Supplement-Nurse Competencies for Diabetic Care
Supplement-Nurse Competencies for Diabetic Care
The American Diabetes Association in Alexandria, VA, published the following competencies for nurses in 1993. Despite numerous advances in diabetes treatment and care since that time, these competencies are still applicable, says Elizabeth Walker, DNSc, RN, CDE, president for health care and education for the American Diabetes Association. Diabetes Management presents them here, as a starting point for nurses to assess their skills in caring for patients with diabetes.
Pathophysiology of Diabetes Mellitus
Describe the delicate balance in the relationship of nutrition, exercise, and medication to blood glucose control.
• Explain the major physiologic changes related to diabetes.
• Compare the effect of carbohydrate, protein, and fat absorption on blood glucose.
• Discuss the four main components of diabetes care as patient education, diet management, exercise, and medication.
• State how exercise affects blood glucose.
Discuss the risk factors for diabetes.
• State that there is an increased risk of non-insulin-dependent diabetes mellitus (NIDDM) in individuals with a strong family history, those who are overweight, and those of African-American, Native American, or Hispanic descent.
• State that the incidence of NIDDM increases with aging.
• Discuss the increased risk of developing NIDDM following gestational diabetes with failure to maintain ideal body weight postpartum.
State the major clinical manifestations of diabetes.
State the major differences between the types of diabetes in terms of pathophysiology, symptoms, and treatment.
State that psychological and physical stress can either raise or lower blood glucose and affect metabolic control.
Meal Planning
Describe the purpose of the meal plan in the management of diabetes.
• Explain the reason for consistency in amount, composition, and time of food intake from day to day.
• Select food within a recommended meal plan.
• State the possible effects of alcohol on the person with diabetes.
Describe the individual factors which influence nutritional meal planning for persons with diabetes.
• Recognize that dietary behavior changes may be the hardest behavior changes to make.
• Recognize that all persons with diabetes should be referred to a dietitian at least yearly.
• Recognize the importance of an individualized dietary plan.
Define the concept of food exchanges.
• List the diabetic exchange categories.
• Indicate appropriate serving sizes within exchange categories.
Physical Activity
Describe both the benefits and the risks of exercise for the person with diabetes.
• Recognize the psychological and physiological benefits of physical activity for people with diabetes.
• Discuss precautions to be followed prior to, during, and following any alterations in activity.
Insulin and Oral Medications
Explain the importance of regular oral medications and insulin use.
• State the recommended timing of taking insulin and oral medications in regard to meals.
Demonstrate the techniques for subcutaneous insulin injection.
• State the rationale for choice insulin injection sites.
• Demonstrate appropriate care of supplies (insulin storage, syringe disposal).
• Discuss the accepted technique for re-use of insulin syringes.
• Describe lipodystrophy, lipoatrophy, and hypertrophy.
State the types and availability of alternative insulin delivery systems.
State the differences in onset and peak and duration of action of the types of insulin.
• Differentiate between strengths, sources, types, and brands of insulin.
• State the rationale for the use of human insulin.
• Differentiate between intensive and conventional insulin therapy.
Discuss the mechanism of action of oral hypoglycemic agents.
• Discuss the side effects/adverse effects of oral hypoglycemic drugs.
Monitoring
Describe the therapeutic use of self-blood-glucose monitoring (SBGM) in persons with diabetes mellitus.
• Interpret the results of a random or fasting blood glucose.
• Discuss the importance of SBGM to state-of-the-art diabetes care.
• Recognize that one high or low blood glucose reading may not be significant, but patterns are the important information for long-term control.
Demonstrate the correct technique for capillary blood glucose monitoring.
• Discuss appropriate quality control for blood glucose monitoring equipment.
• Describe appropriate record keeping (insulin, meals, activity, glucose readings, hypoglycemia).
• Describe appropriate care of supplies.
• Discuss infection control principles in glucose monitoring.
Describe the significance of a glycosylated hemoglobin test.
Describe urine testing for ketones as a metabolic assessment when the blood glucose is elevated at approximately 240 mg/dl and higher and during sick days.
Treatment of Hypoglycemia/Hyperglycemia
State the causes and manifestations of hypoglycemia.
• Identify the signs and symptoms of hypoglycemia.
• State that when in doubt about hyper- vs. hypoglycemia, the nurse and patient should treat the hypoglycemia.
• State the rationale for the treatment of hypoglycemia.
• Demonstrate the treatment of mild, moderate and severe hypoglycemia.
• Describe the rationale for using glucagon to treat a severe hypoglycemic reaction.
• Describe the correct technique for a glucagon injection.
State the causes and manifestations of hyperglycemia.
• Discuss the symptoms and treatment of hyperglycemia.
Discuss the causes of ketosis, ketoacidosis, and diabetic coma.
• Explain DKA (diabetic ketoacidosis).
• Discuss symptoms and treatment priorities for DKA.
• Explain HHNK (hyperosmolar hyperglycemic nonketotic coma), symptoms, and treatment priorities.
• Compare and contrast DKA and HHNK.
Describe principles of sick-day care.
• State specific pre- and post-precautions of the surgical patient with diabetes.
Chronic Complications
State the guidelines for prevention of major complications of diabetes.
• State the rationale for keeping blood glucose levels near the normal range.
State the risk factors for developing major complications of diabetes.
• Acknowledge that people with NIDDM and IDDM are both at risk for the long-term complications.
Recognize the need to seek counseling for coping with chronic complications of diabetes when appropriate.
