabet ic coma. Here are the most usual causes: (a) eat ing too much food; (b) not taking enough d iabet i c medicine (that i s , less i n s u l i n or a n t i d i a b e t i c p i l l than you are supposed t o ) ; (c) taking much less than your usual amount of exerc ise ; (d) a fever or an i n f e c t i o n ; (e) a severe emotional upset . 2. Symptoms Hou u i l l you knou you are going into a d i a b e t i c coma? Here are some of the most common symptoms: (a) dry skin and tongue; (b) severe t h i r s t ; (c) ueakness, drousiness or t i r e d n e s s ; (d) nausea, vomiting or loss of appet i te ; (e) deep rapid breathing and a " f r u i t y " smel l ing breath . 1. Causes (Pa t ien t ' s Copy) 1 9 0 3. Treatment Here's uhat to da i f you f e e l you might be going into a d iabet ic coma: (a) Test your u r i n e : - i t u i l l probably be 2% or greater for sugar and p o s i t i v e for acetone. (b) Phone the doctor : - t e l l him hou you f e e l and uhat your ur ine tes ts s a i d . He u i l l t e l l you uhat to do next. k. Prevention Hou can you keep from having a d iabet i c coma? Here are some usefu l suggest ions: (a) Fo l lou your d iet c a r e f u l l y - never omit foods or meals and never take more than you should . (b) Never skip your diabetes medicine. Aluays measure i t c a r e f u l l y and take i t r i gh t on t ime. (c) Do the same amount of exerc ise every day. (d) Avoid i n f e c t i o n s and emotional ly upsett ing s i t u a t i o n s uhenever yau can . (e) Test your ur ine regu la r l y and-report high sugars to your doctor . (Pat ient 's Copy) 191 Insul in Shock . D iabet ic coma i s sometimes confused u i th i n s u l i n shock. Don't l e t t h i s happen to you! These tuo diabetes problems are complete oppos i tes . Insu l in react ion i s the.problem uhich r e s u l t s uhen your s u g a r - i n s u l i n balance i s t ipped to the i n s u l i n s i d e . That i s to say you have e i ther too much i n s u l i n or not enough sugar in your b lood . Other names for i n s u l i n shock are " i n s u l i n reac t ion" and "hypoglycemia" (meaning not enough blood sugar ) . When your s u g a r - i n s u l i n balance i s t ipped to the i n s u l i n s i d e , the r e s u l t i s that your blood has more i n s u l i n in i t than i t has sugar for the i n s u l i n to uork on. This state of a f f a i r s i s quite harmful for your body. Thus, i n s u l i n shock i s a ser ious d iabet i c problem, and one uhich must' be dealt u i th at once ! There are severa l things uhich might cause you to go into i n s u l i n shock. Here are the most usual causes: (a) not eat ing enough food ( e . g . delaying or skipping meals, or leaving out foods you are supposed to e a t ) ; (b) taking more than the correct amount of diabetes medicine; (c) taking more than the usual amount of da i l y e x e r c i s e . 2. Symptoms Hou u i l l you knou you are going into i n s u l i n shock? Here are some of the most common uarning s igns and symptoms: (a) f e e l i n g nervous, exc i ted , f a i n t or i r r i t a b l e ; (b) sueat ing ; (c) hunger; (d) headache; (e) t rembl ing; ( f ) t rouble seeing c l e a r l y . 3. Treatment Although i n s u l i n shack i s a ser ious problem, i t i s a very easy one to t r e a t . Here's uhat to do i f yau are f e e l i n g the symptoms of i n s u l i n shock: 1 . Causes (Pat ient ' s Copy) 1 9 2 (a) Eat or drink something immediately. ( If you have something sweet r i gh t on hand, take i_t. If not, don't waste time looking for sweets; just eat something!) (b) Wait 15 minutes. (c.) THEN - i f you don't f e e l better - eat or drink some more and phone the doctor . He w i l l t e l l you what to do next. 4. Prevention How can you keep from having i n s u l i n react ions? Follow these suggestions: (a) Never skip or delay your meals. Always eat exact ly what your meal plan says, at the time i t says . (b) Always measure your d iabet i c medicine c a r e f u l l y and take i t on t ime. (c) Eat or drink something extra beforehand i f you know yau are going to do more exercise than u s u a l . 0R_, i f there wasn't time for that , eat or drink something immediately afterwards. (d) Always carry something sweet with yau. (Pat ien t ' s copy) 1 9 3 In fect ion As ue mentioned in our d iscuss ion of d iabet i c coma, an i n f e c t i o n i s one of the things uhich may cause you to go into a d iabet i c coma. This i s because the fever that comes u i th many i n f e c t i o n s acts to t i p the s u g a r - i n s u l i n balance touard the sugar s i d e . Thus, i f you have an i n f e c t i o n (such as a severe co ld or the f l u ) , you.should be on the lookout for the symptoms of a d iabet ic coma. In add i t ion to those uarning s i g n s , i f you take your temperature you u i l l f i n d that i t i s above normal. Because an i n f e c t i o n has much the same e f f e c t on your body as a d i a b e t i c coma, you uould expect to t reat i t the same uay -and you do! (a) Test your ur ine (once again , i t u i l l probably be pos i t i ve for both sugar and acetone) . (b) Phone your doctor . T e l l him hou you f e e l , uhat your temperature i s , and uhat your urine tes ts s a i d . He u i l l give you s p e c i f i c ins t ruc t ions about your diabetes medicine and d i e t . (c) Go to bed - y o u ' l l need rest to a l l o u your body to f igh t that i n f e c t i o n . IMou that you knou that i n f e c t i o n s can be ser ious problems for you, y o u ' l l uant to avoid them uhenever you can . Here are some hints for doing just tha t : (a) Stay auay from people uho you knou already have i n -fect ions of one sort or another. (b) Fo l lou the ru les ue discussed under "Personal Hygiene", (c) Treat simple i n j u r i e s r ight auay so that they don't have a chance to become i n f e c t e d . (Pa t ien t ' s Copy) 13k Protect Yourself