RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCE BANGALORE, KARNATAKA
A study to assess the effectiveness of structured teaching programme on selected diabetic complications and its prevention among
diabetic patients in selected
hospitals at CHINTAMANI.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Mrs. JINEET VARGHESE
SLES COLLEGE OF NURSING, CHINTAMANI-563125
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCE BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE STUDENT / Mrs.JINEET VARGHESEM.ScNURSINGSTUDENT
SLES COLLEGE OF NURSING, CHINTAMANI-563125
2 / NAME OF INSTITUTION / SLES COLLEGE OF NURSING, CHINTAMANI-563125
3 / COURSE OF STUDY / M.Sc NURSING
MEDICAL SURGICAL NURSING.
4 / DATE OF ADMISSION TO COURSE / 01.06.2011
5 / TITLE OF TOPIC / A study to evaluate the effectiveness of structured teaching programme on selected diabetic complications and itsprevention among diabetic patient at selected HOSPITALS, AT CHINTAMANI.
6. BRIEF RESUME OF INTENDED WORK:
INTRODUCTION
“PREVENTION IS BETTER THAN CURE “
Desiderius Erasmus
Diabetes is a complex metabolic disease which can give rise to many circulatory and neurological disorders.
Diabetes is a disease of the endocrine system where the body is not able to maintain the blood sugar at the required level for good health and well being. Diabetic has become a problem of great magnitude recently. It is estimated that 10-12% of the urban and 4-6% ofrural population of India are now diabetic. There is also a corresponding increasing in the diabetic related complication for example –diabetic neuropathy, diabetic retinopathy, and diabeticnephropathy.
Diabetic is due to defect in the Beta cells of islets of langerhans, that is seen in pancreas. This leads to deficient production of insulin that is responsible for maintain of blood glucose there are two types of diabetes - diabetes mellitus characterized by high blood sugar level and diabetic insipidus that is associate with defect in water reabsorption .Diabetes mellitus can be further sub divided into insulin dependent and non insulin dependent diabetes mellitus. The development of disease may be caused by various factors including, hereditary, viruses, and immunological factors.1
Diabetes mellitus has emerged as a major health care problem in India. According to diabetes atlas published by international diabetic federation (IDF) there were estimated 40 million people with diabetes in 2007 and this number predicted to rise to almost 70 million people by 2025. The countries with largest number of diabetes will be in India, China and USA by 2030. It is estimated that every 5thperson with diabetes will be an Indian.2
a study was conducted to estimate the prevalence of diabetes and the number of all age which diabetes for year 2000 and 2030.The prevalence of diabetes for all age group world wide was estimated to be 2.8% in 2000 and 4.4% in 2030 the total number of people with diabetes project to rise from 171 million in 2000 to 366 million in 2030.7
The Even minor trauma can lead to infection of foot ulcers and amputation is major course of morbidity, disability and cost for people with diabetes mellitus.
Diabetic nephropathy is the leading cause of end stage of renal disease worldwide and develops in 20-40% of patient with type I or type II diabetes mellitus. Elevated blood glucose over long period titerwith glomerularhypertension lead to progressive glomerlosclerosis and tubulointestetial fibrosis in susceptible individual.3
Diabetic retinopathyis common complication of diabetes mellitus and is one of the leading causes of visual loss in working age population in developed and developing countries. The known risk of retinopathy is directly related to the degree and duration of hyperglycemic. 4
Diabetes is considered as mother for all diseases. Too much glucose in the bloodfor a long time can cause diabetes problems- can damage many parts of the body, such as heart,blood vessels, eyes and kidneys. Heart and blood vessels diseases can lead to heart attacks and strokes, which are main killer of mankind. Common misbelief is diabetes people should not undergo operations for fear of infections. But it is not the case. Modern surgical techniques and better understanding of the physiology, operative stress will increase sugar level in the body and if we control properly with time to time medicines, any operation including heart operations is relatively safe in modern era. This is encouraging, as enhanced compliance may also result in improved glycemic control and thus reduce diabetic complications.
