A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE AND PRACTICE OF SELF MONITORING BLOOD GLUCOSE LEVEL AMONG PATIENTS WITH TYPE-2 DIABETES MELLITUS AT GOVERMNEMT DISTRICT HOSPITAL, TUMKUR.
PROFORMA FOR REIGISTRATION OF SUBJECT FOR DISSERTATION
NANDEESHA K S
MEDICAL SURGICAL NURSING
ARUNA COLLEGE OF NURSING
RING ROAD MARALUR,
TUMKUR-572105
2010-11
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REIGISTRATION OF SUBJECT FOR DISSERTATION
1) NAME OF THE CANDIDATE : NANDEESHA K S
FIRST YEAR M.Sc. NURSING
ARUNA COLLEGE OF NURSING,RING ROAD MARALUR, TUMKUR-05 .
2) NAME OF THE INSTITUTION :ARUNA COLLEGE OF NURSING, TUMKUR.
3) COURSE OF THE STUDY : 1ST YEAR M.Sc, NURSING
AND SUBJECT MEDICALSURGICAL NURSING
4) DATE OF ADMISSION : 01.10.2010.
5) TITLE OF THE TOPIC : “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTREDTEACHING PROGRAMME ON KNOWLEDGE AND PRACTICE OF SELF MONITRING BLOOD GLUCOSE LEVEL AMONG PATIENT WITHTYPE 2 DIABETES MELLITUS AT GOVERNMENT DISTRIC HOSPITAL TUMKUR.”
6.BREIF RESUME OF THE INTENDED WORK
INTRODUCTION
“He who has health, has hope and who has hope, has everything”.
- Arabian Proverb.
Diabetes mellitus is group of metabolic disease characterized by hyperglycaemic resulting from defect in insulin secretion insulin action or both the basis of the abnormalities in carbohydrates, protein and fat metabolism, this metabolic abnormalitiescomplications.1
Blood glucose monitoring is a way of testing the concentration of glucose in the blood(glycaemia). Self monitoring of blood glucose (SMBG) is an important component of modern therapy for diabetes mellitus. SMBG has been recommended for people with diabetes and their health care professionals in order to achieve a specific level of glycemic control and to prevent hypoglycaemia.2
The goal of SMBG is to collect detailed information about blood glucose levels at many time points to enable maintenance of a more constant glucose level by more precise regimens. It can be used aid in the adjustment of thearapeutic in regimen to blood glucose values and to help individuals adjust their intake, physical activity and insulin doses to improve glycemic control on a day to daybasis.3
India accounts for the largest number of people 50.8 million suffering from diabetes in world, followed by China (43.2 million) andUnited States (26.8 million),reveal new figures released by the International diabetes Federation (IDF). India continues to be the “diabetes capital” of the world, and by 2030 nearly 9% of thecountry’s population is likely to be affected from the disease. The WHO estimates 285 million people with diabetes worldwide. If unchecked the diabetes can cause disease related to Kidney, Heart and nerve at later stage.4
SMBG can aid in diabetes control by, facilitating the development of an individualised blood glucose profile, which can guide care professionals in treatment, planning for an individualised diabetic regimen, giving with diabetes and their families the ability to take appropriate day to day treatment choices in diet and physical activity as well as in insulin or other agents, improving patients of hypoglycaemia or severe hypoglycaemia and enhancing patient education and patient empowerment regarding the effects of lifestyle and pharmaceutical intervention on glycemic control.5
Numerous trials have been carried out to determine the true impact of SMBG on glycemic control. Some including randomized, controlled trials, have demonstrated the efficacy of SMBG. Among patients with type-1 diabetes, SMBG has been associated with improved health outcomes among patients with Type-2 diabetes, a higher frequency of SMBG was associated with better glycemic control among insulin treated patients who were able to adjust their regimen. Other studies however have suggested that SMBG has not achieved its true potential impact has an aid to improving glycemic control.6
Most diabeteologists agree that self management of diabetes needs to incorporate some data, and that motivated patients can benefit from the increasedempowerment that SMG yields, diabetes specialists now recommended the patients use SMBG data for day to day regimen changes and that health care professionals use SMBG data to guide alterations in medications regimens, the American diabetes association has sanctioned efforts to teach people with diabetes to use SMBG data actively as part of a patient centred self management programme .7
For the patients with type-2 diabetes, optimal SMBG frequency varies depending on the pharmaceutical regimen and whether patients are in an adjustment phase or at their target for glycemic control. In such cases patients, can use SMBG data as biofeedback at times of increased stress or changes in diet or physical activity. SMBG data can be helpful in creating or modifying the diabetes management regimen. People with type-2 diabetes who use insulin should perform SMBG at least four times per week, including at least two fasting and two post prandial values, thoughtful interpretation of SMBG data will assist patients and health care providers in selecting appropriate pharmaceutical and lifestyle regimen.8
SMBG can play an important role in improving metabolic control in patients with diabetes. It is recommended for patients treated with insulin and is desirable for all patients with diabetes. Judicious use of SMBG data can help to improve gycemic control, select an anti diabetic regimen, and provide powerful feedback to patients wishing to improve metabolic control.9
