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Case Management of a Diabetic Patient in the Lee County CommunityKarina Romandetti, Christina Rosser, Ashley Riley, and Haley ZoellerAuburn University School of NursingMarvin Isley, of the Isley Brothers musical group, once said, “If I would have listened, if I would have understood diabetes like I understood music, maybe these things wouldn't have happened” (Isley). Marvin was diagnosed with diabetes which later led to his death this past year. Many people do not grasp the severity of this chronic illness. Most risk factors are 100% preventable and are many times overlooked. The purpose of this paper is to investigate the relationship between preventable risk factors such as obesity, nutrition deficits, and a lack of physical activity and diabetes, their effect on the low income populations, and implementation of a community program to aid in the fight with this disease.Lee County Community AssessmentThe city of Opelika is located in north-central Lee County and is bordered by Auburn, AL. The city is rural but is slowly becoming more urbanized. It is a small city with an approximate population of 130,000 and an estimated median income of $23,229 which falls below the state median of $42,666. The main occupations of the citizens are service, sales and office, production, transportation and material moving, education, retail trade and manufacturing. The estimated level of unemployment is 3,241 in the labor force. Opelika is serviced by one major hospital, East Alabama Medical Center, which is also the sole hospital in Lee County (healthstats/assets/chplee07.pdf). Health StatisticsIn 2006, 19 million people were diagnosed with diabetes nationwide and another two milion were considered to have pre-diabetes. Between 2005 and 2009 in Alabama, the incidence has risen from nine out of every 100 people to 14 out of every 100 people. This is mainly the result of the rising incidence of obesity, which is the most common risk factor for type two diabetes mellitus (T2DM); it has increased in prevalence in the United States as 30% of Americans twenty years or older are obese (Rodbard et al., 2007, p. 8). In Auburn alone, 30.2% of the city is obese, compared to the state where 31.7% is considered obese. Research has shown that due to the rising rates of childhood obesity, one out of every 400 will be diagnosed with T2DM (city/Auburn-Alabama.html). Minorities, unfortunately, seem to be effected more with T2DM than Caucasians. According to the 2005 study performed by the CDC, African-Americans are 1.8 times more likely to have T2DM than Caucasians (Rodbard et al., 2007, p. 8). In 2005, the prevalence of T2DM for African Americans 20 years or older was 13.3%, the second highest ethnicity diagnosed with diabetes mellitus. The study also showed that diabetes mellitus (DM) diagnoses were highest in African-American women. (Rodbard et al., 2007, p. 8). According to Healthy People 2010 (2010), the national goal for diabetes is, “Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes” (para. 1). Healthy People 2010 has speculated that by the year 2050 almost half of our population will be an ethnicity other than Caucasian with the breakdown being 53% Caucasian, 24% Hispanic, 14% African-American, and 8% Asian (2010). The issue with this is that these ethnicities are more prone to developing T2DM and along with the growing inactivity as a nation, T2DM rates are going to sky rocket. Statistics have shown that over 800,000 new cases are diagnosed each year which is a little over 2,200 per day (Healthy People 2010, 2010). The researchers have also noted that, “Obesity, improper nutrition, and lack of physical activity are occuring in persons under the age of 15. These behaviors and conditions may explain the increasing diagnosis of Type 2 Diabetes (T2DM) in teenagers” (Healthy People 2010, 2010). Community ResourcesWith the median income of the area being just over $23,000 it is pivotal that there be outlets of care that are not costly and are accessible to the community. The Lee County area has three free clinics that can be utilized different days throughout the week. The first is the Darden Wellness Center which is located in Opelika. It is a free clinic staffed by Parrish nurses who conduct blood pressure screenings and blood sugar testing as well as routine physical evaluations. They also provide education for all clients focused around a healthy lifestyle, including nutrition and exercise. The Parrish nurses also act as patient advocates by communicating with other health care providers to assure the best care possible for each client based on their