There are tuo very simple things you should do to protect y o u r s e l f : 1. Wear and/or carry i d e n t i f i c a t i o n Both d i a b e t i c coma and i n s u l i n shock are se r i o u s problems uhich c a l l f a r quick treatment. Linen they are severe, the d i a b e t i c person can f a i n t . That's uhy i t ' s very important to uear or carry d i a b e t i c i d e n t i f i c a t i o n . This i d e n t i f i c a t i o n u i l l help yau get the treatment you need q u i c k l y . Medic A l e r t i s one very goad source of d i a b e t i c i d e n t i f i c a t i o n . There are ot h e r s . Talk to your doctor about uhich kind of i d e n t i f i c a t i o n you should use. 2. Carry something sueet I n s u l i n shock may come an very suddenly - almost u i t h o u t warning. Uhen i t does, you uant to be able to t r e a t i t promptly. That i s uhy i t uould be u i s e f o r you to get i n t o the hab i t af aluays c a r r y i n g something sueet ( l i k e candy) i n your packet or purse. ( P a t i e n t ' s Copy) 195 Where to get help There are many people and o r g a n i z a t i o n s uho are ready to help you keep your good-health balance even. Here's a quick reference of uho they are and uhat they u i l l do f o r you. SOURCE WHAT THEY CAM DO FOR YOU 1. Doctor (phone number) 2. The Canadian D i a b e t i c A s s o c i a t i o n (branch phone number) 1. Get you s t a r t e d u i t h a good balance of d i e t , e x e r c i s e and diabetes medicine. 2. Change t h i s plan i f i t i s n ' t working f o r you. 3. Advise you what to do when your good-health balance i s i n danger of t i p p i n g . The Canadian D i a b e t i c A s s o c i a t i o n i s a non-p r o f i t o r g a n i z a t i o n dedicated to helping d i a b e t i c s l i v e a f u l l e r and h e a l t h i e r l i f e . Yau may j o i n the CD.A. through the n a t i o n a l o f f i c e or any one of i t s l o c a l branches. The b e n e f i t s of membership i n the CD.A. broadly i n c l u d e : 1. S e r v i c e s . Free d i e t c o u n s e l l i n g and oper-a t i o n of h o l i d a y camps which provide reg-u l a t e d d i e t s f o r c h i l d r e n and a d u l t s are some of the s e r v i c e s you can enjoy as a member of CD.A. 2. Education. At every l o c a l CD.A. meeting, part of the program i s devoted to e i t h e r demonstrations by doctors and d i e t i c i a n s , l e c t u r e s , open forums, or i n s t r u c t i v e f i l m s designed to help you and your f a m i l y l i v e a b e t t e r and more normal l i f e . 3. "The Newsletter". The CD.A. p u b l i c a t i o n "The Newsletter" i s mailed to a l l members four times a year. Information and p r i c e s on other p u b l i c a t i o n s on diabetes are a v a i l a b l e from the n a t i o n a l o f f i c e . 4. Encouragement. You and your f e l l o w members of the CD.A. have common problems and o b j e c t i v e s . In group meetings you have the opportunity of seeing how others have overcome c e r t a i n d i f f i c u l t i e s . Then, too, you may be able to help someone. Many have found encouragement and bene-f i t e d by p a r t i c i p a t i n g i n these meetings. ( P a t i e n t ' s Copy) 196 SOURCE UHAT THEY CAN DO FOR YOU P u b l i c Health 1. • r V i c t o r i a n 2. Order of 3. Nurses v i s i t i n g nurses. Da home teaching. Give i n s u l i n i n j e c t i o n s at home. Help u i t h your food care i f you can't manage i t alone. (phone numbers) D i a l - a - D i e t i c i a n (phone number) Various p r o v i n c i a l d i e t e t i c a s s o c i a t i o n s have organized D i a l - a - D i e t i c i a n programs to ansuer the questions about food and n u t r i t i o n uhich a r i s e i n day-to-day l i v i n g . Inform-a t i o n i s a v a i l a b l e on such t o p i c s as: - every day n u t r i t i o n - foods and food values - budgeting and purchasing - meal planning and preparation - food a d d i t i v e s - l a b e l l i n g - food fads and f a l l a c i e s - t h e r a p e u t i c d i e t m o d i f i c a t i o n s I f you have questions about any of these s u b j e c t s , yau should c a l l the D i a l - a - D i e t i c i a n number. Your questions u i l l be recorded, and a p r o f e s s i o n a l d i e t i c i a n u i l l c a l l you back -u i t h i n 48 hours hours - u i t h the ansuers. ( P a t i e n t ' s Copy) 197 Books f o r D i a b e t i c s Danouski, Thaddeus S. Diabetes as a Uay of L i f e , IMeu York: Couard-McCann, 1964 jrevieued i n Diabetes, X I I I , IMo. 6 (November-December 1 9 6 4 ) , 655-656J . The book's outstanding q u a l i t i e s are i t s d i s p a s s i o n a t e , a b j e c t i v e uay of lo o k i n g at the problems of diabetes and the a r t i c u l a t e , adult manner i n uhich the information i s presented ....In a d d i t i o n to the c a r e f u l l y presented p r a c t i c a l inform-a t i o n , e s p e c i a l l y valuable chapters deal u i t h " S o c i a l Aspects of Diabetes", and " L i v i n g u i t h Diabetes: A t t i t u d e s and Expectations"....The only drawback of the book i s that i t o c c a s i o n a l l y reaches above the l e v e l of even the r a t h e r s o p h i s t i c a t e d layman. Dolger, Henry and Seeman, Bernard. Hou to Live with Diabetes.