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An experimental study to evaluate the effectiveness of a diabetic teaching tool Skelton, Judith Mary 1973

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0 '' l\loir p m s z / AN EXPERIMENTAL STUDY TO EVALUATE THE EFFECTIVENESS OF A DIABETIC TEACHING TOOL \ _ by JUDITH MARY SKELTON B . S . N . McMaster U n i v e r s i t y , 1 9 6 9 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE MASTER OF SCIENCE IN NURSING in the School of Nursing We accept t h i s thes i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1 9 7 3 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements f o r 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 t h a t permission f o r e x t e n s i v e copying o f t h i s t h e s i s f o 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 o f 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 without my w r i t t e n permission. Department of N U R S I N G / APPLIED {?CTENf!F. The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8, Canada Date APRIL 19, 1973 ABSTRACT AN EXPERIMENTAL STUDY TO EVALUATE THE EFFECTIVENESS OF A DIABETIC TEACHING TOOL J u d i t h Mary Ske l t o n The purpose of t h i s study was to answer the q u e s t i o n , ' W i l l d i a b e t i c p a t i e n t s taught "by means of a " D i a b e t i c Tea-ching Tool" demonstrate a 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 p a t i e n t s taught i n the i n s t i t u t i o n ' s u s u a l manner?' The answer t o the question was sought by comparing the s e l f -care knowledge and s k i l l s of two groups of d i a b e t i c p a t i e n t s admitted t o a suburban ge n e r a l h o s p i t a l which, p r i o r t o the study, o f f e r e d no planned programme of d i a b e t i c p a t i e n t edu-c a t i o n . A l l d i a b e t i c p a t i e n t s admitted to t h i s h o s p i t a l over a s i x month p e r i o d were screened f o r e l i g i b i l i t y t o p a r t i c i -pate i n the study according t o c r i t e r i a s t a t e d by the re s e a r c h e r . E l i g i b l e p a t i e n t s admitted i n the f i r s t t hree months were d e s i g -nated as c o n t r o l subjects} those i n the l a s t three months as experimental s u b j e c t s . The twenty s u b j e c t s i n the c o n t r o l group were taught i n an unplanned manner, based upon whether and/or what i n s t r u c t i o n s were deemed p e r t i n e n t by t h e i r nurses. A " D i a b e t i c Teaching T o o l " — d e s i g n e d by the researcher and ad-m i n i s t e r e d by each p a t i e n t ' s own n u r s e ( s ) — w a s used to i n s t r u c t the twenty experimental s u b j e c t s . A f t e r d i s c h a r g e , each of the f o r t y s u b j e c t s was v i s i t e d by the re s e a r c h e r , at which time a i i i p r o f i l e sheet was completed and a te s t of d iabet ic l ea rn ing administered. Demographic and d iabet ic c h a r a c t e r i s t i c s of the subjects-obtained from the pat ient p r o f i l e sheets—were analyzed and described i n terms of d i s t r i b u t i o n s , medians and/or means. The te s t r e su l t s were subjected to t - t e s t analyses on severa l dimensions. And a number of demographic and d iabet ic t r a i t s were compared with t h e i r respect ive tes t scores by means of the Pearson Product Moment Cor re l a t ion C o e f f i c i e n t . The data supported the fo l lowing conclusions t 1. Diabet ic pat ients taught by means of the "Diabet ic Teaching T o o l " demonstrated a s i g n i f i c a n t l y higher l e v e l of l ea rn ing about s e l f - ca re than d id pat ients taught i n the unplanned manner. 2. 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 ferences were found between te s t scores of pat ients taught with the "Diabet ic Teaching T o o l " and those r e c e i v i n g unplanned i n s t r u c t i o n regardless of the durat ion of t h e i r diabetes . Thus ' o l d ' d iabet ic s were able to derive as much benef i t from the teaching t o o l as were 'new' d i a b e t i c s . 3. The l e v e l of l e a rn ing demonstrated by pat ients taught with the "Diabet ic Teaching T o o l " appeared to be i n -dependent of the fo l lowing factors 1 age at time of teaching and t e s t i n g , previous education, and age at onset of diabetes ; each of these factors was s i g n i f i c a n t l y r e l a t ed to the l e v e l of l ea rn ing of pat ients r e c e i v i n g unplanned i n s t r u c t i o n . i v 4. D i a b e 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" c i t e d the nurse as a v a l u a b l e source of i n f o r -mation re g a r d i n g d i a b e t i c management more than f i v e times as f r e q u e n t l y as d i d 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 . Based upon these f i n d i n g s , s e v e r a l i m p l i c a t i o n s f o r nu r s i n g p r a c t i c e and recommendations f o r f u r t h e r research were suggested. (Thesis Chairman) V Other t h i n g s being equal, the d i a b e t i c who knows the most w i l l l i v e the l o n g e s t . ( E l l i o t t P. J o s l i n ) v i TABLE OF CONTENTS Chapter I INTRODUCTION 1 S i g n i f i c a n c e of the Problem • • • . . 1 Statement of the Problem • 6 S p e c i f i c s of the Study 6 Hypothesis • • 6 V a r i a b l e s . 7 Basic Assumptions. . . . . . . . 7 L i m i t a t i o n 7 D e f i n i t i o n of Terms. . . . . . . 8 I I RESUME OF PRESENT KNOWLEDGE 9 Why Should the D i a b e t i c P a t i e n t be Taught? 10 What Should the D i a b e t i c P a t i e n t be Taught? 15 When Should the D i a b e t i c P a t i e n t be Taught? 19 Where Should the D i a b e t i c P a t i e n t be Taught? 20 Who Should Teach the D i a b e t i c P a t i e n t ? 21 How Should the D i a b e t i c P a t i e n t be Taught? 24 What v a r i a b l e s should be considered? 24 What d i a b e t i c t e a c h i n g a i d s are a v a i l a b l e ? . . . . . . . 28 What are the nature and success of c u r r e n t d i a b e t i c t e a c h i n g programmes?. . . . 3 3 I I I METHODOLOGY 40 The Tools 41 The Po p u l a t i o n and the S e t t i n g . . . . 43 The Procedure 44 IV FINDINGS **° Demographic and D i a b e t i c Character-i s t i c s of the Population . . . . ^8 v i i Age 49 Sex 49 M a r i t a l s t a t u s . • 49 Occupation . . . . . 49 Education. • • 53 Reason f o r current h o s p i t a l admission 53 Most recent previous h o s p i t a l admission . . . . . . . . . 53 Age at onset of diabetes . . . . 57 Duration o f diabetes . . . . . . 57 Type of c l i n i c a l c o n t r o l . . . . 57 Sources of Information on diabetes management . . . . 57 Scores Achieved on the Test of D i a b e t i c Learning 62 C o r r e l a t i o n s between Se 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 Subjects and t h e i r Respective Test Scores . . . . . . . . . . . * * 77 V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 86 Summary of the Findings . . . . . . . 87 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 87 Scores on the t e s t of d i a b e t i c l e a r n i n g 88 Other dimensions • • • • • • • • 89 Conclusions . . . . . . 89 I m p l i c a t i o n s 90 Recommendations f o r Further Study . . 93 SOURCES CONSULTED. . 95 APPENDIXES A MATERIALS PERTAINING TO THE RESUME OF PRESENT KNOWLEDGE . . 103 I n s t r u c t i o n of the P a t i e n t . . . . . . 104 Suggested Topics f o r D i a b e t i c Teaching . . . . . 106 Books f o r D i a b e t i c s . . 107 Pamphlets f o r D i a b e t i c s • 109 D i a b e t i c Day Care Centres . . . . . . 110 v i i i B A BASIC COURSE IN DIABETIC SELF-MANAGEMENT H I Objectives . . . . . . . . . . . . . 112 Content . . . . . . 115 S p e c i f i c a t i o n s f o r the Test of D i a b e t i c Learning. . . . . . . . 120 C DATA COLLECTION TOOLS. 121 P a t i e n t P r o f i l e Sheet 122 Test of D i a b e t i c Learning . . . . . . 124 D DIABETIC TEACHING TOOL 140 I n t r o d u c t i o n t o the D i a b e t i c Teaching Tool . . . . . . . . . 142 Contents of the Ea s e l Binder 144 Contents of the Ca r r y i n g Case • • • • 245 E REFERENCES MOST USEFUL IN DEVELOPING THE DIABETIC TEACHING TOOL 290 i x LIST OF TABLES Table Page I Comparison of C o n t r o l and Experimental P a t i e n t s by Age 5 0 I I Comparison of C o n t r o l and Experimental P a t i e n t s by Sex • . • • 5 1 I I I Comparison of C o n t r o l and Experimental P a t i e n t s by M a r i t a l S t a t u s , . 5 2 IV Comparison of C o n t r o l and Experimental P a t i e n t s by Education 5 ^ V Comparison of C o n t r o l and Experimental P a t i e n t s by Reason f o r Current Admission to H o s p i t a l • 5 5 VI Comparison of C o n t r o l and Experimental P a t i e n t s by Most Recent Previous H o s p i t a l Admission 5 6 V I I Comparison of C o n t r o l and Experimental P a t i e n t s by Age a t Onset of Diabetes. • • 5 8 V I I I Comparison of C o n t r o l and Experimental P a t i e n t s by Duration of Diabetes. . . . . 5 9 IX Comparison of C o n t r o l and Experimental P a t i e n t s by Type of D i a b e t i c C o n t r o l . . • 6 0 X Comparison of C o n t r o l and Experimental P i l l - u s e r s by Score on Knowledge Test • . 6 3 XI Comparison of C o n t r o l and Experimental I n s u l i n - u s e r s by Score on Knowledge Test 64-X I I Comparison of C o n t r o l and Experimental P a t i e n t s by Score on D i e t Planning S k i l l Test 6 5 X I I I Comparison of C o n t r o l and Experimental P a t i e n t s by Score on Urine T e s t i n g S k i l l Test 6 6 X XIV Comparison of C o n t r o l and Experimental I n s u l i n - u s e r s by Score on I n s u l i n I n j e c t i n g S k i l l Test 6 8 XV Comparison of C o n t r o l and Experimental P a t i e n t s by Score on Knowledge and S k i l l Tests regarding D i e t . . . . . . . . . . . 6 9 XVI Comparison of C o n t r o l and Experimental P a t i e n t s by Score on Knowledge and S k i l l Tests r e g a r d i n g Urine T e s t i n g . . . 7 1 XVII Comparison of C o n t r o l and Experimental I n s u l i n - u s e r s by Score on I n s u l i n Knowledge and S k i l l Tests . 7 2 X V I I I Comparison of C o n t r o l and Experimental P i l l - u s e r s by T o t a l Percentage Score on Test of D i a b e t i c Learning 7 3 XIX Comparison of C o n t r o l and Experimental I n s u l i n - u s e r s by T o t a l Percentage Score on Test of D i a b e t i c Learning 7 ^ XX Comparison of C o n t r o l and Experimental P a t i e n t s by T o t a l Percentage Score on Test of D i a b e t i c Learning • • • 7 6 XXI The R e l a t i o n s h i p between Age at T e s t i n g and T o t a l Percentage Score. • 7 8 XXII The R e l a t i o n s h i p between Education and T o t a l Percentage Score. • . • . , 8 0 X X I I I Comparison of T o t a l Percentage Scores of a l l P a t i e n t s by Reason f o r Current Admission t o H o s p i t a l 32 XXIV The R e l a t i o n s h i p between Age at Onset of Diabetes and T o t a l Percentage Score. • 8 3 XXV The R e l a t i o n s h i p between Duration of Diabetes and T o t a l Percentage Score . . . 8 5 x i ACKNOWLEDGMENTS The w r i t e r wishes t o extend s i n c e r e thanks t o the many people who made t h i s study p o s s i b l e i t o the Vancouver h e a l t h p r o f e s s i o n a l s who acted as co n s u l t a n t s t o the study f o r t h e i r time and i n t e r e s t ? t o Miles L a b o r a t o r i e s f o r t h e i r generous research g r a n t ; t o Kerry P r i e s t f o r the ima g i n a t i v e i l l u s t r a -t i o n s i n the D i a b e t i c Teaching Tool; t o K. Marion Smith and the n u r s i n g s t a f f of Surrey Memorial H o s p i t a l f o r t h e i r w i l l i n g p a r t i c i p a t i o n ; and e s p e c i a l l y t o Dr. Margaret A. Campbell and Mary Cruise f o r t h e i r many h e l p f u l suggestions and u n f a i l i n g support• CHAPTER I INTRODUCTION S igni f i cance of the Problem Diabetes i s a common c o n d i t i o n , and i n Canada i t a f fects an estimated 300,000 people? pos-s i b l y [an a d d i t i o n a l ] 300,000 are undiscovered . . . When found e a r l y , i t can be c o n t r o l l e d . . . When overlooked, diabetes can smolder, causing ser ious complications without the p a t i e n t ' s knowledge; that i s why everyone should l e a r n something about- the c o n d i t i o n , and why known d iabet ic s should l ea rn every- th ing about i t . 1 Throughout the wor ld , morbidity and morta l i ty s t a t i s t i c s ind ica te that the prevalence of diabetes m e l l i t u s 2 i s r i s i n g .3 A number of reasons have been suggested to expla in t h i s t rend . L i f e expectancy i n general i s inc rea s ing . Therefore more d iabet ic s are being diagnosed. Improvements i n medical care— not the l ea s t of which was the discovery of in su l in—not only have lengthened the l i f e s p a n of o lder d i a b e t i c s , but a lso have allowed younger d iabet ic s to marry and bear c h i l d r e n , thus increas ing the number of infants with an i n h e r i t e d predispo-s i t i o n to the disease. Moreover, obes i ty , an important f ac tor "Manual for Diabet ics i n Canada" (Toronto i The Canadian Diabet ic As soc i a t ion , 1970), 7. Hereafter , the word 'd iabetes ' w i l l connote 'd iabetes m e l l i t u s ' and not 'diabetes i n s i p i d u s ' . 3 Paul S. Entmacher and Herbert H. Marks, "Diabetes i n 1964» A World Survey," Diabetes, XIV, No. 4 ( A p r i l 1965), 212. 2 a s s o c i a t e d w i t h d i a b e t e s , i s a l s o i n c r e a s i n g . In a d d i t i o n , the r e p o r t e d r e l a t i o n s h i p s between diabetes and other e t i o l o -g i c a l v a r i a b l e s have l e d to e a r l i e r d e t e c t i o n of many cases.^ Whatever the causes, the r e s u l t i s a s i t u a t i o n which i s urgent. Success i n the treatment of diabetes today depends to a l a r g e degree on the i n s t r u c t i o n of the p a t i e n t i n the management of the d i s o r d e r under the c o n d i t i o n s o f h i s home l i f e , h i s work and h i s other a c t i v i t i e s . 5 At the same time, there has emerged a tre n d t o centre r e s p o n s i b i l i t y f o r t h a t i n s t r u c t i o n w i t h the p a t i e n t r a t h e r than w i t h h i s doctor or nurse. This t r e n d i s evidenced by such statements a s i MHe, h i m s e l f , w i l l be the h e l m s m a n " " I t ' s up t o you"?? and, "The f u t u r e i s i n your h a n d s . T h e u l t i m a t e message con-t a i n e d i n these statements i s unquestionably v a l i d . In the f i n a l a n a l y s i s i t i s the p a t i e n t h i m s e l f who w i l l make or break h i s treatment regime. However, the onus on h e a l t h p r o f e s s i o n a l s to make a comprehensive job of h e a l t h t e a c h i n g i s nonetheless profound. That they have been l e s s than suc-c e s s f u l i n t h i s endeavour t o date i s i l l u s t r a t e d by such Max E l l e n b e r g and Harold R i f k i n , Diabetes Mellitus» Theory and P r a c t i c e (Toronto i McGraw H i l l , 1970), p. 590. ^ E d i t o r i a l , . "Teaching D i a b e t i c S e l f - C a r e , " New England  J o u r n a l of Medicine. CCLXXVI (January 1967)i 18X ° G a r f i e l d George Duncan, Diabetes M e l l i t u s i P r i n c i p l e s and  Treatment ( P h i l a d e l p h i a i W. B. Saunders Co., 1951)» P» 103. ? G e t t i n g S t a r t e d (Rutherford, New J e r s e y i Becton-Dickinson Company, n.d.), 5» ® "A Guide f o r the Canadian D i a b e t i c on Oral Therapy" (Toronto i E l i L i l l y and Company (Canada) L t d . , n.d.), 4-. 3 observations as those noted i n the next paragraph. A p u b l i c h e a l t h nurse i n Toronto described the f o l l o w i n g two cases of inadequate p a t i e n t knowledge regarding i n s u l i n i n j e c t i o n s ! 1. A p a t i e n t was i n j e c t i n g her i n s u l i n i n t o an orange each day, and e a t i n g the orange. 2. Another p a t i e n t was d r i v i n g h i s needle through the metal p r o t e c t o r on h i s i n s u l i n b o t t l e when p r e p a r i n g h i s i n -j e c t i o n s . Both of these p a t i e n t s had r e c e n t l y been discharged from a h o s p i t a l which had a d i a b e t i c t e a c h i n g programme.9 Stone reporte d t h a t s i x t y - t w o per cent of 160 d i a b e t i c p a t i e n t s s t u d i e d t o determine the degree of c o n t r o l and the f a c t o r s i n f l u e n c i n g t h i s were p o o r l y r e g u l a t e d . The most common cause f o r poor c o n t r o l was f a i l u r e t o adhere t o d i e t . Many p a t i e n t s f a i l e d to f o l l o w t h e i r d i e t s simply because they d i d not understand them. Forty per cent of these p a t i e n t s were able t o achieve good c o n t r o l a f t e r f u r t h e r instruction.^° S i m i l a r f i n d i n g s were report e d by E t z w i l e r . ^ Some more recent s t u d i e s seem t o c o n t r a d i c t the above f i n d i n g s by showing an in v e r s e r e l a t i o n s h i p between d i a b e t i c 9 Anecdotes recounted by a p u b l i c h e a l t h nurse to a group of student nurses. 1 0 D a n i e l B. Stone, MA Study of the Incidence and Causes o f Poor. C o n t r o l i n P a t i e n t s w i t h Diabetes M e l l i t u s , " American  J o u r n a l of Medical Science, CCXLI ( J u l y 1961), ^38", 1 1 Donnell D. E t z w i l e r , "Who's Teaching the D i a b e t i c ? " Diabetes, XVI, No. 2 (February 1967). 111-117. 4 knowledge and c o n t r o l . 1 2 » ! 3 t 1 4 Such s t u d i e s are i n i t i a l l y d i s c o u r a g i n g , and h e a l t h p r o f e s s i o n a l s are tempted t o ask •Why bother?' Some answers t o t h i s q u e stion are suggested by these same authors t B i o l o g i c a l f a c t o r s , s t i l l i n s u f f i c i e n t l y under-stood, are probably of great importance i n determining c o n t r o l . - 0 Although we now t h i n k t h a t f a c t o r s other than •what they know' and 'what they do' may be important i n c o n t r o l l i n g the di s e a s e , we s t i l l t h i n k t h a t i t i s important f o r the p a t i e n t t o apply a l l a v a i l a b l e knowledge i n the management of h i s d i s e a s e . 1 6 The c r i t i c a l i m p l i c a t i o n of these f i n d i n g s i s t h a t to know the f a c t s about diabetes i s not i n i t s e l f the alpha and omega of diabetes p a t i e n t education • • . the ed u c a t i o n a l needs of these p a t i e n t s extend beyond the p o i n t of merely possessing f a c t s . An educated p a t i e n t . . . i s one who i s able t o make the r i g h t d e c i s i o n s on the b a s i s of the f a c t s and i s motivated from w i t h i n to s t r i v e toward the best p o s s i b l e use of the f a c t s he po s s e s s e s . 1 ' The problem, then, becomes l e s s one of 'should we teach?' and more one o f 'how can we b e t t e r our teaching?' Krysan has Edward V. E l l i s , "A Comparative A n a l y s i s of Good, Poor and Very Poor C o n t r o l i n D i a b e t i c P a t i e n t s as a Basis f o r Deter-mining E d u c a t i o n a l Needs" (unpublished Doctoral d i s s e r t a t i o n , U n i v e r s i t y of North C a r o l i n a at Chapel H i l l , 1 9 6 4 ) . J u l i a D. Watkins, "A Study of D i a b e t i c P a t i e n t s at Home," American J o u r n a l of P u b l i c H e a l t h , L V I I , No. 3 (March 1 9 6 7 ) i 452 - 459 . ^ T. F r a n k l i n W i l l i a m s 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 D i a 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 1 9 6 5 ) t 4 6 9 . 1 5 I b i d * 1 6 Watkins, " D i a b e t i c P a t i e n t s at Home," 4 5 3 . 1 ^ E l l i s , " C o n t r o l as a Basis f o r Ed u c a t i o n a l Needs," 215-216. 5 s t a t e d i t t h i s way i "How can we improve and extend the t r a i n i n g programs o f such great numbers of p a t i e n t s I n p a r t i a l response t o t h i s q u e s t i o n , Krysan i d e n t i f i e d the f o l l o w i n g s t a r t i n g p l a c e i F i r s t we must decide what tea c h i n g s e r v i c e s we can provide t o persons w i t h d i a b e t e s . G e n e r a l l y these s e r v i c e s f a l l i n t o f o u r categories» assess-ment and c o u n s e l l i n g ; teaching self-care» C 0"*, Q o r d i n a t i n g community s e r v i c e s } and f o l l o w up.l° Of these f o u r , the one most c l e a r l y w i t h i n the realm of nu r s i n g i s the te a c h i n g o f s e l f care. While i t i s t r u e t h a t a number o f d i a b e t i c treatment centres are c u r r e n t l y e x p e r i -menting w i t h having the nurse assume a key r o l e i n the assess-ment, c o u n s e l l i n g and follow-up of p a t i e n t s , w» t A » such programmes are the exception r a t h e r than the r u l e . S i m i l a r l y , w h i l e some nurses might be capable of assuming r e s p o n s i b i l i t y f o r c o - o r d i n a t i n g community s e r v i c e s f o r d i a b e t i c s , most would not. Regardless of whether o r not the nurse expands her func-t i o n s t o i n c l u d e assessment, c o u n s e l l i n g , c o - o r d i n a t i o n and follow-up of d i a b e t i c p a t i e n t s , she w i l l almost c e r t a i n l y r e t a i n a primary r o l e i n t h e i r i n i t i a l and ongoing h e a l t h 1 8 Germaine S. Krysan, "How do We Teach Four M i l l i o n D i a b e t i c s ? * American J o u r n a l of Nursing, LXV, No. 11 (November 1965). 105. 19 I b i d . 2 0 D i a b e t i c Day Care Centre, Lions Gate H o s p i t a l , North Van-couver, B. C. 2 1 D i a b e t i c C l i n i c , McMaster U n i v e r s i t y Health Sciences Com-p l e x , Hamilton, Ont. 2 2 J u d i t h D. Jordan and Joseph C. Shipp, "The Primary Health Care P r o f e s s i o n a l was a Nurse," American Journal of Nursing, LXXI, No. 5 (May 1971). 922-925. 6 t e a c h i n g . For t h i s reason, i t was decided to concentrate t h i s study on "teaching s e l f - c a r e , " and t o attempt t o devise one method by which nurses could provide t h a t s e r v i c e t o d i a b e t i c persons. Statement of the Problem The purpose of t h i s study was t o answer the q u e s t i o n , • W i l l d i a b e t i c p a t i e n t s taught by means of a " D i a b e t i c Teach-i n g T o o l " demonstrate a higher l e v e l of l e a r n i n g about s e l f -care than p a t i e n t s taught i n the i n s t i t u t i o n ' s u s u a l manner?' The answer to the que s t i o n was sought by comparing the s e l f -care knowledge and s k i l l s of two groups of d i a b e t i c p a t i e n t s . One group, the c o n t r o l group, r e c e i v e d whatever teaching the i n s t i t u t i o n normally provided. The second group, the e x p e r i -mental group, was taught by means of a " D i a b e t i c Teaching T o o l " which was designed by the author and administered by each p a t i e n t ' s own n u r s e ( s ) . A f t e r d i s c h a r g e , each p a t i e n t was asked t o respond t o a number of questions and t o perform s e v e r a l s k i l l s designed t o evaluate h i s l e a r n i n g r egarding s e l f care. S p e c i f i c s of the Study Hypothesis The hypothesis of t h i s study was as f o l l o w s i '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 of p a t i e n t s i n the experimental group as compared w i t h p a t i e n t s i n the c o n t r o l group.• 7 V a r i a b l e s The independent v a r i a b l e i n t h i s study was the " D i a b e t i c Teaching T o o l " , which was u t i l i z e d by each p a t i e n t ' s own nurse or nurses, to teach him about s e l f - c a r e . The dependent v a r i a b l e , which was measured by a t e s t of knowledge and s k i l l , was the p a t i e n t ' s l e a r n i n g about h i s s e l f -c a r e . Basic Assumptions This study r e s t e d on two b a s i c assumptions. The f i r s t o f t h e s e — t h a t d i a b e t i c p a t i e n t s r e q u i r e s p e c i a l l e a r n i n g t o manage t h e i r s e l f - c a r e at home—was introduced i n the d i s c u s s i o n of the s i g n i f i c a n c e of the problem. I t has been f u r t h e r documented i n the resume of present knowledge (Chapter I I ) under the heading •Why Should the D i a b e t i c P a t i e n t be Taught?' The second assump-t i o n — t h a t nurses have a r o l e i n the teac h i n g of d i a b e t i c pa-t i e n t s — w a s based on the f a c t t h a t most, i f not a l l , n u r s i n g educators i n c l u d e the f u n c t i o n of h e a l t h t e a c h i n g as p a r t of the n u r s i n g r o l e . L i m i t a t i o n Because the " D i a b e t i c Teaching T o o l " and i t s use i n t h i s study does not take i n t o c o n s i d e r a t i o n many of the v a r i a b l e s which predispose d i f f e r e n t p a t i e n t s t o respond i n d i f f e r e n t ways.to d i f f e r e n t nurses on d i f f e r e n t occasions, c a u t i o n must be used i n g e n e r a l i z i n g r e s u l t s of t h i s study t o other s e t t i n g s . See d i s c u s s i o n of l e a r n e r , teacher and environmental v a r i a b l e s , Chapter I I . 8 D e f i n i t i o n of Terms D i a b e t i c Teaching T o o l i r e f e r s t o t h a t t o o l designed by the rese a r c h e r and i n c l u d e d i n Appendix D of t h i s study. P a t i e n t l e a r n i n g ! r e f e r s t o the score achieved by the p a t i e n t on the t e s t found i n Appendix C of t h i s study. Graduate n u r s e i r e f e r s t o any nurse who has been em-ployed as a graduate by the i n s t i t u t i o n through which t h i s study was conducted. D i a b e t i c p a t i e n t i r e f e r s t o any p a t i e n t who has a p r i -mary or secondary d i a g n o s i s of diabetes m e l l i t u s . S e l f - c a r e t r e f e r s t o the knowledge and s k i l l s which a d i a b e t i c p a t i e n t must have t o 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 day-to-day b a s i s . Unplanned i n s t r u c t i o n t r e f e r s t o t e a c h i n g which a gi v e n graduate nurse may or may not deem p e r t i n e n t t o a g i v e n d i a b e t i c p a t i e n t . The d e c i s i o n as t o the appropriateness and content of unplanned i n s t r u c t i o n r e s t s w i t h t h i s nurse. 9 CHAPTER I I RESUME OF PRESENT KNOWLEDGE Because l i t e r a t u r e p e r t a i n i n g to the many f a c e t s of diabetes and p a t i e n t t e a c h i n g i s so abundant, the author has e l e c t e d t o present t h i s i n f o r m a t i o n i n the f o l l o w i n g manner i 1. That l i t e r a t u r e which forms the framework upon which the present study i s b u i l t i s reviewed i n the main t e x t of the t h e s i s . This i n f o r m a t i o n i s organized i n response to the questions (a) Why should the d i a b e t i c p a t i e n t be taught? (b) What should the d i a b e t i c p a t i e n t be taught? (c) When should the d i a b e t i c p a t i e n t be taught? (d) Where should the d i a b e t i c p a t i e n t be taught? (e) Who should teach the d i a b e t i c p a t i e n t ? ( f ) How should the d i a b e t i c p a t i e n t be taught? 2. That l i t e r a t u r e which was u t i l i z e d i n s e l e c t i n g and o r g a n i z i n g the content of the " D i a b e t i c Teaching T o o l " i s c r e d i t e d i n a separate b i b l i o g r a p h y . (The t o o l and i t s s e l e c t e d b i b l i o g r a p h y may be found i n Appendix D and Appen-d i x E r e s p e c t i v e l y . ) 10 Why Should the D i a b e t i c P a t i e n t be Taught? Other t h i n g s being equal, the d i a b e t i c who knows the most w i l l l i v e the l o n g e s t . 1 The above q u o t a t i o n was c h a r a c t e r i s t i c of the teachings of E l l i o t t P. J o s l i n , a world l e a d e r i n the treatment of diabetes f o r some 60 years. Throughout h i s w r i t i n g s . Dr. J o s l i n * 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, i f the d i a b e t i c i n d i v i d u a l " s t u d i e s the disease and becomes master of h i s f a t e " 2 he w i l l l i v e a lo n g and happy l i f e . Dr. J o s l i n advocated a r a t h e r s t r i c t (by current standards) regime f o r h i s d i a b e t i c p a t i e n t s , and maintained f i r m l y t h a t t h i s regime, i n combination w i t h extensive p a t i e n t education, would l e a d t o good c o n t r o l and absence of com-p l i c a t i o n s . 3 The study by Stone** i n 1961 gave experimental credence to Dr. J o s l i n ' s b e l i e f s . Stone s t u d i e d 160 p a t i e n t s w i t h diabetes i n an attempt t o determine the degree of t h e i r A Quoted i n the preface t o John W i l l i a m C a l d w e l l , Under- stand Your Diabetes (Toronto t Oxford U n i v e r s i t y Press, 1 9 4 - 9 ) . 2 E l l i o t t P. J o s l i n , D i a b e t i c Manual ( P h i l a d e l p h i a ! Lea and Febiger, 1 9 5 9 ) , p r e f a c e . 3 I f t i d . D a n i e l B. Stone, "A Study of the Incidence and Causes of Poor C o n t r o l i n P a t i e n t s w i t h Diabetes M e l l i t u s , " American  Jo u r n a l of Medical Science, CCXLI ( J u l y 1 9 6 1 ) , 4 3 9 . c o n t r o l and the f a c t o r s i n f l u e n c i n g t h i s c o n t r o l . 5 He concluded from h i s r e s e a r c h t h a t poor c o n t r o l could not be a s c r i b e d t o i n h e r e n t l y "•unstable" d i a b e t e s , but was a f u n c t i o n of a v a r i e t y of f a c t o r s i n c l u d i n g s o c i a l d i f f i -c u l t i e s , emotional problems, r e f u s a l t o attempt r e g u l a t i o n , and—most s i g n i f i c a n t — f a i l u r e t o adhere to d i e t due t o inadequate knowledge t h e r e o f . Reassessment, f o l l o w e d by a p p r o p r i a t e i n s t r u c t i o n s and treatment, brought about the f o l l o w i n g a l t e r a t i o n i n degree of c o n t r o l i Before .. I n t e r v e n t i o n 22-28 months a f t e r Intervention- -Good C o n t r o l 21# 53% F a i r C o n t r o l 1795 11?5 Poor- C o n t r o l 62% 36% More recent s t u d i e s have, however, r e s u l t e d i n con-f l i c t i n g f i n d i n g s . Perhaps the most c o n t r o v e r s i a l o f these was a d e s c r i p t i o n of "The C l i n i c a l P i c t u r e of D i a b e t i c C o n t r o l 5 Degree of c o n t r o l i n t h i s and other s i m i l a r s t u d i e s i s determined by (a) d e v i a t i o n of the p a t i e n t ' s weight from h i s o p t imal l e v e l i (b) frequency of blood sugar l e v e l s above normal? (c) frequency of u r i n e sugar l e v e l s g r e a t e r than l%t and (d) frequency of episodes of d i a b e t i c a c i d o s i s . G e n e r a l l y speaking, the lower the i n c i d e n c e o f these f o u r f a c t o r s , the b e t t e r the c o n t r o l . 1 2 Studied i n Four S e t t i n g s " "by Willi a m s and M a r t i n . 6 A t o t a l o f 2 1 3 p a t i e n t s were i n t e r v i e w e d , t h e i r medical records examined and t h e i r degree of c o n t r o l judged by o b j e c t i v e c r i t e r i a . O v e r a l l , twenty-nine per cent of the s u b j e c t s were i n acceptable c o n t r o l , seventy-one per cent i n l e s s than acceptable c o n t r o l . S i g n i f i c a n t c o r r e l a t i o n s w i t h poor con-t r o l i n c l u d e d ! e a r l y age at onset, h i g h knowledge about d i a b e t e s , l a r g e household s i z e , and presence of major s o c i a l problems. S i g n i f i c a n t c o r r e l a t i o n s w i t h fiqqd c o n t r o l i n -cluded 1 p a t i e n t preference f o r a s t r i c t versus a l e n i e n t p h y s i c i a n , and s a t i s f a c t i o n of the p a t i e n t w i t h h i s p h y s i c i a n , of whatever type. From these data, the authors concluded t h a t " l a c k of knowledge about diabetes i s i n f r e q u e n t l y the cause of poor c o n t r o l . About the same time, i n a study conducted i n two meta-b o l i c c l i n i c s , E l l i s found a s i m i l a r p a t t e r n . The view h e l d by some t h a t a l l the d i a b e t i c needs are the f a c t s about diabetes and tha t t h i s w i l l l e a d t o good c o n t r o l was not s u b s t a n t i a t e d by the f i n d i n g s o f t h i s study • • . [among the p a t i e n t s evaluated] there was an i n v e r s e r e l a t i o n s h i p between knowledge about diabetes and l e v e l of diabetes c o n t r o l . 8 ° T o F r a n k l i n W i l l i a m s 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 D i a 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)t 469. 7 rbifl* 3 Edward V. E l l i s , "A Comparative A n a l y s i s of Good, Poor and Very Poor C o n t r o l D i a b e t i c P a t i e n t s as a Basis f o r Determining T h e i r E d u c a t i o n a l Needs," (unpublished Doctoral d i s s e r t a t i o n , U n i v e r s i t y of North C a r o l i n a at Chapel H i l l , 1 9 6 4 ) , 2 1 3 . 13 E l l i s d i s c usses t h i s r e s u l t at some l e n g t h , and cautions the reader t h a t Because poor and very poor c o n t r o l p a t i e n t s knew more about diabetes than good c o n t r o l p a t i e n t s , i t does not n e c e s s a r i l y mean t h a t a l i t t l e knowledge i s a dangerous t h i n g . The f i n d i n g s imply t h a t the ed u c a t i o n a l approach to the p a t i e n t s . . . should be i n terms not only of a c q u i r i n g f a c t s but a l s o deve-l o p i n g s k i l l e d or i n t e l l i g e n t a c t i o n or behaviour . 9 Both s i d e s of the c o i n have been examined. Whether o r 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 between knowledge about diabetes and c l i n i c a l c o n t r o l o f the disease i s s t i l l a matter o f debate. Whatever the u l t i m a t e t r u t h of t h i s d i s -c u s s i o n , knowledge appears t o be r e l e v a n t t o e f f e c t i v e manage-ment o f s e l f - c a r e at home. This was d r a m a t i c a l l y i l l u s t r a t e d i n a study by W a t k i n s , 1 0 i n which s i x t y p a t i e n t s were r a t e d on management of i n s u l i n , u r i n e t e s t s , d i e t and f o o t care. F o r t y - e i g h t o f these p a t i e n t s had "unacceptable" p r a c t i c e i n a d m i n i s t e r i n g i n s u l i n ? t h i r t y - o n e made e r r o r s i n i n s u l i n dosage; twenty-seven used u r i n e t e s t s i n a way which would probably a f f e c t c o n t r o l a d v e r s e l y ; f o r t y - f o u r had meals and spacing of meals unacceptable f o r d i a b e t i c s ; t h i r t y - o n e c a r r i e d out poor f o o t care. In g e n e r a l , those who knew more managed b e t t e r . Watkins* study stands as a challenge t o a l l h e a l t h p r o f e s s i o n a l s concerned w i t h h e a l t h t e a c h i n g . 9 Ibid".. 2 1 5 . 1 0 J u l i a D. Watkins, "A Study of D i a b e t i c P a t i e n t s a t Home," American J o u r n a l of P u b l i c H e a l t h , L V I I , No. 3 (March 1967)1 14 In 1962 the American Diabetes A s s o c i a t i o n announced i t s stand on p a t i e n t h e a l t h t e a c h i n g i n t h i s statement 1 Because of i t s prevalence and c h r o n i c i t y , diabetes m e l l i t u s should be the c o n t i n u i n g concern of a l l p h y s i c i a n s , r e g a r d l e s s of t h e i r types of p r a c t i c e . An e s s e n t i a l p a r t of t r e a t i n g the c o n d i t i o n i s tea c h i n g the p a t i e n t how t o l i v e w i t h i t . As i n any ed u c a t i o n a l program, a systematic ap-proach should be used. Each p h y s i c i a n should have c e r t a i n s p e c i f i c o b j e c t i v e s c l e a r l y i n mind as he teaches h i s d i a b e t i c p a t i e n t s . To a i d him, the American Diabetes A s s o c i a t i o n has prepared . . . a check l i s t of 9 elements o f treatment, which c o n s t i t u t e s a minimum program f o r diabetes management.H Su r e l y these admonitions have as much relevance f o r nurses as they have f o r p h y s i c i a n s ! _. In c o n c l u s i o n , t o the q u e s t i o n , 'Why teach the d i a b e t i c p a t i e n t ? ' - the r e p l y i s t h i s t S u c c e s s f u l management of a ch r o n i c d i s o r d e r depends not only on the treatment p r e s c r i b e d by the p h y s i -c i a n , but a l s o on the i n s t r u c t i o n g iven the p a t i e n t t o enable him t o f o l l o w d i r e c t i o n s and t o prepare him to meet changing c o n d i t i o n s , i n c l u d i n g p o s s i b l e emergencies. Education o f the p a t i e n t w i t h diabetes can be v i t a l l y important t i t not only can ensure success i n r e s t o r i n g and m a i n t a i n i n g h i s h e a l t h but a l s o may be the means of savi n g h i s l i f e . - 1 - 2 George J . Hamwi,.. " S p e c i a l Announcement 1 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. 1 2 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 , " New England J o u r n a l of Medicine, CCLXVIII (January 10, 1963), 93. What Should the D i a b e t i c P a t i e n t be Taught? 15 P r i o r t o the American Diabetes A s s o c i a t i o n statement i n 1962, which o u t l i n e d a minimum c u r r i c u l u m f o r diabetes p a t i e n t education,^3 very l i t t l e i n the way of concrete g u i d e - l i n e s f o r the h e a l t h educator had been w r i t t e n . C e r t a i n l y , the importance of te a c h i n g was recognized, but what (of the l i m i t -l e s s knowledge of dia b e t e s ) t o teach , was l e f t p r e t t y much t o the d i s c r e t i o n of the i n d i v i d u a l p h y s i c i a n or nurse. One notab l e exception t o t h i s was the s e c t i o n i n Duncan's t e x t o f diabetes e n t i t l e d , " I n s t r u c t i o n of the P a t i e n t . " l i f By v i r t u e of t h e i r i n c l u s i o n i n v a r i o u s t e x t s f o r d i a -b e t i c s , a wide range of t o p i c s has been suggested as appro-p r i a t e and/or necessary f o r d i a b e t i c l e a r n i n g . The v a r i e t y of t e x t s a v a i l a b l e (both from the p o i n t o f content, and t h a t of r e a d i n g - l e v e l d i f f i c u l t y ) has provided d i r e c t i o n f o r many p a t i e n t s over the yea r s . However, i t has l e f t the h e a l t h educator confused as t o where t o begin and how f a r to go. The American Diabetes A s s o c i a t i o n statement provided d i r e c t i o n i n t h i s matter, by pr e p a r i n g the f o l l o w i n g c h e c k l i s t of nine elements of treatment which c o n s t i t u t e a J Hamwi, "Announcement," 1064. G a r f i e l d George Duncan, Diabetes M e l l i t u s t P r i n c i p l e s and  Treatment ( P h i l a d e l p h i a 1 W. B. Saunders Co», 1951 )i PP» 170-171. A copy of t h i s proposed t e a c h i n g o u t l i n e may be found i n Appendix A of t h i s study. ^-5 These t o p i c s have been summarized i n a t a b l e i n Appendix A of t h i s study. 16 minimum programme f o r diabetes t e a c h i n g i 1 ^ 1. D i e t . 2. Urine t e s t i n g . 3. A c t i o n of i n s u l i n and other hypoglycemic agents. 4. Technique of i n s u l i n i n j e c t i o n and s i t e s f o r i t . 5. Care of syr i n g e and of i n s u l i n . 6. Symptoms of hypoglycemia. 7. Symptoms of u n c o n t r o l l e d d i a b e t e s . 8. Care of the f e e t . 9. What to do i n case of acute c o m p l i c a t i o n s . S h o r t l y a f t e r t h i s statement was p u b l i s h e d , and i n d i r e c t r eference to i t , A l l a n w r o t e i The p h y s i c i a n who intends t o make h i s i n s t r u c t i o n thorough should see tha t the p a t i e n t has learne d about each of these nine p o i n t s r e l a t i n g t o t h e r a -p e u t i c measures, techniques of treatment, symptoms r e s u l t i n g from n e g l e c t of treatment and from over-treatment, p r o p h y l a c t i c precautions and emergencies. 