personal needs. The second resource is the Diabetes and Nutrition Center which is located in the Opelika area and is part of the East Alabama Medical community. This center offers many different services such as diabetes management classes, meal planning, blood glucose monitoring, insulin pump initiation, and carb counting. They do charge for their services, but it will be covered by insurance, Medicare, or Medicaid. The third resource is Mercy Medical Clinic which is a non-profit free clinic for anyone in the community to go to. It is located in the city of Auburn. They perform free evaluations, physicals, flu shot clinics, blood pressure and blood glucose screenings, and health education. Contact information for these clinics is provided in Appendix A.Nursing DiagnosesThree nursing diagnoses have been contructed base on the previous information:At risk for obesity among the residents of Lee County related to a knowledge deficit of nutrition At risk for obesity among the residents of Lee County related to a knowledge deficit of lack of exerciseAt risk for diabetes among the residents of Lee County related to the increasing prevalence of obesity.At risk for heart disease among the residents of Lee County related to the increasing number of people being diagnosed with diabetes.Case Management Section: Critical CareA 31 year old African American female presented to the emergency room complaining of shortness of breath with bloody sputum. She had generalized edema in her lower extremities with a prolonged QT interval on the EKG. Upon auscultation, she had diminished breath sounds with a pulse oximetry reading of 90%. She denied chest pain and was transferred to the intensive care unit (ICU). She weighs 472 pounds, and has a history of uncontrolled T2DM, chronic hypertension, chronic kidney disease, chronic diastolic heart failure and she reported gaining 100 pounds within the past year. The patient was on a continuous heart monitor with sinus tachycardia at 108 beats per minute. Her blood pressure (BP) was 200/80 with an ejection fraction between 50-55%. A Swan- Ganz catheter was placed and showed signs of fluid volume overload, an increased wedge pressure, and pulmonary hypertension. A tracheostomy was performed and the patient was placed on the ventilator. Her arterial blood gases revealed a state of compensated metabolic acidosis. In relation to her kidneys, her lab values reported an elevated creatinine level of 7.3, BUN of 118 and a bilirubin level of 5.4. The patient was placed on dialysis three times a week due to renal failure complicated with sepsis. A nasogastric tube was placed to infuse Nepro at 500 calories/day. The patient’s body was tinged yellow despite ethnicity, in particular her mucous membranes. After being bed bound for longer than 20 days, the patient had developed stage two ulcers on her sacral area despite the Big-Turn 2 bed. The main underlying issue with this patient is her morbid obesity that has resulted in uncontrolled T2DM. During her hospital stay she was on sliding scale insulin, consisting of Novolog and Lantus, with blood sugars checked every four hours. Current Evidence Based PracticeIn a randomized clinical trial, the effectiveness of pharmacist-based case management interventions in patients with T2DM was examined. The pharmacist taught the importance of self-care, medications and frequency of screening for HbA1c, LDL’s, urine albumin, along with retinal and foot examination. The intervention group and control group started off with 10.1% and 10.2% respectively, for their baseline mean HbA1c levels. After the pharmacist-based case management intervention the HbA1c levels of the intervention group dropped 2.1% with the control group mean level only dropping 0.9%. The pharmacists’ effect on the process of care showed there was an increase in LDL measurement, retinal and neuropathy examination within two years compared to the control group. Choe et al., (2005) reported that “this improvement in HbA1c levels would be expected to lead to 40% to 50% relative reductions in the risk of intermediate and advanced microvascular complications” (Choe et al., 2005, p. 258). This research indicates that pharmacist-based case management, for high risk diabetic patients, would have the best outcome for both the hospital long-term costs and patient health and satisfaction. Having T2DM puts patients at an increased risk for developing coronary heart disease (CHD). Dislipidemia is a major factor in CHD and current treatment guidelines have been established to keep LDL less than100 mg/dl. A study was performed to test the efficacy of a more aggressive cholesterol goal of