-IMeu York: LI.Id. [Morton and Company, 1959 and 1965 [reviewed i n Diabetes X, No. 1 (January-February 1 9 6 1 ) , 6 9 j . This book i s w e l l w r i t t e n and should be of i n t e r e s t to pa t i e n t s and phy s i c i a n s alike....The authors show an e x c e l l e n t understanding of the psychology and emotional problems confronting the j u v e n i l e d i a b e t i c , and the s e c t i o n on s p e c i a l problems f o r women i s i n t e r e s t i n g and i n s t r u c t i v e . Duncan, G a r f i e l d B. A Modern P i l g r i m ' s Progress with Further  Revelations f o r D i a b e t i c s . P h i l a d e l p h i a : . Ixl. B. Saunders Company, 1967 [reviewed i n Diabetes, XVII, No. 8 (August 1 9 6 8 ) , 5233 . This book i s w r i t t e n i n the form of,a s t o r y about the experiences of a s o c i a l worker u i t h diabetes, assigned to the diabetes c l i n i c and uards of a P h i l a d e l p h i a h o s p i t a l . U i t h t h i s technique, Dr. Duncan i s able to discuss a v a r i e t y of problems presented by d i f f e r e n t p a t i ents....A 67 page appen-dix b r i e f l y o u t l i n e s the various types of i n s u l i n , i t s admin-i s t r a t i o n i n c l u d i n g mixtures, the r e c o g n i t i o n of i n s u l i n r e a c t i o n s and d i a b e t i c coma, urine t e s t i n g , foot care and the exchange system of di e t s . . . . A glossary i s included and a u s e f u l index. X J o s l i n , E l l i o t t P. D i a b e t i c Manual. P h i l a d e l p h i a : Lea and Febiger, 1959 jrevi.eued i n Diabetes, X, No. 1 (January-February 1961) 68 2 • Throughout the book the' author's c o n v i c t i o n i s f r e q u e n t l y r e i t e r a t e d , namely that i f the i n d i v i d u a l u i t h diabetes f o l l o u s treatments u i s e l y , he u i l l l i v e long and h a p p i l y . . . . The young d i a b e t i c u i l l be i n t e r e s t e d to read.of Dr. J o s l i n ' s opinion regarding marriage....From the d i e t a r y standpoint, some of the data....can be challenged. Rosenthal, Helen, and Rosenthal, Joseph. D i a b e t i c Care i n P i c t u r e s . P h i l a d e l p h i a : L i p p i n c o t t , 1968 [reviewed i n Diabetes, XVII, IMo. 11 (November 1968), 709 ] . The authors are to be congratulated f o r a c l e a r , des-c r i p t i v e , v e r b a l and graphic p r e s e n t a t i o n of d i a b e t i c d i e t s ; i n s u l i n preparations and the equipment a v a i l a b l e f o r t h e i r i n j e c t i o n ; urine t e s t i n g ; personal hygiene; foot care and Buerger-Allen exercise....Questions which the d i a b e t i c or h i s f a m i l y may ask regarding o b e s i t y , h e r e d i t y , marriage, pregnancy, exer c i s e and a l c o h o l i c beverages are b r i e f l y but adequately answered by the authors. Schmitt, George F. Diabetes f o r D i a b e t i c s . Miami: Diabetes Press of America, 1966 [reviewed i n Diabetes, XVI, No. 9 (September 1967), 671 J . To the extent that a manual can supplement personal i n s t r u c t i o n , Dr. Schmitt's book does a s a t i s f a c t o r y job. I t i ncludes most of the reference data and t e c h n i c a l f a c t s r equired concerning d i e t , i n s u l i n , o r a l drugs and t e s t i n g methods. An unusual feature i s a c o l l e c t i o n of colour photos which w i l l be u s e f u l to the newly i n s t r u c t e d p a t i e n t . But there are p i c t u r e s of retinopathy and a r t e r i a l o c c l u s i o n which might not, however, be appropriate f o r the apprehensive p a t i e n t . S i n d o n i , Anthony M. The D i a b e t i c ' s Handbook. New York: The Ronald Press Company, 1959 fjreviewed i n Diabetes, IX, No. 6 (November-December 1960), 506J . Dr. Sindoni's handbook in c l u d e s a large' amount of use-f u l data concerning diabetes, i t s complications and i t s treatment....Its f a u l t s are o v e r i n c l u s i v e n e s s and f a i l u r e to confine i t s e l f to the d i a b e t i c p a t i e n t . Much of the m a t e r i a l i s more appropriate to nurses, d i e t i c i a n s or semi-p r o f e s s i o n a l personnel having same background of medical knowledge. Pamphlets f o r Diabetics TITLE SOURCE COST 1. A Guide f o r the Canadian D i a b e t i c on Oral Therapy 2. Care of the C h i l d u i t h Diabetes 3. Care of the Feet k. Diabetes: A Question and Ansuer Book f o r Canadians 5. Diabetes Check Facts 6. D i e t e t i c Foods Without Cyclamate 7. Exchange L i s t s f o r Meal Planning f o r D i a b e t i c s i n Canada 8. Sample Diets f o r Use i n Conjunction u i t h #7 9. Guidebook f o r the Di a b e t i c P a t i e n t 10. I am a D i a b e t i c - I d e n t i f i c a t i o n Card 11. I f You Have Diabetes 12. I n s t r u c t i o n s to Teachers u i t h D i a b e t i c Children i n t h e i r Classes 13. I n s u l i n Use Information K i t , c o n t a i n i n g : "Questions and Answers" f o l d e r , " H o s p i t a l I n s t r u c t i o n Program" f o l d e r , "Techniques f o r S e l f I n-j e c t i o n " chart and f o l d e r , "Tips on F i l l i n g I n s u l i n Syringe" booklet, l i s t of r e f e r -ences, "Knou Your I n s u l i n Syringe" chart and s i t e s e l e c t o r Ik. I n s u l i n and I n s u l i n Preparations 15. Manual f o r D i a b e t i c s i n Canada 16. One Out of Every 50 Canadians may be a Di a b e t i c 17. Right From the S t a r t - Complimentary C l i n i t e s t I n s t r u c t i o n K i t 18. Some Thoughts f o r Young D i a b e t i c s and t h e i r Parents 19. Stop, Read and Understand Food Labels 20. This Could Save Your L i f e - A p p l i c a t i o n Form and Message 21. T r a v e l l i n g with Diabetes E l i L i l l y & Co., Toronto, Ont. Ames Co.,' Rexdale, Ont. Toronto Dept. P u b l i c Health Canadian D i a b e t i c A s s o c i a t i o n Canadian Di a b e t i c A s s o c i a t i o n Canadian Di a b e t i c A s s o c i a t i o n Canadian D i a b e t i c . A s s o c i a t i o n Connaught Labs., Willpwdale, Ont. Ames Co., Rexdale,. Ont. Canadian Di a b e t i c A s s o c i a t i o n Chas. P f i z e r & Co., Montreal, Que. Canadian Di a b e t i c A s s o c i a t i o n Becton-Dickinson and Co., Clarkson, Ont. Connaught Labs., U i l l o u d a l e Canadian Di a b e t i c A s s o c i a t i o n Canadian D i a b e t i c A s s o c i a t i o n Ames Co., Rexdale, Ont. Canadian Di a b e t i c A s s o c i a t i o n Canadian Di a b e t i c A s s o c i a t i o n Canadian Medic-Alert, Toronto, Ont, Canadian Di a b e t i c A s s o c i a t i o n M i l M i l M i l M i l M i l M i l 500 M i l M i l M i l M i l M i l M i l 75t£ M i l M i l M i l M i l M i l M i l APPENDIX G OUTLINE OF DIABETIC TEACHING PROGRAM 2 0 1 DAY 1 F i lm: Uhat i s Diabetes? The pat ients uatch a tuenty minute Trainex f i l m t i t l e d "Uhat i s D iabetes" . This f i l m deals b r i e f l y u i th top ics such as (a) incidence of d iabetes , (b) symptoms of d iabetes , (c) c h a r a c t e r i s t i c s of maturity onset d iabetes , (d) some aspects of treatment, and (e) some aspects of pathophysiology of d iabetes . After the f i l m the d i e t i c i a n conducts a question p e r i o d . 