Population- based studies done by the author and his colleagues in Chennai have shown that nearly one in five of all patients with diabetes have one or more complications arising from the disease. It has emerged as a leading cause of blindness, kidney failure, amputations and heart attacks in India. Recognizing the gravity of the situation, the united nations general assembly passed a historic declaration on diabetes in 2007. the only other disease for which the U.N. has passed a declaration is HIV/ AIDS: that was almost a decade ago.
Ultimately, diabetes prevention needs “ political will”, societal and community support and behavioral change on the part of individual and their families. Now is the time for India to wake up to the imminent problem of diabetes mellitus and act – before it is too late. 5
6.1. NEED FOR STUDY
“Uncontrolled diabetes can damage vitalorgans”.
Diabetes poses a huge economic burden on India. In a recent paper shows thatof five countries study, namely the Us, the U.k, Finland, China and India, India spends the highest share of GDP on diabetes. But more than the economic impact, it is the social impact that is of greater concern. The age at onset of typeII diabetes is progressively decreasing and the disorder now affect a significant number of adolescents and children. The onset of diabetes-related complications typically occurs 10-20 years after the disorder is diagnosed.6
Diabetes mellitus has emerged as the leading disorder world wide affecting more than 350 million people as of 2007. India is the “Diabetic capital” of world with 41 million people affected with the disease. the clinical importance of diabetes lies mainly in its propensity to produce micro and macro vascular complications leading to cardiovascular disease , cerebrovascular disease , retinopathy , nephropathy, neuropathy and foot problems , which counts for considerable morbidity and mortality throught world.
Complications of diabetes include diabetic retinopathy that leads to vision defect and is one of the leading causes for blindness. Diabetic nephropathy leads to renal failure necessitating dialysis and renal transplanta -tion. Diabetic neuropathy that leads to non healing ulcers of foot .1
Rapid urbanization and industrialization have produced dramatic change in life style. Consumption of diet rich in fat and calories combined with a high mental stress have compounded problem further. There are several studies from various part of Indiarevealed a raising trend in the prevalence of diabetes in urban area.2
A study was conducted by Ramchandra A, at Chennai, on 3010 diabetes, the prevalence of micro vascular complications were retinopathy- 23%, nephropathy-5.5%, and prevalence of CHD-1.4%8
In a study comprising 720 type II diabetic, retinopathy was seen in 21.2%, microalbuminuria 41%, peripheral neuropathy in 15.3% CAD 7%, and PVDwas seen in 7.4% of patient.
In recent study in Chennai nearly25% of population studied were unaware of a condition called diabetes, only 40% of participant felt that prevalence of diabetes was increasing and only 22% of population felt that diabetes could be prevented, through the awareness level increased with education only 4.2% of postgraduate and professional including doctors know that diabetes was preventable. The knowledge of risk factor was even low only 11.9% of study reported obesity and physical inactive as a risk factor. Even amongst the known diabetes only 40.6% was aware that diabetes could leads to organ damage andcomplications, many people 46% with diabetes felt that it was a temporary phenomenon.2
In astudy reveled that of all the diabetes patients taking treatment from centers,more than 50% of patient had poor control of diabetes as per the criteria of American diabetic association. The study shown that 4%of patient were on diet therapy alone,53.9% were receiving oral antidiabetic agents,22% were taking insulin and another 19% were on both insulin and oral drugs this study confirmed that care in India level much to be desired.2
A studywas conducted at Bangalore in south India it was observed that majority of patient (70%) were diagnosed by there practitioner among 70% of them had approached general practitioner for some other problem 90% of them went only fasting and post meal blood sugar and urine sugar test. Specialized test like glyosylated Hb(HbA1C),lipid profile, kidney function test, were undertaken only by 4-6%of patient even simple measurement of blood pressure, weight, and examination of feet were not done for majority of patients.2
In India the lack of proper health infrastructure, rapid ignorance and absence of clear cut guidelines mean approach to the management of diabetes is adhoc. The lack of awareness among patient and practitioner is a key factor in the poor care. There are practically no nurse educator or diabetic counselors, no podiatrist (foot experts) and few dieticians which mean that the treating doctor has no support and has to take the entire burden of caring for these patients. The patient inability / unwillingness to pay this additional support also hinder the treatment.2
Finding of various studies suggest that patient education is a fundamental aspect of management of complications in patient with diabetes mellitus. Preventivemeasures have to be focused on the risk profile of the patient and the chronological appearance ofsymptom.