1 7 He f o l l o w e d t h i s admonition w i t h a c l e a r , yet b r i e f , d i s c u s s i o n of what might be covered under each of those nine headings. Krysan touched on very s i m i l a r p o i n t s i n an a r t i c l e de-signed t o guide the nurse i n choosing 'what' t o t e a c h . ^ The main areas she emphasized were i d i e t , medication, exer-c i s e and t h e i r i n t e r r e l a t i o n s h i p s , u r i n e t e s t i n g , hypo- and hyper-glycemia, and hygiene. So f a r 'what t o teach' has been presented from the stand-p o i n t of h e a l t h p r o f e s s i o n a l s . How do the p a t i e n t s f e e l about ^ Hamwi, "Announcement," 1064. 1 7 A l l a n , "Education," 94. 1 g Germaine S. Krysan, "How do We Teach Four M i l l i o n D i a -b e t i c s ? " American J o u r n a l of Nursing, LXV, No. 11 (November 1965), 105-107. 17 t h i s ? E l l i s asked p r e c i s e l y t h i s question i n "A Comparative Analysis of Good, Poor and Very Poor Control Diabetic Patients as a Basis f o r Determining Educational Needs." In order to assess whether or not there was agreement between diabetic patients and health a u t h o r i t i e s on content areas that should be included i n patient education, E l l i s asked his subjects to check which of twelve given items they f e l t were important for them to know i n order to control t h e i r d i a b e t e s . ^ The seven content areas generally considered to be ess e n t i a l to good management, i n contrast to the other f i v e which were not f e l t to be as important, are indicated by a s t e r i s k s i * 1. When i t i s important to see the doctor. 2. Effect of glands on diabetes. * 3» How to measure and give i n s u l i n . 4. Kinds of people most l i k e l y to get diabetes. * 5» How to take care of feet. 6. H i s t o r i c a l facts about diabetes. 7« The hereditary nature of diabetes. * 8. How to recognize and avoid i n s u l i n reactions. * 9» When and how to test urine f o r sugar. *10. Kinds of foods to eat and not to eat. 11. Community agencies to help d i a b e t i c s . *12. How to balance exercise and a c t i v i t y with i n s u l i n . Thus i t i s apparent that there i s f a i r l y high agreement on topics of s i g n i f i c a n c e . But what about the weighting of these items? Watkins and Moss 2 0 attacked t h i s question by attempting to i d e n t i f y those areas of management that patients f i n d most confusing. y E l l i s , "Control as a Basis f o r Educational Needs," 150. 20 J u l i a D. Watkins and Fay T. Moss, "Confusion i n the Manage-ment of Diabetes," American Journal of Nursing, LXIX, No. 3 (March 1969), 521-525T 18 They reporte d the f o l l o w i n g sources of c o n f u s i o n i 1. I n s u l i n A d m i n i s t r a t i o n i the v a r i e t y of sy r i n g e s and i n s u l i n s a v a i l a b l e ; the s t e r i l i z a t i o n process. 2. Urine T e s t i n g i which specimen i s t o be t e s t e d ; how t o use the p r e s c r i b e d t e s t ; how t o read the t e s t . 3« D i e t i c o n v e r t i n g a meal p l a n i n t o day-to-day e a t i n g h a b i t s ; exchange l i s t s . I t would seem reasonable, t h e r e f o r e , t o weight these t h r e e items more h e a v i l y than others i n both the plan n i n g and execu-t i o n of p a t i e n t t e a c h i n g . B r i e f l y , then, one might answer the question 'What should the d i a b e t i c p a t i e n t by taught?* by s t a t i n g t h a t a minimal b a s i c course should be constructed around the nine elements o u t l i n e d by the American Diabetes A s s o c i a t i o n . Serious con-s i d e r a t i o n should be gi v e n t o two a d d i t i o n a l items which d i a -b e t i c p a t i e n t s have i n d i c a t e d are important t 1. When i t i s important t o see the doctor or other h e a l t h p r o f e s s i o n a l ; and 2. How to balance e x e r c i s e and a c t i v i t y w i t h i n s u l i n . Weighting o f the programme should be such t h a t p r i n c i p l e s of i n s u l i n a d m i n i s t r a t i o n , u r i n e t e s t i n g and d i e t r e c e i v e s u f f i -c i e n t a t t e n t i o n t o minimize confusion i n t h e i r a p p l i c a t i o n . When Should the D i a b e t i c P a t i e n t be Taught? 19 Much has been w r i t t e n on the importance of beginning d i a b e t i c t e a c h i n g at the e a r l i e s t o p p o r t u n i t y . Hamwi s t a t e d i The optimum time f o r the education of the p a t i e n t i n r e l a t i o n t o a c h r o n i c i l l n e s s , such as diabetes m e l l i t u s , i s when i t i s o r i g i n a l l y diagnosed. At t h i s time the p a t i e n t w i l l be f a r more r e c e p t i v e than i f the same i n f o r m a t i o n i s presented t o him a f t e r s e v e r a l years, d u r i n g which p e r i o d he has been uninformed about many of the b a s i c p r i n c i p l e s of c o n t r o l . 2 ! A l l a n 2 2 and R i c k e t t s 2 ^ both supported Hamwi*s stand. As commendable as these d i r e c t i v e s are, i n i t i a l t e a c h i n g i s not enough. The d i a b e t i c p a t i e n t i s s t r u g g l i n g d a i l y w i t h an u n n a t u r a l regimen of p r e s c r i b e d meals, hypodermic needles, u r i n e t e s t s , and a l l of the other r e s t r i c t i o n s i m p l i e d by h i s d i s e a s e . The tendency to grow c a r e l e s s and take l i b e r t i e s i n c r e a s e s as time goes on.2** This was c l e a r l y i l l u s t r a t e d i n Watkins 1 study of d i a b e t i c p a t i e n t s at home i n which she found the longer p a t i e n t s had had t h e i r d i s e a s e , the more i n s u l i n e r r o r s they made. 2^ 2 1 Hamwi, "Announcement, M 1064. 2 2 A l l a n , "Education," 95. 2 3 Henry T. R i c k e t t s , Diabetes M e l l i t u s i Objectives and  Methods of Treatment ( S p r i n g f i e l d t C. C. Thomas, 1955)» PP« 21-22. 2 4 I b i d . . p. 42. 2 5 Watkins, " D i a b e t i c P a t i e n t s at Home," 4-58. 20 S i m i l a r f i n d i n g s r e s u l t e d from a survey, conducted by the Diabetes Program of the New Jersey State Health Depart-ment, of the e d u c a t i o n a l needs of d i a b e t i c s . Reports were submitted by p u b l i c h e a l t h nurses from twenty-seven agencies. The nurses r e p o r t e d t h a t i n o n e - t h i r d of the cases, t h e i r s had been the f i r s t i n s t r u c t i o n which the p a t i e n t s had r e c e i v e d . Moreover, of the tw o - t h i r d s who had had previous t e a c h i n g , a d i s t r e s s i n g l y h i g h percentage had f o r g o t t e n or had not under-stood c l e a r l y , and r e q u i r e d r e t r a i n i n g . 2 ^ This study c l e a r l y p o i n t e d up the need f o r an on-going programme of f o l l o w - u p , reassessment, and c o n t i n u i n g education. E t z w i l e r has summarized t h i s problem i A l l too f r e q u e n t l y p a t i e n t education i s regarded as the i n - p a t i e n t t r a i n i n g provided during the i n i t i a l h o s p i t a l i z a t i o n . During t h i s admission the p a t i e n t and h i s f a m i l y may be so overwrought by the di s c o v e r y of t h i s c h r o n i c disease t h a t they may comprehend very l i t t l e i n the t e a c h i n g s e s s i o n s . Older a d u l t s may have d i f f i c u l t y understanding the nature of t h e i r disease and, once l e a r n e d , many q u i c k l y f o r g e t . Thus d i a b e t i c education must not be considered a one-shot program c a r r i e d out i n the h o s p i t a l . I t must be a continued review and te a c h i n g program • • • ' Where Should the D i a b e t i c P a t i e n t be Taught? I f , as the above s t u d i e s i n d i c a t e , i n - h o s p i t a l t e a c h i n g i s f a l l i n g s hort of meeting d i a b e t i c p a t i e n t s * l e a r n i n g needs, c o Arthur Krosnick and Edward T. H a r r i s , "There Must be Follow-Up," P u b l i c Health News (New J e r s e y ) , X L I I I (November 1 9 6 2 ) , 3 4 8 - 3 5 0 . .„..?7. Donnell D. E t z w i l e r , "Who's Teaching the D i a b e t i c ? " Diabetes. XVI, No. 2 (February 1 9 6 7 ) . 117 . where should t h i s i n s t r u c t i o n take p l a c e ? The answer to t h i s q u e s t i o n seems to be, 'wherever i t can be arranged.* 28 Krysan has suggested t h a t nurses may be i n v o l v e d i n d i a -b e t i c i n s t r u c t i o n i n any of the f o l l o w i n g s e t t i n g s i h o s p i t a l , n u r s i n g home, c l i n i c , p h y s i c i a n ' s o f f i c e , s c h o o l , i n d u s t r y and/or p a t i e n t s * homes. In a d d i t i o n , d i a b e t i c day care c e n t r e s 2 ^ are becoming i n c r e a s i n g l y popular. Although they are u s u a l l y based i n h o s p i t a l s , most d i a b e t i c day care centres are designed t o provide the s e r v i c e of d i a b e t i c education t o a l l members of the community, whether they be i n - p a t i e n t s or o u t - p a t i e n t s , •new* or * o l d * d i a b e t i c s , or merely concerned i n d i v i d u a l s . Such centres show r e a l promise as one answer to the q u e s t i o n , •where should the d i a b e t i c be taught?* Who Should Teach the D i a b e t i c P a t i e n t ? H i s t o r i c a l l y , the three major c a t e g o r i e s of personnel i n v o l v e d i n d i a b e t i c t e a c h i n g have been p h y s i c i a n s , nurses and d i e t i t i a n s . Various s t u d i e s have i n d i c a t e d t h a t none of these groups i s f u l f i l l i n g t h i s r e s p o n s i b i l i t y as e f f e c t i v e l y as i t might. One might ask *why not?* Regarding p h y s i c i a n s Hamwi suggested t h a t t C o n t r i b u t i n g to the inadequate education of the i n d i v i d u a l w i t h diabetes m e l l i t u s i s the f a c t t h a t *° Krysan, -How do We Teach?" 105-10?. 29 D i a b e t i c Day Care C e n t r e s i Current Concepts (Rexdale, O n t a r i o i Ames Company, D i v i s i o n M i l e s L a b o r a t o r i e s L i m i t e d , 1969). 22 many p h y s i c i a n s see few i f any p a t i e n t s each year i n whom the d i s g n o s i s has been e s t a b l i s h e d . I t i s obvious t h a t , under these circumstances, much o f the b a s i c knowledge r e q u i r e d to provide adequate education w i l l have been f o r g o t t e n by these p h y s i -c i a n s through l a c k of u t i l i z a t i o n . 30" Furthermore, E t z w i l e r r e p o r t e d t h a t follow-up s t u d i e s of diabetes d e t e c t i o n d r i v e s i n d i c a t e d t h a t not a l l p h y s i c i a n s knew what steps ought to be taken when a p a t i e n t was r e p o r t e d to be a "suspected d i a b e t i c " i I f these responses are i n d i c a t i v e of these p h y s i -c i a n s * general knowledge of d i a b e t e s , [ E t z w i l e r suggests] i t would seem prudent t h a t doctors who are not w e l l informed about diabetes or are un-w i l l i n g to spend the necessary time p a r t i c i p a t i n g i n p a t i e n t education should r e f e r these p a t i e n t s whenever possible.3 1 U n f o r t u n a t e l y , nurses and d i e t i t i a n s d i d not f a r e any b e t t e r than p h y s i c i a n s i n E t z w i l e r * s i n v e s t i g a t i o n . 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 administered t o 289 graduating s e n i o r n u r s i n g students r e v e a l e d a s i g n i f i c a n t l a c k of i n f o r -mation concerning b a s i c concepts of diabetes i t s e l f as w e l l as of fundamental n u r s i n g procedures r e l a t e d t o the disease.32 The b a s i c reason suggested f o r t h i s outcome i s the c u r r e n t t r e n d among n u r s i n g schools t o move away from disease-o r i e n t e d i n s t r u c t i o n i n favour of a more g e n e r a l i z e d approach t o n u r s i n g care. Nevertheless, E t z w i l e r emphasizes i 3° Hamwi, "Announcement," 1064. 3 1 E t z w i l e r , "Who's Teaching the D i a b e t i c ? " 116-117. 3 2 I b i d . 23 The prevalence of diabetes demands that, regard-l e s s of t h e i r f i e l d of i n t e r e s t , a l l nursing per-sonnel should be f a m i l i a r with t h i s condition and i t s management.33 Ninety-five members of the American D i e t e t i c Association were asked to complete the same questionnaire. The r e s u l t s suggested that t h e i r knowledge also was inadequate to deal e f f e c t i v e l y with dia b e t i c p a t i e n t s . 3 ^ Thus i t would seem that the average physician, nurse and d i e t i t i a n are not q u a l i f i e d to teach dia b e t i c patients. Etzwiler recommended, therefore, that i n s t r u c t i o n be conducted by a co-ordinated team of interested and knowledgeable per-sonnel from a l l three f i e l d s . 3 5 This proposal i s , of course, the foundation upon which diabetic day care centres are being organized. However, i t i s important to be r e a l i s t i c about t h i s prob-lem. At present, i n North America, the number of dia b e t i c day care centres i s not adequate to meet the teaching needs of t h i s c o n t i n e n t s f i v e m i l l i o n d iabetics.3^ Therefore the majority of these people s t i l l depend on the s t a f f of our general hospitals to f u l f i l t h e i r learning needs. In these set t i n g s , the answer to the question *who should teach?* must be 'everyone who i s able.* 3 3 Ibid. 3 4 I b i d . 3 5 Ibid. 3^ This figure an approximation based on a 250 m i l l i o n popu-l a t i o n and a I i50 incidence of diabetes. How Should the D i a b e t i c P a t i e n t be Taught? 24 The question of how the d i a b e t i c p a t i e n t ought to be taught i s a many-faceted one. In order t o attempt an answer, one must examine not only the v a r i a b l e s which i n t e r p l a y i n any t e a c h i n g - l e a r n i n g s i t u a t i o n , but a l s o the t e a c h i n g a i d s and v a r i e t y of programmes a v a i l a b l e f o r d i a b e t i c i n s t r u c t i o n . Hence each of these f a c e t s has been considered s e p a r a t e l y i n the f o l l o w i n g d i s c u s s i o n . What v a r i a b l e s should be considered? The v a r i a b l e s t o be considered i n a g i v e n t e a c h i n g -l e a r n i n g s i t u a t i o n are of three t y p e s i l e a r n e r v a r i a b l e s , teacher v a r i a b l e s , and environmental v a r i a b l e s . Learner v a r i a b l e s . — E l l i s has done what i s probably the s i n g l e most exhaustive i n v e s t i g a t i o n o f l e a r n e r v a r i a b l e s . In h i s study extensive r e s e a r c h was c a r r i e d out regarding c u l t u r a l and p s y c h o - s o c i a l f a c t o r s as w e l l as the perceptions h e l d by d i a b e t i c p a t i e n t s regarding t h e i r own needs.37 A d e f i n i t e p a t t e r n emerged. P a t i e n t s i n poor or very poor c l i n i c a l c o n t r o l were l i k e l y t o have had t h e i r d i a g n o s i s of diabetes e s t a b l i s h e d before t h i r t y years of age. They were, moreover, l i k e l y t o be young, male and white, w i t h a h i g h l e v e l of formal education and a high l e v e l of l i v i n g . These p a t i e n t s , s u r p r i s i n g l y , u s u a l l y had a hig h l e v e l of knowledge E l l i s , " C o n t r o l as a Basis f o r E d u c a t i o n a l Needs," 9. 25 about d i a b e t e s , a high l e v e l of knowledge about d i a b e t i c problem s i t u a t i o n s , and high agreement w i t h h e a l t h a u t h o r i -t i e s on the content areas t h a t should be taught to d i a b e t i c p a t i e n t s . And f i n a l l y , the poor or very poor c o n t r o l p a t i e n t s tended to express independent a t t i t u d e s toward l i f e s i t u a t i o n s i n general.38 Quite a d i f f e r e n t p a t t e r n c h a r a c t e r i z e d the good c o n t r o l p a t i e n t s i n t h i s study. Several authors have suggested t h a t poorer c l i n i c a l c o n t r o l i n d i a b e t i c s i s p o s i t i v e l y r e l a t e d to p a t h o l o g i c a l p s y c h i a t r i c c l a s s i f i c a t i o n s i n such areas as dependence-independence balance, s e l f - p e r c e p t , and manifest and l a t e n t a n x i e t y . While the m a j o r i t y of these s t u d i e s were of c h i l d d i a b e t i c s , 39* 40, 41, 42 Murawski's resear c h i n d i c a t e d t h a t such f i n d i n g s might a l s o be a p p l i c a b l e t o the a d u l t . In order to d e s c r i b e the p e r s o n a l i t y p a t t e r n s of p a t i e n t s w i t h diabetes of l o n g d u r a t i o n , Murawski administered the Minnesota M u l t i -phasic P e r s o n a l i t y Inventory t o 112 p a t i e n t s who had been d i a b e t i c f o r 25 to 48 year s . Of these s u b j e c t s , 67 had been 3 8 I b i d . . 189-190. 39 Charles R. S w i f t et a l . , "Adjustment Problems i n J u v e n i l e Diabetes," Psychosomatic Medicine, XXIX (November-December 1967), 555-571. ^ 0 Arthur Krosnick et a l . , "Adjustment Problems and Q u a l i t y of C o n t r o l i n J u v e n i l e Diabetes," Diabetes, XV, No. 7 ( J u l y 1966), 538. ^ John Birkbeck et a l . , "Emotional Disturbances i n J u v e n i l e D i a b e t i c s , " Diabetes, XVII, No. 5 (June 1968), 317-318. ho M a i j a - L i i s a K o s k i , "The Coping Processes i n Childhood Diabetes," ACTA P a e d i a t r i c a Scandinavica (1969). Supplement 198. 26 awarded the Quarter Century V i c t o r y Medal, having been found f r e e of v a s c u l a r c o m p l i c a t i o n s a f t e r t w e n t y - f i v e years or more of dia b e t e s . The data showed t h a t s i g n i f i c a n t l y more non-medal p a t i e n t s had abnormal s c a l e scores than d i d the medal winners.^3 These r e s u l t s would seem to suggest t h a t l a b i l e d i a b e t e s , manifested i n poor c l i n i c a l c o n t r o l , o f t e n r e s u l t s i n p s y c h i -a t r i c pathology. However G r o e n — i n a d i s c u s s i o n of the psycho-somatic aspects of d i a b e t e s — c a u t i o n e d a g a i n s t such a conc l u -s i o n , p o i n t i n g out t h a t c e r t a i n psycho-trumatic l i f e s i t u a t i o n s , l e a d i n g t o f e e l i n g s of depression, l o n e l i n e s s and/or not being understood, may pla y a p a r t i n the m u l t i f a c t o r i a l e t i o l o g y of the c o n d i t i o n . ^ Therefore i t cannot be s a i d t h a t one i s cause and the other e f f e c t but r a t h e r only t h a t the two f a c t o r s — poor c l i n i c a l c o n t r o l and p s y c h o l o g i c a l i n s t a b i l i t y — a r e r e l a t e d . Regarding s o c i a l v a r i a b l e s , the Diabetes Supplement of the N a t i o n a l Health Survey conducted i n the United States i n the f i s c a l year 1964-65 showed c o n s i d e r a b l y lower income and lower e d u c a t i o n a l l e v e l s f o r d i a b e t i c p a t i e n t s than f o r the g e n e r a l p o p u l a t i o n . ^ ^3 Benjamin J . Murawski et a l . , " P e r s o n a l i t y Patterns i n P a t i e n t s w i t h Diabetes of Long Duration," Diabetes, XIX, No. 4 ( A p r i l 1970), 259-263. ^ Johannes J . Groen, "Psychosomatic Aspects of Diabetes M e l l i t u s , " D i a b e t o l o g i a , IV, No. 6 (November-December 1968), 391. ^5 Glen W. McDonald, "The Diabetes Supplement of the N a t i o n a l Health Survey," J o u r n a l of the American D i e t e t i c A s s o c i a t i o n , L I I , No. 2 (February 1968), 119. 2? The above survey of the l i t e r a t u r e indicates that there are many learner v a r i a b l e s — a b i l i t i e s , c a p a c i t i e s , physical l i m i t a t i o n s , a t t i t u d e s , i n t e r e s t s , previous learning and class or group c h a r a c t e r i s t i c s — w h i c h should be considered i n deciding •how' to teach the diabetic patient. Teacher v a r i a b l e s . — E a c h teacher has a unique s o c i a l , psychological, emotional and c u l t u r a l p r o f i l e which w i l l i n f l u -ence his/her a b i l i t y to in t e r a c t with a given diabetic patient. Included i n t h i s p r o f i l e are such variables as a b i l i t i e s , moti-vation, physical l i m i t a t i o n s , self-concept adjustment, a t t i t u d e s , values and i n t e r e s t s . ^ While there i s ample research pertaining to these factors i n the general education l i t e r a t u r e , none was found r e l a t i n g s p e c i f i c a l l y to the teacher of diabetic patients. Environmental v a r i a b l e s . — O n the other hand, environmental variables embrace such things as the teaching-learning community (or s e t t i n g ) , aims and content of the i n s t r u c t i o n , teaching resources or aids employed, and teaching methods and techniques.^ The s e t t i n g has already been discussed i n answer to the question •where should the diabetic patient be taught?' Aims and con-tent of i n s t r u c t i o n were treated under the heading 'what should the diabetic be taught?' E l l i s ' study shed some l i g h t on the matter of teaching techniques. Patients i n t h i s study i d e n t i -f i e d the following as preferred i n s t r u c t i o n a l procedures f o r Professional Teacher Education (Washington, D. C. i American Association of Colleges for Teacher Education, 1968), 8. ^ Ibid. 2 8 teachers i 1. Use of non-medical words; 2. Stating exactly what to do and what not to do; 3. Allowing more time f o r i n s t r u c t i o n s ; 4. Providing opportunity to practice i n s t r u c t i o n s ; 5» Teaching one thing at a time; 6. Adjusting i n s t r u c t i o n s to personal needs; and 7. Making s p e c i a l considerations f o r those who have other ho physical problems. What di a b e t i c teaching aids are a v a i l a b l e ? As noted i n the preceding section, teaching aids and resources may be considered to be one of the environmental variables a f f e c t i n g learning. However, such a v a r i e t y of assistance i s a v a i l a b l e f o r diabetic teaching that i t w i l l be treated here i n a separate discussion. Books and pamphlets.—Perhaps the most t r a d i t i o n a l of diabetic teaching aids are a number of books written f o r d i a b e t i c s . ^ 9 Supplementing these publications are several pamphlets d i s t r i b u t e d by d i a b e t i c associations and drug com-panies. 5° There can be l i t t l e doubt that these and other printed materials, used i n conjunction with personal teaching, ^ 8 E l l i s , "Control as a Basis f o r Educational Needs," 238-239. 49 The best known books fo r diabetics are l i s t e d i n Appendix A, together with excerpts from book reviews about them. A chart summarizing t i t l e s , sources and costs of several diabetic pamphlets may be found i n Appendix A. 29 are important f a c t o r s i n d i a b e t i c education. But they have t h e i r l i m i t a t i o n s . I f the p a t i e n t i s t o b e n e f i t from p r i n t e d a i d s , he must be able t o understand them. Un f o r t u n a t e l y , a l l too o f t e n t h i s i s not the case. I n s t r u c t i o n a l m a t e r i a l i s m i s i n t e r p r e t e d , misunderstood, or con-fused because authors f a i l t o w r i t e understandably and readers are unable t o read w i t h adequate com-prehension. 51 Thrush and Lanese i n v e s t i g a t e d t h a t aspect of the problem r e l a t i n g t o authors' f a i l u r e t o w r i t e understandably. Sampling the d i a b e t i c l i t e r a t u r e of twenty-one te a c h i n g h o s p i t a l s across the United S t a t e s , they computed the median grade l e v e l and found i t to be s l i g h t l y above a n i n t h grade reading d i f f i c u l t y . They compared t h i s f i n d i n g w i t h United States census data, which showed t h a t over h a l f of the n a t i o n a l d i a b e t i c popula-t i o n above f o r t y - f i v e years of age has not completed nine years o f s c h o o l i n g . 5 2 Further i n v e s t i g a t i o n i n d i c a t e d t h a t a s m a l l number (198) of u n f a m i l i a r words c o n t r i b u t e d d i s p r o -p o r t i o n a t e l y to r a i s i n g the reading d i f f i c u l t y of the l i t e r a -t u r e . The authors suggest t h a t f a m i l i a r i t y w i t h or d e l e t i o n of these words would lower the reading score some f o u r school grades.53 Mohammed added t o these suggestions those of ->-L Rudolph S. Thrush and Richard R. Lanese, "The Use of P r i n t e d M a t e r i a l i n Diabetes Education," Diabetes, XI, No. 2 (March-April 1962), 132. 5 2 U. S. Bureau of the Census, S t a t i s t i c a l A b stract of the  U.S.. 1955 (Seventy-sixth E d i t i o n ) (Washington, D.C. t 1955)tP» 112. 3^ Richard R. Lanese and Rudolph S. Thrush, "Measuring Reada-b i l i t y of Health Education L i t e r a t u r e , " J o u r n a l of the American  D i e t e t i c A s s o c i a t i o n , X L I I , No. 3 (March 1963), 217. 30 keeping sentence l e n g t h s h o r t , and a v o i d i n g s u b t l e t y and symbolism.5^ I t i s apparent from these s t u d i e s t h a t much e f f o r t i s yet r e q u i r e d to render d i a b e t i c books and pamphlets t r u l y v a l u a b l e t o t h e i r consumers. F o r t u n a t e l y , some progress has been made w i t h other t e a c h i n g a i d s . Recordings. — In 1957 Schmitt described advantages o f taped l e c t u r e s f o r d i a b e t i c i n s t r u c t i o n . 5 5 Today, s e v e r a l tape recorded speeches may be borrowed from the Canadian Dia-b e t i c A s s o c i a t i o n l i b r a r y f o r use i n r u r a l areas where i t i s d i f f i c u l t to secure competent speakers. Becton-Dickinson Company has co-ordinated a c a s s e t t e tape and graphic book i n G e t t i n g S t a r t e d , an o r i e n t a t i o n programme f o r the d i a -b e t i c p a t i e n t . ^ While t h i s programme i s not a replacement f o r p e rsonal-contact education, i t does o f f e r d i s t i n c t ad-vantages i 1. I t i s easy t o use anywhere; 2. The p a t i e n t r e g u l a t e s h i s own i n t a k e ; 3. The m a t e r i a l i s uncomplicated; 4. I t i s time-saving f o r s t a f f ; and 5. E x t r a t e a c h i n g a i d s may be used i n con j u n c t i o n w i t h i t . 57 S i m i l a r advantages attend "What i s Diabetes?" a f i l m s t r i p and r e c o r d programme put out by Trainex Company of C a l i f o r n i a i 5^ Mary F. B u c k l i n Mohammed, " P a t i e n t s Understanding of Written Health Information," Nursing Research, X I I I (Spring 1964), 100-103. 55 George F r e d e r i c k Schmitt, "Method of Teaching D i a b e t i c Pa-t i e n t s , " J o u r n a l of the F l o r i d a Medical A s s o c i a t i o n , X L I I I (March 1957). 894. ^ G e t t i n g S t a r t e d (Rutherford, New Jersey, 1971). Cn I b i d . , guide t o the k i t . Films.—More sophisticated audio-visual materials are a v a i l a b l e i n the form of 16 mm. films from the Canadian Dia-b e t i c "Association f i l m l i b r a r y . These films are produced by the Association i t s e l f , and by various pharmaceutical com-panies. One of the best films currently a v a i l a b l e f o r patient teaching i s "Four i n a Crowd," a f i l m produced through the Nova Foundation f o r World Health Year, 1971. This f i l m focuses on the diabetic management of four people i a secre-t a r y , a c h i l d , a teenager, and an e l d e r l y male labourer. It has the d i s t i n c t advantage that almost a l l viewers can i d e n t i f y with one of these characters, thus helping to over-come t h e i r f e e l i n g s of hardship and/or i s o l a t i o n . Programmed l e a r n i n g . — A teaching aid which has received much p u b l i c i t y i n the l a s t several years i s programmed learning. Although there are many ways of programming information, one which has been tested f o r i t s diabetes educational value u t i l i z e s a teaching machine (the Auto Tutor Mark II ) . ^ 8 The effectiveness of t h i s programme was tested i n 1962 under the auspices of the Diabetes and A r t h r i t i s Program, D i v i s i o n of Chronic Disease, United States Public Health Service. A random sample of 184 pa-t i e n t s from four diabetic c l i n i c s i n Boston, Massachusetts worked through the programme. McDonald and Kaufman reported that t h i s preliminary study i ^ 8 Taking Care of Diabetes (Skokie, I l l i n o i s J The Welch S c i e n t i f i c Company, n.d. ) 32 r e v e a l e d t h a t the machine was e f f e c t i v e i n teac h i n g p a t i e n t s , was g e n e r a l l y w e l l r e c e i v e d by s u b j e c t s of a l l ages and l e v e l s of i n t e l l e c -t u a l a b i l i t y , and on the average r e q u i r e d two hours f o r completion of testing.5 9 Several authors report e d the same study i n other j o u r n a l s , and added t h e i r p r a i s e of the programme.^ 0* ^ 2 C l o s e r examination of the study however r e v e a l s some d i s t i n c t weaknesses i 1. The median education of the s u b j e c t s was grade 10, which can h a r d l y be considered r e p r e s e n t a t i v e of the d i a b e t i c p o p u l a t i o n at l a r g e ; 2; F o r t y per cent of the s u b j e c t s d i d not complete the course. The reason f o r l a c k of completion was not g i v e n . 3« Of those s u b j e c t s who d i d complete the course, a s i g n i -f i c a n t number complained t h a t they had d i f f i c u l t y w i t h one or more o f t (a) the i n s t r u c t i o n s i (b) the s i z e of p r i n t ; (c) the i l l u m i n a t i o n ; (d) the language of the t e x t ; (e) extreme eye f a t i g u e ; ( f ) minor tiredness.^ 3 59 Glen W. McDonald and Mi l d r e d B. Kaufman, "Teaching Ma-chines f o r P a t i e n t s w i t h Diabetes," J o u r n a l of the American D i e t e t i c A s s o c i a t i o n . X L I I (March 1963), 211. 6° A l l a n D. S p i e g e l , "Teaching D i a b e t i c P a t i e n t s through Auto-mation," H o s p i t a l Topics. XLII (August 1964), 54-60. 6 1 Anna W. S k i f f , "Programmed I n s t r u c t i o n and P a t i e n t Teach-i n g , " American Journal o f P u b l i c Health. LV, No. 3 (March 1965), 409-415. 62 A l l a n D. S p i e g e l , "Programmed I n s t r u c t i o n M a t e r i a l s f o r P a t i e n t Education," J o u r n a l of Medical Education, XLII (October 1967), 958-962. 6 3 I b i d . 33 Thus i t seems t h a t t h i s a i d has d i s t i n c t l i m i t a t i o n s as w e l l . Another type of programmed l e a r n i n g i s e x e m p l i f i e d by Learning About Diabetes, a d i a b e t i c management course put out i n booklet form by the American Diabetes A s s o c i a t i o n . During i t s development, t h i s programme was f i e l d t e s t e d w i t h s e v e r a l groups of d i a b e t i c p a t i e n t s across the United S t a t e s . * ^ This may account f o r the f a c t t h a t i t appears to have at l e a s t the f o l l o w i n g advantages over the Auto Tutor programme i s i m p l e r language and i n s t r u c t i o n s , extensive i l l u s t r a t i o n , lower c o s t . Thus one can see t h a t although a multitude of d i a b e t i c t eaching a i d s i s a v a i l a b l e , many of them do not meet the l e a r n i n g needs of the t a r g e t p o p u l a t i o n . What are-the nature and success of  current d i a b e t i c t eaching programmes? The f i n a l questions t o consider i n determining •how' the d i a b e t i c p a t i e n t should be taught are, 'What i s c u r r e n t l y being done?* and *How s u c c e s s f u l i s i t ? * Types of d i a b e t i c programmes may be roughly d i v i d e d i n t o s i x c a t e g o r i e s i day care c e n t r e s , c l i n i c s , i n s t i t u t e s , home-care programmes, c l a s s e s w i t h i n g e n e r a l h o s p i t a l s , and 'unplanned teaching.* D i a b e t i c day care c e n t r e s . — T h e s e centres are a r e l a t i v e l y new development i n d i a b e t i c programmes and o f f e r p o s s i b l y the most promise f o r comprehensive i n s t r u c t i o n and f o l l o w - t h r o u g h , p a r t i c u l a r l y i n urban c e n t r e s . Ames Company has compiled a Learning about Diabetes (New York i American Diabetes A s s o c i a t i o n , 1969)» acknowledgments. 34 s i x t y - o n e page p u b l i c a t i o n t o a s s i s t i n t e r e s t e d persons i n e s t a b l i s h i n g and o p e r a t i n g d i a b e t i c day care c e n t r e s . Included i n t h i s booklet i s a d e s c r i p t i o n of such centres i what they a r e , what s e r v i c e s they p r o v i d e , and what a c t i v i -t i e s occur t h e r e . E h r e n f e l d ^ 7 and E t z w i l e r ^ 8 have re p o r t e d on two American programmes which might be c l a s s i f i e d as d i a -b e t i c day care c e n t r e s . But, u n f o r t u n a t e l y , no l o n g i t u d i n a l s t u d i e s have yet been p u b l i s h e d which might i n d i c a t e objec-t i v e l y the success of these centres compared to other t e a c h i n g programmes» D i a b e t i c c l i n i c s . — C l o s e l y r e l a t e d t o d i a b e t i c day care centres are d i a b e t i c c l i n i c s . * C l i n i c * i s a r a t h e r broad term, which has been a p p l i e d t o a wide spectrum of t e a c h i n g f a c i l i t i e s . One of the most outstanding d i a b e t i c c l i n i c s i s the one at Boston's New England Deaconess H o s p i t a l u p t o f o r t y ambulatory d i a b e t i c s can be accommodated at a time, the average l e n g t h of stay v a r y i n g from three to seven days. Formal c l a s s e s are g i v e n by a doctor i n the morning, and by ^ 5 D i a b e t i c Day Care Centres. ^ Some of t h i s m a t e r i a l has been reproduced i n Appendix A of t h i s study. ^ I r v i n g E h renfeld and Joseph A. Mattson, "A H o s p i t a l Spon-sored D i a b e t i c I n s t r u c t i o n Program, H H o s p i t a l s . XXXIX (March 1 , 1 9 6 5 ) , 67-68. ^ 8 Donnell D. E t z w i l e r , "Developing a Regional Program to Help P a t i e n t s w i t h Diabetes," J o u r n a l of the American D i e t e t i c  A s s o c i a t i o n , L I I (May 1 9 6 8 ) , 394-400. Marguerite M. M a r t i n , "A Teaching Centre f o r D i a b e t i c s , " American Journa l of Nursing, L V I I I , No. 3 (March 1 9 5 8 ) , 390-391. 3 5 the t e a c h i n g nurse i n the afternoon. P r o v i s i o n i s a l s o made f o r s m a l l group and i n d i v i d u a l teaching where a p p l i c a b l e . Not a l l d i a b e t i c c l i n i c s are as s o p h i s t i c a t e d as t h i s one. A second type of c l i n i c i s the one which operates much l i k e a p r i v a t e p r a c t i c e , u t i l i z i n g the s e r v i c e s of p h y s i c i a n , nurse and d i e t i t i a n t o f o l l o w a group of p a t i e n t s over t i m e . ? 0 * 7 1 A t h i r d type of c l i n i c i s one which o f f e r s c l a s s e s on a regu-l a r b a s i s t o o u t - p a t i e n t s and t h e i r f a m i l i e s and f r i e n d s . ? 2 And f i n a l l y , i t i s necessary t o acknowledge the o u t - p a t i e n t c l i n i c s of general h o s p i t a l s which serve d i a b e t i c s on the b a s i s of meeting problems as they a r i s e . I n s t i t u t e s . — R e c o g n i t i o n of the need f o r education of p a t i e n t s w i t h diabetes l e d t o the p r e s e n t a t i o n of a "community d i a b e t i c d i e t i n s t i t u t e " at the United States P u b l i c Health S e r v i c e H o s p i t a l on Staten I s l a n d , New York, i n 1 9 6 9• The programme was i n three p a r t s , l a s t i n g a t o t a l of two hours, and comprising p h y s i c i a n ' s and d i e t i t i a n ' s t a l k s , meal plan n i n g d i s c u s s i o n s i n s m a l l groups, and a refreshment p e r i o d . Such i n s t i t u t e s ? 3 show the f e a s i b i l i t y of hospital-community p a r t -n e r s h i p s i n h e a l t h education programmes. ' D i a b e t i c C l i n i c conducted by Dr. J. Birkbeck and a s s o c i -ates at C h i l d r e n ' s H o s p i t a l , Vancouver, B. C. 71 D i a b e t i c C l i n i c conducted by Dr. J . Hunt and a s s o c i a t e s at Lions' Gate H o s p i t a l , North Vancouver, B. C. ? 2 D i a b e t i c C l i n i c conducted at St. Paul's H o s p i t a l , Van-couver, B. C. 7 3 Kenneth N. A l s t o n , " H o s p i t a l and Community J o i n i n Dia-b e t i c Education," H o s p i t a l Topics, XLVII (September 1 9 6 9 ) , 3 8 - 4 0 . Home care programmes.—What of those p a t i e n t s who cannot or w i l l not attend agency-sponsored c e n t r e s , c l i n i c s or i n s t i -t u t e s ? Gould and Golden d e s c r i b e d , as e a r l y as 1957» a teach-i n g team of student nurse, i n s t r u c t o r and d i e t i t i a n i n Albany County, Wyoming, w h i c h i makes sure t h a t the p a t i e n t w i t h diabetes and h i s f a m i l y know what care he w i l l need at home, what precautions he must observe and.what gene r a l h e a l t h measures should be followed.7 ^ S i m i l a r s e r v i c e s are provided by many p u b l i c h e a l t h n u r s i n g agencies. 7 5 C l a s s e s . — The f i f t h type o f d i a b e t i c programme i s one i n which organized c l a s s e s are conducted i n a general h o s p i t a l s e t t i n g . In 1961 Bowen, Rich and S c h l o t f e l d t conducted a noteworthy experimental study7^ to determine whether improve-ment i n p a t i e n t w 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 who p a r t i c i p a t e d i n a planned programme of organized i n s t r u c t i o n by r e g i s t e r e d p r o f e s s i o n a l nurses. Two comparable groups of p a t i e n t s r e c e i v e d i n i t i a l assess-ment of 1 1. t h e i r knowledge of d i a b e t e s j ' Gertrude Gould and Jean Golden, "Teaching the D i a b e t i c P a t i e n t at Home," American J o u r n a l of Nursing, LVTI, No. 9 (September 1957), 1170-1171. 75 M i l d r e d Kaufman, "Newer Programs f o r P a t i e n t s w i t h Dia-betes," J o u r n a l of the American D i e t e t i c A s s o c i a t i o n , XLIV ( A p r i l 1964), 277-279. 76 Rhoda G. Bowen et a l . . " 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 w i t h the Diagnosis of Diabetes M e l l i t u s , " Nursing  Research, X (September 1961), 151-157. 2. t h e i r s k i l l i n a d m i n i s t e r i n g i n s u l i n ; 3» t h e i r use of C l i n i t e s t equipment; 4. t h e i r a t t i t u d e s toward diabet e s ; and 5« c l i n i c a l i n d i c e s of t h e i r w e l l - b e i n g . A f t e r t h i s , the experimental group was exposed to 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 , one hour and 15 minutes each i n l e n g t h . F i n a l l y , both groups were reassessed on the same f i v e i n d i c e s as i n i t i a l l y . The f i n d i n g s i n d i c a t e d t h a t pa-t i e n t s i n the experimental group demonstrated s i g n i f i c a n t l y g r e a t e r knowledge about t h e i r disease and s k i l l i n c a r r y i n g out r e q u i r e d procedures. No s i g n i f i c a n t d i f f e r e n c e s were found i n the two groups w i t h respect t o e i t h e r a t t i t u d e s t o -ward diabetes or c l i n i c a l m a n i f e s t a t i o n s of w e l l - b e i n g . Advocates of c l a s s e s f o r d i a b e t i c i n s t r u c t i o n p o i n t out t h a t M i n a d d i t i o n t o p r a c t i c a l i t y . . . group sessions have the advantage of group i n t e r a c t i o n and communication among persons w i t h the same condition. " 7 7 cne wonders, however, whether other v a r i a b l e s — s u c h as the s i z e of the c l a s s , the i n t e r e s t and e x p e r t i s e of the h e a l t h p r o f e s s i o n a l s doing the te a c h i n g , and the f a c t t h a t a p a t i e n t may miss one i n the s e r i e s of c l a s s e s due t o some other h o s p i t a l procedure—may not be s i g n i f i c a n t i n judging the r e l a t i v e m e r i t s of c l a s s -type i n s t r u c t i o n . . 