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The information sharing among health care professionals and retention of information by people with diabetes is not enough to help them to change their behavior vasculogenic erectile dysfunction causes buy generic red viagra. Increased contact time between health care professionals and patients has been associated with better regimen adherence and glucose reduction [15] erectile dysfunction drugs online buy discount red viagra 200mg online. A simple elementary school approach from Anna Devere Smith erectile dysfunction icd 9 order 200mg red viagra fast delivery, which "thinks of edu- 336 Educating the Patient with Diabetes Chapter 21 cation as a garden where questions grow erectile dysfunction statistics singapore order red viagra," seems to describe the learner-centered approach applicable for adults with diabetes most aptly [73]. People with diabetes need an appropriate environment where they can share their challenges with their lives with diabetes, ask health care professionals for help with strategies and consequently concord with the prescribed regimen. The principles of facilitation and patient-centered intervention have been recognized to be superior to a didactic and more passive teaching approach [9,10]. There is strong evidence that goals generated by patients produce better outcomes than goals that are generated by health care professionals [9]. There are many educational approaches that are utilized by diabetes educators to help patients acquire knowledge, skills and commitment to self-care behaviors necessary for effective diabetes care [9]. However, evidence indicates that group diabetes interventions can be more cost-effective, patient-centered and provide interactive learning with a high level of patient satisfaction compatible with individual interventions. The educational approaches and methods utilized in group education differ among diabetes educators. The existing best practices in group education indicate that the best outcomes are produced with an empowerment approach, which focuses on when and what patients want to learn. The general consensus on chronic disease interventions indicates that the most beneficial components of education are individualization, relevance, feedback, reinforcement and facilitation [2325]. The complexity of the individual needs assessment and training in a group setting presents a challenge for effective self-management education. The challenge is to individualize the approaches similar to a typical one-on-one session but in a group session. Successfully individualizing the group session allows the patients to learn, retain their knowledge and be committed to the follow-up action plan. Diabetes knowledge does not guarantee changes in behaviors that eventually lead to better outcomes. The learner-centered approach employs non-didactic and less passive strategies in an attempt to promote active engagement in the learning process. These include facilitation, empowerment, motivational interviewing, behavioral goal-setting, behavioral and psychosocial strategies, and ongoing support [2634]. The process allows for the patients to discuss their understanding of diabetes, internalize their commitment and determine their priorities. This process also allows for ongoing implementation of short and long-term goals, which can then be monitored for progress. Patients come up with their own solutions to their own diabetes challenges instead of being told what they should do by the educator. The expectation is that by identifying what is practical and achievable, patients ultimately own their own commitments and will be more likely to accomplish the requisite lifestyle changes [28,35,36]. Effective diabetes education aligns with the principles of adult learning as adults learn most effectively when information is simple, practical and relevant. This process of learning involves cognition, emotions and environmental factors that impact knowledge level, skill acquisition and views [38]. Educational theory behind the practice: models and methods the core foundation of the diabetes education philosophy is that patients are ultimately responsible for their own self-management. The assumption is that patients want to maximize the quality of their life and self-management education [39]. Health care professionals help patients identify ways to make changes necessary for a healthy way of life. Each person with diabetes differs and therefore requires unique lifestyle skill strategies that are applicable to his or her circumstances. Traditional lecture-based didactic education approaches place the learner in the role of the recipient and the instructor in the role of the "knowledge-giver. Patients develop confidence 337 Part 5 Managing the Patient with Diabetes in making informed decisions about their medical condition and can choose to act on it. An additional approach that aligns with effective diabetes education methodology is motivational interviewing. This is closely linked with the empowerment theory as it focuses on creating opportunities for patients to come up with their own assessments and set their own goals [33]. The proposed theoretical basis evident in a patient-centered diabetes education concept includes the Health Belief Model, the Trans-theoretical Model/Stages of Change, Common Sense Model, the Social Learning Theory and the Dual Processing Theory [4043].