In a view of high incidence of diabetes complications in diabetes patients and also in view of the various studies which suggest the necessity of planned teaching programme for prevention of diabetic complications among diabetes. It was decided to conduct an evaluate study to assess the knowledge of risk factors leading to diabetic complications and measures for its prevention among diabetes and planned for structured teaching programme.
6.2 REVIEW OF LITRATURE.
The review of literature is defined as a broad, comphernsive,in-depth, systematic and critical review of scholarly publication, unpublished scholarly print materials, audiovisual material and personal communication.
The related literaturehas been organized and presented under the following headings.
I. Studies related to diabetic mellitus and factors affecting its
Management.
II. Studies related to diabetic complications.
- Studies related to diabetic nephropathy.
- Studies related to diabetic retinopathy.
- Studies related to diabetic neuropathy.
I. STUDIES RELATED TO DIABETIC MELLITUS AND FACTORS AFFECTING ITS MANAGEMENT.
A study to evaluate the effectiveness of types of patient teaching programme that is agent initiated and instruction teaching method for diabetes self care ability among non insulin dependent diabetic patient. Three small groups of 50 patients each have assigned 2 experiment group and one control group. The experiment groups were exposed to either agent initiate teaching or auto-instructional learning agent. The control group was given only regular incidental health teaching. Findings reveled that significantly higher knowledge and skill gain and reduction in stress level in the two experimentalgroups. 9
In a studies to assess the pattern of relationship between personal-background characteristic and dimensions of quality of life in diabetes patient 117 patient with diabetes type II, 100 female &17 males randomly selected from outpatient referred to sina hospital (tubriz, Iran) the researcher has provided three part questionnaire to patients that includes 1) sociodemographic data 2) general health related instruments 3) disease specific instrument for diabetic patients.The result shows personal backgroundcharacteristics accounted for 27% of variance in the physical functional dimensions. Diabetic patients face great challenges in many conditions of quality of life.10
A study was conducted on knowledge on diabetic mellitus and perform among health carte professional in non-diabetic department the aut5her tested the level of knowledge on diabetes and professional skill in a group of 60 non-diabetic health care professional at a poly clinic regarding the recognition and treatment of hypoglycemia, the storage,mixing, and administration of insulin, blood glucose stick monitoring and prevention of diabetic complication. A majority of subject scored low both in knowledge as well as professional skill.11
In a study measured a diabetic knowledge of nurses in long term care facilities a 36 item diabetic knowledge test was developed for use in this study and administration to nurseemployed in 4 long term care facilitated including foot care and patient education. The respondent attained a mean score of 67% of item correct, less than 70% cutoff score to be perform by researcher the sample scored high mean score >70% educated andlowestmean score <40% on illness blood glucose monitoring medication and hypoglycemia.12
Astudy was conducted on theeffectiveness of post education following progression on diabetic. 31 elderly patients with diabetes were randomly assigned to an experimental subject. In experimental group contacting by telephones within 24-48 hours after discharge from the hospital the calls were repeated at weakly intervals for 3-4 weeks each phone calls consisted of assessor the subject self care. Knowledge and practice in self care activities are behavior. Supplemental instruction were when individual subject. The control group didn’t receive a phone call after discharge.Diabetic self care knowledge and self carebehavior were assessed in both group and the result indicated the experimental group had higher score on knowledge and self care behavior than control group. 13
II. Studies related to diabetic complications
1)studies related to diabetic nephropathy
A study was conducted to determine the effect of on LPD on renal function in patient with type I or type II diabetic renal disease by using a meta-analysis of randomized controlled traits overall, a change in urinary albumin excretion or protenuria for GFR & CCR was not significantly with an LPD. But a decrease in WMD for Hba(1c) was significantly associated with an LPD group.14