77 Donna Nickerson, "Teaching the H o s p i t a l i z e d D i a b e t i c , " American J o u r n a l of Nursing, LXXII, No. 5 (May 1972), 938. 38 Unplanned i n s t r u c t i o n . — W h a t e v e r weaknesses and/or l i m i t a t i o n s the f i r s t f i v e c a t e g o r i e s o f d i a b e t i c programmes may present, they are neve r t h e l e s s f a r s u p e r i o r t o the un-planned t e a c h i n g which s t i l l occurs i n the m a j o r i t y of h o s p i t a l s e t t i n g s . The f o l l o w i n g i s a very graphic d e s c r i p -t i o n of one such programme. Un f o r t u n a t e l y , I could not get one of the H k i t s M t o send t o you - so I d i d the next best t h i n g and wrote down a l l the contents and pamphlets handed out to the new diabetic.78 . . . By the way, I s a i d 'new' d i a b e t i c s because so f a r as I can t e l l no h e a l t h t e a c h i n g follow-up i s g i v en to ' o l d ' d i a b e t i c s admitted to the general wards - unless of course they are admitted s p e c i -f i c a l l y f o r problems re t h e i r d i a b e t e s . As f a r as any organized time t a b l e f o r tea c h i n g the new d i a -b e t i c - there i s nonei I t f i g u r e s doesn't i t ? ' U There's the o l d s y r i n g e and orange b i t and then the supervised s e l f - i n j e c t i o n of course - but most other aspects l i k e s k i n care, c u t t i n g n a i l s , r e s p i r a t o r y i n f e c t i o n , e t c , e t c . , are more or l e s s l e f t to chance. There i s no organized or even suggested p a t t e r n of i n t r o d u c i n g these t o the p a t i e n t - or I might add, of ensuring t h a t they are even mentioned before discharge.'° Summary In summary, the p e r t i n e n t questions regarding diabetes education may be answered as f o l l o w s i WHY? - because the day-to-day nature of diabetes manage-ment r e q u i r e s t h a t the p a t i e n t l e a r n how to assume primary r e s p o n s i b i l i t y f o r h i s care at home. '° S i m i l a r t o l i s t of pamphlets g i v e n i n Appendix A of t h i s study. 79 Excerpt from l e t t e r w r i t t e n t o the author, i n response t o a request f o r a d e s c r i p t i o n of the d i a b e t i c teaching programme of a h o s p i t a l . WHAT? - the knowledge, s k i l l s and attitudes which he needs to care f o r himself adequately. WHEN? - whenever needs, problems and/or questions a r i s e . Diabetes patient education i s a continuous process. WHERE? - wherever there are diabetic patients who could benefit from i n s t r u c t i o n . WHO? - i d e a l l y , a teaching team of physician, nurse and d i e t i t i a n . However, each of these professionals must be prepared to carry the f u l l weight i f the others are unavailable. HOW? - "Programs . • . that appear to have the greatest value to the person with diabetes [are those which] provide p r a c t i c a l and continuing education, guidance On and support." 0" Kaufman, "Programs f o r Diabetes," 277. 4-0 CHAPTER I I I METHODOLOGY Introduction This study was pri m a r i l y concerned with the unplanned type of diabetic patient education described at the end of Chapter I I . In an attempt to improve t h i s s i t u a t i o n , the author designed a "Diabetic Teaching Tool" which could be u t i l i z e d by any graduate nurse to guide and f a c i l i t a t e the learning of her diabetic patients. The general objective of the t o o l was to f a c i l i t a t e change from unplanned i n s t r u c t i o n to planned i n s t r u c t i o n i n a s e t t i n g where classes, c l i n i c s or day care centres for diabetics were not operating. The effec-tiveness of t h i s type of i n s t r u c t i o n was tested by comparing the s e l f - c a r e knowledge 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 planned i n s t r u c t i o n by means of the t o o l . While the author recognized that many other variables i n t e r a c t to determine the effectiveness of a given teaching programme, i t was beyond the scope of t h i s study to control f o r them. I t was hoped that the r e s u l t s of t h i s study might indicate the u t i l i t y of such a t o o l f o r i n s t i t u t i o n s and r u r a l communities where more highly organized diabetic programmes do not e x i s t . 41 The Tools Three t o o l s were employed i n t h i s study, two of which were based on the m a t e r i a l s presented i n Appendix B. The f i r s t t o o l was a p r o f i l e sheet designed to e l i c i t p e r t i n e n t 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 each patient.^" The second t o o l was a t e s t of d i a b e t i c l e a r n i n g . This t e s t i n c l u d e d a number of short-answer questions and a t h r e e -p a r t performance t e s t , designed to evaluate the l e a r n i n g out-comes of the i n s t r u c t i o n given to the p a t i e n t s . Both the t e s t and the p r o f i l e sheet were p r e - t e s t e d by a d m i n i s t e r i n g them to p a t i e n t s a t t e n d i n g a l o c a l d i a b e t i c c l i n i c . On the f i r s t pre-t e s t ( i n v o l v i n g f i v e p a t i e n t s ) some am b i g u i t i e s i n d i r e c t i o n s , wording and s c o r i n g became apparent. In a d d i t i o n , i t seemed wise to separate the knowledge t e s t s f o r i n s u l i n and a n t i -d i a b e t i c p i l l u s e r s . These changes were made, and the r e v i s e d p forms p r e - t e s t e d on f i v e other p a t i e n t s , w i t h s a t i s f a c t o r y r e s u l t s . The t h i r d t o o l used i n t h i s study was the " D i a b e t i c Teaching To o l " i t s e l f . The b a s i c components of t h i s t o o l were t w o f o l d . The f i r s t component was an e a s e l b i n d e r , s i z e d f o r use on an over-bed t a b l e . The m a t e r i a l s i n the b i n d e r — p o s t e r s and nurses' i n s t r u c t i o n s — w e r e designed to d e a l w i t h the eleven A copy of the P a t i e n t P r o f i l e Sheet may be found i n Appen-d i x C. 2 A copy of the Test of D i a b e t i c Learning may be found i n Appendix C. 42 major content areas of diabetic learning, that i s J d i e t ; urine t e s t i n g ; action of i n s u l i n and other hypoglycemic agents; technique and s i t e s f o r i n s u l i n i n j e c t i o n ; care of equipment; symptoms of hypoglycemia; symptoms of uncontrolled diabetes; care of the feet; what to do i n case of acute com-p l i c a t i o n s ; when to consult health professionals; and how to balance exercise and a c t i v i t y with i n s u l i n . The second com-ponent of the t o o l was a carrying case containing kardex s l i p s , d i a b e t i c supplies l i s t s , consent forms, meal planning booklets, urine t e s t i n g k i t s , patient take home fo l d e r s , and a supply of 8^" x 11" pages with content corresponding to that presented i n the easel binder. Prescription-type format was u t i l i z e d on several of these pages to allow i n d i v i d u a l i z a t i o n of the information to the patients' i n t e r e s t s , needs and l e v e l of c l i n i c a l control.3 Every attempt was made to gear the "Diabetic Teaching Tool" to the learning needs of the average diabetic patient. The Dale-Chall r e a d a b i l i t y formula^ was used, i n conjunction with Thrush and Lanese's l i s t of unfamiliar words r e l a t i n g to diabetes,5 i n an attempt to keep the reading l e v e l of the material at or about grade s i x . Abundant use was made of i l l u s t r a t i o n s and diagrams. 3 A copy of the Diabetic Teaching Tool may be found i n Appendix D. 4 Edgar D. Dale and Jeanne S. Chall, "A Formula f o r Pre-d i c t i n g Readability," Education Research B u l l e t i n , XXVII (1948), 11-28. ^ Rudolph S. Thrush and Richard R. Lanese, "The Use of Printed Material i n Diabetes Education," Diabetes, XI, No. 2 (March-A p r i l 1962), 132. 4 3 A p r i n t e d sheet of i n s t r u c t i o n s ^ accompanied the t o o l , t o guide nurses i n t h e i r use of i t . V a l i d i t y of the " D i a b e t i c Teaching Tool" was e s t a b l i s h e d by s u b j e c t i n g i t to a c r i t i c a l review and r e v i s i o n by a panel of e x p e r t s . 7 The P o p u l a t i o n and the S e t t i n g This study was c a r r i e d out on d i a b e t i c p a t i e n t s admitted to the f o l l o w i n g f i v e wards of a suburban general h o s p i t a l over a s i x month p e r i o d t an a c t i v a t i o n ward, two medical wards, the medical s e c t i o n of a m e d i c a l - s u r g i c a l ward, the ante-partum s e c t i o n of an o b s t e t r i c s and gynecology ward. Each p a t i e n t was s e l e c t e d f o r the study according t o the f o l l o w i n g c r i t e r i a i 1. has a primary or secondary di a g n o s i s of diabetes m e l l i t u s : 2. f a l l s i n t o one of the f o l l o w i n g c l a s s e s of a d m i t t i n g d i a g n o s i s i (a) newly diagnosed d i a b e t i c , (b) diabetes out of c o n t r o l , (c) c o m p l i c a t i o n ( s ) of d i a b e t e s , (d) ante-partum, (e) u n r e l a t e d medical c o n d i t i o n ; ^ The i n s t r u c t i o n s f o r use of the D i a b e t i c Teaching Tool are i n c l u d e d w i t h the t o o l i n Appendix D. 7 The panel of experts f o r t h i s study was made up of the author's c o n s u l t a t i o n committee p l u s seven i n d i v i d u a l s having s p e c i a l i n t e r e s t and/or e x p e r t i s e i n the f i e l d of d i a b e t e s i two d i a b e t i c p a t i e n t s , two p h y s i c i a n s , a d i e t i t i a n , and two nurses. 44 3. i s 18 years of age or over* 4. speaks and writes English; 5. i s sighted; 6. i s taking i n s u l i n or an o r a l hypoglycemic agent; 7. i s free of mental or emotional handicaps; 8. consents to p a r t i c i p a t e ; and 9. l i v e s within a 50-mile radius of Vancouver c i t y . Those patients admitted to the i n s t i t u t i o n during the f i r s t three months of the study were assigned to the control group; those i n the l a s t three months to the experimental group. The Procedure The study was conducted i n s i x stages. The f i r s t stage was the development of the t e s t of diabetic learning. This stage was accomplished by following the series of steps sug-o gested by Grondlund f o r the planning of t e s t s , that i s 1. Identify the learning outcomes to be measured by the t e s t . 2. Define the learning outcomes i n terms of s p e c i f i c , observable behavior. 9 3. Outline the subject-matter content to be measured by the t e s t . 1 0 Norman E. Grondlund, Constructing Achievement Tests (Englewood C l i f f s , New Jersey i Prentice H a l l Inc., 1968), p. 13. 9 The learning outcomes are given i n Appendix B under the heading "Objectives f o r a Basic Course i n Diabetic S e l f -Management ." 1 0 The subject-matter content i s given i n Appendix B under the heading "Content of a Basic Course i n Diabetic S e l f -Management." ^5 4. Prepare a t a b l e of s p e c i f i c a t i o n s . ^ 5. Use the t a b l e of s p e c i f i c a t i o n s f o r prepa r i n g the t e s t . When the t e s t was drawn up i t was p r e t e s t e d , r e v i s e d , and pr e t e s t e d again before i t was considered acceptable f o r use i n t h i s study. The second stage i n the study i n v o l v e d a d m i n i s t e r i n g the t e s t of d i a b e t i c l e a r n i n g to a c o n t r o l group of p a t i e n t s . A l l d i a b e t i c p a t i e n t s discharged from the p a r t i c i p a t i n g i n s t i t u t i o n d u r i n g the f i r s t t h r e e months of the data c o l l e o t i o n p e r i o d were designated as p o t e n t i a l c o n t r o l p a t i e n t s . The nu r s i n g s t a f f were not informed t h a t these p a t i e n t s were t o be t e s t e d ; thus no o u t - o f - t h e - o r d i n a r y e f f o r t was made regarding t h e i r d i a b e t i c t e a c h i n g . From t h i s group, each p a t i e n t who met the c r i t e r i a s e t out f o r the p o p u l a t i o n i n t h i s study was con-t a c t e d by telephone s h o r t l y a f t e r h i s discharge. In order t o secure h i s consent t o p a r t i c i p a t e , both the purpose of the study and the requirements of p a r t i c i p a n t s were c a r e f u l l y e x p l a i n e d . I f v e r b a l consent was obtained, arrangements were made f o r the researcher t o v i s i t the sub j e c t at h i s home f o r the purpose of a d m i n i s t e r i n g the t e s t . During t h i s v i s i t a w r i t t e n consent was a l s o obtained, and a p a t i e n t p r o f i l e com-p l e t e d . A t o t a l of twenty s u b j e c t s c o n s t i t u t e d the c o n t r o l group. The t a b l e of s p e c i f i c a t i o n s i s giv e n i n Appendix B under the heading " S p e c i f i c a t i o n s f o r the Test of D i a b e t i c Learning." 46 The t h i r d stage i n the study was the development of the " D i a b e t i c Teaching T o o l . " The major guide u t i l i z e d i n the development of t h i s t o o l was the course o u t l i n e — c o n t e n t and o b j e c t i v e s — d e s c r i b e d i n Appendix B of t h i s study. In a d d i -t i o n , many ideas and suggestions c i t e d i n the resume of p r e -sent knowledge (Chapter I I ) were u t i l i z e d . A commercial a r t student was employed to design the p o s t e r s . Ongoing c o n s u l -t a t i o n w i t h the researcher's t h e s i s committee and s e l e c t e d members of the panel of experts f a c i l i t a t e d t h i s t a s k . V/hen the t o o l was near completion, i t was presented t o the e n t i r e panel of experts f o r c r i t i c a l review. S e v e r a l minor changes were suggested d u r i n g these s e s s i o n s , most of which were i n -corporated i n t o the f i n a l product. The f o u r t h stage i n the study was the u t i l i z a t i o n o f the " D i a b e t i c Teaching T o o l " i n i n s t r u c t i n g an experimental group of p a t i e n t s . Immediately p r i o r to the i n i t i a t i o n of t h i s stage, an i n s e r v i c e programme was undertaken i n order t o f a m i l i a r i z e the n u r s i n g s t a f f w i t h the t o o l and t o ensure c o n s i s t e n t use of i t . Each p a t i e n t i n the experimental group was approached s h o r t l y a f t e r h i s admission to determine h i s w i l l i n g n e s s t o p a r t i c i p a t e i n the study. I f agreement was obtained, a con-sent form was s i g n e d , and arrangements subsequently made t o i n i t i a t e h i s t e a c h i n g . Each p a t i e n t i n the experimental group was thus taught by h i s own n u r s e ( s ) , u s i n g the " D i a b e t i c Teaching T o o l , " between the time of h i s admission and h i s discharge from the i n s t i t u t i o n . 47 The f i f t h stage i n the study i n v o l v e d a d m i n i s t e r i n g the t e s t of d i a b e t i c l e a r n i n g to the experimental group of p a t i e n t s . Those p a t i e n t s who had been taught and who a l s o met the c r i t e r i a f o r t h i s study were contacted by telephone s h o r t l y a f t e r d i s -charge. Home i n t e r v i e w s were then arranged, during which the p a t i e n t p r o f i l e s were completed and the t e s t s of d i a b e t i c l e a r n i n g administered. This stage and the preceding one were continued u n t i l twenty experimental s u b j e c t s were obtained f o r the study. At t h i s time the data c o l l e c t i o n was terminated and the " D i a b e t i c Teaching T o o l " withdrawn from the p a r t i c i -p a t i n g i n s t i t u t i o n . The s i x t h and f i n a l stage i n the study was the a n a l y s i s of the data. The raw data obtained from the p a t i e n t s * p r o f i l e sheets and t e s t r e s u l t s were compiled and t a b u l a 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 of the s u b j e c t s were analyzed and des c r i b e d i n terms of d i s t r i b u t i o n s , medians and/or means. Test r e s u l t s were subjected t o t - t e s t analyses on s e v e r a l dimensions. And a number of demographic and d i a -b e t i c t r a i t s were compared w i t h t h e i r r e s p e c t i v e t e s t scores by means of 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 , A l e v e l of .05 was accepted as s t a t i s t i c a l l y s i g n i f i c a n t throughout. 48 CHAPTER IV FINDINGS Introduction The findings of t h i s study are presented i n three sec-t i o n s . The f i r s t s e ction—hased on data obtained from the patient p r o f i l e s h e e t s — i s devoted to a comparison of the demographic and diabetic c h a r a c t e r i s t i c s of the control and experimental patient groups. The second section contains analyses of the scores which subjects achieved on the tes t of diabetic learning, and re l a t e s these r e s u l t s to the hypo-thesis of the study. The t h i r d section presents an examina-t i o n and discussion of the corr e l a t i o n s between selected demo-graphic or diabetic c h a r a c t e r i s t i c s and respective t e s t scores. Demographic and Diabetic C h a r a c t e r i s t i c s  of the Population Demographic and diabetic data were recorded f o r each patient i n r e l a t i o n to the following items« age, sex, mari t a l status, occupation, education, reason f o r current h o s p i t a l ad-mission, time elapsed since most recent previous h o s p i t a l ad-mission, age at onset of diabetes, duration of diabetes, type of c l i n i c a l c o n t r o l , and most h e l p f u l source of diabetic i n f o r -mation. 4 9 Age. Table I g i v e s the comparative d i s t r i b u t i o n of the s u b j e c t s by age. The median age i n the c o n t r o l group was f i f t y - f o u r y e a r s , w h i l e t h a t i n the experimental group was f i f t y y e ars. Thus the c o n t r o l p a t i e n t s were s l i g h t l y o l d e r than were the experimental p a t i e n t s . Sex Table I I shows the comparative d i s t r i b u t i o n of the sub-j e c t s by sex. In both the c o n t r o l and experimental groups there was a l a r g e r p r o p o r t i o n of females than males (seventy-f i v e per cent females i n the c o n t r o l group and s i x t y per cent females i n the experimental group). M a r i t a l Status M a r i t a l s t a t u s of the study s u b j e c t s i s i n d i c a t e d i n Table I I I . The m a j o r i t y of p a t i e n t s i n both groups were married (seventy per cent i n the c o n t r o l group and e i g h t y -f i v e per cent i n the experimental group). Occupation The c o n t r o l and experimental groups were q u i t e s i m i l a r w i t h respect t o occupation. Four out of f i v e males i n the c o n t r o l group and f i v e out of e i g h t i n the experimental group were r e t i r e d . S i m i l a r l y , eleven out of f i f t e e n females i n the c o n t r o l group and eig h t out of twelve i n the experimental group were housewives. The remaining occupations covered a wide range. TABLE I COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY AGE Age C o n t r o l Experimental (Years) P a t i e n t s P a t i e n t s 15-24 0 1 25-3^ 2 1 35-44 2 5 45-54 6 6 55-64 1 3 65-74 2 2 75-84 5 2 85 and over 2 0 T o t a l 20 20 TABLE II COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY SEX Sex Control Patients Experimental Patients Male 5 8 Female 1 5 1 2 Tota l 2 0 2 0 TABLE III COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY MARITAL STATUS M a r i t a l Status Control Patients Experimental Patients S ingle — 1 Married 14 17 Widowed 4 2 Divorced/Separated 2 . To ta l 20 20 53 Education In education the two study groups were a l s o very s i m i l a r , as i s i l l u s t r a t e d i n Table IV. The median education i n the c o n t r o l group was nine and one h a l f y e a r s , i n the experimental group ten years. Moreover, the p r o p o r t i o n s of s u b j e c t s having elementary, secondary and post-secondary education r e s p e c t i v e l y were very c l o s e f o r the two groups. Reason f o r c u r r e n t h o s p i t a l admission Table V shows the comparative d i s t r i b u t i o n of reasons f o r current h o s p i t a l admission of a l l s u b j e c t s i n the study. I t should be noted t h a t although there was a l a r g e r p r o p o r t i o n of new d i a b e t i c s i n the experimental group than i n the c o n t r o l group, the numbers of admissions d i r e c t l y r e l a t e d t o diabetes were very s i m i l a r i n both groups, t h a t i s , ten and twelve. Most recent previous h o s p i t a l admission As Table VI i n d i c a t e s , the data r e l a t e d to the most recent previous h o s p i t a l admissions of s u b j e c t s were h i g h l y s i m i l a r f o r the two study groups. S i x c o n t r o l and f i v e experimental p a t i e n t s had had t h e i r most recent previous admission w i t h i n one year of the t e s t date; nine c o n t r o l and twelve experimental p a t i e n t s had l a s t been h o s p i t a l i z e d one to ten years p r i o r to the t e s t date, and f i v e c o n t r o l and three experimental p a t i e n t s had not been i n h o s p i t a l f o r over ten years. Moreover, e i g h t out of twenty s u b j e c t s ( f o r t y per cent) i n each group were not d i a b e t i c at the time of t h e i r most recent previous admission; twelve out of twenty ( s i x t y per cent) were d i a b e t i c at t h a t time. TABLE IV COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY EDUCATION Schooling C o n t r o l Experimental Completed P a t i e n t s P a t i e n t s 0-4 years 3 — 5 - 8 years 4 8 ( p u b l i c s c h o o l ) a ( 7 ) a ( 8 ) a 9 - 1 0 years 4 4 1 1 - 1 3 years 5 6 (high s c h o o l ) a ( 9 ) a ( 1 0 ) a post-secondary 4 2 T o t a l 2 0 2 0 a These are s u b - t o t a l s . TABLE V COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY REASON FOR CURRENT ADMISSION TO HOSPITAL Reason f o r Current Admission t o H o s p i t a l C o n t r o l P a t i e n t s . Experimental P a t i e n t s New d i a b e t i c 2 7 Regulation of diabetes 5 2 Complication of diabetes 3 3 Unrelated c o n d i t i o n 1 0 . 8 T o t a l - 2 0 2 0 56 TABLE VI COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY MOST RECENT PREVIOUS HOSPITAL ADMISSION C o n t r o l P a t i e n t s Experimental P a t i e n t s Time of Most Recent Previous H o s p i t a l Admission # D i a b e t i c at the time # not D i a b e t i c at the time # D i a b e t i c at the . . time # not D i a b e t i c at the time 6 weeks ago or l e s s 2 — — — over 6 wk.-under 1 y r . — k 1 1-5 years ago 5 3 7 6-10 years ago — 1 1 — over 10 years ago 1 — 3 T o t a l 12 8 12 8 57 Age at onset of diabetes Table VII shows the comparative d i s t r i b u t i o n of c o n t r o l and experimental p a t i e n t s by age at onset of t h e i r d i a b e t e s . For both groups the median age at onset was i n the f o r t y - f i v e t o f i f t y - f o u r year range, the c o n t r o l being s l i g h t l y h i g h e r than the experimental. Duration o f diabetes Table V I I I g ives the comparative d i s t r i b u t i o n of the sub-j e c t s by d u r a t i o n of t h e i r d i a b e t e s . The d i s t r i b u t i o n s were again q u i t e s i m i l a r , w i t h the median d u r a t i o n f o r the c o n t r o l group being e i g h t years and t h a t f o r the experimental group f i v e and one h a l f y e a r s . Type of c l i n i c a l c o n t r o l Table IX i n d i c a t e s the numbers of s u b j e c t s whose diabetes was c o n t r o l l e d by a n t i d i a b e t i c p i l l s , l e s s than t h i r t y u n i t s of i n s u l i n and t h i r t y or more u n i t s of i n s u l i n r e s p e c t i v e l y . There were t e n p i l l - u s e r s and t e n i n s u l i n - u s e r s i n each group of the study. In the c o n t r o l group s i x out of the t e n i n s u l i n -users were t a k i n g t h i r t y or more u n i t s of i n s u l i n d a i l y ; i n the experimental group f i v e out of the ten i n s u l i n - u s e r s f e l l i n t o t h i s c l a s s i f i c a t i o n . Sources o f i n f o r m a t i o n on diabetes management The data r e l a t e d to sources of i n f o r m a t i o n f o r d i a b e t i c self-management proved d i f f i c u l t to t a b u l a t e f o r two reasons. F i r s t , s u b j e c t s o f t e n s t a t e d t h a t only a s m a l l number of the ten resources suggested had served them i n any way; thus they TABLE VII COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY AGE AT ONSET OF DIABETES Age at Onset of Control Experimental Diabetes (Years) Patients Patients 0-14 2 1 15-24 — 2 2 5 - 3 4 1 5 3 5 - 4 4 4 1 4 5 - 5 4 4 5 55-64 2 3 6 5 - 7 4 6 3 75 and over 1 Total 20 20 TABLE V I I I COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY DURATION OF DIABETES Duration of C o n t r o l Experimental Diabetes P a t i e n t s P a t i e n t s 0-6 days — — 1-5 weeks 1 3 6 w k . - l l mos. 3 5 1-5 years 5 2 6-10 years 2 2 over 10 years 9 8 T o t a l 20 20 TABLE IX COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY TYPE OF DIABETIC CONTROL Co n t r o l Experimental Type of D i a b e t i c C o n t r o l P a t i e n t s P a t i e n t s Diet and a n t i d i a b e t i c p i l l 10 10 Diet and l e s s than 30 u i n s u l i n 4- 5 Diet and 30 u or more i n s u l i n 6 5 T o t a l 20 20 61 were unable to complete the assigned t a s k of ranking a l l t e n . And second, s u b j e c t s f r e q u e n t l y were unable to decide which of two g i v e n resources was the more h e l p f u l ; thus they would a s s i g n both the same rank. For these reasons, the data f o r t h i s s e c t i o n r e f l e c t only the frequency w i t h which resources were reporte d as u s e f u l , and not t h e i r rank. In the c o n t r o l group those sources of i n f o r m a t i o n most f r e q u e n t l y mentioned as "being h e l p f u l were d o c t o r s , pamphlets, f r i e n d s or r e l a t i v e s and d i e t i t i a n s ? i n the experimental group they were nurses, the " D i a b e t i c Teaching T o o l , " doctors and d i e t i t i a n s . Nurses were seen as u s e f u l l e a r n i n g resources by only three ( f i f t e e n per cent) of the c o n t r o l p a t i e n t s . In the experimental group, by c o n t r a s t , nurses were c i t e d as h e l p f u l by s i x t e e n (eighty per cent) of the s u b j e c t s . This f i n d i n g would seem t o i n d i -cate t h a t the " D i a b e t i c Teaching T o o l " — b y v i r t u e of the d i r e c t e d i n t e r a c t i o n i t s p e c i f i e d between p a t i e n t and n u r s e -helped t o i n c r e a s e the nurse's u s e f u l n e s s to the p a t i e n t as a resource f o r l e a r n i n g about home management. In summary, one may say t h a t t h e r e was a high degree of s i m i l a r i t y between c o n t r o l and experimental p a t i e n t s i n the study w i t h respect t o both demographic and d i a b e t i c charac-t e r i s t i c s . 6 2 Scores Achieved on the Test of  Diabetic Learning Scores achieved by subjects on the t e s t of diabetic learning were subjected to t - t e s t analysis on several dimen-sions. F i r s t , scores achieved on the knowledge section of the te s t were examined. Tables X and XI provide a comparison of co n t r o l and experimental scores f o r a n t i d i a b e t i c p i l l - u s e r s and insulin-users r e s p e c t i v e l y . In both sub-groups, the ex-perimental patients scored better on the average than did the control patients. The difference between the scores was s t a -t i s t i c a l l y s i g n i f i c a n t (at the .005 l e v e l ) f o r the p i l l - u s e r s j i t was 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 f o r the i n s u l i n - u s e r s . Two factors may have influenced the l a t t e r r e s u l t . In the f i r s t place, there was a much wider d i s t r i b u t i o n of scores among the control insulin-users than among t h e i r experimental counterparts. Added to t h i s i s the f a c t that one c o n t r o l sub-je c t was a registered nurse; t h i s subject scored higher on the knowledge t e s t than did any other subject i n the en t i r e study. Next, scores of a l l subjects on the d i e t planning s k i l l sub-test were compared. Table XII shows the marked difference between the control and experimental patients on t h i s item, a difference which i s s t a t i s t i c a l l y s i g n i f i c a n t at a l l known l e v e l s . Then scores of a l l subjects on the urine t e s t i n g s k i l l sub-test were reviewed. Here again, a s t a t i s t i c a l l y s i g n i f i -cant difference between control and experimental subjects was evidenced. These data are presented on Table XIII. TABLE X COMPARISON OF CONTROL AND EXPERIMENTAL PILL-USERS BY SCORE ON KNOWLEDGE TEST Scores of Contro l Pat ients (70 max.) Scores of Experimental Patients (70 max.) 13.5 40.0 15.5 44.0 18.5 47.0 19.5 51.5 21.0 52.5 38.0 53.0 42.5 54.0 43.5 56.5 44.0 60.5 57.0 62.5 c = 31.30 E = 52.15 t = 3.911 ( s i g n i f i c a n t at the .005 l e v e l ) TABLE XI COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY SCORE ON KNOWLEDGE TEST Scores of Control Pat ients (75 max.) Scores of Experimental Patients (75 max.) 30.0 44.0 33.5 48.5 44.0 54.0 46.0 56.5 53.5 57.0 57.5 57.5 58.0 61.0 62.5 62.5 63.O 64.0 69.5 64.5 c = 51.75 E = 56.95 t = 1.121 (not s i g n i f i c a n t ) TABLE X I I COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY SCORE ON DIET PLANNING SKILL TEST Scores (20 max.) Scores (20 max.) C o n t r o l P a t i e n t s Experimental P a t i e n t s C o n t r o l P a t i e n t s Experimental P a t i e n t s 3.0 13.5 11.0 17.0 4.0 14.0 11.5 17.0 5.0 14.5 12.0 17.0 5-5 14.5 12.5 17.5 6.0 15.0 13.0 18.0 7.0 15.5 14.0 18.0 8.5 15.5 15.5 18.0 8.5 16.0 16.0 18.0 9.0 16.0 16.0 18.5 9.0 16.0 10.0 16.5 C = 9.85 E = 16.30 t = 6.782 ( s i g n i f i c a n t at a l l known l e v e l s ) TABLE XIII COMPARISON OP CONTROL AND EXPERIMENTAL PATIENTS BY SCORE ON URINE TESTING SKILL TEST Scores (10 max.) Scores (10 max.) Contro l Patients Experimental Patients . Control Patients Experimental Patients 0.0 3.5 5.0 7.0 0.0 4.0 5.5 7.0 2.0 4.5 5.5 7.0 2.0 5.0 6.0 8.0 2.0 5.5 6.0 8.5 3.0 5.5 7.0 8.5 4.0 6.0 7.0 9.0 4,0 6.0 8.0 9.0 4.0 7.0 8.0 10.0 4.0 7.0 5.0 7.0 C = 4.40 E = 6.75 t = 3.560 ( s i g n i f i c a n t at a l l known l e v e l s ) 67 Scores achieved by i n s u l i n - u s e r s on the i n s u l i n proce-dures s k i l l s ub-test were a l s o s t u d i e d . Since a c l e a r ma-j o r i t y of p a t i e n t s i n the study (eighty per cent of the con-t r o l group, and s i x t y per cent o f the experimental group) used disposable needles and s y r i n g e s , the data p e r t a i n i n g t o care of equipment was not s u f f i c i e n t to permit s t a t i s t i c a l a n a l y s i s . Table XIV g i v e s a comparison of c o n t r o l and experimental scores on the i n j e c t i n g s e c t i o n of the s u b - t e s t . Experimental sub-j e c t s performed t h i s s k i l l s i g n i f i c a n t l y b e t t e r than d i d c o n t r o l s u b j e c t s . A f t e r scores on the v a r i o u s sub-tests had been analysed, a number of combined scores were examined. The f i r s t of these data analyses was a comparison of c o n t r o l and experimental p a t i e n t s ' combined scores showing both knowledge and s k i l l i n r e l a t i o n to d i e t . On the knowledge t e s t , a t o t a l of s i x t e e n p o i n t s r e g a r d i n g d i e t c o u l d be a t t a i n e d . This together w i t h . the twenty p o i n t s f o r the d i e t p l a n n i n g s k i l l t e s t made a t o t a l p o s s i b l e score of t h i r t y - s i x p o i n t s r e l a t e d to l e a r n i n g about d i e t . The r e s u l t s of t h i s c o r r e l a t i o n are t a b u l a t e d i n Table XV. The a n a l y s i s showed a h i g h l y s i g n i f i c a n t d i f f e r e n c e be-tween the scores of c o n t r o l and experimental s u b j e c t s , a d i f f e r e n c e which i n d i c a t e s t h a t the experimental s u b j e c t s were b e t t e r able t o understand and use t h e i r d i a b e t i c d i e t s than were t h e i r counterparts i n the c o n t r o l group. A s i m i l a r a n a l y s i s was done on the combined scores i n d i -c a t i n g knowledge and s k i l l r e l a t e d to u r i n e t e s t i n g . In t h i s case the t o t a l p o s s i b l e combined score was twenty p o i n t s , t e n TABLE XIV COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY SCORE ON INSULIN INJECTING SKILL TEST Scores of Control Pat ients (11 max.) Scores of Experimental Patients (11 max. ) 3.5 8.0 6.0 9.0 7.0 9.0 7.5 9.0 7.5 9.0 7.5 9.5 8.0 10.0 8.0 10.0 8.0 10.5 9.0 11.0 C = 7.20 E m 9.50 t = 2.853 ( s i gn i f i c an t at the .01 l e v e l ) TABLE XV COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY SCORE ON KNOWLEDGE AND SKILL TESTS REGARDING DIET Score (36 max.) Score (36 max.) Contro l . Patients . Experimental Patients Control Patients Experimental Pat ients 6.0 21.0 22.5 29.0 9.0 23.O 23.0 29.0 9.5 24.5 23.5 30.0 10.0 26.0 24.5 31.0 10.5 27.0 26.0 31.5 11.0 27.0 28.0 32.0 12.0 27.0 28.5 32.5 12.5 27.5 30.0 33.0 16.0 27.5 30.0 34.0 19.5 28.0 21.0 28.0 c = 18.65 E = 28.42 t = 5.033 ( s i g n i f i c a n t at a l l known l e v e l s ) 70 f o r knowledge and ten f o r s k i l l . Table XVI shows th a t the experimental group scored s i g n i f i c a n t l y higher than d i d the c o n t r o l group on a l l aspects of u r i n e t e s t i n g . The next a n a l y s i s was of the same type as the preceding two, combining the scores of i n s u l i n - u s e r s showing knowledge and s k i l l r e l a t i n g t o t h e i r medication. The ten p o i n t s f o r knowledge about medication and the eleven p o i n t s f o r s k i l l i n the i n s u l i n i n j e c t i o n procedure were summed t o make a t o t a l p o s s i b l e score of twenty-one p o i n t s . As Table XVII i n d i c a t e s , the experimental p a t i e n t s demonstrated s i g n i f i c a n t l y b e t t e r knowledge and s k i l l r e g a rding t h e i r medication than d i d the c o n t r o l p a t i e n t s . The f i n a l three data analyses performed on the t e s t scores concerned the t o t a l percentage scores achieved by s u b j e c t s on a l l aspects of the t e s t i n g . To achieve these s c o r e s , each p a t i e n t ' s sub-scores on the knowledge and three s k i l l t e s t s were summed, and a percentage score c a l c u l a t e d . Table XVIII presents a comparison of c o n t r o l and experimental p i l l - u s e r s by t h e i r t o t a l percentage s c o r e s . A h i g h l y s i g n i f i c a n t d i f f e r e n c e emerged between these two groups, thus i n d i c a t i n g t h a t d i a b e t i c p i l l - u s e r s taught by means of the " D i a b e t i c Teaching T o o l " demonstrated a higher l e v e l of l e a r n i n g about t h e i r d i a b e t i c management than d i d those taught i n the i n s t i -t u t i o n ' s u s u a l manner. Table XIX gi v e s a s i m i l a r comparison of the scores of i n s u l i n - u s e r s . Here again, the experimental s u b j e c t s achieved s i g n i f i c a n t l y b e t t e r t o t a l percentage scores than d i d t h e i r TABLE XVI COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY SCORE ON KNOWLEDGE AND SKILL TESTS REGARDING URINE TESTING Score (20 max.) Score (20 max.) C o n t r o l P a t i e n t s Experimental P a t i e n t s C o n t r o l P a t i e n t s Experimental P a t i e n t s -2.0 9.5 12.0 16.0 2.0 10.0 14.0 16.0 4.0 11.0 14.5 17.0 5.0 12.0 15.0 17.0 7.0 13.5 15.0 17.0 10.0 14.0 16.0 17.5 11.0 14.0 17.0 18.0 11.0 14.5 18.0 20.0 11.0 15.0 12.0 15.0 C = 10.95 E = 14.9 t = 3.110 ( s i g n i f i c a n t at the .005 l e v e l ) TABLE XVII COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY SCORE ON INSULIN KNOWLEDGE AND SKILL TESTS Scores of C o n t r o l P a t i e n t s (21 max.) Scores of Experimental P a t i e n t s (21 max.) 10.0 15.0 12.0 16.0 13.0 16.5 13.0 17.0 14 .5 17.0 14 .5 18.0 14 .5 18 .5 15.0 18 .5 16.5 19.0 18 .5 20.5 C = 14.15 E = 17.60 t = 3 .820 ( s i g n i f i c a n t at the .005 l e v e l ) TABLE XVIII COMPARISON OF CONTROL AND EXPERIMENTAL PILL-USERS BY TOTAL PERCENTAGE SCORE ON TEST OF DIABETIC LEARNING Percentage Score of Percentage Score of Co n t r o l P a t i e n t s Experimental P a t i e n t s 20.5 57.5 23.5 64 .5 24.0 65.5 31.5 71.0 32.0 76.5 5O.5 77.0 59.0 79.5 59.5 80.0 62.0 84 .5 71.5 84 .5 C = 43.40 E = 74.05 t = 4.592 ( s i g n i f i c a n t at a l l known l e v e l s ) TABLE XIX COMPARISON OF CONTROL AND EXPERIMENTAL INSULIN-USERS BY TOTAL PERCENTAGE SCORE ON TEST OF DIABETIC LEARNING Percentage Score of .... C o n t r o l P a t i e n t s Percentage Score of Experimental P a t i e n t s -37.2 65.4 38.8 66.8 5^ .3 72.4 58.2 76.7 72.4 78.4 72.8 79.6 73.7 82.1 73.7 84.1 80.2 86.2 86.6 87.1 C = 64.79 E = 77.88 t = 2.227 ( s i g n i f i c a n t at the .025 l e v e l ) 75 c o n t r o l c o u n t e r p a r t s . I t i s worth n o t i n g at t h i s p o i n t t h a t w h i l e the d i f f e r e n c e between the knowledge scores of the two groups of i n s u l i n - u s e r s was 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 d i f f e r e n c e between the t o t a l percentage scores was s t a t i s -t i c a l l y s i g n i f i c a n t . Therefore, l e a r n i n g at the a p p l i c a t i o n l e v e l — d e m o n s t r a t e d by performance on the s k i l l t e s t s — m u s t have been c o n s i d e r a b l e , e s p e c i a l l y when one considers t h a t s k i l l s c o n t r i b u t e l e s s (forty-one t o f i f t y p o i n t s ) t o the t o t a l score than does knowledge ( s e v e n t y - f i v e p o i n t s ) . These r e s u l t s show t h a t d i a b e t i c i n s u l i n - u s e r s taught by means of the " D i a b e t i c Teaching T o o l " demonstrated a higher l e v e l of l e a r n i n g about t h e i r d i a b e t i c management than d i d those taught i n the i n s t i t u t i o n ' s u s u a l manner. The f i n a l t - t e s t a n a l y s i s o f the data was performed on the t o t a l percentage t e s t scores of a l l c o n t r o l and e x p e r i -mental s u b j e c t s . A c c o r d i n g l y , Table XX presents a comparison of these s c o r e s . Once again a h i g h l y s i g n i f i c a n t d i f f e r e n c e was found between the scores of the two groups. On the b a s i s of t h i s and the preceding analyses the n u l l h y p o t h e s i s — " t h e r e 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 of p a t i e n t s i n the experimental group as compared w i t h p a t i e n t s i n the con-t r o l group"—was r e j e c t e d . TABLE XX COMPARISON OF CONTROL AND EXPERIMENTAL PATIENTS BY TOTAL PERCENTAGE SCORE ON TEST OF DIABETIC LEARNING Percentage Score Percentage Score C o n t r o l ... P a t i e n t s Experimental P a t i e n t s C o n t r o l P a t i e n t s Experimental P a t i e n t s 20.5 5 7 . 5 5 9 . 5 7 9 . 5 23.5 6 4 . 5 6 2 . 0 7 9 . 6 2 4 . 0 6 5 . 4 7 1 . 5 8 0 . 0 3I.5 6 5 . 5 72 .4 8 2 . 1 32.O 6 6 . 8 72.8 8 4 . 1 3 7 . 2 7 1 . 0 7 3 . 7 8 4 . 5 3 8 . 8 72 .4 7 3 . 7 8 4 . 5 50.5 7 6 . 5 8 0 . 2 8 6 . 2 5 4 . 3 7 6 . 7 8 6 . 6 8 7 . 1 5 8 . 2 7 7 . 0 5 9 . 0 7 8 . 4 C = 5 4 . 1 0 E = 7 5 . 9 7 t = 4 . 