202 DAY 2: Lecture by D i e t i c i a n Dietary C o n t r o l of Diabetes Revieu of information the f i l m gave about d i e t : „ The most important s i n g l e f a c t o r i n the treatment of most d i a b e t i c s i s maintaining a proper d i e t . Uhen a person has diabetes, hi s body cannot handle a simple sugar, c a l l e d glucose, because of inadequate i n s u l i n production or a c t i v i t y . Glucose comes from the foods ue eat. The d i a b e t i c must eat c o n t r o l l e d amounts of food. By eating the co r r e c t amounts and kinds of foods, the d i a b e t i c can c o n t r o l the amount of glucose going i n t o the blood. A c e r t a i n part of a l l the foods ue eat i s changed i n t o glucose or sugar i n the body. The foods ue eat are made of three main sub-stances. These are carbohydrate, p r o t e i n , and f a t . Some of these food substances produce more sugar than o t h e r s . Carbohydrate, pro-t e i n , and f a t change to sugar and provide the f u e l f o r our energy needs. Ue u i l l f i n d out nou uhat foods are carbohydrate foods, uhat foods are- high i n p r o t e i n and f a t , and hou much sugar these foods produce i n the body. FOOD carbohydrate p r o t e i n : f a t : 100% 58% glucose (sugar) 10% ^ Carbohydrate foods 1. Starches - bread, potatoes, c e r e a l , corn, p a r s n i p s , f l o u r and foods made u i t h f l o u r , s p a g h e t t i , noodles, r i c e , d r i e d beans and peas, e t c . Pr o t e i n Foods Meat F i s h ' P o u l t r y Eggs Cheese M i l k 2. F r u i t s and f r u i t j u i c e s 3. Vegetables - more starchy (mainly root vegetables) c a r r o t s , beets, anions, t u r n i p s , peas, squash, e t c . - l e s s starchy (salads and greens) l e t t u c e , r a d i s h e s , green beans, spinach, c a u l i f l o w e r , e t c . Fat Butter/Margarine O i l Fats used i n cooking Salad dressing Cream Cream cheese IMuts, o l i v e s Avocado Side Bacon Sueets - sugar, p i e , cake, i c i n g , candy, ordinary s o f t d r i n k s , syrup from ordinary canned f r u i t , jam, j e l l y , honey, marmalade, e t c . 203 I t i s important f o r a d i a b e t i c to avoid t h i s f o u r t h group of carbohydrate-containing foods - v i z . sugar and foods concentrated i n sugar. Reasons: 1. Sugar i s a concentrated form of carbohydrate which r e -quires l i t t l e d i g e s t i o n and enters the blood stream q u i c k l y , e l e v a t i n g the blood sugar because there i s too l i t t l e i n s u l i n a c t i v i t y to handle i t . 2. I t i s easy to make mistakes i n measuring sugar or con-centrated sweets, with greater harm r e s u l t i n g than from mistaken measurements of l e s s concentrated foods. 3. Use of sweets reduces the allowance of starches, f r u i t s , and vegetables. This cuts down on the bulk of the d i e t and the person may become hungry l a t e r . k. These foods are "empty c a l o r i e " foods with few vitamins or minerals - they are the foods that used to excess, make people without diabetes gain weight. Because carbohydrate foods are r e a l l y j u s t complex forms of sugar ( a l l carbohydrate i s converted to sugar i n the body), these carbohydrate foods r e q u i r e a l o t of i n s u l i n so that the body can make good use of the sugar they supply. C o n t r o l l e d amounts of a l l foods are important so t h a t the d i a b e t i c w i l l have a c o n t r o l l e d amount of sugar i n the blood to balance the amount of i n s u l i n h i s own body i s producing, or the i n s u l i n he i s t a k i n g by i n j e c t i o n . Explanation of Exchange You have seen how foods are c l a s s i f i e d as carbohydrate, p r o t e i n , and f a t foods. From these three groups, foods are f u r t h e r subdivided i n t o 6 b a s i c food groups: 1. bread 2. ) k. meat ) ' . f r u i t ) Carbohydrate 5. milk ) P r o t e i n 3. vegetables ) 6 > f g t } f g t To make your meal planning as simple as p o s s i b l e , you are given a meal plan sheet t e l l i n g how many servings to take from each food group at each meal. Because a l l the foods w i t h i n a group have about the same amount of sugar, you can s u b s t i t u t e or "exchange" foods from w i t h i n the same group f o r each other i n the p o r t i o n s i z e s s t a t e d . Remember - s u b s i t u t e foods from w i t h i n the same group but not between groups, because foods i n d i f f e r e n t groups produce d i f f e r e n t amounts of sugar. Think of an exchange as a s e r v i n g , e.g. 1 f r u i t exchange i s one serving of f r u i t i n the amount given i n the f r u i t l i s t . Two f r u i t exchanges are 2 servings of f r u i t or j u i c e , or double of any one s e r v i n g . 204 Two Meal Planning Booklets The booklets contain the 6 food l i s t s . The booklet most s u i t a b l e f o r you has been pre s c r i b e d f o r you by your doctor. CD.A. - Canadian D i a b e t i c A s s o c i a t i o n A.D.A. - American D i a b e t i c A s s o c i a t i o n . (These are s i m i l a r i n p r i n c i p l e . The A.D.A. food l i s t s are simpler and mare e a s i l y learned; they are therefore s u i t e d to many mat u r i t y -onset d i a b e t i c s c o n t r o l l e d by d i e t alone or d i e t and hypoglycemic agents. The CD.A. food l i s t s are mare extensive and b e t t e r s u i t e d to younger d i a b e t i c s and p a t i e n t s uho can approach a neu l e a r n i n g s i t u a t i o n u i t h ease.) Basic P r i n c i p l e s of A l l D i a b e t i c Diets 1. Eat meals at regu l a r times. 