less than 70 mg/dl to further decrease the chances of a cardiovascular event in patients with CHD and DM. In the double blind study half of the participants were given Atorvastatin 10mg and the other half received Atorvastatin 80mg. Patients taking Atorvastatin 10mg had a reduction to a mean LDL level of 96.2 mg/dl and patients taking Atorvastatin 80mg had a reduction to a mean of 77 mg/dl. After the five years, 135 patients taking the 10mg had a primary event while only 103 patients taking 80mg had experienced a primary event. Overall, there was a 25% reduction in the risk of a major cardiovascular event. It is suggested that diabetic patients regardless of their initial LDL cholesterol level, age, duration of diabetes, or glycemic control should implement the use of high dose statins to control LDL levels less than 70 mg/dl (Shepherd et al., 2006).T2DM is the leading cause of end-stage kidney disease. It has been shown that lowering BP can have a profound effect on the progression of kidney disease. The current recommendation is BP less than 125/75mmHg in patients with diabetes. This study tested the efficacy of further lowering the BP using a fixed combination of ACE-inhibitor Perindopril and diuretic Indapamide. Regardless of the baseline BP level, after four years there was a 21% decrease in developing the manifestation of kidney disease in both microalbuminuria and macroalbuminuria. The study found that individuals with the lowest risk of developing kidney disease had a BP of 110/65mmHg (de Galan et al., 2009).Case Management Section: Clinical GuidelinesThe American Association of Clinical Endocrinologists Diabetes Mellitus Clinical Practice Guidelines Task Force is composed of published endocrinologists who are experts and practitioners in the field of diabetes (Rodbard et al., 2007, p. 4). AACE established clinical guidelines for the diagnosis of diabetes to include assessment of risk factors, plasma glucose concentrations, diagnostic criteria, and DM classifications. Risk factors include a family history of DM, cardiovascular disease, an overweight or obese state, sedentary lifestyle, Hispanic, African American, Asian American, Native American or Pacific Islander ethnicity, hypertension, increased levels of triglycerides and low HDL-C levels. Diagnostic criteria for DM include symptoms such as polyuria, polydipsia and unexplained weight loss. Specifically, classification of T2DM accounts for 90-95% of all diabetes diagnoses with most affected individuals obese with a variable degree of insulin resistance. Additionally, results from an epidemiologic study show that hyperglycemia is strongly associated with the subsequent development of cardiovascular disease and risk factors (Rodbard et al., 2007).The AACE also established clinical guidelines specific to prevention strategies of T2DM. Prevention includes lifestyle modifications and referral to a registered dietitian or credible weight loss program for counseling in calorie intake reduction and nutrition strategies (Rodbard et al., 2007, p. 13). Regular physical activity should also be prescribed at a recommended 150 minutes per week. Therapeutic cornerstones to treat both diabetes types are “proper nutrition, exercise, education and appropriate pharmacologic therapy” (Rodbard et., 2007, p. 20). “Therapy should be tailored to the individual to maximize the likelihood of attaining and maintaining appropriate glycemic goals and to reduce frequency of adverse effects. Near-normalization of blood glucose levels in patients with T2DM can be achieved safely by intensive combination therapy” (Rodbard et al., 2007, p. 20). Glycemic management targets include a HbA1c less than or equal to 6.5 mg/dL, a fasting plasma glucose concentration of less than 110 mg/dL and/or a two hour postprandial glucose concentration less than 140 mg/dL. Instruction about self-monitoring of blood glucose levels should be implemented. Specific for T2DM, clinical guidelines should include “aggressively implementing all appropriate components of care including medical nutrition therapy, physical activity, weight management regimen, pharmacologic interventions and diabetes self-management education at the time of diagnosis” (Rodbard et al., 2007, p. 17). Over 50% of individuals with T2DM suffer from hypertension. The BP goal for management of hypertension in patients with DM is less than 130/80 (Rodbard et al., 2007, p. 35). Cardiovascular disease in the leading cause of morbidity and mortality in individuals with DM and it accounts for approximately 80% of deaths in this population (Rodbard et al., 2007, p. 37). The AACE states that, “aggressive management of