3 8 I ( s i g n i f i c a n t at a l l known l e v e l s ) 77 C o r r e l a t i o n s Between Selected 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 Subjects  and T h e i r Respective Test Scores Fi v e demographic and/or 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 study s u b j e c t s — a g e at t e s t i n g , education, reason f o r c u r r e n t admission, age at onset of diabetes and d u r a t i o n of d i a b e t e s -were s e l e c t e d f o r t h i s s e c t i o n of the data a n a l y s i s on the b a s i s t h a t there might be a r e l a t i o n s h i p between one or more of these f a c t o r s and the scores which s u b j e c t s achieved on the t e s t of d i a b e t i c l e a r n i n g . Table XXI shows the r e l a t i o n s h i p between the s u b j e c t s * age at t e s t i n g and t h e i r t o t a l t e s t s c o r e s . Age at t e s t i n g proved to be a h i g h l y s i g n i f i c a n t f a c t o r i n f l u e n c i n g t e s t scores i n the c o n t r o l group (the o l d e r the p a t i e n t , the lower h i s t e s t s c o r e ) ; i t was 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 i n the experimental group. Two p o s s i b l e reasons are suggested f o r t h i s f i n d i n g . In the f i r s t p l a c e , t h e r e was a l a r g e r pro-p o r t i o n o f s u b j e c t s over s e v e n t y - f i v e years of age i n the c o n t r o l group. This might have accounted f o r some d i f f e r e n c e i n the c o r r e l a t i o n c o e f f i c i e n t s , although i t i s questionable t h a t the e n t i r e d i f f e r e n c e could be a t t r i b u t e d t o t h i s f a c t . In the second p l a c e , i t i s p o s s i b l e t h a t nurses (as many other people^") have a negative mind-set toward the l e a r n i n g capa-c i t i e s of a d u l t s . I f t h a t were the case, they would b e l i e v e Adult Educationt Theory and Method. Psychology of the  Adult^ (Washington i Adult Education A s s o c i a t i o n of the U.S.A., I O T . P. 5. 78 TABLE XXI THE RELATIONSHIP BETWEEN AGE AT TESTING AND TOTAL PERCENTAGE SCORE Co n t r o l P a t i e n t s Experimental P a t i e n t s . Age Score Age Score mm m mmmm 1 (15-24 years) 79.6 2 (25-34 years) 72.4 2 (25-34 years) 78.4 2 86.6 — — 3 (35-44 years) 72.8 3 (35-44 years) 57.5 3 73.7 3 76.7 — ~ * * • 3 3 82.1 84.5 -- 3 86.2 4 (45-54 years) 54.3 4 (45-54 years) 71.0 4 58.2 4 76.5 4 71.5 4 77.0 4 73.7 4 84.1 4 80.2 4 84.5 _- — 4 87.1 5 (55-64 years) 38.8 5 (55-64 years) 64,5 5 50.5 5 66.8 — 5 79.5 6 (65-74 years) 23.5 6 (65-74 years) 65.5 6 62.0 6 80.0 7 (75-84 years) 20.5 7 (75-84 years) 65.4 7 31.5 7 72.4 7 32.0 — — 7 37.2 — 7 59.0 — — 8 (85 y r . or more) 24.0 — 8 59.5 r c = -.627 ( s i g n i f i c a n t at = -.38I (not s i g n i f i c a n t a l l known l e v e l s ) £1 • 79 t h a t t h e i r o l d e r p a t i e n t s were unable to l e a r n , and thus would not make the same e f f o r t to teach them t h a t they would w i t h younger p a t i e n t s . In the experimental phase of the study the nurses were i n s t r u c t e d to teach a l l d i a b e t i c p a t i e n t s ; thus t h i s e f f e c t may have been overcome. Table XXII i s concerned w i t h the r e l a t i o n s h i p between the e d u c a t i o n a l background of the s u b j e c t s and t h e i r t e s t s c o r e s . Here again, a h i g h 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 was found between these two f a c t o r s i n the c o n t r o l group (the higher the educa-t i o n the h i g h e r the s c o r e ) ; but v i r t u a l l y no such r e l a t i o n s h i p e x i s t e d i n the experimental group. Once again, two reasons are suggested. Three s u b j e c t s i n the c o n t r o l group had only three or f o u r years of formal s c h o o l i n g , whereas no experimental sub-j e c t s f e l l i n t o t h i s c l a s s i f i c a t i o n . A l l three of these c o n t r o l s u b j e c t s had q u i t e low t e s t s c o r e s , which undoubtedly i n f l u e n c e d the c o r r e l a t i o n c o e f f i c i e n t . Another c o n t r i b u t o r might be a p s y c h o l o g i c a l f a c t o r s i m i l a r t o the one j u s t d e scribed r e l a t i n g to age, t h a t i s i nurses may have a negative mind-set toward the l e a r n i n g c a p a c i t i e s of i n d i v i d u a l s w i t h l i m i t e d education. Such i n d i v i d u a l s are o f t e n not well-spoken, hence there may be a tendency to assume t h a t they have l i m i t e d understanding. D i a b e t i c t e a c h i n g i n such i n s t a n c e s probably tends t o be d i l u t e d or omitted. This f a c t o r could not act i n the e x p e r i -mental phase of the study (since a l l d i a b e t i c p a t i e n t s were to be t a u g h t ) , thus accounting f o r the c o n s i d e r a b l e d i f f e r e n c e i n the scores of s u b j e c t s w i t h j u s t s i x t o e i g h t years of s c h o o l i n g . TABLE XXII THE RELATIONSHIP BETWEEN EDUCATION AND TOTAL PERCENTAGE SCORE Control Patients Experimental Patients Schooling (Years) Score Schooling (Years) Score 3 38.8 mm mm 4 24.0 — 4 32.0 — 6 23.5 6 65.4 6 58.2 — --— — 7 65.5 — — 7 80.0 8 20.5 8 76.5 8 31.5 8 79.5 8 73.7 8 79.6 — — 8 82.1 — — 8 87.1 9 54.3 9 76.7 9 72.8 — — 10 72.4 10 72.4 — — — 10 84.5 — — 10 84.5 11 50.5 11 57.5 11 59.5 11 71.0 11 71.5 — — 12 37.2 12 77.0 12 73.7 12 78.4 — — 12 84.1 — — 13 64.5 14 62.0 14 66.8 14 59.0 -~ — 14 80.2 — — 15 86.6 16 86.2 r c = .801 (significant at r w = .002 (not signi-— a l l known levels] ficant) 81 Table XX I I I examines the r e l a t i o n s h i p between s u b j e c t s ' scores and t h e i r reason f o r current admission to h o s p i t a l . I t was f e l t t h a t p a t i e n t s admitted f o r t h e i r diabetes (that i s , new d i a b e t i c s , or long-standing d i a b e t i c s having c o m p l i c a t i o n s or needing r e g u l a t i o n ) might r e c e i v e more teaching and thus score b e t t e r on the subsequent t e s t of d i a b e t i c l e a r n i n g than p a t i e n t s admitted f o r u n r e l a t e d c o n d i t i o n s . This d i d not prove to be the case i n e i t h e r the c o n t r o l or the experimental group. Table XXIV shows the r e l a t i o n s h i p between age at onset of diabetes and subsequent t e s t s c o r e s . Once again the r e s u l t s of t h i s c o r r e l a t i o n were markedly d i f f e r e n t i n the two study groups. There was a h i g h l y s i g n i f i c a n t c o r r e l a t i o n between age at onset and t e s t score i n the c o n t r o l group (the l a t e r the age at onset, the lower the t e s t s c o r e ) , but 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 i n the experimental group. The f a c t t h a t there were f o u r more c o n t r o l than experimental s u b j e c t s w i t h an age at onset over s i x t y - f i v e years might account f o r p a r t of t h i s d i f f e r e n c e . A r a t h e r complex p s y c h o l o g i c a l f a c t o r might a l s o have i n f l u e n c e d the r e s u l t s . When younger i n d i v i d u a l s become a f f l i c t e d w i t h a chronic c o n d i t i o n , there may be a tendency f o r h e a l t h care personnel t o i d e n t i f y w i t h them and thus put f o r t h an e x t r a e f f o r t to a s s i s t these p a t i e n t s t o cope w i t h t h e i r a l t e r e d l i f e s t y l e . With o l d e r i n d i v i d u a l s , however, e s p e c i -a l l y i f the t e a c h i n g does not progress e a s i l y , there may be a tendency to l e t matters s l i d e w i t h the r a t i o n a l i z a t i o n t h a t these people have ' l i v e d good l i v e s ' and are 'too o l d to change anyway.' Complicating t h i s i s the e t i o l o g i c a l f a c t t h a t when 82 TABLE XXIII COMPARISON OF TOTAL PERCENTAGE SCORES OF ALL PATIENTS BY REASON FOR CURRENT ADMISSION TO HOSPITAL Contro l Pat ients ' Scores Experimental Pat ient s ' Scores Diabetes-Related Unrelated Diabetes-Related Unrelated Admissions Admissions Admissions Admissions 20.5 24.0 64.5 57.5 23.5 32.0 65.4 65.5 31.5 37.2 66.8 72.4 50.5 38.8 71.0 76.7 54.3 59.0 76.5 77.0 58.2 59.5 78.4 79.6 72.4 62.0 79.5 84.5 73.7 71.5 80.0 84.5 80.2 72.8 82.1 86.6 73.7 84.1 86.2 87.1 5 =-55.14 c 1 = 53.05 E = 76.80 E 1 = 74.71 t = .220 (not s i g n i f i c a n t ) t = .534 (not s i g n i f i c a n t ) 83 TABLE XXIV THE RELATIONSHIP BETWEEN AGE AT ONSET OF DIABETES AND TOTAL PERCENTAGE SCORE Co n t r o l P a t i e n t s Experimental P a t i e n t s Age at Onset Score Age at Onset Score 1 ( 0 - 1 4 years) 72 .4 1 ( 0 - 1 4 years) 76.7 1 72.8 — — — — 2 (15-24 years) 7 9 . 6 — 2 8 2 . 1 3 (25-34 years) 8 6 . 6 3 (25-34 years) -- 3 7 8 . 4 — 3 8 4 . 1 — _ — 3 8 4 . 5 — - — 3 8 6 . 2 4 ( 3 5 - 4 4 years) 2 4 . 0 4 ( 3 5 - 4 4 years) 76 .5 4 5 9 . 5 -- — 4 7 3 . 7 — — 4 8 0 . 2 — — 5 ( 4 5 - 5 4 years) 5 4 . 3 5 ( 4 5 - 5 4 years) 6 6 . 8 5 5 8 . 2 5 7 1 . 0 5 7 1 . 5 5 7 7 . 0 5 7 3 . 7 5 8 4 . 5 — 5 87 . I 6~ ( 5 5 - 6 4 years) 2 0 . 5 6 ( 5 5 - 6 4 years) 6 4 . 5 6 50 .5 6 7 2 . 4 — - — 6 7 9 . 5 7 ( 6 5 - 7 4 years) 23 .5 7 ( 6 5 - 7 4 years) 6 5 . 4 7 31 .5 7 6 5 . 5 7 32.0 7 8 0 . 0 7 3 7 . 2 — 7 5 9 . 0 — — 7 6 2 . 0 -- — 8 ( 7 5 y r . o r over) 3 8 . 8 —— — — = - . 6 1 1 ( s i g n i f i c a n t at r „ = - . 3 4 4 (not s i g n i -c . - a l l known l e v e l s ) 1 1 f i c a n t ) 84 diabetes has i t s onset e a r l y i n l i f e i t i s l i k e l y t o be more d i f f i c u l t to c o n t r o l . Thus the l e a r n i n g needs of the p a t i e n t w i t h an e a r l y onset would be more apparent, and he would r e -ceive more a t t e n t i o n on t h i s count as w e l l . The e f f e c t of these i n f l u e n c e s would to some degree have been abated i n the experimental group where a l l p a t i e n t s were to be taught. Table XXV i n d i c a t e s the r e l a t i o n s h i p between d u r a t i o n of diabetes and t e s t s c o r e s . I t was suggested t h a t , on the one hand, persons w i t h a longer d u r a t i o n of diabetes would have had more l e a r n i n g o p p o r t u n i t i e s and so would score b e t t e r . On the other hand, i t was f e l t t h a t the l e a r n i n g needs of l o n g -standing d i a b e t i c s might not be apparent to t h e i r nurses? thus they would r e c e i v e no review or reinforcement of t h e i r l e a r n i n g , and would not achieve good t e s t s c o r e s . For both the e x p e r i -mental and c o n t r o l groups the c o r r e l a t i o n c o e f f i c i e n t s f o r t h i s a n a l y s i s were not s i g n i f i c a n t . This may i n d i c a t e t h a t d u r a t i o n of diabetes and t e s t scores are simply not r e l a t e d , or i t may i n d i c a t e t h a t both of the above suggestions are v a l i d , but t h a t t h e i r e f f e c t s c a n c e l one another. In summary, 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 s were found between the t o t a l percentage t e s t scores of c o n t r o l pa-t i e n t s and the f o l l o w i n g f a c t o r s i age at t e s t i n g , education, and age at onset of dia b e t e s . 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 group. 85 TABLE XXV THE RELATIONSHIP BETWEEN DURATION OF DIABETES AND TOTAL PERCENTAGE SCORE Co n t r o l P a t i e n t s Experimental P a t i e n t s Duration Score Duration Score 1 ( l e s s than 1 year) 23.5 1 ( l e s s than 1 year) 64 .5 1 38.8 1 71.0 1 50.5 1 77.0 1 62.0 1 78.4 1 73.7 1 79.5 - - 1 80 .0 — - — 1 86.2 — - — 1 87.1 2 (1-5 y e a r s ) 31.5 2 (1-5 years) 65.5 2 58.2 2 79.6 2 71.5 — — 2 73.7 - - — 2 86.6 mm mm 3 (6-10 years) 32.0 3 (6-10 years) 84 .5 3 54.3 3 (over 10 years) 84 .5 4 (over 10 years) 20.5 4 57.5 4 24 .0 4 65.4 4 37.2 4 66.8 4 59.0 4 72.4 4 59.5 4 76.5 4 • 72.4 4 76.7 4 72.8 4 82 .1 4 80 .2 4 84 .1 = -.028 (not s i g n i f i c a n t ) r E = -.230 (not s i g n i f i c a n t ; 86 CHAPTER V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS The purpose of t h i s study was to answer the q u e s t i o n , • W i l l d i a b e t i c p a t i e n t s taught by means of a " D i a b e t i c Teaching T o o l " demonstrate a h i g h e r l e v e l of l e a r n i n g about s e l f - c a r e than p a t i e n t s taught i n the i n s t i t u t i o n ' s u s u a l manner?' The answer to the q u e s t i o n was sought by comparing the s e l f - c a r e knowledge and s k i l l s of two groups of d i a b e t i c p a t i e n t s admitted t o a suburban general h o s p i t a l which, p r i o r t o the study, o f f e r e d no planned programme of d i a b e t i c p a t i e n t education. The twenty s u b j e c t s i n the c o n t r o l group were taught i n an unplanned manner, based upon whether and/or what i n s t r u c t i o n s were deemed p e r t i n e n t by t h e i r nurses. A "Dia-b e t i c Teaching T o o l " — d e s i g n e d by the researcher and adminis-t e r e d by each p a t i e n t ' s own n u r s e ( s ) — w a s used t o i n s t r u c t the twenty experimental s u b j e c t s . A f t e r d i s c h a r g e , each o f the f o r t y s u b j e c t s was v i s i t e d by the r e s e a r c h e r , at which time a p r o f i l e sheet was completed and a t e s t of d i a b e t i c l e a r n i n g a d ministered. 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 — obtained from the p a t i e n t p r o f i l e s h e e t s — w e r e analyzed and described i n terms of d i s t r i b u t i o n s , medians and/or means. The t e s t r e s u l t s were subjected t o t - t e s t analyses on s e v e r a l 87 dimensions. And a number of demographic and d i a b e t i c t r a i t s were compared w i t h t h e i r r e s p e c t i v e t e s t scores by means o f 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 . Summary of the Findings The major f i n d i n g s of the study are presented here i n summary form. 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 t y p i c a l c o n t r o l p a t i e n t i n t h i s study was a married female f i f t y - f o u r years of age at the time of t e s t i n g . She had completed nine and one h a l f years of s c h o o l i n g , and was p r e s e n t l y not working o u t s i d e o f her home. She was f i r s t diagnosed as having diabetes at f i f t y - o n e years of age, and had thus been d i a b e t i c f o r three y e a r s . She viewed the docto r , the d i e t i t i a n , f r i e n d s or r e l a t i v e s and pamphlets as her most h e l p f u l sources of i n f o r m a t i o n r e g a r d i n g diabetes management. The t y p i c a l experimental p a t i e n t , on the other hand, was a l s o a married female, but s l i g h t l y younger (approximately f i f t y years o f age at the time of t e s t i n g ) . She had completed ten years of s c h o o l i n g , and was not employed ou t s i d e of her home. She was f o r t y - s i x years o l d when her d i a g n o s i s of d i a -betes was e s t a b l i s h e d , and had thus been d i a b e t i c f o r four years at the time of t h i s study. She named the nurse, the " D i a b e t i c Teaching T o o l , " the doctor and the d i e t i t i a n as the sources of d i a b e t i c i n f o r m a t i o n which she found most u s e f u l i n teac h i n g her home care. 88 F i f t y per cent of the s u b j e c t s i n each study group were c o n t r o l l e d by a n t i d i a b e t i c p i l l s , and f i f t y per cent by i n s u l i n . Reason f o r current h o s p i t a l admission was r e l a t e d t o the d i a b e t i c c o n d i t i o n f o r h a l f the c o n t r o l s u b j e c t s and twelve o f the twenty experimental p a t i e n t s . Scores on the t e s t of d i a b e t i c l e a r n i n g 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 s were found between c o n t r o l and experimental s u b j e c t s ' scores i n the f o l l o w i n g areas» (1) knowledge sub-test f o r a n t i d i a b e t i c p i l l - u s e r s , (2) d i e t p l a n n i n g s k i l l s ub-test f o r both i n s u l i n - and p i l l - u s e r s , (3) u r i n e t e s t i n g s k i l l sub-test f o r both i n s u l i n - and p i l l - u s e r s , and (4) i n s u l i n i n j e c t i n g s k i l l s u b - t e s t . While experimental s u b j e c t s d i d achieve a b e t t e r mean score on the knowledge sub-t e s t f o r i n s u l i n - u s e r s than d i d t h e i r c o n t r o l c o u n t e r p a r t s , t h i s f i n d i n g was 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 . When the knowledge and s k i l l scores f o r s e l e c t e d areas o f d i a b e t i c management were combined, 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 s were found between c o n t r o l and experimental s u b j e c t s on each of the f o l l o w i n g i t e m s i d i e t p l a n n i n g , u r i n e t e s t i n g and medications. Moreover, there was 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 d i f f e r e n c e between the t o t a l percentage t e s t scores achieved by the c o n t r o l s u b j e c t s and those of the experimental s u b j e c t s . On the b a s i s of these f i n d i n g s , the n u l l h y p o t h e s i s — t h e r e 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 of p a t i e n t s i n the c o n t r o l group as compared w i t h p a t i e n t s i n the experimental group—was r e j e c t e d . 89 Other dimensions H i g h l y s i g n i f i c a n t c o r r e l a t i o n s were found between the t o t a l percentage t e s t scores of the c o n t r o l s u b j e c t s and the f o l l o w i n g c h a r a c t e r i s t i c s i age at t e s t i n g , education, and age at onset of dia b e t e s . However, no such c o r r e l a t i o n s were found f o r the experimental s u b j e c t s , a f a c t which may be a t t r i b u t a b l e , at l e a s t i n p a r t , t o the i n s t r u c t i o n s accompanying t h e " D i a b e t i c Teaching Tool." F i n a l l y , i n n e i t h e r of the study groups was there 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 between t o t a l percentage t e s t scores and d u r a t i o n of diabetes or reason f o r cur r e n t h o s p i t a l admission. Conclusions From the f i n d i n g s the f o l l o w i n g c o n c l u s i o n s are drawni 1. D i a b e t i c p a t i e n t s taught by means o f the " D i a b e t i c Teaching T o o l w demonstrated a s i g n i f i c a n t l y h i g h e r 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 which had p r e v i o u s l y been employed by graduate nurses i n the i n s t i t u t i o n s t u d i e d . 2 . 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 s were found between t e s t scores of p a t i e n t s taught w i t h the " D i a b e t i c Teaching To o l " and those r e c e i v i n g unplanned i n s t r u c t i o n r e g a r d l e s s of the du-r a t i o n of t h e i r d i a b e t e s . Thus * o l d ' d i a b e t i c s were able t o de r i v e as much b e n e f i t from the te a c h i n g t o o l as were 'new* d i a b e t i c s . 3. The l e v e l of l e a r n i n g demonstrated by p a t i e n t s taught w i t h the " D i a b e t i c Teaching To o l " appeared to be independent of the 90 f o l l o w i n g f a c t o r s t age at time of teaching and t e s t i n g , pre-v i o u s education, and age at onset of diabete s ; whereas each of these f a c t o r s was 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 , 4, D i a b e 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 T o o l " c i t e d the nurse as a v a l u a b l e source of i n f o r m a t i o n r e -garding d i a b e t i c management more than f i v e times as f r e q u e n t l y as d i d 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 m p l i c a t i o n s Success i n the treatment of diabetes today depends to a l a r g e degree on the i n s t r u c t i o n of the p a t i e n t i n the management of the d i s o r d e r under the c o n d i -t i o n s of h i s home l i f e , h i s work and h i s other a c t i v i t i e s . 1 Regardless of whether or not the nurse expands her f u n c t i o n s to i n c l u d e assessment, c o u n s e l l i n g , co-o r d i n a t i o n and follow-up of d i a b e t i c p a t i e n t s , she w i l l almost c e r t a i n l y r e t a i n a primary r o l e i n t h e i r i n i t i a l and ongoing h e a l t h t e a c h i n g . 2 The prevalence of diabetes demands t h a t , r e g a r d l e s s of t h e i r f i e l d of i n t e r e s t , a l l n u r s i n g personnel should be f a m i l i a r w i t h t h i s c o n d i t i o n and i t s management.3 In l i g h t of the above statements, the f i n d i n g s of t h i s study have s e v e r a l i m p l i c a t i o n s f o r nurses l i k e l y to be i n t e r a c t i n g w i t h d i a b e t i c p a t i e n t s . The f o l l o w i n g are the major i m p l i c a -t i o n s drawn from these f i n d i n g s i See page 2. 2 See page 5« Donnell D. E t z w i l e r , "Who's Teaching the D i a b e t i c ? " Diabetes, XVI, No. 2 (February 1967), 116. 91 1. The low t e s t scores achieved by p a t i e n t s i n the c o n t r o l group of t h i s study (m = 54.15 per cent) suggest t h a t the unplanned type of d i a b e t i c p a t i e n t i n s t r u c t i o n provided i n many s e t t i n g s does not s a t i s f y p a t i e n t s ' l e a r n i n g needs regarding home management. Therefore, nurses c u r r e n t l y employed i n such s e t t i n g s would do w e l l t o co n s i d e r other means of d i a b e t i c p a t i e n t education, 2. The t e s t scores achieved by p a t i e n t s i n the experimental group of t h i s study (m = 75*97 per cent) suggest t h a t the "Dia-b e t i c Teaching T o o l " i s a u s e f u l a i d t o nurses p r o v i d i n g i n -s t r u c t i o n s f o r d i a b e t i c home-management. Therefore, nurses c u r r e n t l y employed i n s e t t i n g s g i v i n g an unplanned type of d i a b e t i c i n s t r u c t i o n might consider t h i s t o o l as one a l t e r n a -t i v e i n t h e i r search f o r more s u c c e s s f u l methods of d i a b e t i c p a t i e n t education. 3. P a t i e n t s i n t h i s study appeared t o b e n e f i t from the planned type of i n s t r u c t i o n provided by the " D i a b e t i c Teaching Tool" r e g a r d l e s s of the d u r a t i o n of t h e i r d i a b e t e s . Therefore, nurses cannot s a f e l y assume t h a t p a t i e n t s w i t h long standing diabetes are knowledgeable and/or s k i l f u l w i t h respect t o home-management. Rather, each contact w i t h a d i a b e t i c p a t i e n t ought to be viewed and u t i l i z e d by the nurse as a teaching o p p o r t u n i t y . 4. The f a c t t h a t the l e v e l of l e a r n i n g demonstrated by p a t i e n t s i n the c o n t r o l group showed a high negative c o r r e l a t i o n w i t h age at the time of teaching and t e s t i n g (while t h i s was not the case i n the experimental group) suggests t h a t nurses may have i n t e r -n a l i z e d s o c i e t y ' s b i a s a g a i n s t the l e a r n i n g a b i l i t y of o l d e r 92 i n d i v i d u a l s . Nurses should be aware of t h i s b i a s , and o f the f a c t t h a t i t has not been s u b s t a n t i a t e d i n a d u l t education r e s e a r c h . ^ They should, t h e r e f o r e , make a wholehearted e f f o r t to provide i n s t r u c t i o n s i n home management to a l l d i a b e t i c p a t i e n t s , r e g a r d l e s s of age. 5. The f a c t t h a t the l e v e l of l e a r n i n g demonstrated by p a t i e n t s i n the c o n t r o l group showed a high p o s i t i v e c o r r e l a t i o n w i t h previous education (while t h i s was not the case i n the e x p e r i -mental group) suggests t h a t nurses may act on the assumption t h a t p a t i e n t s w i t h l i t t l e formal education are l e s s able t o l e a r n adequate d i a b e t i c management than p a t i e n t s w i t h more s c h o o l i n g . Rather than o m i t t i n g or d i l u t i n g d i a b e t i c t e a c h i n g f o r p a t i e n t s w i t h l i t t l e formal education nurses should a t t e n d t o a l t e r n a t e ways i n which the r e q u i s i t e knowledge and s k i l l s can be presented to these p a t i e n t s . 6. The f a c t t h a t the l e v e l o f l e a r n i n g demonstrated by pa-t i e n t s i n the c o n t r o l group showed a hi g h negative c o r r e l a t i o n w i t h age at onset of diabetes (while t h i s e f f e c t was much l e s s marked i n the experimental group) suggests t h a t nurses may put f o r t h a g r e a t e r e f f o r t to teach home management to p a t i e n t s whose diabetes i s diagnosed at an e a r l y age than those diagnosed l a t e r i n l i f e . Nurses must be aware of t h i s tendency and s t r i v e t o overcome i t by i n c r e a s i n g the e f f o r t expended on the d i a b e t i c t e a c h i n g of o l d e r i n d i v i d u a l s . Adult Education! Theory and Method. Psychology of the Adult^ (Washington1 Adult Education A s s o c i a t i o n of the U.S.A., 19627, P. 5. 93 7. The frequency w i t h which p a t i e n t s i n the experimental group c i t e d the nurse as a h e l p f u l source of i n f o r m a t i o n about d i a -b e t i c management suggests t h a t a planned programme of diabetes p a t i e n t education (such as t h a t provided f o r by the " D i a b e t i c Teaching Tool") can s i g n i f i c a n t l y a f f e c t the success nurses have i n f i l l i n g t h e i r r o l e as i n i t i a l and ongoing d i a b e t i c h e a l t h - t e a c h e r s . Recommendations f o r Further Study As has been f r e q u e n t l y mentioned, c u r r e n t methods, t e c h -niques and devices f o r d i a b e t i c p a t i e n t education are not ade-quately meeting the l e a r n i n g needs of the t a r g e t p o p u l a t i o n . The r e s u l t s of t h i s study i n d i c a t e t h a t the " D i a b e t i c Teaching To o l " designed by the researcher may have p o t e n t i a l f o r im-p r o v i n g t h i s s i t u a t i o n . However, before these r e s u l t s can be g e n e r a l i z e d to the d i a b e t i c p o p u l a t i o n at l a r g e , s e v e r a l other avenues of research need to be pursued. The f o l l o w i n g recom-mendations f o r f u r t h e r study are t h e r e f o r e madei 1. In order t o assess the d u r a b i l i t y of the l e a r n i n g of pa-t i e n t s taught by means of the " D i a b e t i c Teaching T o o l , " repeat t e s t i n g of t h e i r knowledge and s k i l l s should be conducted s i x months to one year a f t e r the o r i g i n a l t e s t date. 2. In order t o assess the t r a n s f e r a b i l i t y of the r e s u l t s of t h i s study t o s e t t i n g s other than suburban h o s p i t a l s which c u r r e n t l y have no planned programme of d i a b e t i c p a t i e n t educa-t i o n , the procedures of the study should be r e p l i c a t e d i n a 94 v a r i e t y of other se t t ings (for example, pub l i c heal th u n i t s , phys i c i ans ' o f f i ce s and the d iabe t i c out-pat ient departments of urban h o s p i t a l s ) . 3. In order to assess the r e l a t i v e merits of the "Diabet ic Teaching T o o l " as compared with other planned methods of d i a -b e t i c i n s t r u c t i o n , s tudies should be undertaken i n which the l e a r n i n g of pat ients taught with the "Diabet ic Teaching T o o l " i s compared with that of pat ients taught i n d iabe t i c day care centres , i n d iabe t i c c l i n i c s , i n d iabet ic classes and i n d i a -be t i c home care programmes which are cur ren t ly operat ing . 4. In order that nurses may take into account the teacher , l ea rner and environmental vari ables which predispose d i f f e rent pat ients to respond i n d i f f e rent ways to d i f f e rent nurses on d i f f e r e n t occas ions , s tudies should be undertaken i n which these va r i ab le s and t h e i r r e l a t i o n to pa t i en t s ' u l t imate l e v e l of l e a rn ing are c l o s e l y examined. 9 5 SOURCES CONSULTED Books Adult Educat ion; Theory and Method. 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Rexdale, O n t a r i o i Ames Company, n.d. I n s t r u c t i o n s t o Teachers w i t h D i a b e t i c C h i l d r e n i n t h e i r C l a s s e s . Toronto, Ontario i Canadian D i a b e t i c A s s o c i a t i o n , 1964. Insulin-Use Information K i t . Clarkson, O n t a r i o i Becton-Dickinson and Company, n.d. I n s u l i n and I n s u l i n P r e p a r a t i o n s . Willowdale, O n t a r i o i Connaught L a b o r a t o r i e s , n.d. Manual f o r D i a b e t i c s i n Canada. Toronto, Ontario t Canadian D i a b e t i c A s s o c i a t i o n , 1968. One Out of Every F i f t y Canadians may be a D i a b e t i c . Toronto, Ontario t Canadian D i a b e t i c A s s o c i a t i o n , 1971. Right from the S t a r t i Complimentary C l i n i t e s t I n s t r u c t i o n K i t . Rexdale, O n t a r i o j Ames Company, n.d. Some Thoughts f o r Young D i a b e t i c s and t h e i r Parents. Toronto, Ontario t Canadian D i a b e t i c A s s o c i a t i o n , 1965. Stop, Read and Understand Food Labels. Toronto, O n t a r i o i Canadian D i a b e t i c A s s o c i a t i o n , 1967. This Could Save Your L i f e . Toronto, Ontario 1 Canadian Medic-A l e r t , n.d. T r a v e l l i n g w i t h Diabetes. Toronto, Ontario 1 Canadian D i a b e t i c A s s o c i a t i o n , n.d. Films and F i l m s t r i p s Four i n a Crowd. A f i l m produced through the Nova Foundation f o r World Health Year, 1971. What i s Diabetes? A f i l m s t r i p and record programme produced by Trainex Company of C a l i f o r n i a , n.d. Taking Care of Diabetes. A t u t o r f i l m produced by the Welch S c i e n t i f i c Company of Skokie, I l l i n o i s , n.d. Interviews and Correspondence Be s s i e , S. D i e t i t i a n a t Royal Columbian H o s p i t a l , New West-min s t e r , B.C. Interview h e l d February, 1972. 101 Beyers, Rene. D i e t i t i a n at Diabetic C l i n i c , Lions Gate Hospital, North Vancouver, B.C. Interviews held A p r i l and September, 1972. Birkbeck, Dr. John. Interviews held at Children's Hospital and the University of B r i t i s h Columbia, Vancouver, B.C., January, March and May, 1972. Cairns, Dr. Alexander. Interviews held at Vancouver General Hospital, Vancouver, B.C., February and September, 1972. Elfstrom, Kerry. Diabetic Patient, Vancouver, B.C. Interview held September, 1972. Foley, Maureen. Nursing Instructor, University of Ottawa, Ottawa, Ont. Letter received January, 1972. Hunt, Dr. John. Interviews held at Lion's Gate Hospital, North Vancouver, B.C., August and September, 1972. Moellenkamp, Karen. Nursing Instructor, Women's College Hos-p i t a l , Toronto, Ontario. Letter received March, 1972. Pagan, W. Diabetic Teaching C l i n i c Coordinator, St. Paul's Hospital, Vancouver, B.C. Letter received January, 1972. Raine, Helen. Supervisor, Vancouver General Hospital, Vancouver, B.C. Interview held January, 1972. Shamess, Dorothy. Inservice Education Coordinator, St. Michael's Hospital, Toronto, Ontario. Letter received January, 1972. Smith, Diane. Diabetic Patient, Vancouver, B.C. Interview held September, 1972. Smith, Judith. Nurse C l i n i c i a n , Diabetic C l i n i c , McMaster University Health Sciences Complex, Hamilton, Ontario. Letter received A p r i l , 1972. Smith, K. Marion. Assistant Director of Nursing, Surrey Memorial Hospital. Frequent interviews held between February, 1972 and March, 1973. Stevens, N. Director of Nursing, Royal Columbian Hospital, New Westminster, B.C. Interview held February, 1972. Tyson, Jean. Nurse at Diabetic C l i n i c s held at Children's and Lion's Gate Hospitals, Vancouver, B.C. Frequent i n t e r -views held between September, 1971 and December, 1972. Wadsworth, P a t r i c i a . Interview held at Vancouver General Hospital, Vancouver, B.C., February, 1972. 102 Whiting, J . Health Teacher, U n i v e r s i t y H o s p i t a l , Saskatoon, Sask. L e t t e r r e c e i v e d January, 1972. Other D i a b e t i c Day Care Centres t Current Concepts. Rexdale, Ontario t Ames D i v i s i o n , M i l e s L a b o r a t o r i e s , 1969. E l l i s , Edward V. "A Comparative A n a l y s i s of Good, Poor and Very Poor C o n t r o l D i a b e t i c P a t i e n t s as a Basis f o r Deter-mining E d u c a t i o n a l Needs." Unpublished Doctoral D i s s e r t a -t i o n , The U n i v e r s i t y of North C a r o l i n a at Chapel H i l l , 1964. G e t t i n g S t a r t e d t A Program f o r Learning about Diabetes. Rutherford, New Jersey i Becton-Dickmson & Company, 1971. Learning About Diabetes. New York» American Diabetes A s s o c i -" a t i o n , 1969. Wadsworth, P a t r i c i a M. "A Study on the Perception of the Nurse and the P a t i e n t i n I d e n t i f y i n g h i s Learning Needs." Unpublished Master's T h e s i s , The U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1970. APPENDIX A MATERIALS PERTAINING TO THE RESUME OF PRESENT KNOWLEDGE I n s t r u c t i o n of the P a t i e n t Suggested Topics f o r D i a b e t i c Teaching Books f o r D i a b e t i c s Pamphlets f o r D i a b e t i c s D i a b e t i c Day Care Centres 104 I n s t r u c t i o n of the P a t i e n t [ i n G a r f i e l d George Duncan, Diabetes M e l l i t u s i P r i n c i p l e s and  Treatment* P h i l a d e l p h i a ! W.B. Saunders Co., 1951J 1. General knowledge of diabetes 2. Causes of the symptoms of diabetes Hunger T h i r s t Loss of weight P o l y u r i a Weakness 3. Sugar i n the u r i n e Source and amount R e l a t i o n to blood sugar Tests f o r sugar i n the u r i n e What u r i n e specimens to t e s t Is sugar i n the u r i n e always an i n d i c a t i o n of d i a b e t e s ? 4. The blood sugar Normal values Why blood sugar determinations are necessary Range of blood sugar values i n untreated diabetes and i n c o n t r o l l e d diabetes 5. Diet p r e s c r i p t i o n P r o t e i n , f a t , carbohydrate and t o t a l c a l o r i e s Diet menu from d i e t p r e s c r i p t i o n S e l e c t i o n and p r e p a r a t i o n of foods Measuring of foods Weighing of foods - r a r e l y necessary D i s t r i b u t i o n of d i e t 6. E x e r c i s e E f f e c t on p a t i e n t ' s weight E f f e c t on blood sugar E f f e c t on need f o r i n s u l i n Adjustment of d i e t and i n s u l i n needs because of e x e r c i s e 7. I n s u l i n Need f o r i n s u l i n and dosage Commercial brands and t h e i r i d e n t i f i c a t i o n A d m i n i s t r a t i o n S t e r i l i z a t i o n and maintenance of equipment Measurement, and mixing when i n d i c a t e d S i t e of i n j e c t i o n Timing of i n j e c t i o n Continued . . . 105 I n s t r u c t i o n of the P a t i e n t (Continued) 8. I n s u l i n r e a c t i o n s (Hypoglycemia) D e f i n i t i o n Symptoms Treatment Cause and pre v e n t i o n Times th a t r e a c t i o n s are most l i k e l y to occur 9 . Changes i n body weight and diabetes Loss of weight i n treatment f o r diabetes Loss of weight i n untreated d i a b e t i c p a t i e n t Gain i n weight 10. What t o do i n case of unretained food - vo m i t i n g or d i a r r h e a - and i n case of complete l o s s of a p p e t i t e w i t h a v e r s i o n to food 11. I n f e c t i o n s and diabetes Sugar i n u r i n e Blood sugar K e t o s i s (coma) What t o do i n case of i n f e c t i o n 12. D i a b e t i c coma ( k e t o s i s ) D e f i n i t i o n Causes Prevention What to do i f k e t o s i s i s suspected 13. Care of the f e e t 14. Surgery and diabetes 15. M i s b e l i e f s - e s p e c i a l l y about the outlook, i n s u l i n s u b s t i t u t e s - there are none - and i n s u l i n a d d i c t i o n . o o H CD tX o O g ft 03 CD CD 3 P 3 CD el-s' P Of CD c+ CD CO • a „ — s P Jo cr CD Du 3 ca c+ 3 H - o in O i ic 5g» P* 3 C CD P ca ro CD 3 O CD ca 01 o 01 CD 3 e+ 3-P M P 3 £L W O (0 CD 3 <+ tr ft a P cr CD c+ H * O O P *1 CD H * 3 Tl H * O c f d CD CO W o o ca > a > tx o w Ui Personal Factors parenthood, t r a v e l s o c i a l , employ & insurance Injur ies & in fec t ions Hygiene Eyes, t ee th , h a i r foot care Exercise Blood tes t s Urine tes t s  Insu l in Shock Diabet ic Acidos i s & Coma Oral Hypoglycemics In su l in Kinds of i n s u l i n s Equipment In jec t ion procedure Rotation of s i t e s Insu l in a l l e r g y  Diabet ic Diet Meal p lan Food exchanges D i e t e t i c & food fads Normal d ie t Signs and symptoms Causes of Diabetes What i s Diabetes? Complications Community Resources 90T 107 Books fo r Diabet ics 1. Danowski, Thaddeus S. Diabetes as a Way of L i f e . New York i Coward-McCann, 1964 I reviewed i n Diabetes, XI I I , No. 6 (November-December 19o4), 655-656]. The book's outstanding q u a l i t i e s are i t s d i spass ionate , ob jec t ive way of looking at the problems of diabetes and the a r t i c u l a t e , adult manner i n which the information i s presented . . . In add i t ion to the c a r e f u l l y presented prac-t i c a l informat ion, e s p e c i a l l y valuable chapters deal with " S o c i a l Aspects of Diabetes" , and " L i v i n g with Diabetes 1 Att i tudes and Expectat ions" • • . The only drawback of the book i s that i t occa s iona l ly reaches above the l e v e l of even the ra ther sophi s t i ca ted layman. 2. Dolger, Henry and Seeman, Bernard. How to Live with Diabetes. New York 1 . W.W. Norton and Company, 1959 and 1965 [reviewed i n Diabetes X, No. 1 (January-February 1961), 69]• This book i s w e l l wr i t t en and should be of i n t e r e s t to pat ients and physic ians a l i k e . . . The authors show an ex-c e l l e n t understanding of the psychology and emotional prob-lems confront ing the juven i l e d i a b e t i c , and the sec t ion on s p e c i a l problems for 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 . 3. Duncan, G a r f i e l d B. A Modern P i l g r i m ' s Progress with Further  Revelations fo r D iabe t i c s . Ph i l ade lph ia 1 W.B. Saunders Company, 1967 [reviewed i n Diabetes, XVII , No. 8 (August This book i s wr i t ten i n the form of a s tory about the experiences of a s o c i a l worker with diabetes , assigned to the diabetes c l i n i c and wards of a Ph i l ade lph ia h o s p i t a l . With t h i s technique, Dr. Duncan i s able to discuss a v a r i -ety of problems presented by d i f f e rent pat ients . . . A 67 page appendix b r i e f l y out l ines the var ious types of i n s u l i n , i t s admini s t ra t ion inc lud ing mixtures , the r ecogn i t ion of i n s u l i n react ions and d i abe t i c coma, ur ine t e s t i n g , foot care and the exchange system of d ie t s . . . A glossary i s inc luded and a use fu l index. 4. J o s l i n , E l l i o t t P. Diabet ic Manual. Ph i l ade lph ia 1 Lea and Febiger , 1959 [reviewed i n Diabetes, X, No. 1 (January-February 1961) 68], Throughout the book the author ' s conv ic t ion i s f r e -quently 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 with d i a -betes follows treatments w i s e l y , he w i l l l i v e long and happi ly . . . The young d iabe t i c w i l l be in teres ted to read of Dr. J o s l i n ' s opinion regarding marriage • • . From the d ie tary standpoint , some of the data • . . can be chal lenged. 108 Rosenthal, Helen, and Rosenthal, Joseph. Diabetic Care  i n P i c ture s . P h i l a d e l p h i a » L i p p i n c o t t , 1968 I reviewed i n Diabetes, XVII, No. 11 (November 1968), 709J. The authors are to be congratulated for a c l e a r , des-c r i p t i v e , verba l and graphic presentat ion of d iabet ic d i e t s ; i n s u l i n preparations and the equipment ava i l ab le for t h e i r i n j e c t i o n ; ur ine t e s t i n g ; personal hygiene; foot care and Buerger-Al len exercise . . . Questions which the d i abe t i c or h i s family may ask regarding obes i ty , hered i ty , marriage, pregnancy, exercise 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 for D iabe t i c s . Miami t Dia-betes Press of America, 1966 1 reviewed i n Diabetes, XVI, No. 9 (September 1967), 671]. 