• Indicate how complications may affect both the individual and the family.
• Indicate body image changes that may occur, related to diabetes and its complications.
• Determine that persons with diabetes may be hesitant in describing sexual difficulties as a long-term complication of diabetes.
Discuss the major complications of diabetes.
• Recognize the early signs and symptoms of the chronic complications of diabetes.
• Discuss macro- and microvascular complications of diabetes.
• Discuss peripheral and autonomic neuropathy.
• State that persons with diabetes are at risk for dental problems.
State available treatment for different kinds of diabetes complications.
• State appropriate referral patterns for the early detection and treatment of complications of diabetes.
Foot Care
Describe the essentials of a nursing assessment of the foot.
• Demonstrate foot assessment.
Explain the rationale for daily foot care.
• State the importance of preventive care of the feet.
• Describe the relationship between wound healing, infections, and metabolic control of diabetes.
• Recognize the early signs and symptoms of infection.
• Describe the elements of the daily care of the feet that must be taught to persons with diabetes and their families.
Psychosocial Adjustment to Diabetes
Recognize that diabetes is a serious illness requiring extensive behavioral, medical, and education interventions.
• Recognize the significance of the demands that diabetes management has on the individual with diabetes.
• Realize that diabetes effects the entire family no matter what the persons' age at diagnosis.
• Describe how the diagnosis of diabetes can affect the lifestyle of young adults, middle-aged adults, and older adults.
Describe the adaptation process and individual coping styles as they relate to diabetes.
• Assess the patient's emotional responses to the diagnosis of the diabetes.
• Assess individual/family lifestyle activities and coping skills.
• Describe the importance of stress management techniques for the person with diabetes.
• Recognize symptoms that indicate the need for psychological counseling.
Impact of Diabetes on Children and Family
Identify appropriate developmental goals in relation to diabetes care.
• Recognize the importance of monitoring normal growth and development in a child with diabetes.
• Indicate the psychosocial and treatment issues related specifically to diabetes in childhood and adolescence.
• Recognize that the demands of diabetes management will change as the developmental needs of the child change.
• Recognize that family support and involvement is an integral part of successful diabetes management.
Demonstrate the correct method of insulin injections for a child with diabetes.
• Demonstrate holding the child during the insulin injection procedure.
• Recognize symptoms of hypoglycemia in the young child.
Recognize the importance of preventive health practices for children and adolescents with diabetes (e.g. smoking, alcohol use, drug abuse, and contraception).
Impact of Diabetes on the Elderly
Describe how diabetes may affect and be affected by the aging process and developmental tasks of later life.
• Recognize the impact of acute and chronic illnesses in diabetes management.
• Recognize intensive therapy should be available for older persons with diabetes.
Describe strategies for compensating for physical effects of aging on diabetes self-care practices.
• Recognize safety issues specific to the older adult with diabetes.
Diabetes Mellitus and Pregnancy
State the rationale for screening for diabetes in all pregnancies.
• Describe the effect of gestational diabetes on the outcome of pregnancy.
Describe the effect of preexisting diabetes on the outcome of pregnancy.
• State the importance of counseling and blood glucose control for women with diabetes prior to pregnancy.
• Describe the effects of pregnancy on long-term complications of diabetes.
Explain the importance of blood glucose control during pregnancy.
Cultural Issues
Discuss the impact of cultural background, beliefs, and environment on adaptation for diabetes.
Discuss the impact of culture on self-care practices.
Discuss economic issues related to diabetes care.
Components of Diabetes Patient Education
Recognize that diabetes education is necessary for patients to make informed choices regarding diabetes care.
• Tailor diabetes education to the needs and appropriateness of the learning setting.
• Individualize diabetes education to the appropriateness of the learning setting.
• Perform an educational needs assessment.
• Establish learning goals with the patient.
• Develop and implement an individualized education plan.
• Establish a follow-up educational plan.
• Document the teaching/learning process.
Discuss appropriate methods for teaching various aspects of diabetes self-care.
• Describe the rationale for the different levels of content within the teaching plan.
• Use appropriate and current teaching materials (pamphlets, booklets, films).
• Include family/significant others in teaching as appropriate.
• Recognize the importance of continuing diabetes education.
Understand the importance of regular medical/health care for persons with diabetes.
• Refer patient to other services as needed (social service, sexual counseling, home health care, etc.).
• Provide information about appropriate community services/resources.
• State the importance of referral to appropriate specialty medical care and educational services.
• Recognize the value of team approach to diabetes care.
• Describe community and national resources for persons with diabetes.
Patient Adherence
Respect the right of the patient to choose therapeutic goals and care options related to diabetes.
• Discuss the concepts of motivation, knowledge of self-care, health beliefs, quality of life, locus of control, and social support on adherence with prescribed regimens.
• Recognize that poor metabolic control is not necessarily related to nonadherence to the therapeutic regimen.
• State that adherence to one aspect of the regimen does not necessarily predict adherence to all aspects of the regimen.
Recognize positive and negative influences to adherence in the therapeutic regimen for diabetes.
• Discuss the value of a therapeutic alliance with the person who has diabetes.
• Describe situations where adherence may be difficult and generate replace prevention strategies.
Research
Discuss the current trends of research in diabetes.
• Discuss the outcomes associated with the Diabetes Control and Complications Trial (and the United Kingdom Prospective Diabetes Study).
• Describe the implications of these outcomes for nursing.
Source: American Diabetes Association. Diabetes Spectrum. Alexandria, VA; 1993. Reprinted with permission.
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