dyslipidemia in patients with DM is critical; treat patients with the following goals: LDL-C less than 100 mg/dL, HDL-C greater than 40 mg/dL for men and greater than 50 mg/dL for women, and triglyceride level less than 150 mg/dL. For T2DM, kidney disease screening should begin at the time of diagnosis. Diabetics with kidney disease, protein intake should be between 0.8-1.0 g/kg per day. Hemodialysis and/or kidney transplantation should be considered if glomerular filtration rate falls lower than 30 mL/min/1.73 m2 (Rodbard et al., 2007, p. 50). Annual examinations should also include evaluation of the feet, specifically assessing skin, nails, pulses, temperature, and hygiene. “Medical nutrition therapy is an essential component of any comprehensive diabetes mellitus management program” (Rodbard et al., 2007, p. 47). Weight control and a controlled-calorie diet are critical facets of DM management to lower glucose levels and to reduce the risk for cardiovascular disease. Risks are dramatically decreased when BMI is less than 25 kg/m2, patients exercise 30-90 minutes per day, salt is restricted to less than 1.5 g/d, fresh fruits and vegetables are heavily incorporated into diet, and alcohol is limited to one drink per day for women and two drinks per day for men. Obesity is associated with decreased insulin sensitivity and increased risk for developing cardiovascular disease. Hospitals should have previously established diabetes management protocols. Blood glucose and HbA1C levels should be measured upon hospital admission, “diabetes mellitus” should be clearly labeled on the patient’s medical chart and glucose monitoring should be ordered. For hyperglycemic patients who are able to eat solid foods, patients should maintain a consistent carbohydrate diet or be under an advanced carbohydrate counting and provider-determined or self-determined prandial insulin dose. Upon hospital discharge, education should be presented to each patient regarding administration of medications, monitoring of glucose, nutrition choices, exercise, and other lifestyle aspects. Situations that necessitate a call to the physician should be reviewed and follow up visits should be planned in order to further discuss glycemic control and provide continuous DM education (Rodbard et al., 2007, p.60). To treat the patient, she was given Metoprolol, Clonidine, and Hydralazine for hypertension. In addition to her other medication, Zocor was prescribed to reduce her cholesterol and lipid levels. She was also immediately started on sliding scale insulin with a blood glucose assessment every four hours, before breakfast and before bedtime. The proper safety measures were also followed as “diabetes mellitus” was visibly labeled on the patient’s chart, electronic charting and computerized order entry systems were utilized, and typed algorithms for insulin were clearly displayed throughout nursing staff areas. The nursing staff also routinely assessed peripheral pulses and capillary refill as well as practiced proper foot care and hygiene.The patient was informed about lifestyle modification, dietary management specific to lowering her body weight and BMI to normal level, physical activity requirements of thirty minutes five times per week and the risks of uncontrolled T2DM and maintaining her current lifestyle choices. Additionally, the patient was properly educated on annual screenings for various complications associated with diabetes. The nurse also reviewed glucose management, monitoring, and treatment methods in order to control her hyperglycemia. Psychosocially, her measures of support were also assessed as she lives with her parents and she has means of transportation to comply with her dialysis schedule. Home health care was also established and a schedule was developed. A dietician also counseled the patient concerning her individual nutrition needs and diet plan. Conclusively, in terms of following AACE Clinical Guidelines of 2007, it is evident that the East Alabama Medical Center ICU nursing and medical staff closely followed the standards and protocols within the treatment of this patient. Cost AnalysisSixty days and $240,499 later, the morbidly obese patient, with T2DM and numerous other co-morbidities was discharged from the hospital. To provide the comprehensive care needed for this patient, it averaged out to be over $4,000 a day. As seen in Appendix B, medication was the largest amount totaling in $79,330. Room charges were not far behind with 19% of the total cost. The cost of a room in the intensive care unit (ICU) per day is $937. Nursing care is included in the cost of the room. The average BSN ICU nurse