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 ac to ry job . It includes most of the reference data and t e c h n i c a l facts required 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 use fu l to the newly ins t ructed p a t i e n t . But there are p ic ture s of ret inopathy and a r t e r i a l occ lus ion which might not , however, be appropriate for the apprehen-s ive p a t i e n t . S indoni , Anthony M. The D i a b e t i c ' s Handbook. New York t The Ronald Press Company. 1959 [reviewed i n Diabetes. IX, No. 6 (November-December I960), 506]. Dr. S indoni ' s handbook includes a large amount of use-f u l data concerning diabetes , i t s complicat ions and i t s treatment . . . Its f au l t s are over inclus iveness and f a i l u r e to confine i t s e l f to the d iabe t i c p a t i e n t . Much of the mater ia l i s more appropriate to nurses , d i e t i c i a n s or semi-pro fe s s iona l personnel having some background of medical knowledge. Pamphlets for Diabet ics TITLE SOURCE COST 1. A Guide for the Canadian Diabetic on Oral Therapy 2. Care of the C h i l d with Diabetes 3. Care of the Feet 4. Diabetes 1 A Question and Answer Book for Canadians 5« Diabetes Check Facts 6. D i e t e t i c Foods Without Cyclamate 7. Exchange L i s t s for Meal Planning for Diabetics i n Canada 8. Sample Diets for Use i n Conjunction with #7» 9. Guidebook fo r the Diabetic Patient 10. I Am A Diabet ic — I d e n t i f i c a t i o n Card 11. I f You Have Diabetes 12. Instruct ions to Teachers with Diabetic Chi ldren i n t h e i r Classes 13« Insu l in Use Information K i t , containing 1 "Questions and Answers" f o l d e r , "Hospi ta l Instruct ion Program" f o l d e r , "Techniques for Se l f In jec t ion" chart and f o l d e r , "Tips on F i l l i n g Insu l in Syringe" booklet , l i s t of references, "Know Your I n s u l i n Syringe" chart and s i t e s e l ec tor . 14. Insu l in and Insu l in Preparations 15. Manual f o r Diabet ics i n Canada 16. One Out of Every 50 Canadians may be a Diabetic 17. Right From the Start — Complimentary C l i n i t e s t Ins t ruct ion K i t 18. Some Thoughts fo r Young Diabetics and t h e i r Parents 19. Stop, Read and Understand Food Labels 20. This Could Save Your L i f e — Appl ica t ion Form and Message 21. T r a v e l l i n g with Diabetes E l i L i l l y & C o . , Toronto, Ont. N i l Ames C o . , Rexdale, Ont. N i l Toronto Dept. Publ ic Health N i l Canadian Diabet ic Assoc ia t ion N i l Canadian Diabet ic Assoc ia t ion N i l Canadian Diabet ic Assoc ia t ion N i l Canadian Diabet ic Assoc ia t ion 500 Connaught Labs . , Willowdale, Ont. N i l Ames C o . , Rexdale, Ont. N i l Canadian Diabet ic Assoc ia t ion N i l Chas. P f i z e r & C o . , Montreal , Que. N i l Canadian Diabet ic Assoc ia t ion N i l Becton-Dickinson and C o . , Clarkson, Ont. N i l Connaught Labs . , Willowdale Canadian Diabet ic Assoc ia t ion 75£ Canadian Diabet ic Assoc ia t ion N i l Ames C o . , Rexdale, Ont. N i l Canadian Diabet ic Assoc ia t ion N i l Canadian Diabet ic Assoc ia t ion N i l Canadian Medic -Aler t , Toronto,Ont. N i l Canadian Diabet ic Assoc ia t ion N i l 110 A. D i a b e t i c Day Care Centres [ i n D i a b e t i c Day Care Centres t Current Concepts* Rexdale, O n t a r i o i Ames Company, D i v i s i o n M i l e s L a b o r a t o r i e s L i m i t e d , 1969.] T y p i c a l Time Table > 7 i 3 0 a.m - 7 « 4 0 a.m - 7 1^5 a.m - 81I5 a.m - 9 » 3 0 a.m - 10 1 3 0 a.m - 1 1 1 3 0 a.m - 11«45 a.m - 12 1 3 0 p.m - I130 p.m - p a t i e n t s a r r i v e . Test u r i n e f o r sugar and acetone, under s u p e r v i s i o n . - f a s t i n g blood sugar ( i f r e q u i r e d ) . - a d m i n i s t r a t i o n of a n t i - d i a b e t i c drugs or i n s u l i n under s u p e r v i s i o n . - b r e a k f a s t . - supervised a c t i v i t y . - l e c t u r e . - t e s t u r i n e f o r sugar and acetone under s u p e r v i s i o n . - l u n c h . - l e c t u r e . - end of the Centre day. B. Lecture Subjects Includedt Diabetes M e l l i t u s , the dis e a s e . Techniques of i n s u l i n i n j e c t i o n and the care of equipment. D i f f e r e n t types of i n s u l i n , and the o r a l hypoglycemic agents. Complications of di a b e t e s , and how t o avo i d them. D i a b e t i c s e l f - c a r e . Why and how of t e s t i n g u r i n e . The d i e t i n dia b e t e s . Care i n s p e c i a l s i t u a t i o n s , such as t r a v e l l i n g . I n t r o d u c t i o n t o the Canadian D i a b e t i c A s s o c i a t i o n . APPENDIX B A BASIC COURSE IN DIABETIC SELF-MANAGEMENT Objectives Content Spec i f i c a t ions for the Test of Diabet ic Learning 112 A Basic Course i n Diabet ic Self-Management Objectives Upon completion of t h i s course each d iabet ic pat ient w i l l have the knowledge and s k i l l s necessary to assume primary res-p o n s i b i l i t y for managing h i s s e l f - ca re at home, that i s , he w i l l A. Know common terms regarding diabetes . 1. ret d ie t -a . define an exchange. b . define an exchange group or exchange l i s t . c . name the C D . A . exchange l i s t s . 2. re t complicat ions -a . define hyperglycemia. b . define hypoglycemia. B. Know s p e c i f i c facts regarding diabetes . 1. ret d ie t -a . i d e n t i f y foods which are not permitted i n a d i abe t i c d i e t . 2. i f taking an o r a l hypoglycemic agentt a . s tate the name of h i s drug. b . s tate the dose of h i s drug. c . s tate the time of day he takes h i s drug. d . describe how h i s drug helps hi s d iabetes . 3. i f taking i n s u l i n t a . s tate the type of i n s u l i n he takes . b . s tate the s trength of i n s u l i n he uses . c . s tate the dose of i n s u l i n he takes . d . s tate the time of day he takes h i s i n s u l i n . e. s tate what time of day he must be most wary of an i n s u l i n r e a c t i o n . f . describe how hi s i n s u l i n helps h i s d iabetes . g . s tate how he should s tore h i s i n s u l i n at home. 4. ret exercise -a . s tate the ef fect of exercise on the sugar-i n s u l i n balance of the body. b . s tate the ef fect of taking more exercise than normal. c . s tate what he would do i f he took more exercise than normal. d . s tate what he would do i f he were planning more exercise than normal. 5. ret ur ine t e s t i n g -a . s tate what he would do i f h i s ur ine-sugar te s t s were repeatedly p o s i t i v e . b . s tate what he would do i f h i s urine-acetone were p o s i t i v e . 113 6. r e i f o o t care -a. i d e n t i f y the importance of c a r e f u l foot care f o r d i a b e t i c s . 7. r e i c o m p l i c a t i o n s -a. match signs and symptoms w i t h the acute c o m p l i c a t i o n they are i n d i c a t i v e o f . b. i d e n t i f y symptoms of hyperglycemia. c. s t a t e how h i s u r i n e would t e s t i f he were s e v e r e l y hyperglycemic. d. i d e n t i f y events which might cause hyperglycemia. e. o u t l i n e what he would do i f he had a hyperglycemic r e a c t i o n . f . i d e n t i f y symptoms of hypoglycemia. g. s t a t e how h i s u r i n e would t e s t i f he were hypoglycemic. h. i d e n t i f y events which might cause hypoglycemia. i . o u t l i n e what he would do i f he had a hypoglycemic r e a c t i o n . j . o u t l i n e what he would do i f he had an acute i n f e c t i o n . 8. r e i community resources -a. i d e n t i f y events which would m e r i t c o n s u l t a t i o n w i t h h i s p h y s i c i a n . b. l i s t community resources f o r d i a b e t i c a s s i s t a n c e . c. recognize how each of these persons or agencies might be h e l p f u l t o him. C. Know methods and procedures necessary f o r optimal d i a b e t i c management• 1. r e i i n s u l i n -a. l i s t the equipment he r e q u i r e s t o g i v e h i s i n s u l i n i n j e c t i o n s . 2. r e t u r i n e t e s t i n g -a. s t a t e how o f t e n he should t e s t h i s u r i n e . 3. re« f o o t care -a. o u t l i n e acceptable d a i l y f o o t c a r e . b. s t a t e what he would do i f h i s f e e t were sweaty. c. s t a t e what he would do i f h i s f e e t were dry or s c a l y . d. d e s c r i b e the c o r r e c t method f o r c u t t i n g h i s t o e n a i l s . e. s t a t e what he would do f o r corns or c a l l o u s e s on h i s f e e t . f . s t a t e ( d e s c r i b e ) the dangers of hot water, hot water b o t t l e s or h e a t i n g pads f o r d i a b e t i c s . D. Understand f a c t s and p r i n c i p l e s r e g a r d i n g d i a b e t e s . 1. r e i d i e t -a. e x p l a i n how he would a l t e r h i s d i e t i f he were i l l . 2. r e i i n s u l i n i n j e c t i o n s -a. o u t l i n e how he decides where t o g i v e each i n j e c t i o n . b. e x p l a i n why i t i s important to r o t a t e the s i t e s of h i s i n j e c t i o n s . 114 3. r e t s u g a r - i n s u l i n balance -a. e x p l a i n why i t i s important f o r a d i a b e t i c t o maintain a r e g u l a r and balanced l i f e -schedule. b. r e l a t e the s c h e d u l i n g of h i s meals to h i s type of i n s u l i n . c. r e l a t e e x e r c i s e - t i m e t o meal-time. d. r e l a t e e x e r c i s e - t i m e t o h i s type of i n s u l i n . 4. re t u r i n e t e s t i n g -a. e x p l a i n the importance of u r i n e t e s t i n g . b. i n f e r what sugar i n h i s u r i n e might i n d i c a t e . c. i n f e r what acetone i n h i s u r i n e might i n d i c a t e . 5. re t c o m p l i c a t i o n s -a. r e l a t e hyperglycemia to u n c o n t r o l l e d d i a b e t e s . b. e x p l a i n why i n f e c t i o n may be an acute compli-c a t i o n of d i a b e t e s . c. e x p l a i n why hyperglycemia may be an acute c o m p l i c a t i o n of d i a b e t e s . d. e x p l a i n why hypoglycemia i s an acute c o m p l i c a t i o n of d i a b e t e s . e. e x p l a i n why i t i s important f o r a d i a b e t i c to wear or c a r r y d i a b e t i c i d e n t i f i c a t i o n . Demonstrate c o r r e c t usage of s k i l l s necessary f o r optimal d i a b e t i c management. 1. r e i d i e t -a. g i v e n h i s own meal p l a n and the CD.A. exchange l i s t s , p l a n h i s t o t a l day's menu. 2. r e t i n s u l i n i n j e c t i o n s -a. handle h i s s y r i n g e and needle i n such a way as not t o contaminate them. b. use a s e p t i c technique i n p r e p a r i n g and g i v i n g h i s i n s u l i n i n j e c t i o n . c. demonstrate accuracy i n p r e p a r i n g and g i v i n g h i s i n s u l i n i n j e c t i o n . d. demonstrate adequate d a i l y care of h i s s y r i n g e and needle by d i s i n f e c t i o n w i t h a l c o h o l . e. demonstrate adequate weekly care of h i s s y r i n g e and needle by s t e r i l i z a t i o n by b o i l i n g . 3* r e t u r i n e t e s t i n g -a. f o l l o w i n g the p r e s c r i b e d procedure f o r the urine-sugar t e s t he uses, t e s t u r i n e specimens a c c u r a t e l y . b. f o l l o w i n g the p r e s c r i b e d procedure f o r the urine-acetone t e s t he uses, t e s t u r i n e specimens a c c u r a t e l y . 115 A Basic Course i n Diabet ic Self-Management Content I. INTRODUCTION A. What i s diabetes? 1. How does a nondiabetic person use the food he eats? 2. What happens when you have diabetes? B. How do you f i n d out that you have diabetes? C. What w i l l diabetes mean for your l i f e ? 1. How many people have diabetes? 2. What kind of work can you do? 3* Can you get l i f e insurance? 4. What about sports and a c t i v i t i e s ? 5. What about marriage and ch i ld ren? 6. How can you be sure to stay healthy? I I . DIET A. What makes up a normal healthy d i e t ? 1. Carbohydrate. 2. Fat . 3« P ro te in . B. How i s a d i abe t i c d iet d i f f e r e n t ? __ o u t l i n e . 2. Foods not a l lowed. 3. Goals . C. How w i l l the doctor f igure out the best d ie t f o r you? 1. Age. 2. Sex. 3. Weight. 4. A c t i v i t y . 5. Heal th . D. What w i l l you need to fol low your d i e t ? 1. Your own Meal Plan . a . D e f i n i t i o n . b . I l l u s t r a t i o n . 2. Food Exchange L i s t s . a. D e f i n i t i o n s . b . Names of the Exchange Groups. c . Use of the food exchange l i s t s for fo l lowing the meal p l a n . E . How should you prepare these foods? 1. General r u l e s . 2. Measurement. 3. Mixed d i shes . F. General Rules About Diabet ic Die t s . G. Other Considerat ions . 1. Food shopping. 2. Spec ia l foods. 3. A l c o h o l . 4. Restaurant ea t ing . 5. I l l n e s s . 6. C D . A . counse l l ing s e r v i c e . 116 I I I . DRUGS A. Ant id i abe t i c P i l l s 1. Names and a c t i o n . 2. How they d i f f e r from i n s u l i n . 3. Side e f f ec t s . 4. Rules for tak ing them. B. Insu l in 1. Review funct ion of i n s u l i n . 2. Names and durat ion of a c t i o n . a. Short-act ing i . regular i i . semi-lente b. Intermediate-act ing. i . N . P . H . i i . l ente i i i . g l o b i n c . Long-acting i . P . Z . I . i i . u l t r a - l e n t e 3. I d e n t i f i c a t i o n of types of i n s u l i n . 4. Peak of ac t ion of three groups of i n s u l i n . 5. Measurement of i n s u l i n . a . Define ' u n i t s per c c ' . b. D i f f e r e n t i a t e U40 from U80. i . s trength i i . colour of stopper and p r i n t 6. Care of i n s u l i n . a . temperature. b . expiry date. ?• Cost of i n s u l i n . 8. Equipment for i n s u l i n i n j e c t i o n . a. In su l in syr inge . i . U40 v s . U80 i i . cost i i i . g lass v s . disposable b . Needles. i . s i ze i i . cost i i i . reusable v s . disposable c . Container for syringe and needles . d . A l c o h o l . e. Cotton. f . Hints fo r buying equipment. 9 . I n s u l i n i n j e c t i o n procedure. a. P r i n c i p l e s . i . accuracy i i . asepsis b . Steps fo r i n j e c t i n g one type of i n s u l i n , i . preparat ion i i . i n j e c t i o n c . Preparation i f mixing two i n s u l i n s . d . Rotation of s i t e s . i . s i t e s ava i l ab le i i . how to i i i . reasons for r o t a t i o n 10. Care of Insu l in In jec t ion Equipment. a. Dai ly care—Storage i n A l c o h o l . i . p r i n c i p l e s i i . equipment i i i . steps b . Weekly c a r e — B o i l i n g . i . p r i n c i p l e s i i . equipment i i i . steps i v . cloudiness 11. Rules for taking i n s u l i n . 117 C. How Diet and Insu l in Work Together 1. Importance of "balance. 2. Relat ion of meal times to type of i n s u l i n . IV. EXERCISE A. Exercise i s good for everybody. B. What ef fect does exercise have on diabetes? C. What kinds of exercise can d iabet ic s do? D. Planning for exerc i se . 1. with doctor . 2. regular r o u t i n e . E . D i e t , i n s u l i n and exercise work together . 1. Importance of balance. 2. Unexpected exerc i se . 3 . Time of exercise i n r e l a t i o n to meals. 4. Time of exercise i n r e l a t i o n to type of i n s u l i n . 5. Importance of ca r ry ing sugar. F. General Rules fo r Exerc i s ing V. HYGIENE A. Why i s good hygiene so important to d i abe t i c s ? B. General Rules. 1. Care with sharp ob jec t s . 2. Care of sk in and h a i r . 3 . Care of teeth and gums. 4. Care of eyes. 5. Care of minor cuts and bru i se s . 6. Smoking. C. Spec ia l Foot Care 1. Importance. 2 . Equipment• 3 . General ru les fo r foot care . h. Spec ia l cons idera t ions . a. sweaty f ee t . b . dry , s ca ly fee t . c . cu t t ing t o e n a i l s . d . corns, ca l louse s . e. heating pads, hot water, hot water b o t t l e s . VI . TESTS A. B. Purpose of t e s t i n g . Kinds of t e s t s . 1. Blood. a. kinds b. where done c . how often d . who done by 118 2. Ur ine . a . kinds b . where done c . how often d . who done by e. which ur ine should be tes ted (N.B. double-voided specimen f . what does each te s t t e l l 3. Test ing ur ine for sugar. a. C l i n i t e s t t a b l e t s . i . equipment i i . 5-drop method i i i . "Pass-Through" b . Other tes t s for sugar. i . names i i . comparison of cos t , convenience, accuracy c . Act ion for repeated p o s i t i v e t e s t s . 4. Test ing ur ine for acetone, a. (Ames) Acetest t a b l e t s . i . equipment i i . procedure b o Other tes t s for acetone. i . names i i . comparison of cos t , convenience, accuracy 5. Keeping a record of ur ine t e s t i n g . 6. General rules fo r ur ine t e s t i n g . V I I . THE DIABETIC IN TROUBLE A. Diabet ic Coma T~. D e f i n i t i o n . 2. Other names f o r i t . 3. What happens when you get i t ? 4. Signs and symptoms. a. p h y s i c a l s i gns . b . ur ine t e s t s . 5« What might cause i t ? 6. Treatment of acute hyperglycemia. 7« How can you keep i t from happening? B. In su l in Reaction T~, D e f i n i t i o n . 2. Other names fo r i t . 3» What happens when you get i t ? 4. Signs and symptoms. a. p h y s i c a l s i gns . b . ur ine t e s t s . 5. What might cause i t ? 6. Treatment of i n s u l i n shock. 7. How can you keep i t from happening? C. Comparison of Hypo- and Hyper-glycemia 1. onset 2. warning signs 3. ur ine sugar k. ac t ion to take 119 D. Infect ions 1. D e f i n i t i o n s . a. s imple . b . more ser ious (acute) . 2. Why may in fec t ions mean trouble for d i abe t i c s ? 3. How can you keep from ge t t ing i n f e c t i o n s ? 4. What to do i f you get an acute i n f e c t i o n . E . Diabet ic I d e n t i f i c a t i o n Kinds. 2. Importance. 3. Where they can be obtained. V I I I . WHERE THE DIABETIC CAN GET HELP A. People and Agencies 1. Phys i c i an . 2. Canadian Diabet ic As soc i a t ion . 3. V i c t o r i a n Order of Nurses. 4. Publ ic Health Nurses. 5. Medic A l e r t Foundation. 6. Health Teaching C l i n i c s for D iabe t i c s . 7. D i a l - a - D i e t i c i a n . B. What w i l l these people or agencies do f o r you? IX. SUMMARY Points to remember - r e i !U d i e t . 2. i n s u l i n . 3. exerc i se . 4. records . 5. I .D . 6. good use of doctor . A Basic Course i n Diabet ic Self-Management Spec i f i ca t ions for the Test of Diabet ic Learning 120 Insul in-Users Topics Know-ledge S k i l l To ta l Know-ledge S k i l l T o t a l 1 Diet 16 20 36 16 20 36 2 Medication 10 20 30 5 0 5 3 Urine te s t s 10 10 20 10 10 20 Exercise k 0 0 4 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 T o t a l 75 50 125 70 30 100 Ant id i abe t i c P i l l - U s e r s APPENDIX C DATA COLLECTION TOOLS Patient P r o f i l e Sheet Test of Diabet ic Learning 1 2 2 PATIENT PROFILE SHEET Pat ient Numbert A. AGE 1 . 1 5 - 2 4 5 . 55-64 2 . 2 5 - 3 4 6 . 65-74 3 . 35-44 7 . 7 5 - 8 4 4. 4 5 - 5 4 8 . 85 and over C . MARITAL STATUS T~. S ing le 2 . Married 3 . Widowed 4 . Divorced/separated E . EDUCATION Highest l e v e l of education a t ta ined ! B. SEX 1 . Male 2 . Female D. OCCUPATION own spouse's or parent ' s r e t i r e d ? F . RE .AS ON FOR CURRENT ADMISSION TO HOSPITAL 1 . new d iabet ic 2 . r egu la t ion of diabetes . complicat ion of diabetes . unrelated c o n d i t i o n G. MOST RECENT PREVIOUS  HOSPITAL .ADMISSION T~, less than 6 weeks ago 2 . over 6 weeks-under 1 y r . 3 . 1-5 years 4 . 6-10 years 5 . over 10 years H . AGE AT ONSET OF  DIABETES T. 0^14* y r . 5 . 2 . 1 5 - 2 4 y r . 6 . 3 . 2 5 - 3 4 y r . 7 . 4 . 3 5 - 4 4 y r . 8 . 4 5 - 5 4 y r . 5 5 - 6 4 y r . 6 5 - 7 4 y r . 7 5 or over I . DURATION OF DI ABETES 0-6 days 1 . 2 . 3 . 4 . 5 . 6 . 1 - 5 weeks 6 weeks-11 months 1 - 5 years 6 - 1 0 years over 1 0 years CONTROL OF CONDITION :H di e t and ant i d i a b e t i c p i l l 2 . d i e t and less than 3 0 units i n s u l i n 3 . d i e t and more than 3 0 units i n s u l i n K. BEST SOURCES OF INFORM ATI ON REt MANAGEMENT OF DIABETES (Please rank 1 , 2 , 3, ... 1 0 . ) classes t e l e v i s i o n pamphlets f r i e n d or r e l a t i v e books doctor radio nurse newspaper d i e t i c i a n L. ANTIDIABETIC PILLS i Name Dose (milligrams) 123 M. INSULINi Name Strength _ _ _ _ _ _ _ Dose (units ) Time N. URINE TESTINGi Reagents & Time(s) 0. DIET P L A N J Attached 124 TEST OF DIABETIC LEARNING ( f o r I n s u l i n Users) PART I i KNOWLEDGE (75 p o i n t s ) DO NOT WRITE .ANYTHING ON THIS PAPER! ! Please p l a c e ALL your answers f o r t h i s t e s t on the answer sheet provided. 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 on the answer sheet. 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 on the answer sheet. 1. 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 t (A) b u t t e r m i l k True F a l s e (B) i c e cream True F a l s e (C) marmalade True F a l s e (D) mayonnaise True F a l s e (E) noodles True F a l s e 2. What are the names of the Canadian D i a b e t i c A s s o c i a t i o n Exchange Groups? 3. Foods i n one exchange group may bei (A) changed f o r foods i n another True F a l s e l i s t (B) changed f o r foods i n the same True F a l s e l i s t (C) changed f o r d i e t e t i c foods of True F a l s e any s o r t (D) a l l eaten at the same meal True F a l s e k. 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 F a l s e 5. (A) What i s the name of the i n s u l i n you are t a k i n g ? (B) Do you use U40 or U80 i n s u l i n ? (C) How many u n i t s of your i n s u l i n do you take each time? (D) What time of day do you take your i n s u l i n ? (E) What time of 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 t o he l p your diabetes? (G) May e x t r a i n s u l i n be sto r e d 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 twice i n the same month? Yes No ( 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 6. I f a d i a b e t i c person has had no c o m p l i c a t i o n s , he need not t e s t h i s u r i n e . True F a l s e 125 7. Routine u r i n e t e s t s f o r sugar should be madei (A) j u s t before meals. True F a l s e (B) on "double-voided" specimens. True F a l s e (C) one hour a f t e r meals. True F a l s e (D) each time a d i a b e t i c u r i n a t e s . True F a l s e 8. Your u r i n e 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. True F a l s e (B) you had taken too much i n s u l i n . T r u e F a l s e (C) you had a f e v e r . True F a l s e (D) you were em o t i o n a l l y upset. True F a l s e (E) you e x e r c i s e d too much. True F a l s e 9 . E x e r c i s e tends to r a i s e the blood sugar l e v e l . True F a l s e 10. The amount of e x e r c i 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 F a l s e 11. What would 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. D. an i n f e c t i o n . 12. What would you do i f you had taken more e x e r c i s e than normal? A. take o n l y k the u s u a l amount of i n s u l i n the next day. B. eat twice as much bread at the next meal. C. take twice the u s u a l amount of i n s u l i n the next day. D. eat or d r i n k something sweet immediately. 13. You should take e s p e c i a l l y good care of your f e e t becauses (A) a number of years of i n j e c t - True F a l s e i n g i n s u l i n i n t o the legs may cause s w e l l i n g of the f e e t . (B) as d i a b e t i c p a t i e n t s become True F a l s e o l d e r 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 . (C) f o o t i n j u r i e s may be harder True F a l s e t o h e a l i n d i a b e t i c s than i n other people. 14. I f you have a sore on your f o o t 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 i o d i n e . 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 w i t h warm water and apply i o d i n e . 15. The BEST t h i n g to do i f you have corns or c a l l o u s e s on your f e e t i s t o A, t r i m them c a r e f u l l y w i t h manicure s c i s s o r s , B. t r e a t them w i t h a commercial c o m 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 o f f w i t h an emery board. 126 1 6 , 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 f e v e r . (D) too much e x e r c i s e . True True True True Fa l s e F a l s e F a l s e False 1 7 . 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 True (B) too much food True (C) a f e v e r . True (D) too much e x e r c i s e . True F a l s e F a l s e F a l s e F a l s e 1 8 . Column A cont a i n s 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 . On the answer sheet w r i t e the l e t t e r of the c o m p l i c a t i o n which each i s c h a r a c t e r i s t i c of. Each response i n Column B may be used once, more than once or not at a l l . (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 1 9 . I f you were going i n t o a d i a b e t i c coma, how would your u r i n e 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 o r acetone C. negative f o 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 2 0 . When f e e l i n g the symptoms of a d i a b e t i c coma, you would A. take your p r e s c r i b e d i n s u l i n . B. phone the doctor. C. eat some sugar. D. go f o r a walk. B. both A and B. 2 1 . When 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 would A. eat some sugar. B. take some e x t r a i n s u l i n , C. go f o r a walk, D. l i e down and r e s t . E. both B and D. 2 2 . I f nauseated and i l l w i t h the f l u , you would A. s k i p your r e g u l a r i n s u l i n and eat l e s s , B. s k i p your u r i n e t e s t s , C. take your r e g u l a r i n s u l i n and eat l e s s , D. take your r e g u l a r i n s u l i n and eat s o f t foods or f l u i d s . COLUMN A COLUMN B ( 1 ) dry s k i n and tongue ( 2 ) hunger (3) f e v e r A, i n f e c t i o n B, d i a b e t i c coma C, i n s u l i n r e a c t i o n t e s t ? 127 23. 24. You (A) (B) (C) (D) (E) (F) (G) (H) should c o n s u l t your you have an i n s u l i n you have acetone i n u r i n e . you are planning an unusual amount of e x e r c i s e . you have a cut or scrape. a corn or c a l l o u s , a f e v e r , sugar i n your doctor wheneveri r e a c t i o n , your you have you have you have u r i n e , you wish to a l t e r your d i e t . True Fa l s e True Fa l s e True Fa l s e True Fa l s e True F a l s e True F a l s e True F a l s e True F a l s e Column A contains a l i s t of s e r v i c e s provided by va r i o u s people or o r g a n i z a t i o n s f o r d i a b e t i c s . On the answer sheet w r i t e 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 (1) adjust your d i e t p r e s c r i p t i o n A, (2) provide f r e e d i e t c o u n s e l l i n g B. (3) a d j u s t your p r e s c r i p t i o n f o r i n s u l i n C. (4) give i n s u l i n i n j e c t i o n s at home COLUMN B V i c t o r i a n Order of Nurses Canadian D i a b e t i c A s s o c i -a t i o n doctor 128 TEST OF DIABETIC LEARNING ( f o r I n s u l i n Users) PART 11 KNOWLEDGE P a t i e n t Numbert Answer Sheet S c o r e i l . ( A ) True F a l s e 6. True F a l s e 17.(A) True Fa l s e (B) True F a l s e 7.(A) True F a l s e (B) True F a l s e (C) True F a l s e (B) True F a l s e (C) True F a l s e (D) True F a l s e (C) True F a l s e (D) True F a l s e (E) True F a l s e (D) True F a l s e 18. (1) 2. 8.(A) True F a l s e (2) (B) True F a l s e ( 3 ) (C) True F a l s e (4) (D) True F a l s e ( 5 ) 3.(A) True F a l s e (E) True F a l s e ( 6 ) (B) True F a l s e 9. True F a l s e 19. A B C D (C) True F a l s e 10. True F a l s e 20. A B C D E (D) True F a l s e 11. A B C D 21. A B C D E 4. True F a l s e 12. A B C D 22. A B C D 5.(A) 1 3 . ( A ) True F a l s e 2 3 . ( A ) True F a l s e (B) (B) True F a l s e (B) True F a l s e (C) (C) True F a l s e (C) True F a l s e . (D) 14. A B C D (D) True F a l s e (E) 1 5 . A B C D (E) True F a l s e (F) 1 6 . ( A ) True F a l s e (F) True F a l s e (B) True F a l s e (G) True Fa l s e (G) Yes No (C) True F a l s e (H) True F a l s e (H) Yes No (D) True F a l s e 24. (1) ( I ) A B C D E (2) ( 3 ) (4) 129 TEST OF DIABETIC LEARNING ( for .Antidiabetic P i l l Users) PART It KNOWLEDGE (70 points ) DO NOT WRITE ANYTHING ON THIS PAPER!! Please place ALL your answers fo r t h i s tes t on the answer sheet provided. For mul t ip le -cho ice or t rue- fa l se questions, c i r c l e the cor rec t response on the answer sheet. For a l l other types of questions, wri te the cor rec t response i n the space provided on the answer sheet. 1. The fo l lowing foods are allowed on a d iabe t i c d ie t t (A) buttermi lk True False (3) i ce cream True False (C) marmalade True False (D) mayonnaise True False (E) noodles True False 2. What are the names of the Canadian Diabet ic Assoc ia t ion Exchange Groups? True False True False True False True False the blood to True False 3. Foods i n one exchange group may bet (A) changed fo r foods i n another l i s t (3) changed fo r foods i n the same l i s t (C) changed f o r d i e t e t i c foods of any sor t (D) a l l eaten at the same meal 5. (A) What i s the name of the an t id i abe t i c p i l l you are taking? (B) How many mil l igrams of your an t id i abe t i c drug do you take each time? (C) What time of day do you take your an t id i abe t i c drug? (D) How does your a n t i d i a b e t i c drug act to help your diabetes? 6. I f a d i abe t i c person does not take i n s u l i n , he need not te s t h i s u r i n e . True False 7. Routine ur ine tests fo r sugar should be madei (A) just before meals True False (B) on "double-voided" specimens True False (C) one hour a f ter meals True False (D) each time a d iabe t i c ur inates True False 8. Your ur ine might tes t po s i t i ve fo r sugar i f t (A) you had eaten too much True False (B) you had not taken your True False an t id i abe t i c p i l l (C) you had a fever True False (D) you were emotional ly upset True False (E) you exercised too much True False 130 9. Exerc i se tends to ra i se the blood sugar l e v e l . True False 10. The amount of exercise amount of an t id i abe t i c a d iabet ic person does drug he requ i re s . True affects the False 11. What would you be a l e r t f o r i f you took more exercise than normal? (A) i n s u l i n reac t ion (B) d iabet ic coma (C) muscle cramps (D) an i n f e c t i o n 12. What would you do i f you had taken more exercise than normal? (A) take only \ an an t id i abe t i c p i l l the next day. (B) eat twice as much bread at the next meal'. (C) take twice as many ant id i abe t i c p i l l s the next day. (D) eat or dr ink something sweet immediately. 13. You should take e s p e c i a l l y good care of your (A) a number of years of taking True an t id i abe t i c drugs may cause swel l ing of the f ee t . (3) as d i abe t i c pat ients become True o lder they may have poor c i r c u l a t i o n i n t h e i r f ee t . (G) foot i n j u r i e s may be harder True to hea l i n d iabe t i c s than i n other people. 15. 16. feet b e c a u s e « False False False 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 cold water and apply i o d i n e . (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 . The BEST th ing to do i f you have corns or ca l louses on your feet i s to (A) trim them c a r e f u l l y with manicure s c i s s o r s . (B) t rea t them with a commercial corn and ca l lous remover. (G) n o t i f y your doctor . (D) soak them i n hot water and rub them of f with an emery board. A d iabe t i c coma might be caused by (A) not enough ant id i abe t i c drug True False (B) not enough food True False (C) a fever True False (D) too much exercise True False 131 17. .An i n s u l i n reac t ion might be caused by (A) too much ant id i abe t i c drug True False (B) too much food True False (C) a fever True False (D) too much exercise True False 18. Column A contains a l i s t of signs and symptoms of d iabet ic compl icat ions . On the answer sheet write the l e t t e r of the compl icat ion which each i s c h a r a c t e r i s t i c o f . Each response i n Column B may be used once, more than once or not at a l l , COLUMN B .A. i n f e c t i o n B. d iabet ic coma i n s u l i n reac t ion C. COLUMN A (1) dry sk in and tongue (2) hunger (3) fever (4) f r u i t y breath (5) t h i r s t (6) f e e l i n g of fa intness 19. I f you were going into a d iabet ic coma, how would your ur ine tes t? (A) po s i t i ve f o r sugar; negative fo r acetone (B) p o s i t i v e f o r sugar; p o s i t i v e f o r acetone (C) negative fo r sugar; negative fo r acetone (D) negative for sugar; p o s i t i v e f o r acetone 20. When f e e l i n g the symptoms of a d i abe t i c coma, you should (A) take your prescr ibed an t id i abe t i c p i l l . (B) phone the doctor . (C) eat some sugar. (D) go f o r a walk. (E) both A and B. 21. When f e e l i n g the symptoms of an i n s u l i n r eac t ion , you would (A) eat some sugar. (B) take an extra an t id i abe t i c p i l l . (C) go for a walk. (D) l i e down and r e s t . (E) both B and D. 22. I f nauseated and i l l with the f l u , you would (.A) sk ip your regular an t id i abe t i c p i l l and eat l e s s . (B) skip your urine t e s t s . (C) take your regular an t id i abe t i c p i l l and eat l e s s . (D) take your regular an t id i abe t i c p i l l and eat soft foods or f l u i d s . 23. You (A) (B) (G) (D) (E) (F) (G) (H) should c you have you have you are amount o you have you have you have you have you wish onsult your doctor whenever! an i n s u l i n r e a c t i o n , acetone i n your u r i n e , planning an unusual f exercise a cut or scrape a corn or c a l l o u s , a fever . sugar i n your u r i n e , 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 132 Column A contains a l i s t of services provided "by various people or organizat ions for d i a b e t i c s . On the answer sheet write the l e t t e r of the person or organizat ion 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 fo r B. an t id i abe t i c drug. (4) give i n s u l i n in j ec t ions at C . home. V i c t o r i a n Order o f Nurses Canadian Diabet ic Assoc ia t ion Doctor 133 TEST OF DIABETIC LEARNING ( for Ant id iabet i c P i l l Users) PART I i KNOWLEDGE Pat ient Numbert Answer Sheet Score i l . ( A ) True False 8 . ( A ) True False 18. (1) (B) True False (B) True False (2) (c) True Fal se (C) True False ( 3 ) (D) True False (D) True False (4) (E) True False (E) True False ( 5 ) 2. 9 . True False ( 6 ) 10. True False 1 9 . A B C D 11. A B C D 20. A B C D E 12. A B C D 21. A B C D E 3 . ( A ) True False 1 3 . (A) True False 22. A B C D (B) True False (B) True False 2 3 . ( A ) True False (C) True False (C) True False (B) True False (D) True Fa l se 14. A B C D (c) True False 4. True Fal se 1 5 . A B C D (D) True False 5.(A) 1 6 . (A) True False (E) True False (B) (B) True Fa l se (P) True False (C) (C) True False (G) True False (D) (D) True False (H) True Fa l se 17. (A) True False 24. (1) 6 . True Fal se (B) True False (2) 7 . ( A ) True False (C) True False ( 3 ) (B) True Fa l se (D) True False (4) (C) True False (D) True Fa l se 134 TEST OF DIABETIC LEARNING  PART H i SKILLS  A. Die t Planning (20 points ) Pat ient Numberi S c o r e » You have been g iveni ( l ) a copy of your own meal p lan , and (2) a set of the Canadian Diabet ic Associat ion food exchange l i s t s . Using these, p lan your meals for a t o t a l day. Be sure to write down both the name and the amount of each food to be eaten at each meal. Indicate the amount i n terms of standard household measurements (e .g . teaspoons, tablespoons, cups, e t c ) . 135 TEST OF DIABETIC LEARNING  PART H i SKILLS Pat ient Numberi Scorei B. Urine Tes t ing ( 1 0 points) 1 . Tes t ing fo r Sugar (a)with C l i n i t e s t STEPS YES NO ( 1 ) Holds dropper i n upr ight p o s i t i o n . ( 2 ) Places 5 (or 2 ) drops o f ur ine i n tes t tube. ( 3 ) Places 1 0 drops of water i n te s t tube. ( 4 ) Puts water i n te s t tube f i r s t or r inses dropper a f ter put t ing ur ine i n . . ( 5 ) Pos i t ions dropper so that drops do not s l i d e down sides of t e s t tube. ( 6 ) Adds C l i n i t e s t t ab le t without touching i t with moist f ingers - -( 7 ) Waits 1 5 seconds a f ter b o i l i n g has stopped to read. . ( 8 ) Shakes tube gently a f ter reac t ion has stopped. - — (b)with C l i n i s t i x STEPS YES NO ( 1 ) Does not touch te s t area of s t i c k with fingers..-. _ - _. ( 2 ) Dips tes t -area of s t i c k into ur ine to moisten. ( 3 ) Waits 1 0 seconds before reading re su l t s ( 4 ) Does not set s t i c k down while wai t ing to read r e s u l t s . (c)with Testape STEPS YES NO ( 1 ) Does not touch test-end of tape with f i n g e r s . - . . . - - -( 2 ) Moistens test-end of tape by d ipping i n u r ine . - -( 3 ) Waits 1 minute before reading re su l t s . . . ( 4 ) Does not set tape down while wai t ing to read r e s u l t s . 136 Urine Tes t ing (continued) (d)with D i a s t i x STEPS YES NO (1) Does not touch tes t area of s t i c k with f i n g e r s . - „ . - . — _ (2) Dips tes t area of s t i c k into ur ine fo r 2 seconds. . _.. . ._ . .. . (3) Taps edge of s t r i p against s ide of urine container or s ink to remove excess u r i n e . (4) Waits 30 seconds before reading r e s u l t s . ... Reads own sugar specimen c o r r e c t l y . Reads greater than 2% sugar specimen c o r r e c t l y . 2. Tes t ing for Acetone (a)with Acetest Tablets STEPS YES NO ( l ) Places Acetest t ab le t on piece of c lean whit<=» paper. (2) Places 1 drop of ur ine on t a b l e t . (3) Waits 30 seconds before reading. (b)with Acetone Test Powder STEPS YES NO (1) Pours small mound of powder on c lean white paper. (2) Adds enough urine to moisten completely (2-3 drops) . \ *—i* J .La \mJ %0 •# M 9 ~-~ ~~ • 1 " "—» • • • 1, — — * ••• ' — (3) Waits 1 minute before reading. (c)with Ketost ix STEPS YES NO (1) Does not touch tes t area of s t i c k with f ingers _ ._ (2) Waits 15 seconds a f ter removing from ur ine before reading re su l t s . - _ (3) Does not set s t i c k down while wai t ing to read r e s u l t s . . .. .... — Reads acetone te s t specimen c o r r e c t l y . 137 Urine Test ing (continued) 3. Tes t ing for Sugar and Acetone together (Ketodiast ix) Mark as for D ia s t i x and Ketos t ix . SCORING URINE TESTSi TECHNIQUE. / 4 for ur ine sugar t e s t /3 for ur ine acetone tes t ACCURACYi /2 fo r ur ine sugar te s t / l for ur ine acetone tes t TOTAL« /10 138 TEST OF DIABETIC LEARNING  PART Hi SKILLS  C. I n s u l i n Procedures (20 p o i n t s ) P a t i e n t Numberi Score i 1• I n s u l i n I n j e c t i o n STEPS YES NO (1) Gathers equipment., ._ ... (2) Washes hands.. (3) R o l l s b o t t l e of modified i n s u l i n between hands to mix.. _ _ _. (4) Moistens c o t t o n w i t h a l c o h o l . ... ._ (5) Cleans rubber stopper of i n s u l i n b o t t l e w i t h a l c o h o l . . -(6) EITHER empties s y r i n g e and needle of a l l a l c o h o l (or H2O) l e f t from s t e r i l i z a t i o n procedure OR opens di s p o s a b l e needle and sy r i n g e packages without contaminating. (7) F i l l s s y r i n g e 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. - -(9) 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 y r i n g e w i t h 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 w i t h c o t t o n soaked i n a l c o h o l . (13) Pinches up large 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 60-90 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 of i n s u l i n . . (18) P r o t e c t s s k i n w i t h (alcohol-soaked) c o t t o n w h i l e withdrawing needle. _.. _ • Number of times a s e p t i c technique v i o l a t e d (up t o 4) SCORE = 22 - (#No + ^Breaks i n Asepsis) ( t o t a l p o s s i b l e = u ) 139 2. D a i l y Care of Equipment — Storage i n A l c o h o l STEPS (1) Uses 70% i s o p r o p y l or rubbing a l c o h o l . (2) Uses c l e a n c o n t a i n e r . (3) EITHER separates p a r t s of sy r i n g e (and needle) OR draws a l c o h o l i n t o s y r i n g e 2 or more times. Covers s y r i n g e (and needle) w i t h the alcohol.