2. Eat three meals a day and snacks as o u t l i n e d on your meal plan, sheet. Reasons: (a) to provide the body u i t h a steady amount of food through-out the day (body can't handle a large amount of sugar at one t i m e ) . (b) to provide the body u i t h food at the time that i n j e c t e d i n s u l i n i s mast e f f e c t i v e i n i t s a c t i o n , e.g. IMPH - most a c t i v e i n l a t e r afternoon and evening - have afternoon and evening snacks, dinner on time. Measuring Measuring your food at home i s important. I t i s the only accurate uay of knouing you are g e t t i n g the c o r r e c t amounts of food. The household measurement of one ser v i n g or exchange of each food i s stat e d i n the food l i s t s i n the booklet. U i t h p r a c t i c e , you u i l l l e a r n to v i s u a l i z e the c o r r e c t amount of each food according to your oun i n d i v i d u a l meal pl a n . Houever, measure your food (a) uhen you are a neu d i a b e t i c and j u s t l e a r n i n g , (b) uhen you rece i v e a neu d i e t copy, (c) uhen your diabetes i s not under good c o n t r o l , (d) p e r i o d i c a l l y as a checkup against your v i s u a l e s t i m a t i o n of serving s i z e s . . Your t o o l s are: glass measuring cup - f o r l i q u i d s (milk, j u i c e ) set of four graduated measuring cups,(1/4, 1/3, 1/2, 1 cup) fo r s o l i d s ; l e v e l , not heaped, measuring spoons - f o r b u t t e r , salad d r e s s i n g , o i l , e t c . Study your booklet to become f a m i l i a r u i t h the food l i s t s : 1. M i l k Exchange L i s t (CD.A., p. 7, A.D.A., p. 5) l i s t s uhole, 2%, skim, b u t t e r m i l k , e t c . Difference i s the f a t content. Your meal plan sheet s t a t e s uhat type of milk you are to take. Refer 205 to your sheet . Measure your t o t a l day's milk allouan.ce into a p i tcher in the morning and use i t throughout the day so that you don't need to measure small amounts for co f fee , t e a . 2. Vegetable L i s t s More Starchy ( C D . A . Group A, p. 8) (A.D.A. Group B, p. 7) Ask pat ients to r e c a l l examples. Usual ly one serving of these vegetables i s a l loued d a i l y , at main meal. Must measure. Less Starchy ( C D . A . Group B, p. 10) (A .D.A . Group A, p. 6) Contain only a smal l amount of carbohydrate so may be taken in average amounts at both meals and betueen meals as snacks, i f d e -s i r e d . (Snack ideas - ce lery s t i c k s , rad ishes , lettuce/cabbage uedge). Better to take a larger serv ing of these vegetables uhen hungry than to take extra servings of some other food . 3. F r u i t L i s t ( C D . A . p. 12, A .D .A . p. 8) Includes f resh , d iet canned, unsueetened cooked, f rozen , dr ied f r u i t s and f r u i t j u i c e s . Important - f r u i t contains natura l sugar or carbohydrate, even uhen rau or unsueetened, so unsueetened f r u i t cannot be eaten f ree ly in any amount. Some f r u i t s contain more natura l sugar than others so the serv ing s i ze var ies u i th each f r u i t . Learn.by heart the serving s i zes for the f r u i t s that yau eat . Do not use ordinary canned f r u i t uhich has a l o t of sugar added. Diet canned f r u i t s a v a i l a b l e : 1. packed in uater only 2. u i t h a r t i f i c i a l sueetener, saccharine 3 . u i th a small amount of added sugar. This i s not a concentrated sueet and i s pe r fec t l y safe to use. Read the l a b e l c a r e f u l l y for the s ize serv ing to be used far one f r u i t exchange. 4. Bread L i s t ( C D . A . p. 14, A .D .A . p. 10) Contains a l l the starchy , high carbohydrate foods uhich produce a l o t of sugar and require a l o t of i n s u l i n . Correct measurement of these foods i s therefore very important. Corn, parsnips and potatoes are bread s u b s t i t u t e s . Uhen using uns l i ced bread or odd-shaped loaves , get 16 s l i c e s from a 16 oz . (1 l b . ) l o a f . Canned soup and b i s c u i t s may be used as bread (or bread and f a t ) subst i tutes to allow var ie ty in meals and snacks. L i s t s are ava i lab le uhich state the correct subs t i tu t ions or exchanges for canned soups and b i s c u i t s . 206 5. Meat L i s t (CD.A.p.16, A.D.A. p. 12) Contains a l l the high p r o t e i n foods, except milk (examples). May use a l l kinds of meat and f i s h . Cooking method important-recommend cooking without added f a t by: 1. b r o i l i n g 2. baking 3. using Teflon pan 4. using heavy cast i r o n pan 5. cooking by moist heat - u i t h stock or.vegetable uater - u i t h beef or chicken cubes - j u i c e from canned tomatoes, e t c . 6. pressure cooker I f f a t i s used, must be part of f a t allouance at the meal, not e x t r a . Remove v i s i b l e f a t from meat before cooking, d r a i n u e l l i f f a t comes out of meat i n cooking. 