makes $28.88 per hour or $693.12 a day (Payscale, 2010). Within the ICU, each nurse is typically responsible for two patients. For 24 hours, the total cost of two patient rooms in the ICU is $1,874. After the nursing cost is subtracted $1,180 per day goes to the hospital to pay the other health care professionals and services. There has been discussion on changing the way nurses get reimbursed in proportion to the work they provide to each patient. Each patient has varying degrees of care needed, therefore nurses should be payed accordingly, but no improvements have been made. Discharge Plans to the CommunityT2DM is preventable and primary prevention starts before being diagnosed with the disease. Primary prevention can be made through a few simple lifestyle changes. Diet and exercise are the most important factors in preventing T2DM. Avoiding foods high in sugar and simple carbohydrates is a good place to start. The Mayo Clinic states that losing 5% of total body weight reduces the risk of developing T2DM (Jones, 2009). Exercising at least 30 minutes five times a week is also recommended in losing weight. Once diabetes is diagnosed, secondary prevention can be implemented to control the severity and long-term implications of the disease. Checking and controlling blood sugar is the single most important way to control diabetes. Limiting fat calories in order to loose weight is also strongly stressed. If possible, it is recommended to meet with a dietitian to design a specific meal plan according to weight and lifestyle. Co-morbidities such as hypertension and microablbuminuria also need to be treated and controlled. If needed, cigarette-smoking cessation is implemented to optimize body defenses and further control hypertension. Tertiary prevention with diabetes focuses on the long term consequences of the disease. In addition to keeping blood sugars under control, it is important to have regularly scheduled exams for retinopathy, nephropathy, cardiovascular disease and peripheral vascular disease. HbA1c levels should also be tested every three months along with blood pressure and cholesterol. With the recent opening of Publix in Lee County, it has brought an array of services that can be offered to diabetics. As mentioned in the prevention recommendations, Publix offers free blood pressure screenings and total cholesterol and HDL testing for $15. They have also implemented a new program called Publix Pharmacy Direct Care. It is a service that delivers free diabetes testing supplies including: blood glucose meters and strips, lancet devices, lancets, batteries and control solution for blood glucose meters, insulin syringes and insulin pen needles at no charge. Online registering is available for homebound persons. In addition, Publix offers free generic immediate-release metformin. All that is needed is a prescription from their doctor and refills are unlimited. If unable to meet with a dietitian, Publix website has a comprehensive shopping list focused on specific diets such as gluten free, low sodium, low fat, 100 calories, four grams of sugar, kosher products, and casein free (Publix Asset Management Company, 2010)?Transportation can also be a barrier for diabetics in following through with their treatment. If no persons are available in the home to help, there is Lee-Russell Public Transit system that is provided for a small charge. Dial-A-Ride is now being implemented and is a call ahead curb-to-curb service available to all public. Home CareAlacare delivers the highest level of skilled care within the patient’s home. The Alacare team consists of nurses, home care aides, physical therapists, occupational therapists, speech-language pathologists, medical social workers, medical nutritionists, certified diabetes educators and chaplains. Services provided by Alacare include admissions services, diabetes education, enterostomal therapy or wound care, home care aides, hospice care, medical nutrition therapy, medical social services, mental health nursing, occupational therapy, palliative care, physical therapy, speech language pathology and terminal illness services (Alacare Home Health & Hospice, 2010). Specifically, Alacare offers home health for DM patients known as Diabetescare. Diabetescare is a comprehensive program providing all the services necessary to help patients monitor and control DM while simultaneously fulfilling and following the protocols and standards of the American Diabetes Association and Joint Commission. Within Diabetescare, full-time certified diabetes educators are actively involved in the care plans of newly diagnosed DM patients, patients with elevated