-(4) (5) Leaves p a r t s of s y r i n g e (and needle) submerged i n a l c o h o l f o r at l e a s t 20 minutes. (6) Reassembles s y r i n g e without contamin-a t i n g i t . _ (7) Attaches needle to s y r i n g e without contaminating e i t h e r ... (8) EITHER leaves s y r i n g e (and needle) i n a l c o h o l whenever not i n use OR s t o r e s s y r i n g e (and needle) i n such a way t h a t they are not contaminated.- -(9) Knows t o re p l a c e a l c o h o l (a) i f i t evaporates? (b) i f i t becomes d i s c o l -ored. SCORE = ( t o t a l p o s s i b l e » 5) 3. Weekly Care of Equipment — B o i l i n g STEPS (1) Separates p a r t s of s y r i n g e (and ne e d l e ) . (2) EITHER places p a r t s of s y r i n g e (and needle) i n s e i v e OR l i n e s pot w i t h c l o t h to prevent breakage. . (3) Covers a l l p a r t s w i t h water. (4) B o i l s a l l p a r t s i n water f o r at l e a s t 10 minutes. (5) Removes p a r t s from water without contamin-a t i n g them. (6) E j e c t s a l l water from s y r i n g e . (7) Stores s y r i n g e (and needle) i n such a way th a t they do not become contaminated. (8) Knows to e i t h e r soak s y r i n g e i n vinegar o r b o i l i t i n vin e g a r and water before s t e r i l -i z i n g to remove s c a l e .  SCORE SCORING INSULIN TESTS i ^X|s ( t o t a l p o s s i b l e = 4) on i n s u l i n i n j e c t i o n on d a i l y care of equipment on weekly care of equipment APPENDIX D DIABETIC TEACHING TOOL Introduct ion to the Diabet ic Teaching Tool Contents of the Easel Binder Contents of the Carrying Case 141 INTRODUCTION TO THE DIABETIC TEACHING TOOL Philosophy of the Diabet ic Teaching Tool Increased pat ient knowledge of techniques of d iabet ic s e l f -care should r e s u l t through use of the Diabet ic Teaching Tool because i t o f fers i l l u s t r a t i o n s , uncomplicated terminology, and the ac t ive ass istance of nurs ing personnel . Purpose of the Diabet ic Teaching Tool To present and c l a r i f y the information the d iabe t i c pat ient needs to assume r e s p o n s i b i l i t y f o r managing h i s s e l f - ca re at home. What i s the Diabet ic Teaching Tool? The Diabet ic Teaching Tool i s a teaching aid designed to a s s i s t nurses with the i n s t r u c t i o n of d i abe t i c pa t i en t s . The basic components of the Diabet ic Teaching Tool a r e « 1. An ease l b inder , s i zed for use on the p a t i e n t ' s overbed t a b l e . S p e c i f i c pages i n th i s b inder have been designed to deal with the ma.jor content areas of d i abe t i c teaching and l ea rn ing . The binder i s designed i n such a way that each poster contains a  message, which i s conveyed to the pat ient i n a p i c t o r i a l image. At the same time, on the back of the preceding poster are the "nurse ' s i n s t r u c -t i o n s " . These in s t ruc t ions per ta in to the poster the pat ient i s c u r r e n t l y looking at . They w i l l a s s i s t the nurse i n her teaching of that p a r t i c u l a r aspect of d i abe t i c s e l f - c a r e . 2. A c a r r y i n g case conta in ing : (1) Kardex s l i p s , one to be attached to the Kardex of each d iabe t i c p a t i e n t . (2) Take-home f o l d e r s , one to be given to each d i a b e t i c p a t i e n t . (3) An assortment of i n d i v i d u a l 8 | " by 11" pages, each corresponding i n content and design to one or more posters i n the easel b inder . P r e s c r i p t i o n type format has been u t i l i z e d on severa l of these pages, to allow i n d i v i d u a l i z a t i o n of the information to the p a t i e n t ' s own i n t e r e s t s , needs and l e v e l of c l i n i c a l c o n t r o l . From t h i s assortment, those pages which apply d i r e c t l y to each p a t i e n t ' s care are to be given to him fo r i n c l u s i o n i n h i s "Take-home f o l d e r " . (4) "Meal Planning f o r Diabet ics i n Canada" pamphlets, one to be given to each d iabe t i c p a t i e n t . 142 (5) "Right from the S t a r t " , C i i n i t e s t i n s t r u c t i o n  k i t s , one to be given to each d iabe t i c p a t i e n t . ( 6 ) "Diabet ic Suppl ies" l i s t s , one to be given to each d iabet ic pa t i ent , along with h i s medical pre-s c r i p t i o n , on discharge. (7) Consent Forms (#2) - two to be signed by each p a t i e n t . How to Use the Diabet ic Teaching Tool 1. Approach each d iabe t i c pat ient (new or o ld) who i s admitted to your ward. Exp la in to him that Surrey Memorial H o s p i t a l i s cooperating with a graduate nurs ing student i n t e s t i n g a d iabet ic teaching a i d . Would he be w i l l i n g to p a r t i c i p a t e . I f so, review consent form #2 with him, and complete two copies by f i l l i n g i n the body of the consents and having the pat ient s ign them. Leave one copy of the consent at the p a t i e n t ' s bedside, and f i l e the other on h i s char t . 2. Attach one of the Kardex s l i p s to the p a t i e n t ' s Kardex. As each sec t ion of teaching i s completed, i t should be i n i t i a l l e d on the Kardex s l i p . In that way, should there be any change of s t a f f , the second nurse would know where to take up the teaching. Moreover, i t i s good insurance that nothing i s omitted. 3. Give the pa t ient one of the Take-home f o l d e r s . Each of these contains a t i t l e page, a. b r i e f in t roduct ion and a l i s t of the topics which h i s nurse w i l l discuss with him. As teach-ing progresses, add the pages indicated i n the " Ins t ruct ions to the Nurse", being sure to complete those which contain blanks . Only those pages which apply d i r e c t l y to the p a t i e n t ' s care should be given him to take home ( for example, an t id i abe t i c p i l l users should not receive take-home sheets on insul in? the drug, the i n j e c t i o n process, or the care of the equipment). 4. Proceed through the Diabet ic Teaching Tool at the pa t i ent ' s  own pace. I f he i s rushed, i t i s l i k e l y that h i s learning w i l l be l i m i t e d . 5. Work on only one sec t ion at a time, and stay with that topic u n t i l the pat ient seems to have mastered i t ( for example, i f the pat ient i s an i n s u l i n - u s e r , teaching should be frozen at the "medicine" sec t ion u n t i l the pat ient i s able to give h i s own in j ec t ions s a t i s f a c t o r i l y ) . 6. Once a sec t ion has been completed, encourage the pat ient to take over as much of that aspect of h i s care as i s possible (e .g . (1) Having learned about d i e t , he should mark his own menus. (2) Having learned about h i s medicat ion, he should give his own i n j e c t i o n s . (3) Having learned about ur ine t e s t ing , he should take r e s p o n s i b i l i t y for doing h i s own tests and recording the r e s u l t s ) . 144 a. Contents of the easel binder are found on pages 145 to 244, fo l lowing . a n d d i a b e t e s 146 (Nurse's Ins t ruct ions) Introduct ion EXPLAIN i "Diabetes i s not an i l l n e s s . You d i d n ' t "catch i t " , and when you care for i t proper ly , i t won't stop you from enjoying l i f e . Diabetes cannot be cared for by your doctor alone. Indeed, your doctor i s depending on you to learn as much as you can about diabetes , so that you w i l l be able to care fo r your se l f . There i s quite a b i t to learn, 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 div ided into s i x p a r t s » 1. Introduct ion 2. Diet 3. Medicine 4. Exercise and Hygiene 5. Urine Tes t ing 6. Problems I s h a l l work with you on t h i s course. I s h a l l only go as fa s t as you want me to . Most of the things I w i l l teach you are things that you w i l l do yourse l f every day at home. Ask me lots of questions to be sure you understand what I'm t a l k i n g about. Remember, i n the long run, your d iabe t i c care i s up to you! V 147 i n t r o d u c t i o n A 148 (Nurse's Ins t ruct ions) Food-Energy Cycle EXPLAIN t "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 . Therefore, 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 i n order to work. When everything i s working proper ly i n the body, they make that energy by burn-ing fue1 which comes from the food one eats . The body's biggest sources of fue l are sweet and starchy foods such as sugar, bread and cerea l s . However, other foods (such as meat, f r u i t and vegetables) can provide f u e l too. .After these foods are swallowed, the body changes them a l l to a simple form of sugar. I t i s th i s sugar which the c e l l s use as f u e l . Sugar i s c a r r i ed to each c e l l i n the body by the blood-stream. In order for the sugar to get ins ide the c e l l how-ever, 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 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." RELATE the above explanation to the poster provided -by p o i n t i n g out where organs or processes occur - wherever po s s ib l e . GIVE the pat ient the sheet t i t l e d "Food-Energy C y c l e " for h i s Take-home f o l d e r . 149 energy f o o d — e n e r g y c y c l e 150 (Nurse's Ins t ruct ions ) Diabet ic Food-Energy Cycle EXPLAIN i "As we s a id , 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 for some reason, sugar won't be able to get into 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 into 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 condi t ion 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 cyc le to work p r o p e r l y . " RELATE the above explanation to the poster provided -by po int ing out where organs or processes occur - wherever pos s ib l e . GIVE the pat ient the sheet t i t l e d "Diabet ic Food-Energy C y c l e " for hi s Take-home f o l d e r . d i a b e t i c f o o d - e n e r g y 152 (Nurse's Ins t ruct ions) Symptoms EXPLAIN» Here 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 cyc le to work properly — therefore the amount of sugar i n 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 has to pass large  amounts of urine quite o f ten . 2. Because you were lo s ing so much extra water th 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 sugar-fuel prop-e r l y , you might have lo s t weight, no matter how much you ate. 4. Because much of what you did eat was being lo s t as sugar i n your ur 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 jus t your body's way of t e l l i n g you that something needs to be done." GIVE the pat ient the sheet t i t l e d "Symptoms" fo r h i s Take-home f o l d e r . 1 5 3 of urine 154 (Nurse's Ins t ruct ions ) One i n Every F i f t y Canadians EXPL.AIN i "Knowing that you have diabetes may make you f e e l very lonely or very d i f f e r e n t from your f r iends 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 5 ° Canadians has i t , and most of them are leading per-f e c t l y normal l i v e s . Many success ful and famous people (businessmen, p o l i t i c i a n s , a th le tes , a r t i s t s and performers) are d i a b e t i c . Because they are able to care fo r t h e i r diabetes so e a s i l y and so w e l l , i t hardly in te r f e re 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 hab i t s ; but i t won't mean miss ing old p leasures . " GIVE the pat ient the sheet t i t l e d "One i n Every F i f t y Canadians" for hi s Take-home f o l d e r . one in every m f i f t y ' Canadians 156 (Nurse's Ins t ruct ions) General Questions DISCUSS any of the fo l lowing mater ia l which i s of concern to the p a t i e n t i 1 . Marriage and Family (a) " 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 for , i t causes no problems i n r e l a t i o n to ge t t ing or s taying married. (b) In add i t ion , diabetes i n i t s e l f i s no reason fo r not having c h i l d r e n . Diabet ic people can and do have p e r f e c t l y healthy babies . However, the chance of having a d iabet ic 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 would be wise to t a lk to your doctor some more about th i s before s t a r t i n g a f ami ly . (c) I f you have c h i l d r e n however, there i s a be t ter 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 fo r sugar r e g u l a r l y . " 2. L i f e Insurance 'J\ny l i f e insurance p o l i c y you had before you developed diabetes w i l l not be cance l l ed . As for 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 iabet ic people who are taking good care of themselves." 3. Work "Diabetes should not stop you from working. Indeed, i t probably won't even have much ef fect 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 non-d i a b e t i c s . " 4. 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 fac t , exercise i s e s p e c i a l l y good fo r the person with diabetes . I t helps to burn up sugar. However, i f your exercise pattern i s l i k e l y to change grea t ly 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 into account." GIVE the pat ient one of the sheets t i t l e d "General Questions f o r h i s Take-home f o l d e r . NOTE that there are two types of these sheets - one type fo r younger pat ients and one type for o lder pa t i en t s . 1 5 7 158 (Nurse's Ins t ruct ions) Balance = Good Health EXPLAIN» "You and your doctor share severa l aims or goals i n the care of your diabetes . They arei 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 ge t t ing any complications of d i abe te si 3. to keep you heal thy; and at the same time 4. to in te r f e re as l i t t l e as poss ib le 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 exercise - which help your body use t h i s sugar fo r energy. T ipping the balance to e i t h e r s ide 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 hea l th . " BE SURE that the pa t ient has grasped the idea of "balance" i n r e l a t i o n to his diabetes , as th i s concept i s basic to severa l other explanations throughout the course. GIVE the pat ient the sheet t i t l e d "Balance = Good Heal th" fo r h i s Take-home f o l d e r . 1 5 9 b a l a n c e g o o d h e a l t h SUGAR (food) INSULIN & EXERCISE 160 (Nurse's Ins t ruct ions) Diet EXPLAIN t "You may be asking yourse l f why i t i s necessary fo r d iabet ic s to fol low a d i e t . By seeing to i t that you 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 into 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 serious problems. Therefore, i t i s e s p e c i a l l y important for you to watch both the kind and the amount of food that you eat. No two d iabet ic s are exact ly a l i k e . So, each d iabet ic person's d ie t w i l l be d i f f e rent 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 for you. Now there i s no need to be discouraged about the idea of d i e t . You won'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 tores . You w i l l have to learn a new way of planning your meals — but th i s w i l l soon become second nature to y o u . " GIVE the pat ient the sheet t i t l e d " D i e t " for h i s Take-home f o l d e r . 161 d i e t 162 (Nurse's Ins t ruct ions) Kinds of Food EXPLAINi "Your d i e t plan w i l l c a l l for foods such as mi lk , meat, vegetables, f r u i t , bread and ce rea l s . These foods are nece-ssary for good heal th and should be eaten every day by every-one - - non-diabet ics and d iabet ic s a l i k e ! Nearly a l l foods have some carbohydrate, pro te in and fa t i n them. However, the amounts of each w 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, cerea l s , f r u i t s and vegetables . Foods that have more prote in than carbohydrate or fat are c a l l e d pro te in foods. Pro te in foods are mi lk , cheeses, eggs, meats or f i s h . Foods that have more fat than carbohydrate or pro te in are c a l l e d fat foods. Some fat foods are but ter , nuts and bacon. In planning your d i e t , your doctor w i l l make sure that you eat some carbohydrates, some prote ins and some fats at every meal. Each of these 3 types of food has a s p e c i a l job to perform i 1. Carbohydrate foods are used by the body i n the same way that a car uses gaso l ine . 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 te s t . Thus we may say that they are l i k e "premium" gaso l ine . 2. Prote in foods are used by the body for growth, f o r b u i l d i n g muscles and fo r r e p a i r i n g any body damages, i . e . fo 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 fo r the body. However, they do not act as q u i c k l y as carbohydrates — so they are more l i k e " regular " gaso l ine . Furthermore, i f fats are not needed by the body at the time they are eaten, they may be stored — sort of l i k e a "spare tank" — i n the form of body f a t . " GIVE the pat ient the sheet t i t l e d "Kinds of Food" for h i s take-home f o l d e r . kinds of food 163 r P R E M I U M carbohyrates sugar, bread, cereals, fruit, vegetables. protein milk, cheese, eggs, meat, fish. Home Bui lding and Mai ntenance -0^ fat butter; nuts, bacon. 164 (Nurse's Instructions) How the Doctor Plans Your Diet EXPLAINt "As we said before, as a diabetic, you w i l l need your own personalized d i e t . The doctor w i l l take many things into account i n planning t h i s d i e t f o r you. Here are some of them. 1. Your age Children, teenagers, pregnant women, and older adults a l l have s p e c i a l needs which determine the kind and amount of foods they should eat. Your doctor w 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 weight I f you are overweight, your doctor w i l l give you a die t that w i l l help you to lose weight at f i r s t . Cnce you have reached the correct weight f o r you, your diet w i l l be changed so that i t helps you keep that weight. 3. Sex Men and women have d i f f e r e n t food needs. Your doctor w i l l take these into account. 4. A c t i v i t y As we said before, exercise causes the body to use up sugar. Therefore, more active people w i l l need more food than less active ones. I f your a c t i v i t y w i l l change greatly from day to day, you may even need more than one diet plan. Talk t h i s over with your doctor. 5. Over-all 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, when you are i l l , your doctor w i l l adjust your di e t to meet the sp e c i a l needs your body has at that time. In addition, i f you have some other condition besides diabetes, i t may have to be considered i n your d i e t plan as well." GIVE the patient the sheet t i t l e d "How the Doctor Plans Your Diet" f o r his Take-home fo l d e r . 1 6 5 how the doctor plans your diet . . . age weight sex activity over-all health 166 (Nurse's Ins t ruc t ions ) Things You Need to ?oLLow Your Diet EXPLAIN» "Fo l lowing you d i e t on a day-to-day basis involves the use of two th ings . 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 Diabet ic Assoc ia t ion booklet "Meal PLanning for Diabet ic s i n Canada". Usua l ly the meal plan i s given very simpLy — for example, i n terms of f r u i t , meat, bread, fa t , milk and vegetables . With the food exchange l i s t s these in s t ruc t ions can be followed out with a v a r i e t y of tas ty food c h o i c e s . " GIVE the pat ient 1. a copy of hi s meal p lan , and 2_. a Canadian Diabet ic Assoc ia t ion "Meal Planning" booklet . The meal plan nay be obtained from the h o s p i t a l d i e t i c i a n . REVIEW the p a t i e n t ' s own meal plan with him, po in t ing out how much of the various food types he may have at each meal. Keep t h i s review general , i . e . "one por t ion of f r u i t , two portions o f meat," e t c . EXPLAIN i "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 Diabet ic Assoc ia t ion Exchange L i s t s take care of both these th ings . F i r s t , they d i v i d e a l l of the foods you w i l l eat into d i f f e r e n t k inds . 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 for 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 " f ree foods" . These l i s t s are found on pages 7 to 20 of your "meal Planning" b o o k l e t . " 1 6 7 things you need to follow your diet EXCHANGE LISTS FOR m e a l p l a n n i n g FOR DIABETICS IN CANADA I S R I V M \ S I Fruit Exchange! s) I isi 3 Meal Exchange!*) Lisi 5 Bread Exchange's) List 4 Fat Exchangcis) List h Milk Exchanged! List I M I D - M O R N I M , s\ \< k I I \( I I I O N O R NI I ' l M K Exchangcls) List S Exchange List 2A Exchange List 2B Exchangcls) List 4 Exchangcls) List h Exchangcls) List 3 Exchangcls) List I M l l ) - \ 1 T l R N O O N N N \ ( K D I N N E R O R M \ 1 N M l XI I xchangcis) List 5 Ixchange List 2A Exchange List 2B Exchangc(s) List 4 Exchangcls) I ist 6 I'xchangcis) List 3 Exchangcls) List I I X 1 MN(. SN \( k 168 (Nurse's Ins t ruc t ions ) Exchange System EXPLAIN J "In addi t ion to he lp ing you choose the cor rec t kinds of food for your d i e t , the Canadian Diabet ic 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 ze of the serv ing alLowed. The idea behind t h i s i s that any measured serv ing of food on a given l i s t can be traded f o r any other measured serv ing on the same L i s t . For example, your meal plan may say that you can have a meat exchange fo r break-f a s t . When 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-hal f 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« ONE 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, t ab le -spoons and inches . I f you don ' t a lready have them, i t would be wise to get a standard 8-ounce measuring cup, a set of measuring spoons and a smal l r u l e r . Measurements should be " l e v e l " - not heaped - and should u sua l ly be made a f ter the food i s cooked." GIVE the pa t ient the sheet t i t l e d "Things You Need to Follow Your D i e t " and "Exchange System" f o r h i s Take-home f o l d e r . 3E SURE that the pa t ient also has 1. a copy of h i s own meal p l an , and a "Meal Planning" bookTet. REVIEW each of the Canadian Diabet ic Assoc ia t ion exchange l i s t s with the pa t ient by means of the fo l lowing nine posters . 1 6 9 exchange system 1 exchange = 1 measured serving 1 1 I 1 i 1 1 I [ ' i 1 1 I f i 170 M i l k Exchanges REVIEW the milk exchanges shown in th i s p ic ture with the pa t i en t . HELP him to locate each i n h i s "Meal Planning booklet . E4PH.ASIZE that any of these milk products i n the^ amount shown i s equal to one milk exchange. 172 Vegetable .A Exchanges REVIEW the vegetables shown i n th i s p i c ture with the pat ient . HELP him to locate each i n his "Meal Planning" booklet . EXPLAIN that the " A " vegetables are the ones that have more carbohydrate i n them. EMPHASIZE that any of these vegetables i n the amount shown i s equal to one vegetable A exchange. 174 Vegetable B Exchanges REVIEW the vegetables shown in th i s p ic ture with the pa t i en t . HELP him to locate each i n his "Meal Planning" booklet . EXPLAIN that the 3 vegetables are the ones that have less carbohydrate i n them. EMPHASIZE that any of these vegetables i n the amount shown i s equal to one vegetable 3 exchange. I f you f e e l that i t w i l l not confuse the pa t ient , expla in to him that he may subs t i tute 2 measured servings of "B" vegetables for one measured serving of "A" vegetables any time "A"vegetables are ca l l ed for on h i s meal p lan . 1 7 5 176 F r u i t Exchanges REVIEW the f r u i t s shown i n th i s p i c ture with the pat ient . HELP him to locate each i n h i s "[.leal Planning" booklet . 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 178 Bread Exchanges REVIEW the bread exchanges shown i n t h i s p i c ture with the pa t ient . HELP him to locate each i n h i s "Meal Planning" booklet . EMPHASIZE that any of these bread products i n the  amount shown i s equal to one bread exchange. 1 7 9 180 Meat Exchanges REVIEW the meats shown i n th i s p ic ture with the pa t i ent . HELP him to locate each i n h i s "Meal Planning" booklet . EMPHASIZE that any of these meat products i n the amount shown i s equal to one meat exchange. 1 8 1 182 Fat Exchanges REVIEW the fa t exchanges shown i n th i s p i c ture with the p a t i e n t . HELP him to locate each i n h i s "Meal Planning" booklet . EMPHASIZE that any of these fat products i n the  amount shown i s equal to one fa t exchange. 184 C a l o r i e Free Foods REVIEW the foods shown i n th i s p ic ture with the pa t i en t . HELP him to locate each i n h i s "Meal Planning" booklet . EMPHASIZE that any of these foods may be used as desired to add zest to the d i e t . 1 8 5 186 C a l o r i e Poor Foods REVIEW the foods shown i n th i s p i c ture with the p a t i e n t . HELP him to locate each i n his "Meal Planning" booklet . EMPHASIZE that he may choose two measured servings of these foods each day i n add i t ion to his d i e t . 1 8 7 188 (Nurse's Ins t ruc t ions ) There Aren ' t Many Foods You Can ' t Have EXPLAINi When you have had a good Look at a lL of the foods on the Canadian Diabet ic Exchange L i s t s , you w i l l r e a l i z e that there r e a l l y are not many foods which you 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 fo l lowing foods, except on the advice of your doctor i sugar honey p ie sweetened candy jam cake condensed For exceptions to t h i s advice , plus seasonings and free foods which w i l l add zest to your d i e t , see pages 19 and 20 of your "Meal Planning" b o o k l e t . " GIVE the pat ient the sheet t i t l e d "There Aren ' t Many Foods That You Can ' t Have" f o r h i s Take-home f o l d e r . j e l l y cookies mi lk chewing gum regular sof t dr inks preserves syrup marmalade 1 8 9 190 (Nurse's In s t ruc t ions ) Questions re Diet DISCUSS any of the foLLowing information which i s o f concern to the p a t i e n t i 1. ?ood Shopping I t i s not necessary to buy s p e c i a l foods because you have d iabetes . You can eat the same food as the res t of your f ami ly . 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 for the words "no sugar added" on the l a b e l . You may wish to buy some d i e t e t i c foods, such as non-ca lo r i c sof t dr inks or d i e t e t i c jam and j e l l y . Some of these are indeed al lowed. But be c a r e f u l , some a r t i f i c i a l sweeteners do con-t a i n carbohydrates . Check with your "Meal Planning" booklet or the Canadian Diabet ic Assoc ia t ion Die t Counse l l ing Service whenever you are i n doubt. 2. L iquor Genera l ly speaking, wine, beer and other a l c o h o l i c bever-ages are not permitted on a d i abe t i c d i e t . However, i f you enjoy a dr ink , i t would be wise to discuss the matter with your doctor . He might show you how to include an occa s iona l dr ink i n your d i e t p l a n . 3. Ea t ing Out There i s no reason why having diabetes should stop you from eat ing out . When you are i n a res taurant , ask about the way the food has been cooked. Try to eat p l a i n foods ( i . e . those v/hich have not been breaded, f r i e d o r cooked i n a sauce), s ince 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 qui te easy to prepare. Just fo l low your meal p l an , and choose exchanges which may be wrapped and c a r r i e d e a s i l y . 4. E n t e r t a i n i n g A d i abe t i c d i e t i s a heal thy and ta s ty 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 to add extra fa t or f l o u r ' to a given d i s h , simply remove your own por t ion before you do so. 5. I l l n e s s I f you are nauseated or vomit ing, or i f you have d iarrhea > or a poor appet i te , you may not f e e l l i k e eat ing your regular 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 into 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 . 192 (Nurse's Ins t ruct ions ) Medicine EXPLAIN i "Some d iabet ic s can keep t h e i r condi t ion i n balance by just fo l lowing t h e i r d i e t s . Other d iabet ic s require some sort of medicine i n addi t ion to t h e i r d ie t s to stay hea l thy . Diabet ic medicine comes i n two f o r m s » - i n s u l i n and o r a l ant id iabet i c p i l l s . I f a d iabet ic persons' pancreas i s making l i t t l e or no i n s u l i n , his doctor may wish him to take i n s u l i n . I n s u l i n must be in jected beneath the sk in because, i f i t i s swallowed, i t i s destroyed by the d iges t ive juices of the stomach. I f a d iabet ic person 's pancreas i s making some i n s u l i n , but not enough - o r ' 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 an t id iabe t i c p i l l . I t i s c a l l ed 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 ights against diabetes . Some d iabet ic persons can use the an t id i abe t i c p i l l s j others cannot. Don't t ry to compare your diabetes with that of other people! Each d iabe t i c pat ient needs s p e c i a l study and care . After c a r e f u l study, your doctor has decided which medicine you need to care fo r your diabetes . Follow h i s adv ice ! " GIVE the pat ient the sheet t i t l e d "Medicine" f o r h i s "Take-home f o l d e r " . 1 9 3 m e d i c i n e s (Nurse's I n s t r u c t i o n s ; 194 Ant id i abe t i c P i l l s EXPLAIN! "Your doctor has decided that your diabetes w 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 add i t ion to fo l lowing your d i e t . " HELP the pa t ient to locate h i s a n t i d i a b e t i c p i l l among those i l l u s t r a t e d on the poster . Then choose the information which appl ies to him from that given below, DO NOT give the pa t i ent information about drugs other than h i own. NA«1E STRENGTH MODE OP ACTION Group I (Sulfonylureas) - Orinase (tolbutamide) 500 - Mobenal (tolbutamide) 500 - Genarex (tolbutamide) 500 - Diabinese (chlorpropamide) 250 - Chloronase (chlorpropamide) 100 - Dimelor 500 Group II (Biguanides) - D ia Beta 5 nig - DBI (phenformin) 25 mg - DBI-TD 50 mg mg mg mg mg or mg 250 mg Helps the pancreas to make more i n s u l i n Helps the body use i t s i n s u l i n more e f f e c t i v e l y . EXPLAIN! " 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 fo l low your doc tor ' s i n s t r u c t i o n s f o r taking i t exac t ly . I f you do t h i s , your good hea l th balance w i l l s tay even. I f you d o n ' t , the balance w i l l t i p , and you may run in to ser ious problems. Although your diabetes i s w e l l managed v/ith your a n t i -d i a b e t i c p i l l , there may be some few times then you w i l l have to take i n s u l i n as w e l l . When your body needs more i n s u l i n than i t can make (even with the help o f your p i l l ) - such as when you are s i c k , when you have a bad i n f e c t i o n , or when you have an operat ion - t h i s extra i n s u l i n may need to be suppl ied 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 w i l l be able, to arrange fo r i t to be given by a v i s i t i n g nurse. (NOTEi - As with 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 s ide ef fects i n some people. These are very r a r e . However, should you have any nausea, vomit ing , loss o f appet i te or any other such symptom, report i t to your doctor immediate ly . ) " GIVE the pa t i ent 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 " for h i s Take-home f o l d e r . BE SURE that the pat ient knows the 1^ namei 2± s t rength ! 3» d o s e » k_z_ admini s t ra t ion times, and j j ^ mode of ac t ion fo r h i s  own drug. ASSIST him to f i l l i n t h i s information on the sheet" provided. r iH M A T 1 ( T l i r A + V> i <- (nfnyv./,*:^ J - - 1 MOBENAL ORINASE GENAREX antidiabetic pills O CHLORONASE100 CHL0R0NASE-250 J DIMELOR DI A - BETA ^DBI 6 DIABINESE 196 (Nurse's Ins t ruct ions ) Insul ins EXPLAINi "Your doctor has decided that your diabetes w i l l be kept i n i t s best balance i f you take i n s u l i n as we l l as fo l lowing your d i e t . I n s u l i n helps you manage your diabetes by making i t eas ier fo r sugar to get from your blood into the c e l l s , where i t can be burned fo r energy." HELP the pat ient to locate h i s i n s u l i n among those i l l u s trated on the poster . Then choose the information which applies to him from that given below. Action Name Time of Strongest E f fec t Rapid (fast Acting - Regular(Toronto) - Semilente just before lunch Medium Acting - N . P . H . - Glob in - Lente just before supper Prolonged (slow) Acting - P . Z . I . - U l t r a l e n t e during the night ASSIST the pat ient to i d e n t i f y which strength of i n s u l i n he i s to use (U40 or U80). EXPLAIN that t h i s type of measure ment of strength means that there are 40 or 80 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 ) . Point out that the strength of the i n s u l i n i s always indicated by the colour of the p r i n t on the l a b e l - red f o r U40 and green f o r U80. EXPLAINi " 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 fo l low your doctor ' s in s t ruc t ions fo r taJting i t exact ly . I f you do t h i s , your good health 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 into serious problems." GIVE the pat ient the sheet t i t l e d " I n s u l i n s " f o r h i s Take-home f o l d e r . EE SURE that the pat ient knows the l_j. name, 2_j_ s trength, 3. dose, 4_j_ adminis trat ion time(s) jj^ mode of ac t ion , and 67 time of strongest e f fect for hi s i n s u l i n . ASSIST him to f i l l i n th i s information on the sheet provided. DO NOT give t h i s information to an t id i abe t i c p i l l users . fCOWMAUCWT ) INSULIN TORONTO INSULIN MADE F R O M ZINC INSULIN CRYSTALS 10 cc. 40 UNITS PER CC. C O N N A U G H T MFDICAl Rf SEARCH LABORATORIES Univrmrty ol Toronto Toronto C j n * d * CONNAUGHTy— SEMILENTE INSULIN R A P I D INSULIN ZINC S U S P t r N S RAPID AO UNITS PER CC. 10 CC. C O N N A U G H T MEDICAL R E S E A R C H L A B O R A T O R I E S UnivorBrtv ol Tofonio Toronto, C j r u d a 80 UNITS PER CC SEMILENTE INSULIN INSULIN ZINC SUSPENSION - RAPID RAPID I 80 UNITS PER CC p j 10 CC. " \ T M E D I C A L R E S E A R C H L A B O R A T O R I E S 197 RAPID (fast) ACTING i n s u l i n s GLOBIN INSULIN WITH ZINC • W. I CO. MMTSrttCt. Wellcome -(CONNAUOMI ) — —(CONNAUCHT)— N P H I N S U L I N 10 C C 40 UNITS PER CC. C O N N A U G H T MEDICAL RESEARCH LABORATORIES University ol Toronto Toronto Canad . —<CONNAUGHT >-LENTE INSULIN INSULIN ZINC S U S P E N S I O N - M E D I U M 40 UNITS PER CC. U in r.c MEDIUM C O N N A U G H T M E D I C A L R E S E A R C H I Un iwsr tv ol Toronto N P H I N S U L I N io cc 80 UNITS PER CC. f O ' C A L RESEARCH LABORATORIES into Toronto. Cjrrwdtf - ( C O N N A U G H T } -LENTE INSULIN NSULIN ZINC S U S P E N t l O K - M E D I U M UNITS PER CC. I U I ®(f[) io cc: I " MEDIUM GLOBIN INSULIN WITH ZINC I.W. t CO. N UNITS K l CC. Wellcome MEDIUM ACTING PROLONGED (slow) —(CONNAUGHT PROTAMINE ZINC INSULIN 10 cc. 40 UNITS PER CC. C O N N A U G H T MEDICAL RESEARCH LABORATORIES Unitfor;.'tv ol Toronto Toronto (..n-.nl.i P R O T A M I N E Z I N C I N S U L I N myj) 80 UNITS PER CC. ©4J ACTING — ( C O N W U C M T ) -U L T R A L E N T E I N S U L I N INSULIN ZINC SUSPENSION • IPBOIONGEOI I 40 UNITS PER CC. 10 cc. C O N N A U G H T MEDICAL R E S E A R C H L A B O » A T O » I I S Univoniry of Toronto Toronto. Conodn U L T R A L E N T E I N S U L I N P 80 UNITS PER CC. 10 cc. p CHT MIDICAL «!%! Al tCH IA Pi. 198 (Nurse's Instructions) Equipment EXPLAINi "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 tray or i n a s p e c i a l cupboard). Here are the things you w i l l needi 1. Syringesi You should buy _U_i syringes. 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 glass or p l a s t i c disposable (throw-away) syringes. I f you choose glass, you should buy at least 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 less expensive that way. Glass syringffi are somewhat less expensive than the disposable ones, but glass must be b o i l e d or soaked i n alcohol to make i t safe ( s t e r i l e ) f o r use. 2. Needlesi 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 you to use. Here again, you may choose from 2 types of neediest metal hub, reusable or p l a s t i c hub disposable. I f you choose reusable needles, you should buy at least two. I f you choose disposables, buy them i n quantity. 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 m You shoulduse 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 extra. Each i n s u l i n b o t t l e i s marked with an expiry 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, return i t to your drug store. I f i t expires once you have started using i t , throw i t away. You may store the b o t t l e of i n s u l i n which you are using at room temperature. Extra bottles 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 freezer! The extreme cold reduces i t s e f f e c t i v e n e s s . k. Alcoholi You w i l l need alcohol f o r cleaning your skin and some of your i n j e c t i n g equipment. You should buy 70^ isopropyl alcohol f o r t h i s purpose. Store your alcohol i n a covered glass con-tain e r , as i t evaporates very quickly i f l e f t uncovered. 5. Cottoni Absorbent cotton w i l l be needed to apply the alcohol to your sk i n . E i t h e r bulk cotton or cotton b a l l s w i l l serve t h i s purpose w e l l . Store your cotton i n a clean covered container." SHOW the patient as much of t h i s equipment as possible. Point out the names of the various parts of the syringe and needle. Discuss which parts he may and may not touch. Encourage him to handle the equipment and to ask questions about anything that puzzles hira. GIVE the patient the sheet t i t l e d "Equipment" f o r h i s Take-home f o l d e r . ASSIST him by f i l l i n g i n the blanks pro-vided. 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 patient, you could suggest 25 gauge l/2" or 5/8". 4 0 equipment < 10 20 30 40 UNITS I 8 0 < 20 40 60 80 UNITS J n LiluiiLiiliinl k c I WM PtUNGH I ( | |B9E9E3B9^^^H|HH| fflffllfflllnllllllmllB^HlHH| I 200 (Nurse's Ins t ruc t ions ) Preparing Your I n s u l i n EXPLAIN: "Here are the nine steps to fol low in preparing your i n s u l i n i n j e c t i o n : 1. v/ash 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 between your hands. 3. Moisten some cotton v/ith a l c o h o l . 4. Clean of f the top of your i n s u l i n b o t t l e v/ith the alcohol-soaked co t ton . 5. Remove any a l coho l or water that may be i n your syr inge . 6. Draw the r i g h t amount of a i r into the sy r inge . ' 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 into the i n s u l i n b o t t l e . 9. P u l l the plunger back to withdraw the cor rec t amount of i n s u l i n . Check f o r a i r bubbles i n the syr inge , 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 preparat ion 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 w i n g : (a) the stem of the plunger, (b) the top of the syr inge , (c) the point of the needle, (d) the top of the i n s u l i n b o t t l e . " DEMONSTRATE the above nine steps to the pa t i en t , us ing h i s own i n s u l i n (and syringe i f p o s s i b l e ) . Encourage him to p a r t i c i p a t e i n i d e n t i f y i n g each step as you are doing i t . REPEAT th i s demonstration as often as necessary to be assured that the pat ient understands the procedure. HAVE THE PATIENT RETURN THE DEMONSTRATION. Encourage him to i d e n t i f y each step as he does i t . Have him REPEAT the pro-cedure u n t i l you are s a t i s f i e d that he can perform i t accurate ly and sa fe ly ( i . e . without contamination) . LEAVE the i n j e c t i o n equipment with the pat ient so that he may continue to prac t i ce the procedure. GIVE the pat ient the sheet t i t l e d "Prepar ing Your I n s u l i n " fo r h i s Take-home f o l d e r , I? the pat ient w i l l be us ing a mixture of two i n s u l i n s , fol low the same steps as above, but use the sheet t i t l e d "Prepar ing Your I n s u l i n Mixture" (v/hich may be found i n the Carry ing Case which accompanies t h i s fo lder ) for the steps i n preDarat ion. GIVE the pat ient t h i s sheet fo r h i s Take-home f o l d e r . p r e p a r i n g y o u r I n s u l i n 202 (Nurse's Instructions) Giving Your I n s u l i n EXPLAINi "Once you have prepared your i n s u l i n , most of the work i s done. There are only six steps l e f t to f i n i s h giving your i n s u l i n . 