1 l b . meat = 16 ounces - 12 ounces uhen cooked f o r 4 meat exchanges, use 1/3 l b . rau meat f o r 3 meat exchanges, use 1/4 l b . rau meat f o r 2 meat exchanges, d i v i d e 1 lb-, meat i n t o 6 por t i o n s 6. Fat L i s t (CD.A. p. 18, A.D.A. p. 14. Fat foods are high i n c a l o r i e s , so i f your doctor uahts you to lose weight, there may only be a sm a l l amount of f a t included i n your d i e t . Measure a l l f a t c a r e f u l l y . Free Foods (CD.A. p. 19, A.D.A. p. 4) These are foods uhich contain l i t t l e or no food value and may be used as d e s i r e d . Examples: c l e a r c o f f e e / t e a a r t i f i c i a l sueeteners c l e a r broth, b o u i l l o n cubes lemon j u i c e , vinegar spices and seasonings sugar-free s o f t d r i n k s (examples) - do not use d i e t s o f t d r i n k s c o n t a i n i n g reduced amounts of sugar. S p e c i a l Diet Foods S p e c i a l d i e t foods are NOT necessary. A d i e t planned f o r a d i a b e t i c i s a u e l l - b a l a n c e d food p a t t e r n that the uhole f a m i l y can enjoy - a l l the basic foods f o r good n u t r i t i o n are in c l u d e d . Do not u s u a l l y need to cook separately f o r a d i a b e t i c member of the family (except under c e r t a i n circumstances). Same foods i n measured amounts. Warning re s p e c i a l d i e t foods: read l a b e l s c a r e f u l l y . Check i f l a b e l s t a t e s hou many c a l o r i e s are i n one ser v i n g ( i f l e s s than 10 207 ca lo r ies/se rv ing , may take one serv ing in addi t ion to those foods l i s t e d on your meal p l a n . Sugar - f ree does not mean c a l o r i e - f r e e or free to take in any amount. The product may contain other forms of carbohydrate ( s o r b i t o l , l a c t o s e , e t c . ) D T p rote in and fa t which provide some sugar and also provide c a l o r i e s . S p e c i a l d iet chocolate bars contain about the same c a l o r i e s as ordinary cha lo late bars and should not be used unless the correct subs t i tu t ion i s made on the d i e t . Show Cookbooks If in te res ted in a cookbook, get the one publ ished by C D . A . or A .D.A. whichever exchange system has been prescr ibed for you. Eating Out D iabet ics can eat away from home as e a s i l y as anyone e l s e . Main considerat ions are that you must -(a) know your meal pattern by heart (b) se lec t wisely (c) be able to v i s u a l i z e the correct amounts of food according to your own meal pa t te rn . Foods se lected should be p l a i n foods of known composit ion. Sauces, cassero les , deep - f r i ed foods and desserts should be avoided. Meat choice - roas t , s teak, chops, meat patty , baked f i s h . From bread exchange l i s t - baked/whole potato, smal l r o l l . Vegetables - without sauce, s a l a d , p la in or with lemon. Fat exchange <- probably some fat used in cooking, but te r : 1 pat = 1 t s p . cream for c o f f e e ; i f enough fat exchanges for sa lad dressing or sour cream, serve your own. Ask that meat be served without gravy. F ru i t - eat f r u i t serv ing l a t e r at home i f f resh f r u i t or unsweetened ju ice not a v a i l a b l e . Ice cream may be chosen for dessert i f subst i tu ted c o r r e c t l y , as indicated on the food l i s t s . (Could discuss eat ing at d r i v e - i n s , quick lunches, on hol iday t r i p s , i f time a l lows . ) Eating dinner out often means eat ing at a l a t e r hour than u s u a l . If taking i n s u l i n , i t i s important tD eat some food, e . g . your evening snack, at your regular dinner time or may r i s k a low blood sugar r e a c t i o n . I l l ness If you cannot to le ra te ordinary s o l i d foods, i t i s important to get a comparable intake of sof t or l i q u i d foods. Examples of foods from the food l i s t s which are often to le ra ted when i l l : 2 0 8 Fru i t l i s t - j u i ces Bread - canned scup from soup l i s t , soda crackers or b i s c u i t s from b i s c u i t l i s t , cooked c e r e a l , milk toast Meat l i s t - eggs; scrambled, u i th milk as eggnog or custard , u i th orange ju ice as f r u i t eggnog; cottage cheese Milk - as beverage, in soup, on c e r e a l , in tea or coffee Vegetable l i s t - mixed vegetable ju ice or tomato j u i c e , i f desired Fat - omit u n t i l to le ra ted C D . A . booklet pp. 20-22 give suggestions for f l u i d diet on day of i l l n e s s . Clear broth and tea are usual ly u e l l t o l e r a t e d , but have no c a l o r i e value. Warm f l u i d s taken frequent ly in small amounts are best t o l e r a t e d . Consult your doctor ear ly i f you cannot take your meals. Exerc ise : The importance of eat ing extra food before doing unusual exercise u i l l be discussed on Wednesday. Importance of Not Changing the Diet A d i a b e t i c person should not change h is d iet without con-su l t ing h is doctor because: (a) the amount of food prescr ibed for you has been c a r e f u l l y balance u i th your medication and amount of a c t i v i t y . (b) i f not enough food i s eaten, a lou blood sugar react ion may occur ( in d iabet i cs uho are taking i n s u l i n ) . . (c) i f too much food or the wrong type of food i s eaten, urine tes ts w i l l show sugar and the diabetes may go out of c o n t r o l . (d) undesirable weight gain or loss could r e s u l t and make the diabetes mare d i f f i c u l t to t r e a t . 209 DAY 3: Lecture by Nurse Urine Testing, Skin Care and Exercise  Urine Testing The urine testing t e l l s hou controlled the diabetes is in relation to diet, exercise and medication. Sugar does not s p i l l into urine unless the blood sugar is approximately tuice the normal, ISO - 200 mgm. Testing materials for testing for sugar Testape is a paper uhich is very specially treated and extremely sensitive. It u i l l pick up small amounts of sugar. Make certain fingers are dry as reading u i l l be inaccurate i f uet or damp. LJet portion of tape should not touch fingers and should be held doun. Storage is important so the package should be kept in a coal, dry place and out of the sunlight. Timing i s very important. Test for one minute and i f +3 uait one more minute and record the darkest portion. Clinitest tablets are more accurate and are best for insulin users. Put five drops of urine and ten drops Df uater in test tube. Add the tablet. Do not shake uhile bubbling. After bubbling ceases shake gently and read. Test takes 15 seconds. Pass through phenonema. Careful observance of test during 15 second uaiting period is necessary to detect rapid pass-through color