6.1. NEED FOR THE STUDY.
India has nearly 50 million diabetic subjects today, which is briefly contributed by the population the scenario is changing rapidly due to socio –economic transition occurring in the rural area also. Availability of improved mode of transport and less strenuously as in the vicinity have resulted in decreased physical activities. The conditions are more favourable for expression of diabetes in the population which already has a racial genetic susceptibility of disease. Recent epidemiological data shown that situations aresimilar throughout the country. The conversion to diabetes is enhanced by the low thresholds for the risk factor such as age, body index and upper body adiposity. Indians have a genetic phenotype characterised by low body mass index, but with higher upper body adiposity, high body fat percentage and high level of insulin resistance with a high genetic predisposition and the high susceptibility to the environmental insults the Indian population faces a high risk for diabetes and its associated complications.10
As per international diabetes federation [IDF] globalprojections for people with diabetes [between age group27-29yrs old] in 285million in 2010and 380 million in 2025 which is 55% increase in diabetes population.India in 2010 has 50 million people with diabetes which will increase by 73% in2025 up to 80.5 million,the total number of diabetes people with diabetes isprojected to rise from 171million in 2000 to 366 million in 2030. The prevalence ofdiabetes is higher in menthan women, but there are more women with diabetes than men, theurban population of the developing countries is projected to double between 2000 and 2030. The estimated number of people with diabetes in India in 2000 is 31 million which will increase to 79 million in 2030 therefore a concertedglobal initiative is required to address the diabetic epidemic the number of peoplewith diabetes is increasing due to the population growth aging urbanisation andincreasing prevalence of obesity and physical inactivity.11
An article analysing data from the 3rd national and nutrition examination survey (NHANES-III) concluded that for patients with type-2 diabetes, there was little co-relation between SMBG frequency and glycemic control and the article was sparked considerable controversy , including questions regarding the validity of the NHAMES-III study design to properly examine the relationship between SMBG and glycemic control so the prospective study design used to be employed to better understand the role of SMBG in all patients with diabetes.2
Self monitoring blood glucose level is an key element of home blood glucose monitoring by people with diabetes mellitus or hypoglycaemia since approximately 1980, a primary goal of the management of type-2 diabetes mellitus has been achieving closer to normal levels of glucose in the blood for as much of the time as possible , guided by HBGM several times a day the benefits included a reduction in the occurrence rate and severity of long term complication from hyperglycaemia as well as reduction in the short term potentially life threatening complications of hypoglycaemia12.
Patients therefore require a traditional finger sticks measurements for typically twice per day and are often advised to use fingersticks measurements to confirm hypo or hyper glycemia before taking corrective action. However blood sugar levels when changing rapidly may read in normal range on a continuous blood glucose monitoring system while in reality the patients in already experiencing symptoms of an out of range blood glucose value and may require treatment patients using CGM are therefore advised to consider both absolute volume of the blood glucose level given by the system as well as any trend in the blood glucose levels. continuous monitoring allows examination of how the blood glucose levelreacts to insulin exercise, food and other factors. While technologyhas limitations studies have demonstrated that patients with continuous sensors experience less hyperglycaemia and also reduced their glycosyleted Hb levels. Here there wassignificant improved knowledge was found by researcher in patients.13
Diabetes is the single most important metabolic which can affect nearly every organ system in the body. It has been projected that 300 million individuals would be affected with diabetes by the year 2025. The reason for this escalation are due to change in lifestyle, People living longer than before (aging) and low birth weight could lead to diabetes during adulthood. Diabetes related complications are coronary artery disease, peripheral vascular disease, Neuropathy, Retinopathy, Nephropathy etc., people with diabetes are 25 times more likely to develop blindness, 17 times more likely to develop kidney disease, 30-40 times more likely to undergo amputation, 2 to 4 more likely to develop myocardial infarction and twice more likely to suffer a stroke than non diabetes lifestyle modifications, inclusive of dietary modification, regular physical activity and weight reduction or indicated for prevention of diabetes 14.
Diabetes is chronic illness it requires continuing medical care and patientself management education to prevent acute complications and to reduce the riskof long term complications diabetes care in complex and requires that many issues,behind glycemic control, be addressed. Type-2 diabetes mellitus forms more than95 % of cases. In the last two decades type-2 diabetic mellitus is on the rise degreeof which varies in different countries. The world Health organisation (WHO) hasprojected that global prevalence of type-2 diabetes mellitus will be more thandouble from 135 million in 1995 to 300 million by 2025 today. India has primary position in the global diabetes epidemiology map as it is the home for nearly 15 million diabetics, which is the highest number in the world and disease expected to increase to 80 million by 2030. The national urban diabetes survey in India has shown standardised prevalence of diabetes and impaired glucose tolerance (IGT) to be 12.5% and 14 % respectively with no gender difference subjects under 40 years of age and higher prevalence of IGT than diabetes (12.8 Vs 4.6 P< 0.001) so India has gownedthe notoriety of being the diabetic capital of the world 15
6.2. REVIEW OF LITERATURE.
The review of literature helps the investigator to develop deeper insight into the problems and gain information on what has been done earlier and what are found to be relevant to the present study.