1. Clean the skin at the i n j e c t i o n s i t e with 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. 4. Remove the hand that was pinching the skin. Using that hand, p u l l back on the plunger to be sure that the needle i s not i n a blood vessel. (If blood should come back into your syringe, you must discard 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 quickly at the same angle that i t was inserted, bracing your skin with a clean piece of cotton." POINT OUT the above s i x steps to the patient as you are giving his morning i n j e c t i o n . Then, DEMONSTRATE the procedure to the patient using an orange or a sponge f o r the i n j e c t i o n s i t e . Encourage the patient to i d e n t i f y esch step as you are doing i t . REPEAT th i s demonstration as often as necessary to be assured that the patient understands the procedure. HAVE THE PATIENT RETURN THE DEMONSTRATION, i d e n t i f y i n g the steps as he does so, often enough that you are convinced he can perform the procedure s a f e l y and accurately. LEAVE the i n j e c t i o n equipment with the patient so that he may continue to practice the procedure. GIVE the sheet t i t l e d "Giving Your I n s u l i n " f o r his Take-home f o l d e r . ENCOURAGE the patient to begin giving his own i n j e c t i o n as soon as possible. Once he has mastered t h i s procedure, he should give his own i n j e c t i o n every day to REINFORCE th i s learn-ing. (NOTEt i f the patient i s unable to overcome the psycho-l o g i c a l b a r r i e r of a c t u a l l y passing the needle through h i s skin, a Busher Automatic Injector may be recommended.) Once the patient has mastered the i n j e c t i o n technique, EXPLAIN the following! "Insulin should always be injected to reach the loose space under your skin 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 surface, i t may go into the f a t or the skin and cause a p a i n f u l stretching and swelling. In time, t h i s may lead to shrinkage of the skin and f a t , causing "hollows"." "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 less to give your in j e c t i o n s i n these places, 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 possible of the areas shown 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 two 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!" 203 g i v i n g y o u r I n s u l i n 204 (Nurse's Ins t ruc t ions ) Care of Your Equipment - D a i l y Care with Alcohol EXPLAIN« " 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 for you to use. This may be done i n two ways. 1 . Da i ly Care with Alcohol Alcohol 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 between weekly b o i l i n g s . Here's how to use i t$ (a) Pour 70% i s o p r o p y l a l coho l into a c lean 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 which you can buy at your drug s t o r e ) . (b) Draw enough a l coho l in to your syringe to f i l l i t . Squir t i t out . Repeat 2 or 3 t imes. (c) Put your syringe into the conta iner . I t should be covered with a l c o h o l . Place the l i d on the conta iner . (d) Leave your syr inge i n the a l c o h o l u n t i l you are ready to use i t again. (It must have been soaking i n the a l coho l at leas t 20 minutes to be s t e r i l e . ) (e) You w i l l f ind that a f t e r many uses, the a l c o h o l i n your conta iner w i l l have evaporated or become d i s c o l o u r e d . I f i t evaporates,• just add some more (there should always be enough to cover your equipment). I f i t becomes d i s -coloured, throw i t away and get some fresh a l c o h o l . " GIVE the pat ient the sheets t i t l e d "Care of your Equipment" f o r h i s Take-home f o l d e r . 205 care of your equipment... daily care 206 (Nurse's Ins t ruc t ions ) Weekly Care - B o i l in Water EXPLAIN» "To be very sure that your i n j e c t i n g equipment i s absol-u te ly s t e r i l e , you should b o i l i t i n water once a week. The steps fo r doing th i s are quite easyj (a) Take your syringe apart . Put the parts in to 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 o i l i n g water. Be sure that the water covers the equipment. (c) B o i l 10 minutes. (d) Pick up the s t r a i n e r , hold i t and pour the water out of the pan. Put the s t r a i n e r back into the pan u n t i l everything has coo led . (e) To reassemble your s y r i n g e i i . Pick up the outside part of the syringe (the " b a r r e l " ) v/ith one hand, i i . With the other hand grasp the handle end of the plunger . i i i . Without touching any other par t , s l i d e the plunger into the b a r r e l to put the syr inge together . (f) Wrap your equipment i n a f r e s h l y ironed piece of c l o t h , or re turn i t to the a l coho l conta iner - 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 w i l l f ind that your syringe w i l l become cloudy a f ter many b o i l i n g s . To get r i d of th i s e i t h e r soak i t i f v inegar or b o i l i t i n vinegar and water before s t e r i -l i z i n g . (NOTEi I f you have re-usable needles , they too must be s t e r i l i z e d . Treat them exact ly the same as your syr inge , i . e . soak i n a l coho l every day and b o i l once a week. To put re-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 of the needle or the t i p o f the s y r i n g e ! ) " weekly care boil in water 208 exercise AND hygiene 209 (Nurse's In s t ruc t ions ) Exercise EXPLAINi "Exerc i se i s good for everyone. I t helps keep weight down, muscles strong and blood f lowing proper ly . In short - i t helps people stay hea l thy . This i s e s p e c i a l l y true fo r d i a b e t i c s . I f you w i l l think back to the good-health balance you w i l l remember that exerc i se , as w e l l as d i e t , has an e f fec 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 exerc i se . And a l l exercise 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 just enough i n s u l i n to use up the sugar i n your blood fo r energy. Therefore, to keep your good-health balance even, you should do about the same amount of exercise every day. The kind of exercise i s not near ly as important as the amount. You can do just about any-thing you please - provided that you do i t every day. I f you do more exercise than usual , i t may r e s u l t i n too l i t t l e sugar i n your b lood. I f you do less exercise than usua l , i t may r e s u l t i n too much sugar i n your b lood . Neither one of these condit ions 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 weekdays, 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 less than normal (such as working overtime, planning an act ive vacat ion , or s t ay ing in bed with a c o l d ) , get i n touch v/ith 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 the pat ient the sheet t i t l e d "Exerc i s e " f o r h i s Take-home f o l d e r . 210 same amount everyday weekday ----- weekend 211 Personal Hygiene EXPLAIN i "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 poster show f i v e aspects of hygiene that you should learn, 1. About your teeth and gumsi A l l of the things we have talked about so f a r (diet, medicine and exercise) are aimed at keeping the sugar and i n s u l i n i n your blood in balance. Infection i s another thing which 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 regular check-ups by your dentist. Be sure to t e l l your dentist that you are d i a b e t i c . 2. About smokingi In diabetes blood c i r c u l a t i o n may be lessened. The chem-i c a l s that get into your system when you smoke tend to make your blood vessels contract (or tighten). This i n t e r f e r e s with 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, how much) i s something you should t a l k to your doctor about. 3. and h. About your hands and f e e t i In diabetes, the blood supply i s often decreased (lessened) to the extremities, e s p e c i a l l y the legs and fe 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 heal. I t also means that you may not be able to f e e l leat, cold or sharp objects that may danage your fee t . These simple rules w i l l help you avoid trouble with your f e e t i (a) Wash your feet d a i l y with a s o f t c l o t h and warm soapy water. Dry them thoroughly. I f your skin tends to be rough or dry, apply a gentle skin cream (such as l a n o l i n ) . I f your skin tends to be moist or sweaty, apply talcum powder. Check with your doctor before using s p e c i a l creams, salves or powders on your s k i n . (b) Wear shoes that f i t and are comfortable. Break new shoes i n slowly by wearing them a few hours each day at f i r s t . (c) Don't wear round garters, socks or stockings that are too t i g h t , or anything else that i n t e r f e r e s with the blood supply to your legs and fe e t . Put on clean socks or stockings every day. (d) Never go barefoot, (e) Cut your toenails (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 - when they are s o f t . Cut s t r a i g h t across the n a i l (not too short.) and don't dig into the corners. (f) Don't t r y to cut corns and callouses by yourself. Get them treated by your doctor. (g) I f your feet are cold at night, wear clean socks to bed. Never use a heating pad or hot water b o t t l e because these may cause bums on your feet. (h) Check your feet c a r e f u l l y every day, and report any skin changes which do not go away to your doctor. 5. General Cleanliness i Keep your skin and h a i r clean with regular bathing. Use lukewarm (never hot!) water and mild soaps and shampoos. Dry yourself gently with a s o f t towel. Treat minor cuts and scrapes as follows i - wash with warm, soapy water and put on a clean bandage. Never put iodine on cuts, as i t could burn your skin. I f cuts, scrapes or bruises do not heal i n a reasonable time, t e l l your doctor. GIVE the patient the sheet t i t l e d "Personal Hvgiene" for his Take-home fol d e r . personal hygiene 213 (Nurse's Ins t ruc t ions ) Urine Test ing EXPLAINi "One of the most accurate ways of checking that your good-health balance i s even - - ra ther than tipped to one s ide or the other - - i s by t e s t i n g your u r i n e . Your ur ine tes t re su l t s w i l l t e l l the doc tor whether a l l the things you are doing to manage your diabetes are working O.K. Based on the re su l t s of your te s t s , he may make a change i n your d i e t , medicine or exercise which w i l l help you f e e l be t te r and keep a be t ter balance. You should know how to make two tests on your u r i n e « One for sugar and one for acetone. Whichever ur ine te s t you are making, you should always use a "double-voided" specimen of u r i n e . Here's how to get onei (a) About §• hour before your time to t e s t , ur inate as much as you can. Don't save any of th i s u r i n e . (b) Drink a glass of water and wait about k hour. (c) Urinate again and use th i s specimen fo r t e s t i n g . (This second urine i s c a l l e d a "double-voided" specimen. You w i l l be given de ta i l ed i n s t r u c t i o n s for one sugar and one acetone t e s t . There are many other tests f o r ur ine sugar and acetone a v a i l a b l e . I f you wish to use these, discuss the matter with your doctor . I f he approves, be sure to read and fol low the package d i r e c t i o n s 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 accura te . " »• 2 1 4 urine testing 215 (Nurse's Ins t ruct ions ) Urine Test ing - For Sugar EXPLAIN i " I f you eat more food than i s allowed, forget to take your medicine or do less exercise than usual , sugar w i l l b u i l d up i n your blood. (The same thing 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 bui lds up, some of i t w i l l overflow into your u r ine . .An unusual amount of sugar i n the urine i s a sure s ign that your good-health balance i s t ipped . One of the most accurate means of t e s t ing your urine for sugar i s with G l i n i t e s t t a b l e t s . Here's how. 1. C o l l e c t your urine i n a c lean conta iner . With the dropper i n an upright p o s i t i o n place 5 drops of ur ine i n the test tube. 2. Rinse the dropper and add 10 drops of water. 3. Drop one C l i n i t e s t t ab le t into the tes t tube (be care fu l not to touch i t with damp f i n g e r s ) . Watch while the complete reac t ion takes p lace . k. Do not shake the tube during the react ion nor for 15 seconds a f ter the b o i l i n g has stopped. 5« After the 15-second wait ing per iod , shake the tes t tube gently and compare i t with the colour char t . NOTE: Carefu l observation of the so lu t ion i n the te s t tube while reac t ion takes place and during the 15-second wait ing period i s necessary to detect rapid "pass through" colour changes caused by amounts of sugar over 2%. Should the colour r a p i d l y "pass through" green, tan and orange to a dark greenish-brown, record as over 2% sugar without comparing f i n a l co lour develop-ment with colour c h a r t . " DEMONSTRATE C l i n i t e s t procedure to the pat ient us ing his own u r i n e . Encourage him to p a r t i c i p a t e i n i d e n t i f y i n g each step as you are doing i t . REPEAT th i s demonstration as often as necessary to be assured that the pat ient understands the procedure. HAVE THE PATIENT RETURN THE DEMONSTRATION, i d e n t i f y i n g the steps as he does so, often enough that you are convinced he can perform the procedure sa fe ly and accurate ly . 216 217 (Nurse's Ins t ruct ions) Urine Tes t ing - for Acetone EXPL.AIN t "Genera l ly speaking, your body uses sugar for energy. However, i t can also get energy from f a t . When your c e i l s are not ge t t 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 ca l l ed acetone, which w i l l s p i l l over into your ur ine i n the same way that sugar does v/hen i t gets too Moderate amounts of acetone i n your blood w i l l cause nausea, vomiting, flushed and dry s k i n , s leepiness and deep rapid breathing . Large amounts of acetone cause unconscious-ness. So you can see that i t i s important to know when you are b u i l d i n g up acetone. The way to do th i s i s by t e s t i n g . One simple and accurate te s t fo r acetone can be done with .Acetest t a b l e t s . Just fol low these steps : 1 . C o l l e c t your urine i n a c lean conta iner . Place one .Acetest t ab le t on a c lean piece of white paper. 2. Put one drop of urine on the t a b l e t . Compare the co lour of the t ab le t with the co lour c h a r t . " DM OlfS TR .ATE Acetest procedure to the pa t ient using his own ur ine . Encourage him to p a r t i c i p a t e i n i d e n t i f y i n g each step as you are doing i t . REPEAT t h i s demonstration as often as necessary to be assured that the pat ient understands the procedure. HAVE THE PATIENT RETURN THE DEMONSTRATION, i d e n t i f y i n g the steps as he does so, often enough that you are convinced he can perform the procedure sa fe ly and accurate ly . ENCOURAGE the pat ient to begin doing a l l of h i s own urine tests as soon as pos s ib le . He may need supervi s ion at f i r s t , but once he has mastered the procedure, he should be able to take the r e s p o n s i b i l i t y for t e s t i n g and repor t ing the r e su l t s on his own. GIVE the pat ient the sheets t i t l e d "Urine Tes t ing" for hi s Take-home f o l d e r . FILL IN the ur ine t e s t i n g times on these sheets i n the spaces provided. EXPLAIN: I f your urine tests greater than 1% fo r sugar on severa l tes ts i n a row OR i f you get a p o s i t i v e acetone te s t , n o t i f y your doctor . h igh . Wait 3° seconds. 218 i acetone 219 (Nurse's Ins t ruct ions ) Keep .A Record EXPLAIN: "In order for your doctor to get an o v e r a l l p i c ture of how w e l l balanced your diabetes i s , he w 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." REVIEW the sample record with the pa t ient . Be sure he understands what and how to record i n each column. 220 keep a record LATE 7A s A S A 4* s n A 9 A 7 0 0 221 (Nurse's Ins t ruct ions) Problems EXPLAIN t ".As we have s a id , you w i l l u sua l ly be able to keep the sugar and i n s u l i n i n your blood i n balance by fo l lowing your doc tor ' s orders about d i e t and medicine, and by ge t t ing the same amount of exercise every day. There are, however, some other things — things you can ' t help — which 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 whenever you "cheat" on your d i e t , medicine or exerc i se , you are i n danger of developing a problem with your diabetes . I t i s important that you should be aware of these problems (what causes them and how to know you have them) so that you can t rea t them when they occur and avoid them i n the f u t u r e , " 222 7 problems 223 (Nurse's Ins t ruct ions ) Diabet ic Coma EXPLAIN t "Diabet ic coma i s the problem which re su l t s when your sugar - insu l in balance i s t ipped to the sugar s ide . As we mentioned when we were d i scuss ing ur ine t e s t ing , your body can make energy from fat as we l l as sugar. I t does th i s when there ' s not enough i n s u l i n around to use your blood sugar i n the way i t o r d i n a r i l y should. When your body burns fa t for energy, i t produces f a t t y acids l i k e acetone. Too much acetone i s bad for your body. I t causes a condi t ion c a l l e d ac idos i s , which can lead to a d iabet ic coma. You may hear d iabet ic coma c a l l e d other names, such as "d iabe t i c a c i d o s i s " , "d i abe t i c ke to s i s " , or "hyperglycemia" (which means extra blood sugar) . Whatever name you use, i t i s important to remember that d iabet ic coma i s a very serious d iabet ic problem! There are severa l things which 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 diabetes medicine (that i s , less i n s u l i n or an t id i abe t i c p i l l than you are supposed to ) ; (c) taking much less than your usual amount of exerc i se , (d) a fever or an i n f e c t i o n ; (e) a severe emotional upset . " diabetic coma 225 (Nurse's Instructions) Symptoms (of Diabetic Coma) EXPLAIN i "How w i l l you know i f you are going into a diabetic coma? Here are some of the most common symptomsi (a) dry skin and tonguei (b) severe t h i r s t ? (c) weakness, drowsiness or tiredness? (d) nausea, vomiting or loss of appetite? (e) deep rapid breathing and a " f r u i t y " smelling breath." 226 symptoms DIABETIC COMA Fruity T h i r s t y Dry Tongue 227 (Nurse's Ins t ruct ions ) What To Do ( for Diabet ic Coma) EXPLAINi "Here's what to do i f you f e e l you might be going into a d iabet ic c o m a i (a) Test your urinet i t w i l l probably be 2fo or greater for sugar and p o s i t i v e for acetone. (b) Phone the doctor i 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 you what to do next . How can you keep from having a d i abet ic coma? Here are some usefu l suggest ionsi (a) Follow your d i e t 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 iabe t i c medicine. Always measure i t c a r e f u l l y and take i t r i g h t on time. (c) Do the same amount of exercise every day. (d) Avoid in fec t ions and emotionally upset t ing s i tua t ions whenever you can. (e) Test your ur ine r e g u l a r l y and report high sugars to your d o c t o r . " GIVE the pa t ient the sheet t i t l e d "Diabet ic Coma" fo r h i s Take-home f o l d e r . 228 o Q 1 o TEST your urine w h a t t o d o u FOR D I A B E T I C COMA phone the DOCTOR 229 (Nurse's Ins t ruct ions ) I n s u l i n Shock EXPLAIN i " I n s u l i n reac t ion i s the problem which re su l t s 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 ide . That i s , you have e i t h e r too much i n s u l i n or not enough sugar i n 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 sugar - in su l in balance i s t ipped to the i n s u l i n s ide , the r e s u l t i s that your blood has more i n s u l i n i n i t than i t has sugar for the i n s u l i n to work 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 serious d iabet ic problem, and one which must be dea l t with at once! There are severa l things which might cause you to go into i n s u l i n shock. Here are the most usual causes i (a) not eat ing enough food (e .g . de laying or sk ipping meals, or leaving out foods you are supposed to eat ) ; (b) taking more than the correc t amount of diabetes medicine; (c) taking more than the usual amount of d a i l y e x e r c i s e . " insulin shock 231 (Nurse's Ins truct ions) Symptoms (of I n s u l i n Shock) EXPLAINi "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 symptomst (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) trembling? (f) trouble seeing c l e a r l y . " 232 symptoms O F I N S U L I N S H O C K Headache & / or Feeling Faint 233 (Nurse's Ins t ruct ions ) What To Do ( for I n s u l i n Shock) EXPLAIN« ".Although i n s u l i n shock i s a serious problem, i t i s a very easy one to t r ea 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 i (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 for sweets; just eat something! (b) Wait 15 minutes. (c) THEN - i f you don' t f e e l be t ter - eat or dr ink some 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 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 ic medicine c a r e f u l l y and take i t on time. (c) Eat or drink something extra beforehand i f you know you are going to do more exercise than usua l . OR of there wasn't time for that , eat or dr ink something immediately afterwards. (d) Always carry something sweet with you . " GIVE the pa t ient the sheet t i t l e d " I n s u l i n Shock" for h i s Take-home f o l d e r . 234 what to do T H E N IF YOU DONT FEEL BETTEF Eat or Drink some more and Call the Doctor 235 (Nurse's Ins t ruct ions ) Infect ion EXPLAIN t ".As we mentioned i n our d i scuss ion of d iabet ic coma, an i n f e c t i o n i s one of the things which may cause you to go into a d iabet ic coma. This i s because the fever that comes with many infect ions acts to t i p the sugar - in su l in balance toward the sugar s ide . 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 warning s igns , i f you take your temperature you w i l l f ind that i t i s above normal . " infection •• 235 237 (Nurse's Instructions) What To Do (for Infection) EXPLAINi "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 diabetic coma, you would expect to treat i t the same way — and you doI (a) Test your urine (once again, i t w i l l probably be po s i t i v e f o r both sugar and acetone). (b) Phone your doctor. T e l l him how you f e e l , what your temperature i s , and what your urine tests sa i d . He w i l l give you s p e c i f i c instructions about your diabetes medicine and d i e t . (c) Go to bed — y o u ' l l need rest to allow your body to f i g h t that i n f e c t i o n . Now that you know that infe c t i o n s can be serious problems f o r you, y o u ' l l want to avoid them whenever you can. Here are some hints f o r doing just thatt (a) Stay away from people who you know already have infections of one sort or another. (b) Follow the rules we discussed under "Personal Hygiene". (c) Treat simple i n j u r i e s r i g h t away so that they don't have a chance to become infected." GIVE the patient the sheet t i t l e d "Infection" f o r his Take-home fo l d e r . go to bed 239 (Nurse's Instructions) Protect Yourself EXPLAIN! "There are two very simple things you should do to protect yourself« 1• Wear and/or Carry I d e n t i f i c a t i o n Both diabetic coma and i n s u l i n shock are serious problems which c a l l f o r quick treatment. When they are severe, the diabetic person can f a i n t . That's why i t ' s very important to wear or carry diabetic 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 w i l l help you get the treatment you need quickly. Medic .Alert i s one very good source of diabetic i d e n t i f i c a t i o n . There are others. Talk to your doctor about which kind of i d e n t i f i c a t i o n you should use. 2. Carry Something Sweet Insulin shock may come on very suddenly — almost without warning. When i t does, you want to be able to treat i t promptly. That i s why i t would be wise f o r you to get into the habit of always carrying something sweet ( l i k e candy) i n your pocket or purse." protect yourself! wear & / o r carry IDENTIFICATION (Nurse's Ins truct ions) 241 Where to Get Help EXPLAIN: "There are many people and organizat ions who are ready to help you keep your good-health balance even. Here's a quick reference of who they are and what they w i l l do for you. SOURCE WHAT THEY CAN DO FOR YOU 1. Doctor (phone number) 2. The Canadian Diabetic Associ-at ion (branch phone number) 1. Get you started with a good balance of d i e t , exercise and diabetes medicine. 2. Change t h i s plan i f i t i s n ' t working for you. 3. Advise you what to do when your good-heal th balance i s i n danger of t i p p i n g . The Canadian Diabet ic Associat ion i s a non-prof i t organizat ion dedicated to help-ing d iabet ic 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 C D . 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 benef i ts of membership i n the C D . A. broadly inc lude : 1. Serv ices . Free d i e t counse l l ing and operat ion of hol iday camps which pro-vide regulated d ie t s for c h i l d r e n and adults are some of the services you can enjoy as a member of C D . A . 2. Educat ion. At every l o c a l C D . A. meet-ing , part of the program i s devoted to e i ther demonstrations by doctors and d i e t i c i a n s , l ec tures , open forums, or i n s t r u c t i v e f i lms designed to help you and your family l i v e a be t ter and more normal l i f e . 3. "The Newsletter" . The C D . A. pub l i ca t ion "The Newsletter" i s mailed to a l l members four times a year . Information and pr ice on other publ ica t ions on diabetes are ava i lab le from the n a t i o n a l o f f i c e . k. Encouragement. You and your fe l low mem-bers of the C D . A. have common problems and ob jec t ive 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. continued next page. 242 help 243 SOURCE (Nurse's Instructions) WHAT THEY CAN DO FOR YOU 3. Public Health or V i c t o r i a n Order of Nurses v i s i t i n g nurses. (phone numbers) k. D i a l - a - D i e t i c i a n (phone number) 1. Do home teaching. 2. Give i n s u l i n i n j e c t i o n s at home. 3. Help with your food care i f you can' manage i t alone. Various p r o v i n c i a l d i e t i e t i c associations have organized D i a l - a - D i e t i c i a n programs to answer the questions about food and n u t r i t i o n which aris e i n day-to-day l i v i n g . Information i s available on such topics asJ - everyday n u t r i t i o n - foods and food values - budgeting and purchasing - meal planning and preparation - food additives - l a b e l l i n g - food fads and f a l l a c i e s - therapeutic d i e t modifications I f you have questions about any of these subjects, you should c a l l the D i a l - a -D i e t i c i a n number. Your questions w i l l be recorded, and a professional d i e t i -cian w i l l c a l l you back - within 48 hours - with the answers." GIVE the his Take-home patient f o l d e r . the sheet t i t l e d "Where to Get Help" f o r your body responds loving care treat it that way \ PHOTOGRAPH OP THE CARRYING CASE SECTION a OF THE DIABETIC TEACHING TOOL Contents of the carry ing case are found on pages 246 to 289, f o l lowing . DIABETIC TEACHING Date Nurse's Topic Completed I n i t i a l s 1. Introduct ion 2. Diet 3. Medicine (Addressograph Stamp) Comments t -b. Exerc i se and Hygiene 5* Urine Tes t ing 6. Problems DIABETIC SUPPLIES (Name) You w i l l need the supplies checked below which can be purchased at your drugstore. Food Scale O f f i c i a l hypodermic syringe cc units cc units Hypodermic needles gauge inch Syringe s t e r i l i z i n g tube S t e r i l e cotton Isopropyl alcohol CLINITEST Set CLINISTIX Reagent S t r i p s ACETEST Reagent Tablets KETOSTIX Reagent S t r i p s (Nurse) 248 249 and diabetes 250 Introduction Diabetes i s not an i l l n e s s . You didn't "catch i t " , and when you care f o r i t properly, 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 learn as much as you can about diabetes, so that you w i l l be able to care f o r yourself. There i s quite a b i t to learn, 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 divided into six partst 1. Introduction 2. Diet 3. Medicine k. Exercise and Hygiene 5. Urine Testing 6. Problems Your nurses w i l l work with you on t h i s course. They w i l l only go as fa s t as you want them to. Most of the things they w i l l teach you are things that you w i l l do yourself every day at home. .Ask them lots of questions to be sure you understand what they are saying. Remember, i n the long run, your diabetic care i s up to you! (Patient's Copy) 251 Food-Energy Cycle 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 . Therefore, each thing that the body does (work-ing, playing 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 i n order to work. When 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 cereals . However, other foods (such as meat, f r u i t and vegetables) can provide f u e l too. After these foods are swallowed, the body changes them a l l to 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 carried to each c e l l i n the body by the blood stream. In order f o r the sugar to get inside 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 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 cycle w i l l work smoothly without any problems. (Patient's Copy) 252 Diabet ic Food-Energy CycLe As we sa id , 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 for some reason, sugar won't be able to get into your c e l l s . When th i s happens, the sugar keeps backing up i n your blood u n t i l i t overflows into your u r i n e . I t i s when th i s happens that you are found to have diabetes . i n Diabetes, then, which there i s n ' t i s a cond i t ion enough i n s u l i n i n the blood to allow your food-energy cyc le to work proper ly . (Pa t ient ' s Copy) 253 Sympt orris 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 cyc le to work properly — therefore the amount of sugar i n your blood rose and s p i l l e d over into your u r ine . 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 ur ine quite o f ten . 2. Because you were lo s ing so much extra water th 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 sugar- fuel prop-e r l y , you might have lo s t weight, no matter how much you ate. 4. Because much of what you did eat was being lo s t as sugar i n your ur 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. (Pa t ient ' s Copy) 254 One i n Every F i f t y Canadians Knowing that you have diabetes may make you f e e l very lonely or very d i f f e r e n t from your f r iends 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 per-f e c t l y normal l i v e s . Many success ful and famous people (businessmen, p o l i t i c i a n s , a thletes , a r t i s t s and performers) are d i a b e t i c . Because they are able to care fo r t h e i r diabetes so e a s i l y and so w e l l , i t hardly in ter fe re s with t h e i r l i ve 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 hab i t s ; but i t won't mean miss ing old pleasures . (Pa t ient ' s Copy) 255 General Questions There are probably a few 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. What about marriage and children? v j I f you are si n g l e , diabetes shouldn't change your plans , to marry. Because diabetes i s so easy to care for, i t causes^ no problems i n r e l a t i o n to getting or staying married. In addition, 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 . Diabetic people can and do have p e r f e c t l y healthy babies. However, the chance of having a diabetic 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 would be wise 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 family. 2. What about l i f e insurance? Any l i f e insurance p o l i c y you had before you developed diabetes w i l l not be cancelled. As f o r new insurance, many /sjjfc companies today w i l l give l i f e insurance p o l i c i e s to diabetic people who are taking good care of themselves. 3. What 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 well i n t h e i r work — i n every way as do non-diabetics. 4. What 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 , exercise 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 exercise pattern i s l i k e l y to change grea 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 into account. (Patient's Copy - f o r younger patients) 2 5 6 General Questions There are probably a few questions that are r e a l l y worry-ing you about your d iabetes . Le t ' s answer them r i g h t now. 1. What about marriage and ch i ldren? Because diabetes i s so easy to care fo r , i t causes no problems i n r e l a t i o n to ge t t ing or s tay ing marr ied . So put your mind to res t about that ! I f you have c h i l d r e n however, there i s a be 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 ur ine 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 you 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 g ive l i f e insurance p o l i c i e s to d i abe t i c people who are taking good care of themselves. 3. What about work? Diabetes w i l l not stop you from working. Indeed, i t probably won't even have much ef fect 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 non-d iabet ic s . k. What 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 ac t , exercise 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. (Pa t i ent ' s Copy - f o r o lder pa t ient s ) 257 Balance = Good Health You and your doctor share severa l aims or goals i n the care of your diabetes . They a r e i 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 ge t t ing any complications of d iabetes i 3. to keep you heal thyi and at the same time k. to i n t e r f e r e as l i t t l e as poss ib le 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 exercise - which help your body to use t h i s sugar f o r energy. T ipp ing 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 . (Pa t ient ' s Copy) 258 Die t You may be asking your se l f why i t i s necessary f o r d iabe t i c s to fol low a d i e t . By seeing to i t that you 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 into 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 serious problems. Therefore, i t i s e s p e c i a l l y important fo r you to watch both the kind and the amount of food that you eat . No two d iabe t i c s are exact ly a l i k e . So, each d i abe t i c person's d i e t w 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. Now there i s no need to be discouraged about the idea of d i e t . You won'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 tores . You w i l l have to learn a new way of p lanning your meals — but t h i s w i l l soon become second nature to you. (Pa t i en t ' s Copy) 259 Kinds o f Food Your d i e t plan w i l l c a l l f o r foods such as mi lk , meat, vegetables, f r u i t , bread and cerea l s . These foods are nece-ssary fo r good heal th and should be eaten every day by every-one — non-diabet ics and d iabet ic s a l i k e ! Nearly a l l foods have some carbohydrate, p ro te in and fat i n them. However, the amounts of each w 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 pro te in or fa t are c a l l e d carbohydrate foods. Carbohydrate foods are sugars, breads, cerea l s , f r u i t s and vegetables . Foods that have more pro te in than carbohydrate or f a t are c a l l e d p r o t e i n foods. Pro te in foods are mi lk , cheeses, eggs, meats or f i s h . Foods that have more fa t than carbohydrate or p ro te in are c a l l e d fa t foods. Some fa t foods are but ter , nuts and bacon. In planning your d i e t , your doctor w i l l make sure that you eat some carbohydrates, some proteins and some fats at every meal. Each of these 3 types of food has a s p e c i a l job to perform i 1. Carbohydrate foods are used by the body i n the same way that a car uses gaso l ine . 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 te s t . Thus we may say that they are l i k e "premium" gaso l ine . 2. P ro te in foods are used by the body f o r growth, f o r b u i l d i n g muscles and fo r repairing 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 fo r the body. However, they do not act as qu i ck ly as carbohydrates — so they are more l i k e " regular " gaso l ine . Furthermore, i f fats are not needed by the body at the time they are eaten, they may be stored — sor t of l i k e a "spare tank" — i n the form of body f a t . (Pa t ient ' s Copy) 260 How the doctor Plans Your Diet As we sa id before, as a d i a b e t i c , you w i l l need your own personal ized d i e t . The doctor w i l l take many things into account i n planning th 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 women, and o lder adults a l l have s p e c i a l needs which determine the kind and amount of foods they should eat . Your doctor w 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 weight I f you are overweight, your doctor w i l l give you a d i e t that w i l l help you to lose weight at f i r s t . Once you have reached the correc t weight fo r you, your d i e t w i l l be changed so that i t helps you keep that weight. 3. Sex Men and women have d i f f e rent food needs. Your doctor w i l l take these into account. 4. A c t i v i t y As we sa id before, exercise causes the body to use up sugar. Therefore, more act ive people w i l l need more food than w i l l less act ive ones. I f your a c t i v i t y w i l l change grea t ly from day to day, you may even need more than one d ie t p l an . Talk th i s over with your doctor . 5. O v e r - a l l heal th 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, when you are i l l , your doctor w 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 add i t ion , i f you have some other cond i t ion besides diabetes , i t may have to be considered i n your d i e t plan as w e l l . (Pa t ient ' s Copy) Things You Need to Follow Your Diet Fol lowing your d i e t on a day-to-day basis involves the use of two t h i n g s i 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 Diabet ic Assoc ia t ion booklet "Meal Planning fo r Diabet ics i n Canada". Usua l ly the meal p lan i s given very simply — for 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 p l an , which t e l l s you how much of each of these foods you may have at each meal. With the food exchange l i s t s these in s t ruc t ions can be followed out with a v a r i e t y of t a s ty food choices . You w i l l r e c a l l that both the kind and the amount o f food that you eat are important. The Canadian Diabetic Assoc ia t ion Exchange L i s t s take care of both these things . F i r s t , they d iv ide a l l of the foods you w i l l eat in to d i f f e r e n t k inds . 