changes caused by amounts of sugar aver 2%. Should the color rapidly "pass through" green, tan and orange to a dark greenish-braun record as over 2% sugar. The patient should understand his condition uell enough to ask himself these questions uhen s p i l l i n g sugar: (a) Diet - Too much? Change of hours? (b) Exercise - Change from active days to much less active days? (c) Insulin - Incorrect dosage? Change of site because i f the same site is used too frequently i t leads to thickening of the skin uhich prevents the insulin from being absorbed by the system at a constant speed. (d) Infection or illness such as cough, fever, nausea, vomiting or inflamed wound 7 Urine testing and frequency of testing depends upon the doctor and severity of diabetes. If testing once a day, test at different times during the day. Explain double or second voided specimen. This is important especially for the before breakfast test. Those an oral medication may be required to test two or three hours after meals. Trace +1 +2 +3 +4 %% Vz% 2/3% 1% 2% 1/10% 1/4% 1/2% 2% Negative Clinitest  Testape 210 Acetest i s a t e s t f o r Ketones and acetone. Method f o r t e s t i n g f o r acetone. Place one drop of urine on an acetest t a b l e t . In 30 seconds compare c o l o r of t a b l e t u i t h c o l o r c h a r t . Tablets are expensive so da not use i n d i s c r i m i n a t e l y . K e t o s t i x are very s e n s i t i v e and are not used very much. Acetone bodies are only produced uhen there i s i n s u f f i c i e n t i n s u l i n to use blood sugar f o r heat and energy. Body turns to the abnormal process of f a t metabolism. The bipraduct i s acetone uhich i s a t o x i c or poisonous a c i d . The build-up of these products leads to a c i d o s i s or d i a b e t i c coma. There i s no need to t e s t f o r acetone every time one t e s t s f o r sugar. C r i t e r i a f o r t e s t i n g f o r acetone. (a) Sugar t e s t shous +3 to +k r e g u l a r l y f o r three to four consecutive t e s t s . (b) Increased t h i r s t or v o i d i n g . (c) F e e l i n g i l l and uhen d e f i n i t e l y s u f f e r i n g from an i l l n e s s or i n f e c t i o n . Skin Care Reason'for s p e c i a l precautions i s a r t e r i o s c l e r o s i s uhich i s a normal aging process but d i a b e t i c s are more prone and should be auare of hou to prevent t r o u b l e from i t . D i a b e t i c s are more prone to i n f e c t i o n s . S p e c i a l reference should be given to feet as they are f a r t h e s t auay from the blood supply and are more prone to s m a l l v e s s e l disease. Wash the feet d a i l y u i t h uarm uater and m i l d soap and dry c a r e f u l l y , p a r t i c u l a r l y betueen the toes. I f f e e t p e r s p i r e t r y mild foot pouder. I f the s k i n i s dry use l a n o l i n but never betueen the toes. Trim toe n a i l s a f t e r bath but s t r a i g h t across. Do not use s c i s s o r s or razor on corns or c a l l u s e s . Wear clean socks or nylons d a i l y . Do not uear gar t e r s or t i g h t g i r d l e as i t i n t e r f e r e s u i t h c i r c u l a t i o n . Wear proper f i t t i n g shoes and break i n g r a d u a l l y to avoid b l i s t e r s . Do not go barefooted. Do not cross legs or at ankles. Do not use hot uater b o t t l e s or heating pads. Wear socks to bed i f feet are c o l d . I f legs are t i r e d elevate even u i t h the h i p s . Any•abrasion, b l i s t e r , or small cut or b r u i s e should be c a r e f u l l y cleaned u i t h a l c o h o l or d i l u t e d D e t t o l s o l u t i o n and a dry s t e r i l e dressing a p p l i e d . Use scotch tape i n s t e a d of adhesive tape. Avoid i o d i n e or strong a n t i s e p t i c s . I f not improving or g e t t i n g uorse i n tuo or three days see the doctor. Hand cuts are not a problem. . When having dental uork done make c e r t a i n the d e n t i s t knous and have the uork done i n small amounts to avoid missing a meal. Go to an ophthamologist i n s t e a d of an optometrist f o r an eye examination. Glasses should not be f i t t e d f o r tuo months a f t e r i n s u l i n i s s t a r t e d as during t h i s p e r i o d the v i s i o n u i l l change. This a p p l i e s also uhen out of c o n t r o l . 211 Exercise Muscles an exercise burn blood sugar without i n s u l i n being requ i red . Doctors never r e s t r i c t a c t i v i t y because of diabetes but u i l l t e l l you to try and keep your a c t i v i t y constant from day to day. As t h i s i s not aluays pass ib le the eas iest thing to adjust in your rout ine i s your d i e t . On the days uhen you u i l l be more act ive than usual eat more food. As an example before h i k i n g , suimming or any form of more strenuous exercise have an extra snack to prevent a react ion in the middle of an a c t i v i t y . UJhen you return home test urine and i f negative, t race or +1 you probably ate the r igh t amount. If +k you ate too much. There i s n ' t anything to uorry about provid ing you go back to your regular d iet the next day. This i s a guide' far future a c t i v i t i e s . 