blood sugars, patients on insulin pumps and frequently admitted patients for uncontrolled glucose levels. They are active participants in diabetic patient education on the disease process and methods of self-care. Diabetescare also includes registered nutritionists who teach patients and their caregivers about optimal nutritional choices to meet the patient’s unique needs. Nurses also closely monitor foot care as well as educate the patients to recognize warning signs of impending issues. Diabetescare also includes Anodyne therapy, which improves circulation, restores sensation and decreases pain (Alacare Home Health & Hospice, 2007). Cynthia Ruffin is the diabetes educator for Alacare Home Health and Hospice. In speaking with Ruffin, she addressed various issues pertaining to Alacare’s home health services and Diabetescare as well as specific information regarding the patient care. The agency can be accessed via publicity tactics, word of mouth throughout the community, referral from physicians, hospital staff or other health care facilities. Since 85-95% of the patients have Medicaid or Medicare it is required that the patient must be homebound, in need of skilled care, under a physician’s care, and must express the desire for service. Once Alacare receives physician referral, home care service episodes known as “certification periods” begin and are 60 days each. Two weeks prior to the conclusion of the certification period, the home health nurse must reassess for patient exacerbation, medical changes and the need for continuous home health services. Services can also be terminated at any time within the 60 days if the criteria for services are no longer met or the patient expresses the desire to cease home health care. The cost of home health care varies with each patient and medical condition, but with Medicaid or Medicare, patients have no cost or co-pay. Alacare relies on Home Health Resource Groups (HHRGs) to receive specified funds to treat certain diseases and conditions (C. Ruffin, personal communication, November 1, 2010).Specific to the patient, Ruffin provided her opinion on potential home health services. First, home health should assess the patient’s support system within the home. Secondly, due to recent hospitalized intubation, respiratory status and function should be evaluated. Furthermore, knowledge of current condition, date of the diabetes diagnosis, mobility status, activity level and diet should be appraised. Given the patient’s morbid obesity the type of bed should also be considered. Due to the complexities stemmed from the patient’s diabetes, Ruffin recommends an in-patient facility for morbid obesity in order to concentrate on lifestyle modifications. She also dictated that the patient must be provided a working glucometer as well as continuous education for diabetes treatment, management and self-care. A schedule should also be formulated to plot annual tests for retinopathy, neuropathy and vascular circulation diseases as well as a three-month HbA1c screening. She also recommends a contract dietitian to formulate individualized nutritional education and plans. Initially, home health will visit the home two to three times for the first week, which is known as “Front Loading” visits. Visits will eventually taper depending on the patient’s need. Alacare cannot discharge the patient without physician order. When visited by the home health nurse, our patient was at the nail salon, the hair salon, or running errands indicating she was not homebound. This disqualifies her from home health as the patient no longer meets Alacare criteria. After multiple failed visits, physician referral can report that the patient is not homebound and is capable to travel for medical necessities (C. Ruffin, personal communication, November 1, 2010). Community Intervention ProgramThrough research we found two studies that solidified the need for community interventions that focus on the core of the problem and primary prevention stratgeies to prevent and reduce the risk factors associated with diabetes. The target is obesity within low income communities and school age children. A study by Jenum et al., promoted physical activity interventions in a community for three years because, “Community-based strategies are urgently needed to stem the worldwide epidemic of obesity and T2DM especially in low-income communities” (2006, p. 1605). Interventions included using mass media communication and distributing health pamphlets reminding people to take the stairs instead of elevators. The authors noted that using an inexpensive, multilevel intervention to increase activity produced an increase