a study was conducted onagents in development for the treatment ofdiabetic nephropathynew therapies including those targeting the accumulation of advanced glycotion end product (AGE) and reactive oxygen species generation are likelyto feature in future treatment regimen other approaches that at this stage do not appear to be progressing include the glycoaminoglycan suloxide and the protein kinase.15
A study was conducted on cardiovascular complications in patients with diabetic nephropathyreceiving pharmacological versus renal transplantation. In hemodialysis patients with diabetic nephropathy had lower complete blood count, less severe-calcium phosphate disorder. The risk factor for cardiovascular complications is greater in patient with diabetic nephropathy.16
A study was conducted to investigate detectability of anemia, it’s clinical and patrhophysiological feature in patient with diabetes nephropathy. The trial included 1020 patient with type I and type II diabetes mellitus, diabetic nephropathy was diagnosed in 50% of them incidence of anemia was compared in 92 diabetic nephropathy patients in type I and in 230 patients with chronic glomerulonephritis. Anemia developed in type I and II diabetic mellitus patients free of diabetic nephropathy and unaffected renal filtration function. GFR 60ml/min was 23.3% and 18.3% respectively, anemia occur more often and is more sever than CGN.17
A study was conducted on subacute renal failure in diabetic nephropathy due to endocapillary glomerulonephritis and cholesterol embolization. Patient with established diabetic nephropathy could have other glomerular disease superimposed on diabetic glomrulosclerosis.18
2)Studies related to diabetic retinopathy.
A study was conducted to find out the prevalence of diabetic retinopathy among diabetics on treatment to find out the presences of associated risk factor and to determine the knowledge of diabetic retinopathy among patients with diabetic mellitus.It was estimated that 21% of known diabetes had evidence of various grade of diabetic retinopathy although 75.38% of patient had history of diabetes mellitus less than 10 years associated risk factor were present in 66.4% however only 50% diabetic had the knowledge of diabetic retinopathy.19
A study was conducted to assess whether patient were receiving regular diabetic retinopathy screening and to examine influencing screening uptake. out of 209 people who completedquestionnaire 169(81%) had a dilated fundus examination within last year. The most significant predictor for receiving screening was a a previous physical recommendation about the necessity of a regular eye examination. It is essentialthat patient is fully aware of need for a regular eye examination.20
A study to evaluate the influence of elevated level of nocturnal blood pressure on diabetic retinopathy. A total of 88 diabetic retinopathy patients were divided according to the stage of diabetic retinopathy. They underwent 24 hour ambulatory blood pressure monitoring and opt homological evaluation and their average level of fasting blood glucose as well as their glycemic control index were calculated.The presence study suggest that the absence of normal pressure rhythm can interfere with the prevalence and severity of diabetic retinopathy.21
3.Studies related to diabetic neuropathy.
A studywas conducted to determine major risk factor and management out come of diabetic foot ulcers in order to prevent amputation. Cross sectional descriptive study design was adopted.116 consecutive diabetic patient with foot ulcer of Wagner’s grade 1-4 were assessed. Effective glycemic control, optimal wound care, aggressive medical management and timely surgical intervention may decrease disabling morbidity with better outcome of diabetic foot ulcers.22
A study was conducted ondiabetic foot ulcer assessment and its management. Up to 85% of all diabetic foot related problem are preventable through a combination of good foot care and appropriate education for patient, and use of adjunctive treatment such as various growth factor, skin replacement dressing and vacuum assisted closure will be accelerated healing in selected cases. 23
A study was conducted on for detection of risk factors and its prevailing clinical forms of diabetic foot infections in dependence on type diabetes mellitus. 157 patients with DM and DFI and 689 DM patients without DFI were examined. DFI risk factors in type 1 DM to be a combination of sensor and autonomic neuropathy. In type 1 DM and DFI neuropathic form of DFI prevailed (88%), in type 2 DM-neuroischemic form of DM cases with DFI there was revealed a high rate of risk factors of atherosclerosis.24
A study was conducted on mechanism of disease : the oxidative stress theory of diabetic neuropathy. In this review, discuses the idea that excess glucose over loads the electron transport chain leading to the production of superoxides and subsequents mitocondrial and cytosolic oxidative stress.25