212 DAY 4: Lecture by IMurse Insulin If your pancreas is not able to produce enough insulin for your daily needs then i t has to be given by injection uhich is usually once a day but sometimes tuice. Insulin is made from either beef or pork pancreas. It comes in tuo concentrations and is measured in units per c c . Example: 40 units strength or 80 units strength. Uhen doses are over 35 units the 80 unit/cc insulin is used to reduce to half the amount of solution being injected. The Doctor states uhich you are to use on the prescription. Insulin in use may be kept at room temperature. The extra bottle should be in the refrigerator auay from freezing department. Equipment Syringes are either 40 units or 80 unit scales. IM.B. Buy syringes uith one scale only to correspond uith your insulin so that there is no chance for confusion and use of incorrect scale uhich may result in either giving yourself a double dose or half the dose. Glass syringes are reusable. Disposable syringes are convenient for travelling and as an extra in cases of emergency. If using disposable equipment the most economical uay to buy is in quantity. There is a neuer type of disposable syringe on the market that has vertical labelling, uider scale and a smaller needle. If one has a small hand and on a high dose of insulin•there may be difficulty plunging the barrel. Stainless steel needles can be purchased uhich are reusable until d u l l . Disposable needles are aluays sharp and convenient. Sterilizing Methods 1. Place separated syringe and metal needle ( i f used) in sieve in sauce pan. Cover uith uater and boil for five minutes. L i f t sieve, pour out uater and allou to s i t unt i l cool enough to handle. Demonstrate. 2. Keep syringe and needle in. 70% alcohol. Tie string around barrel and louer into container uhich has cotton baton in bottom to protect point of needle. Change alcohol once a month or more often. Add more alcohol i f i t evaporates belou level of plunger. Rinse syringe, after using and reassemble before returning to alcohol. Injection Sites 1. Mid thigh in front to mid thigh in back. 2. Above, belou and to either side of naval. 3. Upper arm - inner and outer aspect. 4. Hips i f able to manage. 213 Young diabetics are encouraged to use abdomen more often. IM.B. Important to rotate sites from day to day to prevent tissue damage and atrophy of muscle. Areas suggested relatively free of major blood vessels and nerves. When returning to same injection area after tuo to three days leave at least 1 - 2" betueen neu and old sites. Irritation i f not deep enough. Types of Insulin Time actions of insulin, assuming i t uas given before breakfast. (Bhoun by X) Quick Acting Breakfast Toronto) Regular) Semi - Lente Medium Acting IM.P.H.. . Lente Glabin - rarely used Long Acting Protamine Zinc Ultra Lente Dinner Supper X lasts approx-imately 4 hours X lasts longer Bed X lasts 24 hrs. lasts 36 hrs Mixes Possible 1. IM.P.H. and Regular 2. Semi Lente and Lente 3. Semi Lente and Ultra Lente 4. Semi Lentre, Lente, and Ultra Lente 5. Lente and Regular Do not mix Regular and Protomine Zinc. It must be given as tuo separate injections. Important to knou individual insulin and uhen i t is at i t s peak of action, because this is uhen they must eat. i.e. IM.P.H. - supper is the largest meal of the day and must be eaten on time or may have reaction. Injection Demonstrate holding syringe - different parts. Preparation of Insulin bottle - mixing and cleansing. Give at right angles to skin. Cotton used to cleanse skin and bottle top. Buy r o l l of cotton baton rather than individual balls as i t is cheaper. 21k Mixing - TLJD Insulins i.e. Regular and IM.P.H. 1. Air into IM.P.H. 2. Air into Regular ) . 3 . Withdraw Regular ) ^ k. Withdraw IM.P.H. There are two different theories on mixing insulins. Some authorities suggest IM.P.H. to be withdrawn f i r s t . IM.B. Must be same strength i.e. both kO units or 80 units. Oral Tablets Oral tablets are hypoglycaemic agents. These tablets are not insulin but antidiabetic agents. Two different types are sulfonylureas and biguanides. Sulfonylurea :• 1) Tolbutamide (trade names Crinase and Mobenol) 2) Acetohexamide (trade name Dimelor) 3) Chlorpropamide (trade name Diabenese) Action - stimulates pancreas to produce more insulin. Dosage depends upon the individual. Biguanides 1) DBI (Phenformin) 2) DBI-TD Action - have blood sugar lowering effect independent of insulin. Not used as frequently. 215 Distinguishing Reaction or Coma  Lou Blood Sugar Reaction 1. Too much insulin 2. Not enough food 3. Unusual amount of exercise 4. Illness - sudden nausea and vomiting 5. Neu injection site Symptoms Insulin Reaction Onset - sudden skin - pale, moist, cold Thirst - absent. Can experience trembling,ueakness, head-ache, numbness, tingling of mouth and fingers Breathing - normal or rapid and shallau Behaviour - Excited, confused, loss of memory, belligerent Vomiting - absent Vision - impaired Can become unconscious and have convulsions Treatment Insulin Reaction Food -take something that requires l i t t l e digestion and u i l l be quickly absorbed into the blood sugar such as sugar, regular pop, sueetened fruit juices, honey, 4-5 lifesavers, chocolate bar, etc. This is temporary and should be folloued by a meal i f at mealtime or snack i f betueen meals, e.g. bread, butter and piece of bologna. DAY 5: Lecture by Nurse High Blood Sugar Reaction 1. Omitting or reducing medication 2. Too much food 3. Not enough exercise 4. Infections Diabetic Acidosis or Coma - gradual - flushed, dry often uarm - present, passing urine frequently - breath, acetone, fruity smell - drousy - present - impaired - can d r i f t into coma Diabetic Acidosis or Coma If suspected contact your doctor. If alone have some-body stay. To prevent de-hydration take fluids -lou calorie or no calorie. If nauseated take small amounts of f l u i d often. Continue usual insulin orders D T tablets according to doctor's orders. 216 C o n t r o l l e d ? Hou to t e l l i f c o n t r o l l e d . 1. Hou do you f e e l ? I f u e l l and not t i r e d , hungry, t h i r s t y , passing urine f r e q u e n t l y . 2. Most urine t e s t s should be negative or +1 and at same time not having a l o t of r e a c t i o n s . 3. Are you maintaining your ueight an a u e l l balanced d i e t ? I f an a reducing d i e t , yau should only lose 1-2 pounds a ueek. I f underueight you should only gain 1-2 pounds a ueek. 4. On a r e g u l a r doctor's v i s i t your blood sugar should be u i t h i n a normal range. 

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