of 9% in activity compared to a 5% reduction in the group that did not receive the intervention. This shows that programs are essential to education. The next article is based on a program conducted over 10 years that also studied the relationship of physical inactivity, obesity, and a high fat/low fiber diet. Some of its objectives were to, “increase knowledge about risk factors such as inappropriate diet, obesity, tobacco use and lack of physical activity and to facilitate access to physical activities in the community” (Andersson, Bj?r?s, and ?stenson, 2002, p. 322).From these findings, we decided to focus on college freshman and first year weight gain, commonly referred to as the “Freshman 15”. This weight gain can be a springboard for obesity. In a study to assess the incidence of college weight gain, Delinksy and Wilson state, “The freshman year may be a critical period for women in terms of weight gain, dietary restraint, body image disturbance, and disordered eating” (2007, p. 89). With this knowledge we decided to execute our program on 60 local freshman female Auburn University students. To appraise the health risk, we administered a pre-test prior to our presentation. The pre-test consisted of common knowledge about diabetes, healthy eating habits, and exercise (see Appendix C). Question one, which was the definition of T2DM, was missed the most with 35 out of the 60 girls getting it wrong; the second most missed question was number three which was the number of servings of fruits and vegetables a day. A presentation followed outlining diabetes as a disease, its causes, and its risk factors. It included tips on staying fit and healthy eating in the dorm. Next we administered a post-test to evaluate the effectiveness of our teaching. Upon question anaylsis, question one was still missed by 14 participants revealing that our teaching was not entirely clear. In the future, we find it to be benificial to teach more about diabetes and make sure it is easy enough to understand. Conclusively, the students evaluated us; from their report, our teaching was effective overall but certain things should be reiterated. All teaching materials can be found in Appendix C.ConclusionThroughout this paper, it is seen that with proper nutrition and exercise individuals can live healthy lives without fear of being diagnosed with diabetes. ReferencesAlacare Home Health & Hospice. (2007). Retrieved? from Home Health & Hospice. (2010). Retrieved from , C. M., Bjaras, G. E., & Ostenson, C. (2002). A stage model for assessing acommunity-based diabetes prevention program in Sweden.?Health PromotionInternational,?17(4), 317-327.Choe, H. M., Mitrovich, S., Dubay, D., Hayward, R. A., Krein, S. L., & Vijan, S. (2005, April).Proactive Case Management of High-risk Patients With Type 2 Diabetes Mellitus by aClinical Pharmacist: A Randomized Controlled Trial. The American Journal of ManagedCare, 11(4),253-260.Retrieved from Galan, B. E., Perkovic, V., Ninomiva, T., Pallai, A., Patel, A., Cass, A., . . . Chalmers, J.(2009).Lowering Blood Pressure Reduces Renal Events in Type 2 Diabetes. Journal ofthe AmericanSociety of Nephrology, 20, 883-892. doi:10.1681/ASN.2008070667Delinsky, S. S., & Wilson, G. T. (2007, June 6). Weight gain, dietary restraint, and disorderedeating in the freshman year of college. ScienceDirect, 9, 82-90. doi:10.1016/j.eatbeh.2007.06.001 Healthy People 2010. (2010). Diabetes. Retrieved from , A. K., MD, MPH, PhD., Anderssen, S. A., PhD., Birkeland, K. I., MD, PhD., Holme, I.,PhD.,Graff-Iversen, S., MD, PhD., Lorentzen, C., MSC., . . . Bahr, R., MD, PhD.(2006,July).Promoting Physical Activity in a Low-Income Multiethnic District: Effectsof a Community Intervention Study to Reduce Risk Factors for T2DM andCardiovascular Disease. Diabetes Care, 29(7), 1605-1612. doi:10.2337/dc05-1587Jones, M. S. (2009, November 19). Primary, Secondary & Tertiary Prevention of Diabetes.Retrieved from eHow website: Isley. (n.d.). . Retrieved October 25, 2010, from Web site: . (2010). Hourly Rate Snapshot for Nurse, Intensive Care Unit (ICU) Jobs. Retrievedfrom Career Research website: (ICU)/Hourly_RatePublix Asset Management Company. (2010). The Publix Pharmacy Diabetes ManagementSystem.Retrieved from Pharmacy website: , H., Blonde, L., Braithwaite, S., Brett, E., Cobin, R., Handelsman,Y., Hellman, R., Jellinger, P., Jovanovic, L., Levy, P., Mechanick, J. & Zangeneh, F.(2007). American association of clinical endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus.?Endocrine Practice, 13. Retrieved from , J., Barter, P., Carmena, R., Deedwania, P., Fruchart, J.-C., Haffner, S., . . . Waters,D.