The review of literature in a broad comprehensive in death, symptomatic and critical review of scholarly publications , unpublished scholarly print materials , audio visual materials and personal communications. It also provides the reader with a background for understanding current knowledge on a topic illuminates the significance of the new study.
A study was conducted on the diabetes knowledge in patients and family care givers in an urban emergency department the purpose of the study was to described the base line level of disease specific knowledge in predominantly Latino patients with diabetes in their family, and to elucidatecharacteristicswhich are associated with increased diabetes knowledge with 24 item diabetes knowledge questionnaire (DKQ) was administered to a convenience sample of 291 primarily Latino adults in the emergency department who either had diabetes or who identified themselves as a care giver for an immediate family member with disease , the patients with diabetes received higher score on the DKQ than their family care givers (13.9 Vs 12.3, P < 01). However, on multivariate analysis only years since diagnosis and education reached statistical significance. Here the significant improved knowledge was observed.16
A study was conducted on the self glucose monitoring and glycemic control with the objective to explore the association between self monitoring of blood glucose(SMBG) levels and improved glycemic control (HbA1c level) among type-2 diabetic patients, receiving oral hypoglycaemic agents and insulin, and to ascertain the factors influencing SMBG the method was used comparative cross sectional design five hundred type-2 diabetes patients through convenient sampling between 30 to 70 years were interviewed through a structured questionnaire in year 2006 and 2007 by ambulatory setting those 500 subjects were divided as 250 in case (doing SMBG) and 250 in control (not doing SMBG) groups. The result was that HbA1 value was maintained at good and faire levels in case (56%) as compared to controls (P=0.002). there was high associations of SMBG with education level, has graduate and above were monitoring SMBG at high level as evidently(P=0.005). here the conclusion was on self monitoring of blood glucose levels was associated with clinically and statistically better glycemic control regardless of diabetes type of therapy . therefore, health personal must increase awareness on the importance of SMBG and strongly promote this practice among diabetic patients.17
A study was conducted on association between glycemic control and the level of knowledge ad disease awareness in type-2 diabetic patients. The aim of the study was to assess the relationship between glycemic control and effective diabetes education the knowledge and awareness (KA) questionnaire in type-2 diabetic patients. Moreover, the effect of age, duration of diabetes, sex, body mass index (BMI), and education level on glycemic control was assessed cross sectionally. This study included 164 patients with type-2 diabetes with the KA questionnaire. The result was shown a significant negative co relation was observed between KA score and HbA(1c) and FBG levels. Sixty three patients had received diabetes education. These patients had higher KA score compared with the remaining group (24.0+/- 4.0 Vs.16.8+/-5.37, respectively, P<0.0001) and lower HbA1C levels (6.5% Vs 8.5 % respectively P<0.0001). The type-2 diabetic patients the higher the KA score, the more efficient glycemic control can be achieved. patients who require diabetes education can be identified by using questionnaire that determine their KA level and by using HbA(1c) tests.18
A study was conducted on self care beliefs and behaviours in adults with type-2 diabetes thepurpose of the study was to describe illness beliefs and diabetes self care behaviours of Ugandan adults with type-2 diabetes. A convenience sample of 340 adults with type-2 diabetes was recruited from two out patient’s settings in Uganda. Participants were interviewed by a nurse about diabetes, self care behaviours and showed with interviewer the blood glucose and blood pressure values obtained during their clinic visits. The result was showed the majority of participants viewed diabetes as serious, lifelong condition that they had a good deal of control over , however while 88% believed they could tell high blood glucose by the presence of symptoms , only 39% said they could detect low blood glucose by the presence of symptoms . The results from the study high light the challenges diabetes self care in resource-poor countries improving diabetes care will require systems level interventions to improve access to basic resources as well as to social support and educational interventions.19
A study was conducted on blood glucose self monitoring among patients with diabetes mellitus type-2 in family medicine practice good knowledge of diabetic patients about their decease is often not related with good glycemic control. The aim of the study was to determine the level of application of acquired knowledge about diabetes in recognised and resolving hypo and hyper glycemic conditions in patients who did or didnot do blood glucose self monitoring as well as the impact of self monitoring on HbA1c during education of patients with diabetes type -2. There were 91 patients with the type -2 diabetes who completed 6 months education about their disease in four family medicine practices in Tuzla canton during the period from march to September 2005 out of 91 interviewed patients, there were 29 who did self monitoring by glycol meter at the beginning of the education, 30 patients during the passive education and 34 after the intensive education. At the end of education their knowledge was better at both recognising and resolving hypo glycemia (P=0.01). Only 1/3rd of patients with type-2 diabetes had done self monitoring with gluco metre and although their knowledge about hypo and hyper glycemia was improved during education.20