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 for f r u i t s , a l i s t f o r breads, a l i s t f o r fa 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 on pages 7 to 20 of your "Meal Planning" booklet . Exchange System In add i t ion to he lp ing you choose the correct kinds of food f o r your d i e t , the Canadian Diabet ic Exchange L i s t s also t e l l you the amounts o f food to eat . They do t h i s by the s i ze of the serv ing al lowed. The idea behind thi s i s that any measured serv ing of food on a given l i s t can be traded fo r any other measured serv ing on the same l i s t . For example, your meal p lan may say that you can have a meat exchange f o r break-f a s t . When 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 o f c r i s p bacon or one and one-hal f 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 rememberi ONE 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 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 sua l ly be made a f ter the food i s cooked. (Pa t ient ' s Copy) 262 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 Diabetic Exchange L i s t s , you w i l l r e a l i z e that there r e a l l y are not many foods which you 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 following foods, except on the advice of your doctori sugar candy honey jam j e l l y preserves syrup marmalade pie cake cookies sweetened condensed milk chewing gum regular s o f t drinks For exceptions to this advice, plus seasonings and free foods which w i l l add zest to your di e t , see pages 19 and 20 of your "Meal Planning" booklet. (Patient's Copy) 263 Questions re Diet There may s t i l l he a number of small questions which worry you about your d i e t . Let's c l e a r them up here and now. 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 rest of your family. 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 words "no sugar added" on the l a b e l . You may wish to buy some d i e t e t i c foods, such as non-caloric 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 allowed. But be c a r e f u l . Some a r t i f i c i a l sweeteners do con-t a i n carbohydrates. Check with your "Meal Planning" booklet or the Canadian Diabetic Association Diet Counselling Service whenever you are i n doubt. 2. What about liquor? Generally speaking, wine, beer and other alcoholic bever-ages are not permitted on a diabetic 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 you how to include an occasional 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 restaurant, ask about the way the 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. Just follow your meal plan, and choose exchanges which may be wrapped and carried e a s i l y . 4. What about entertaining? As we said before, a diabetic d i e t i s a healthy and tasty 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 yourself. I f you wish to add extra f a t or f l o u r to a given dish, simply remove your own portion 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 appetite, you may not f e e l l i k e eating your regular 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 into f l u i d exchanges. I f he does, turn to pages 20 and 21 of your "Meal Planning" booklet f o r d i r e c t i o n s . (Patient's Copy) 2 6 4 6. Canadian Diabet ic Associat ion Diet Counse l l ing Service I f you have any questions or problems regarding your d i e t , the C D . A. Diet Counse l l ing Service i s a good place to t u r n . This serv ice i s offered free of charge to a l l d i abe t i c pa t i en t s . Contact your l o c a l C D . A. branch fo r d e t a i l s . (Pa t ient ' s Copy) 265 Medicine Some diabetics can keep t h e i r condition i n balance by-just following t h e i r d i e t s . Other diabetics require some sort of medicine i n addition to t h e i r diets to stay healthy. Diabetic medicine comes i n two formst - i n s u l i n and o r a l antidiabetic p i l l s . I f a diabetic person's pancreas i s making l i t t l e or no i n s u l i n , h is doctor may wish him to take i n s u l i n . I n s u l i n must be injected beneath the skin because^ i f i t i s swallowed, i t i s destroyed by the digestive juices of the stomach. I f a diabetic 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 - his doctor may wish him to take an o r a l antidiabetic p i l l . I t i s ca 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. Some diabetic persons can use the antidiabetic p i l l s j others cannot. Don't t r y to compare your diabetes with that of other people! Each diabetic patient needs s p e c i a l study and care. After c a r e f u l study, your doctor has decided which medicine you need to care f o r your diabetes. Follow his advicel (Patient's Copy) 266 Ant id iabet ic P i l l s Your doctor has decided that your diabetes w i l l be kept i n i t s best balance i f you take an an t id i abe t i c p i l l i n addi t ion to fo l lowing your d i e t . This p i l l w i l l help you manage your diabetes by . The name of the p i l l he wishes you to take i s . Each of these p i l l s contains ^ _ mil l igrams of drug. You are to take mil l igrams or p i l l ( s ) at the fo l lowing time(s) every day» -I t i s most important that you take only t h i s an t id i abe t i c drug, and that you fol low your doctor ' s in s t ruc t ions fo r taking i t exac t ly . I f you do t h i s , your good heal th balance w i l l s tay even. I f you don ' t , the balance w i l l t i p , and you may run into serious problems. Although your diabetes i s w e l l managed with your a n t i -d iabe t i c p i l l , there may be some few times when you w i l l have to take i n s u l i n as w e l l . When your body needs more i n s u l i n than i t can make (even with the help of your p i l l ) - such as when you are s i c k , when you have a bad i n f e c t i o n , or when you have an operat ion - t h i s extra i n s u l i n may need to be supplied 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 w i l l be able to arrange fo r i t to be given by a v i s i t i n g nurse. (NOTEt - As with a l l kinds of medicine, an t id i abe t i c p i l l s may cause unpleasant s ide ef fects i n some people. These are very r a r e . However, should you have any nausea, vomit ing, loss o f appetite or any other such symptom, report i t to your doctor immediately.) (Pa t ient ' s Copy) 267 Insu l ins Your doctor has decided that your diabetes w i l l be kept i n i t s best balance i f you take i n s u l i n as well as following your d i e t . I n s u l i n helps you manage your diabetes by making i t easier f o r sugar to get from your blood into the c e l l s , where i t can be burned f o r energy. The name of the i n s u l i n your doctor wishes you to take i s . I t i s a (rapid, medium, prolonged) acting i n s u l i n , which w i l l have i t s strongest e f f e c t on your body at the following 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 exercising 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 which you w i l l use i s U  which 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 syringefuiTI 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 following ti,me(s) every day. I t i s most important that you take only t h i s kind o f i n s u l i n , and that you follow your doctor's in s t r u c t i o n s f o r taking i t exactly. I f you do t h i s , your good health 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 into serious problems. Two quick and sure ways of checking that you have the correct i n s u l i n f o r you are the f o l l o w i n g i 1. Name on the l a b e l i yours should be 2. Colour of the p r i n t on the la b e l , yours should be ; , which indicates U (Pat ient ' s Copy) 268 Equipment 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 th i s equipment together i n one place (such as on a t ray or i n a s p e c i a l cupboard). Here are the things you w i l l need i 1. Syr inges i You should buy U syr inges . I t i s important fo r you to have th 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 us ing . Your U syringes w i l l have coloured markings on them. You may wish to use e i t h e r glass or p l a s t i c disposable (throw-away) syr inges . I f you choose g lass , you should buy at least 2 syringes (to allow for 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 less expensive that way. Glass syringes are somewhat less expensive than the disposable ones, but glass must be bo i led or soaked i n a l coho l to make i t safe ( s t e r i l e ) for use. 2. Needles : You should buy gauge* inch long needles . This i s the s i ze that the doctor fee l s i s best for you to use. Here again, you may choose from 2 types .o f needles : metal hub, reusable OR p l a s t i c hub disposable . I f you choose reusabl needles, you should buy at least two. I f you choose disposable buy them i n quant i ty . 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 least 2 bo t t l e s of i n s u l i n on hand - the one your are us ing, and an extra . Each i n s u l i n b o t t l e i s marked with an expiry date. I t i s not safe to use that i n s u l i n a f ter the date g iven. I f the bo t t l e expires before i t i s opened, return i t to your drug store I f i t expires once you have started using i t , throw i t away. You may store the b o t t l e of i n s u l i n which you are us ing at room temperature. Extra bot t l e s should be kept in 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 freezerJ The extreme cold reduces i t s e f fec t iveness . (Pa t ient ' s Copy) 269 4. Alcohol i You w i l l need a lcohol for c leaning your sk in and some of your i n j e c t i n g equipment. You should buy 7Q>% i sopropy l a l cohol for th i s purpose. Store your a lcohol i n a covered glass con-t a i n e r , as i t evaporates very qu ick ly i f l e f t uncovered, 5. Cottont .Absorbent cotton w i l l be needed to apply the a l coho l to your s k i n . E i t h e r bulk cotton or cotton b a l l s w i l l serve t h i s purpose w e l l . Store your cotton i n a c lean covered conta iner . (Pa t i ent ' s Copy) 270 Preparing Your I n s u l i n Here are the nine steps to fol low 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 bo t t l e between your hands. 3. Moisten some cotton with a l c o h o l . h. Clean o f f the top of your i n s u l i n bo t t l e with the alcohol-soaked cot ton . 5. Remove any a l coho l or water that may be i n your syr inge . 6. Draw the r i g h t amount of a i r into the syr inge . 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 into the i n s u l i n b o t t l e . 9. P u l l the plunger back to withdraw the correc t amount of i n s u l i n . Check fo r a i r bubbles i n the syr inge , 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 preparat ion 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 w i n g i (a) the stem of the plunger, (b) the top of the syr inge , (c) the point of the needle, (d) the top of the i n s u l i n b o t t l e . (Pa t ient ' s Copy - fo r pat ients using only one kind of i n s u l i n ) 271 P r e p a r i n g Your I n s u l i n M i x t u r e Here are the steps to f o l l o w i n p r e p a r i n g 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 between your hands. 3. M o i s t e n some c o t t o n with a l c o h o l . k. Clean o f f the tops o f both i n s u l i n b o t t l e s with the alcohol-soaked c o t t o n . 5. Remove any a l c o h o l o r water t h a t may be i n your s y r i n g e . 6. Draw a i r equal to the amount o f c l o u d y 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 s t o p p e r o f the cloudy i n s u l i n b o 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 o f the st o p p e r without drawing any i n s u l i n . 7. Draw a i r equal to the amount o f r e 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 s t o p p e r o f the r e g u l a r (Tornto) i n s u l i n b o 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 . Leave the needle i n p l a c e . 8. Turn the b o t t l e o f r e g u l a r (Toronto) i n s u l i n upside down. P u l l the plun g e r back to withdraw the c o r r e c t amount o f r e g u l a r (Toronto) 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 o f the r e g u l a r (Toronto) i n s u l i n b o t t l e . 9. T i p the b o t t l e o f clo u d y i n s u l i n upside down. H o l d i n g the p l u n g e r o f the s y r i n g e f i r m l y i n p o s i t i o n - a t the dose o f Toronto i n s u l i n - push the needle through the rubber s t o p p e r o f the c l o u d y i n s u l i n . P u l l the plunger back to withdraw the c o r r e c t amount o f c l o u d y i n s u l i n on top o f the Toronto i n s u l i n a l r e a d y i n the s y r i n g e . P u l l the needle out o f the b o t t l e . Throughout the p r e p a r a t i o n and g i v i n g o f your i n s u l i n i t i s important to keep from t o u c h i n g the f o l l o w i n g : (a) the stem o f the plunger, (b) the top o f the s y r i n g e , (c) the p o i n t o f the needle, (d) the top o f 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 u s i n g a mixture o f two i n s u l i n s ) 272 Giving, Your I n s u l i n Once you have prepared your i n s u l i n , most of the work i s done. There are only s ix 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 sk in at the i n j e c t i o n s i t e with a l c o h o l -soaked cot ton . 2. Pinch up a large area of s k i n . 3 . Insert the needle qu ick ly into the sk in at 6 0 to 9 0 degree angle. 4. Remove the hand that was p inching the s k i n . Using that hand, p u l l back 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 into your syr inge , you must d i scard that i n s u l i n and begin a l l over again.) 5. Push the plunger i n s lowly to i n j e c t the i n s u l i n . 6 . Remove the needle qu ick ly at the same angle that i t was in ser ted , bracing your sk in with a c lean piece of co t ton . I n s u l i n should always be in jec ted to reach the loose space under your sk in between your fat and your muscle. I f you i n j e c t your i n s u l i n too close to the surface, i t may go into the fa t or the sk in and cause a p a i n f u l s t r e t ch ing and s w e l l i n g . In time, th i s may lead to shrinkage of the sk in and f a t , causing "ho l lows" . Too frequently in j ec t ions of i n s u l i n i n the same s i t e lead to th ickening 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 less to give your i n j e c t i o n s i n these places , you should not do so! Rotate the s i t e of your in j ec t ions through as many as poss ib le of the areas shown 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 two in j ec t ions c l o s e r than one inch apart i n the same month! (Pa t ient ' s Copy) 273 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 for you to use. This may be done i n two waysi 1 . D a i l y Care with Alcohol Alcohol 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 between weekly b o i l i n g s . Here's how to use i t i (a) Pour 70% i sopropy l a lcohol into a c lean 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 which you can buy at your drug s t o r e ) . (b) Draw enough a lcohol into your syringe to f i l l i t . Squir t i t out . Repeat 2 or 3 t imes. (c) Put your syringe into the conta iner . I t should be covered with a l c o h o l . Place the l i d on the conta iner . (d) Leave your syringe i n the a lcohol u n t i l you are ready to use i t again. (It must have been soaking i n the a l coho l at least 20 minutes to be s t e r i l e . ) (e) You w i l l f ind that a f ter many uses, the a lcohol i n your container w i l l have evaporated or become d i s co loured . I f i t evaporates, just add some more (there should always be enough to cover your equipment). I f i t becomes d i s -coloured, throw i t away and get some fresh a l c o h o l . 2. Weekly Care - E o i l i n Water To be very sure that your i n j e c t i n g equipment i s absol-u t e l y s t e r i l e , you should b o i l i t i n water once a week. The steps fo r doing t h i s are quite easy. (a) Take your syringe apart . Put the parts into 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 o i l i n g water. Be sure that the water covers the equipment. (c) B o i l 10 minutes. (Pa t ient ' s Copy) 274 (d) Pick up the s t r a i n e r , hold i t and pour the water out of the pan. Put the s t r a i n e r back into the pan u n t i l everything has cooled . (e) To reassemble your syringes i . Pick up the outside part of the syringe (the " b a r r e l " ) with one hand, i i . With the other hand grasp the handle end of the plunger. i i i . Without touching any other part , s l i d e the plunger into the b a r r e l to put the syringe together. (f) Wrap your equipment i n a f r e s h l y ironed piece of c l o t h , or return i t to the a lcohol 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 w i l l f i n d that your syringe w i l l become cloudy a f ter 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 water 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 exact ly the same as your syr inge , i . e . soak i n a l coho l every day and b o i l once a week. To put re-usable needles onto the s y r i n g e i - p ick up the b i g part of the needle (the " h u b " ) i 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 syr inge ! ) (Pa t ient ' s Copy) 275 Exercise Exerc i se i s good fo r everyone. I t helps keep weight down, muscles strong and blood f lowing proper ly . In short , i t helps people stay hea l thy . 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 think back to the good-health balance you w i l l remember that exerc i se , as w e l l as d i e t , has an e f fect 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 walking, swimming, gardening) are kinds of exerc i se . And a l l exercise bums 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 usua l ly do. He has planned your medicine to see that you have just enough i n s u l i n to use up the sugar i n your blood fo r energy. There-fore , to keep your good-health balance even, you should do about the same amount of exercise every day. The kind of exercise i s not near ly as important as the amount. I f you do more exercise than usual , i t may r e s u l t i n too l i t t l e sugar i n your b lood . I f you do less less e i e r t i s t exercise than usual , i t may r e s u l t i n too — + h 6 r \ usu.*.l much sugar i n your b lood . Neither one of these condit ions i s good, because both of . them upset your good-health balance. ifr"-—C_T ™ D r e c*ere\*e 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 weekdays, 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 less than normal (such as working overtime, planning an ac t ive vacat ion , or s tay ing 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. (Pat ient ' s Copy) 276 Personal Hygiene 1 . General Care In managing your diabetes , personal hygiene i s very important. Ml of the things we have talked about so f a r (d ie t , medicine and exercise) are aimed at keeping the sugar and i n s u l i n i n your blood i n balance. In fec t ion i s another th ing which 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 w e l l . To avoid i n f e c t i o n , fo l low these simple r u l e s i (a) Be c a r e f u l with anything sharp or hot . (b) Keep your sk in and h a i r c lean with regular bathing . Use lukewarm (never hot ! ) water and mild soaps and shampoos. Dry your se l f gent ly with a sof t towel . (c) Take good care of your teeth and gums; by brushing a f ter meals and having regular check-ups by your d e n t i s t . Be sure to t e l l your dent i s t that you are d i a b e t i c . (d) Treat minor cuts and scrapes as fo l lows , wash with warm, soapy water and put on a c lean bandage. Never put iodine on cuts , as i t could burn your s k i n . I f cuts , scrapes or bruises do not hea l i n a reasonable time, t e l l your doctor . 2 . Spec i a l Foot Care In diabetes , 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 ee 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, co ld or sharp objects that may damage your f ee t . These simple rules w i l l help you avoid trouble with your f e e t i (a) Wash your feet d a i l y with a sof t c l o t h and warm soapy water. 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 sweaty, apply talcum powder. Check with your doctor before us ing s p e c i a l creams, salves or powders on your s k i n . (b) Wear shoes that f i t and are comfortable. Break new shoes i n s lowly by wearing them a few hours each day at f i r s t . (c) Don't wear round garters , socks or stockings that are too t i g h t , or anything else that in ter fe re s with the blood supply to your legs and fee t . Put on c lean socks or stockings every day. (d) Never go barefoot . (Pa t i ent ' s Copy) 277 (e) Gut your toena i l s (and f i n g e r n a i l s too, f o r that matter) a f ter you bathe - when they are so f t . Cut s t r a i g h t across the n a i l (not too shor t ! ) and don' t d i g into the corners . (f) Don't t r y to cut corns and ca l louses by your se l f . Get them treated by your doctor . (g) I f your feet are co ld at n ight , wear c lean socks to bed. Never use a heat ing pad or hot water b o t t l e because these may cause burns on your fee t . (h) Check your feet c a r e f u l l y every day, and report any sk in changes which do not go away to your doctor . 3. Smoking As we s a id , i n diabetes blood c i r c u l a t i o n may be lessened. The chemicals that get into your system when you smoke tend to make your blood vessels contract (or t i g h t e n ) . This i n t e r -feres with 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, how 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 year ly check-up by an eye s p e c i a l i s t . (Pa t ient ' s Copy) 278 Urine Tes t ing One of the most accurate ways of checking that your good-health "balance i s even — rather than t ipped to one s ide or the other — i s by t e s t i n g your u r i n e . Your ur ine t e s t r e su l t s 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 re su l t s of your t e s t s , he may make a change i n your d i e t , medicine or exercise which w i l l help you f e e l be t te r and keep a be t ter balance. You should know how to make two tests on your u r i n e i one fo r sugar and one fo r acetone. Whichever ur ine t e s t you are making, you should always use a "double-voided" specimen of u r i n e . Here 's how to get onei (a) About | -hour before your time to te s t , ur inate as much as you can. Don't save any of t h i s u r i n e . (b) Drink a glass of water and wait about | - h o u r . (c) Urinate again and use t h i s specimen fo r t e s t i n g ( this second urine i s c a l l e d a "double-voided specimen"). 1 . Tes t ing fo r Sugar I f you eat more food than i s allowed, forget to take your medicine or do less exercise than usual , sugar w i l l b u i l d up i n your b lood . (The same th ing 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 bu i ld s up, some of i t w i l l overflow into your u r i n e . An unusual amount of sugar i n the ur ine i s a sure s ign that your good-health balance i s t ipped . One of the most accurate means of t e s t i n g your ur ine f o r sugar i s with the C l i n i t e s t t a b l e t s . Here's howi (a) C o l l e c t your ur ine i n a c lean conta iner . With the dropper i n an upright p o s i t i o n place 5 drops of ur ine i n the te s t tube. Rinse the dropper and add 10 drops of water. (b) Drop 1 C l i n i t e s t t ab l e t into the te s t tube (be c a r e f u l not to touch i t with damp f i n g e r s ) . Watch while the complete reac t ion takes p lace . Do not shake the tube during the reac t ion nor for 15 seconds a f te r the b o i l i n g has stopped. (c) After the 15-second wai t ing per iod , shake the te s t tube gent ly and compare i t with the co lour char t . Notet Care fu l observation of the s o l u t i o n i n the te s t tube while reac t ion takes place and during the 15-second wai t ing period i s necessary to detect rap id "pass through" co lour changes caused by amounts of sugar over 2%. Should the co lour r a p i d l y "pass-through" green, tan and orange to (Pa t ient ' s Copy) 279 a dark greenish-brown, record as over T.% sugar without comparing f i n a l co lour development with co lour char t . Your doctor wishes you to tes t your urine fo r sugar at the fo l lowing timei 2. Tes t ing for Acetone General ly speaking, your body uses sugar fo r energy. However, i t can also get energy from f a t . When your c e l l s are not ge t t ing enough sugar to provide the energy they need, your body breaks down i t s own fa t f o r energy. This process makes a substance ca l l ed acetone, which w i l l s p i l l over into your ur ine i n the same way that sugar does when i t gets too h igh . Moderate amounts of acetone i n your blood w i l l cause nausea, vomit ing, f lushed and dry s k i n , s leepiness , and deep rapid brea th ing . Large amounts of acetone cause unconsciousness. So you can see that i t i s important to know when you are b u i l d -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 te s t fo r acetone can be done with Acetest t a b l e t s . Just fol low these s teps i (a) C o l l e c t your ur ine i n a c lean conta iner . Place one Acetest t ab le t on a c lean piece of white paper. (b) Put one drop of urine on the t a b l e t . (c) Wait 30 seconds and compare the co lour of the tab le t with the co lour char t . Your doctor wishes you to te s t your urine fo r acetone at the fo l lowing times 1 Notes* 1. I f your ur ine tests greater than 1% for sugar on severa l tests i n a row, or i f you get a p o s i t i v e acetone te s t , n o t i f y your doctor . 2. There are many other tests for ur ine sugar and acetone a v a i l a b l e . I f you wish to use these, discuss the matter with your doctor . I f he approves, be sure to read and fo l low the package d i r e c t i o n s 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. (Pa t i ent ' s Copy) 280 3« Keeping a Record In order for your doctor to get an o v e r a l l p i c ture of how w e l l balanced your diabetes i s , he w 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 (Pa t ient ' s Copy) 281 Problems .As we have sa id , you w i l l u sua l ly be able to keep the sugar and i n s u l i n i n your blood i n balance by fo l lowing your doctor ' s orders about d i e t and medicine, and by ge t t ing the same amount of exercise every day. There are, however, some other things — things you c a n ' t help — which 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 whenever you 'cheat' on your d i e t , medicine or exerc i se , you are i n danger of developing a problem with your diabetes . I t i s important that you should be aware of these problems (what causes them and how to know you have them) so that you can t rea t them when they occur and avoid them i n the fu ture . (Pa t ient ' s Copy) 282 Diabet ic Coma Diabet ic coma i s the problem which re su l t s when your sugar - in su l in balance i s t ipped to the sugar s ide . As we mentioned when we were d i scuss ing ur ine t e s t ing , your body can maJce energy from fat as we l l as from sugar. I t does t h i s when there ' s not enough i n s u l i n around to use your blood sugar i n the way i t o r d i n a r i l y should. When your body burns fat for energy, i t produces f a t t y acids l i k e acetone. Too much acetone i s bad for your body. I t causes a cond i t ion c a l l e d ac idos i s , which can lead to a d iabet ic coma. You may hear d iabet ic coma c a l l e d other names, such as "d i abe t i c a c i d o s i s " , "d i abe t i c ke to s i s " or "hyperglycemia" (which means extra blood sugar) . Whatever name you use, i t i s important to remember that d iabet ic coma i s a very serious d iabe t i c problem! 1 . Causes There are severa l things which might cause you to have a d iabet ic coma. Here are the most usual causesJ (a) eat ing too much foodi (b) not taking enough d iabet ic 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 ) i (c) taking much less than your usual amount of exerc i se ; (d) a fever or an i n f e c t i o n ; (e) a severe emotional upset. 2 . Symptoms How w i l l you know you are going into a d iabet ic coma? Here are some of the most Common symptomst (a) dry sk in and tongue; (b) severe t h i r s t ; (c) weakness, drowsiness or t i redness ; (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. (Pa t ient ' s Copy) 283 3. Treatment Here's what to do i f you f e e l you might be going into a d i abe t i c comai (a) Test your u r i n e i - i t w i l l probably be 2% or greater fo r sugar and p o s i t i v e 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 you what to do next. 4. Prevention How can you keep from having a d iabet ic coma? Here are some usefu l suggestions: (a) Follow your d ie t c a r e f u l l y - never omit foods or meals and never take more than you should . (b) Never sk ip your diabetes medicine. Always measure i t careful lyand take i t r i g h t on time. (c) Do the same amount of exercise every day. (d) Avoid in fec t ions and emotionally upset t ing s i tua t ions whenever you can. (e) Test your ur ine r e g u l a r l y and report high sugars to your doctor . (Pa t ient ' s Copy) 284 I n s u l i n Shock Diabet ic coma i s sometimes confused with i n s u l i n shock. Don't l e t th i s happen to you! These two diabetes problems are complete opposi tes . I n s u l i n reac t ion i s the problem which re su l t s when your s u g a r - i n s u l i n balance i s tipped to the i n s u l i n s ide . That i s to say you have e i t h e r too much i n s u l i n or not enough sugar i n your b lood. Other names fo r 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 ide , the r e s u l t i s that your blood has more i n s u l i n i n i t than i t has sugar fo r the i n s u l i n to work on. This s tate of a f f a i r s i s quite harmful fo r your body. Thus, i n s u l i n shock i s a serious d iabe t i c problem, and one which must be dea l t with at once! 1. Causes There are severa l things which 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 . de laying or sk ipping meals, or leaving out foods you are supposed to e a t)i (b) taking more than the correc t amount of diabetes medicine?, (c) taking more than the usual amount of d a i l y exerc i se . 2. Symptoms 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 symptomst (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) trembling! (f) t rouble seeing c l e a r l y . 3. Treatment Although i n s u l i n shock i s a serious 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 i (Pa t ient ' s Copy) 285 (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 fo r sweetsi just eat something!) (b) Wait 15 minutes. (c) THEN - i f you don' t f e e l bet ter - 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 sk ip or delay your meals. Always eat exact ly what your meal plan says, at the time i t says. (b) Always measure your d iabe t i c medicine c a r e f u l l y and take i t on time. (c) Eat or drink something extra beforehand i f you know you are going to do more exercise than usua l . OR, i f there wasn't time fo r that , eat or dr ink something immediately afterwards. (d) Always carry something sweet with you. (Pa t ient ' s Copy) 2 8 6 Infec t ion As we mentioned i n our d i scuss ion of d iabet ic coma, an i n f e c t i o n i s one of the things which may cause you to go into a d i abe t i c coma. This i s because the fever that comes with many in fec t ions acts to t i p the sugar - in su l in balance toward the sugar s ide . 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 i abe t i c coma. In add i t ion to those warning s igns , i f you take your temperature you w i l l f ind that i t i s above normal. Because an i n f e c t i o n has much the same ef fect on your body as a d i abe t i c coma, you would expect to t rea t i t the same way - and you do! (a) Test your ur ine (once again, i t w i l l probably be p o s i t i v e fo r both sugar and acetone). (b) Phone your doctor . T e l l him how you f e e l , what your temperature i s , and what your urine tests s a i d . He w i l l give you s p e c i f i c in s t ruc t ions about your diabetes medicine and d i e t . (c) Go to bed - y o u ' l l need re s t to allow your body to f i g h t that i n f e c t i o n . Now that you know that in fec t ions can be serious problems f o r you, y o u ' l l want to avoid them whenever you can. Here are some h int s fo r doing just tha t i (a) Stay away from people who you know already have in fec t ions of one sor t or another. (b) Follow the rules we discussed under "Personal Hygiene". (c) Treat simple i n j u r i e s r i g h t away so that they don ' t have a chance to become i n f e c t e d . (Pa t ient ' s Copy) 287 Protect Yourself There are two very simple things you should do to protect y o u r s e l f i 1. Wear and/or carry i d e n t i f i c a t i o n Both diabetic coma and i n s u l i n shock are serious problems which c a l l f o r quick treatment. When they are severe, the diabetic person can f a i n t . That's why i t ' s very important to wear or carry diabetic 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 w i l l help you get the treatment you need quickly. Medic  .Alert i s one very good source of diabetic i d e n t i f i c a t i o n . There are others. Talk to your doctor about which kind of i d e n t i f i c a t i o n you should use. 2. Carry something sweet In s u l i n shock may come on very suddenly - almost without warning. When i t does, you want to be able to treat i t promptly. That i s why i t would be wise f o r you to get into the habit of always carrying something sweet ( l i k e candy) i n your pocket or purse. (Patient's Copy) 288 Where to get help There are many people and organizatipns who are ready to help you keep your good-health balance even. Here's a quick reference of who they are and what they w i l l do f o r you. SOURCE WHAT THEY CAN DO FOR YOU 1. Doctor (phone number) 2. The Canadian Diabetic Associ-ation (branch phone number) 1. Get you started with a good balance of d iet, exercise and diabetes medicine. 2. Change th 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 tipping. The Canadian Diabetic Association i s a non-profit organization dedicated to help-ing diabetics 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 national o f f i c e or any one of i t s l o c a l branches. The benefits of membership i n the CD. A. broadly include i 1. Services. Free d i e t counselling and operation of holiday camps which pro-vide regulated diets f o r childr e n and adults are some of the services you can enjoy as a member of CD. A. 2. Education. At every l o c a l C D. A. meet-ing, part of the program i s devoted to eithe r demonstrations by doctors and d i e t i c i a n s , lectures, open forums, or i n s t r u c t i v e films designed to help you and your family l i v e a better and more normal l i f e . 3. "The Newsletter". The CD. A. publication "The Newsletter" i s mailed to a i l members four times a year. Information and prices on other publications on diabetes are available from the national o f f i c e . 4. Encouragement. You and your fellow mem-bers of the CD. A. have common problems and objectives. In group meetings you have the opportunity of seeing how others have overcome ce 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. (Patient's Copy) 289 SOURCE WHAT THEY C M DO FOR YOU 3. Publ ic Health or V i c t o r i a n Order of Nurses v i s i t i n g nurses . (phone numbers) k. D i a l - a - D i e t i c i a n (phone number) 1. Do home teaching. 2. Give i n s u l i n in j ec t ions at home. 3. Help with your food care i f you can ' t manage i t alone. Various p r o v i n c i a l d i e t e t i c associat ions have organized D i a l - a - D i e t i c i a n programs to answer the questions about food and n u t r i t i o n which ar i se i n day-to-day l i v i n g . Information i s ava i l ab le on such topics as. - everyday n u t r i t i o n - foods and food values - budgeting and purchasing - meal planning and preparat ion - food addi t ives - l a b e l l i n g - food fads and f a l l a c i e s - therapeutic d i e t modif icat ions I f you have questions about any of these subjects , you should c a l l the D i a l - a -D i e t i c i a n number. Your questions w i l l be recorded, and a p ro fe s s iona l d i e t i -c i an w i l l c a l l you back - wi th in *4-8 hours - with the answers. (Pa t ient ' s Copy) APPENDIX E REFERENCES MOST USEFUL IN DEVELOPING THE DIABETIC TEACHING TOOL 291 Books Danowski, Thaddeus Stanley. Diabetes As a Way of L i f e . New York! Coward-McCann, 1964. Duncan, G a r f i e l d George. A Modern P i l g r i m ' s Progress w i t h  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 ! W.B. Saunders Co., 1967. Rosenthal, Helen and Rosenthal, Joseph. D i a b e t i c Care i n P i c t u r e s . Toronto i J.B. L i p p i n c o t t Company, 1968. Schmitt, George F r e d e r i c k . Diabetes f o r D i a b e t i c s . Miami i Diabetes Press of America, 1966. A r t i c l e s A l l a n , Frank No "Education of the D i a b e t i c P a t i e n t . " New England J o u r n a l of Medicine, CCLXVIII (January 10, 1963), 93-95. Dale, Edgar D. and C h a l l , Jeanne S. "A Formula f o r P r e d i c t i n g R e a d a b i l i t y . " Education Research B u l l e t i n , XXVII (1948), 11-28, Hamwi, George J. " S p e c i a l Announcement! Treatment of Diabetes." Journa l of the American Medical A s s o c i a t i o n , CLXXI (Sept-ember 22, 1962), 1064. ' Krysan, Germaine S. "How do We Teach Four M i l l i o n D i a b e t i c s ? " American J o u r n a l of Nursing, LXV, No. 11 (November I965K 105-107. Lanese, Richard R. and Thrush, Rudolph S. "Measuring R e a d a b i l i t y of Health Education L i t e r a t u r e . " Journal of the American  D i e t e t i c A s s o c i a t i o n . X L I I (March I963), 214-217. Nickerson, Donna. "Teaching the H o s p i t a l i z e d D i a b e t i c . " American J o u r n a l of Nursing. LXXII, No. 5 (May 1972), 935-938. Thrush, Rudolph S. and Lanese, Richard R. "The Use of P r i n t e d M a t e r i a l i n Diabetes Education." Diabetes, XI, No. 2 (March-April 1962), 132-137. Watkins, J u l i a D. and Moss, Fay T. "Confusion i n the Management of Diabetes." American J o u r n a l of Nursing, LXIX, No. 3 (March 1969), 521-524. 292 Pamphlets A Guide for the Canadian Diabet ic on Oral Therapy. Toronto, Ontario i E l i L i l l y and Company, n . d . Exchange L i s t s for Meal Planning for Diabet ics i n Canada. Toronto, Ontar io i Canadian Diabetic As soc i a t ion , 1970. Guidebook fo r the Diabet ic Pat ient . Rexdale, Ontar io i Ames Company, n . d . Insulin-Use Information K i t . Clarkson, O n t a r i o « Becton-Dickinson and Company, n . d . Manual fo r Diabet ics i n Canada. Toronto, Ontar io i Canadian Diabet ic As soc ia t ion , 1968. Other E l l i s , Edward V. H A Comparative Analys i s of Goody Poor and Very Poor Control Diabet ic Patients as a Basis for Determining Educational Needs." Unpublished Doctoral D i s s e r t a t i o n , The Univer s i ty of North Caro l ina at Chapel H i l l , 1964. Gett ing S ta r ted . A Program for Learning about Diabetes. Rutherford, New Jersey: Becton-Dickinson and Company, 1971. Learning About Diabetes. New York t American Diabetes Asso-c i a t i o n , 1969. 

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