(2006, June). Effect of Lowering LDL Cholesterol Substantially Below CurrentlyRecommended Levels in Patients With Coronary Heart Disease and Diabetes. DiabetesCare, 29(6), 1220-1226. doi:10.2337/dc05-2465Appendix ACommunity Resources- East Alabama Medical Center: The Diabetes and Nutrition Center Office 500 E. Thomason CircleOpelika, AL 36801334-528-6800- Mercy Medical Clinic 1702 Catherine CtAuburn, AL 36830334-501-1081-Darden Wellness Center1323 Auburn Street Opelika, AL 36801 Appendix BCost AnalysisRoom Charges: $46,500.00Medications: $79,330.40Medical Supplies: $31,784.54Labs: $26,540.00Diagnostics: $8,903.00Procedures: $21,918.00Therapy: $18,600.00 Specialized Services: $6,924.00Appendix CCommunity InterventionPre-test for diabetes and nutrition knowledgeWhat is T2DM?is caused by eating too much sugar and sweet foodsis a condition in which the body cannot use food properlyresults when the kidney cannot control sugar in the urineis caused by liver failureWhat is the most common risk factor associated with T2DM?Having a sweet toothObesityChromosomal Defect Too much exerciseHow many servings of fruits and vegetables should you eat per day?1-27-93-5NoneIt is important to eat a balanced diet containing breads (whole grains), fruits, vegetables, meat, fish, and poultry, dairy products, sparse fats and oilsTrueFalseHow much, on average, should someone exercise each week?60 minutes a day, every day10 minutes once a week30 minutes a day, 3-5 times a weekExercise is not importantWhat health problems can the freshman 15 lead to?ObesityDiabetesHypertensionHeart DiseaseAll the abovePost-test for diabetes and nutrition knowledgeWhat is T2DM?is caused by eating too much sugar and sweet foodsis a condition in which the body cannot use food properlyresults when the kidney cannot control sugar in the urineis caused by liver failureWhat is the most common risk factor associated with T2DM?Having a sweet toothObesityChromosomal Defect Too much exerciseHow many servings of fruits and vegetables should you eat per day?1-27-93-5NoneIt is important to eat a balanced diet containing breads (whole grains), fruits, vegetables, meat, fish, and poultry, dairy products, sparse fats and oilsTrueFalseHow much, on average, should someone exercise each week?60 minutes a day, every day10 minutes once a week30 minutes a day, 3-5 times a weekExercise is not importantWhat health problems can the freshman 15 lead to?ObesityDiabetesHypertensionHeart DiseaseAll the aboveTeaching outlineSummarize Type 2 DiabetesFactsRisk factors§?????Obesity·?????Freshman 15·?????What other health problems can stem from diabeteso?????Heart diseaseo?????Renal failureo?????Hypertensiono?????Skin Integrity issues·?????What is the freshman 15?o?????Causes:§?????Weight gain due to:·?????Lack of exercise·?????Eating late at night·?????Keeping unhealthy snacks on hand·?????(in the dorm room)·?????Eating unhealthy cafeteria food·?????Drinking excessive amounts of alcoholo?????What you can do to avoid it§?????Exercise 30 minutes per day at least 3 time a week§?????Snack on fruits and vegetables, you need 3-5 servings per day!§?????Avoid late night pizza orders or fast food trips!§?????Avoid excessive amounts of alcoholo?????Places in Auburn to go for exercise§?????Running trails/ parks§?????Student Act/ Gym Memberships§?????Walking to and from class instead of riding the transito?????Eat this and not that ideas for dorm room snacking§?????Water or Green Tea instead of Soda-caffeine craving§?????Yogurt instead of ice cream – sugar craving§?????Grapes or Strawberries instead of Candy- sugar craving§?????Dark Chocolate instead of Milk Chocolate-chocolate craving§?????Air-popped popcorn instead of potato chips-salty craving§?????Triscuits/Goldfish instead of Potato Chips-salty craving§?????Trail Mix / Pretzels instead of cookies-sweet /salty craving·?????QuestionsStudent Evaluation for Community Intervention Program“Defeating the Freshman 15”Ashley Riley, Haley Zoeller, Christina Rosser, Karina RomandettiOctober 4, 2010Please rate the following items based on the information received on the following scale:Poor??Weak??Average??Good??Excellent 1 ????? 2 ??????? 3?????? 4???????? 5?1.?????Intent of the presentation is clear??1?2?3?4?52.?????Knowledge of content apparent??1?2?3?4?53.?????Content at appropriate level for group?1?2?3?4?54.?????Content relevant to clients’ needs??1?2?3?4?55.?????Appropriate instructional material used?1?2?3?4?56.?????Two way participation stimulated 1?2?3?4?57.?????Attention of client maintained???1?2?3?4?58.?????Validate client’s understanding attempted?1?2?3?4?5 ................
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