This may create a problem-orientated approach for adolescents rather than a preventive model of care that may inhibit the promotion of self-care erectile dysfunction neurological causes purchase 200 mg red viagra amex. By contrast erectile dysfunction diabetes causes buy 200 mg red viagra otc, previous research revealed that living with long-term illness appears to be about incorporating the consequences of illness into everyday life [10 erectile dysfunction pills amazon 200mg red viagra,52] erectile dysfunction treatment phoenix generic 200mg red viagra fast delivery. Dalton and Gottlieb [51] provided an alternative view that conceptualized readiness as a process of becoming ready over time. Baker and Stern [53] described a process of readiness that involved making the illness a part of life and coming to terms with self-care teaching and having a sense of control. Relationshipbuilding between health care professionals and adolescents, as a means for mapping individual context and identifying shifting values over time, dealing with difference and miscommunication, is perhaps the first step to facilitating this transition. There have been a number of studies that found that adolescents were keen to receive written and verbal information about transition and that they wanted to be provided with opportunities to meet the new team prior to transition [3,26,45,47]. Transition literature from the diabetes and cystic fibrosis fields agree that there is a lack of outcome data that can clearly support one model over another [1,21,32]. Suggestions such as young adult clinics, stepped transition, joint clinics with pediatricians and adult physicians and transition nurses have all been described in the literature. Similarly, only one of the adult services had an established pathway in place to ensure that all of the adolescents were offered dietitian and diabetes nurse educator appointments at the time of the transition. Furthermore, health care professionals reported a poor uptake of these appointments. The ramifications of these findings, which have been replicated in other studies, are that adolescents are not receiving holistic preparation for transition in terms of developing self-management skills required for adaptation to an adult health setting. Transition might be easier if adolescents were involved in early planning and informed about what to expect from the adult service and how it may differ to the pediatric service. Research studies have revealed that transition to adult services is often based on the medical model. Transition needs to be viewed holistically as opposed to focusing solely on the referral from one medical doctor to another. A problem-focused or reactive approach to diabetes care effectively relinquishes the potential for independence and control for the adolescent. If nurses and dietitians are only involved during periods of diabetes instability, then adolescents may not be provided opportunity to learn selfcare skills. It is important that diabetes nurses and dietitians become involved in working with adolescents towards self-care as many were diagnosed as children and may never have received first-hand information about diabetes. The role of diabetes nurse educators in preparation and facilitation of the transition process and follow-up has not been fully realized. Preparation needs to be expanded so that there is a larger focus on developing self-care skills. This approach would assist individuals in taking on the extra responsibilities expected by adult services. Frank [22] stated that a gradual preparation of both youth and parents is an important principle for transition. Care plans to facilitate a coordinated and planned transition process have been proposed by Weissberg-Benchell et al. The care plans should be developed in consultation with the adolescent and parents, and incorporate all aspects of the transition process such as identifying information regarding specific health services, appointments, and health and education goal planning; however, the effectiveness of the use of care planning as a process to facilitate seamless transition and improve outcomes for adolescents does not appear to have been evaluated. The optimal goal of transition between services is to provide health care that is uninterrupted, coordinated and developmentally appropriate. The value of early preparation in late childhood from a multidisciplinary team is important for transition. To summarize the evidence, it is proposed that transition programs contain the following elements: · Early introduction to adolescents of the concept of transition; · Based on capacity building principles and promotion of confidence and independence and self-advocacy skills; · Both the pediatric and adult diabetes services have a documented transition program for adolescents; · Transition care plans incorporating all elements of the transition process; · Timing of the transition based on maturity and skill rather than age; · A senior member of the clinical staff from each service is responsible for the successful implementation and maintenance of the transition program; · A designated professional, who collaborates with the adolescent and family, takes responsibility for the transition of each adolescent; · the transition program has a multidisciplinary focus with input from consumers, primary care and allied health professionals; · Adolescents are encouraged to develop a relationship with their primary care physician; · the transition program should include the details of the process of transition, the expected outcomes and evaluation processes; · the transition program should promote individualized plans for each adolescent inclusive of expected outcomes and timeframes, opportunity for the adolescent to have a voice in articulating their needs, early involvement with the adult team, opportunity for adolescents and their families to meet with new carers, opportunities to meet with other adolescents who have successfully transitioned to adult services, and access to psychosocial support for adolescents experiencing difficulty in the transition; · All staff, including clerical and administrative staff as well as clinicians, should be educated in the philosophies and features of the transition program. Parents and children should also have the purpose and principles of structured transition explained and have access to details of the program well before transition commences; · Include opportunity to address common concerns of adolescents such as growth and development, sexuality, mood and mental health, substance misuse and other high risk behaviors. Adolescents and young adults are at the developmental age where new technologies are quickly and easily integrated into peer culture and daily life. The text message provides a weekly reminder of the goal set during clinic, with follow-up messages that reinforce the goal by providing information and reminders.
Health care cannot be seen in isolation erectile dysfunction clinic raleigh generic 200 mg red viagra mastercard, occurring as it does within a broad societal framework which places varying degrees of emphasis on ensuring that quality care is prioritized impotence pills for men generic 200mg red viagra amex. Thus erectile dysfunction trimix purchase 200 mg red viagra fast delivery, in the first instance erectile dysfunction emedicine buy genuine red viagra on-line, for effective health care delivery, a positive policy environment needs to be in place, nationally and locally. So too is the need for an inter-sectoral approach or collaboration to building a healthy society, encompassing, for example, urban Positive policy environment · Strengthen partnerships · Support legislative frameworks Community · Raise awareness and reduce stigma · Encourage better outcomes through leadership and support · Mobilize and coordinate resources · Provide complimentary services · Integrate policies · Provide leadership and advocacy Links Health care organization · Promote continuity and coordination · Encourage quality through leadership and incentives · Organize and equip health care teams · Use information systems · Support self-management and prevention · Promote consistent financing · Develop and allocate human resources I He y alt nit h mu ers tea car om r tn m e C a p Mo d tiv me ate for Patients n d and families Figure 58. Better outcomes for chronic conditions Prepared 985 Part 11 Delivery and Organization of Diabetes Care planning (with the provision of green areas, easy public transport, access to sport and recreation facilities), the introduction of health promotion activities within schools and the food industry. The model has core principles and elements in addition to an agreed upon agenda for implementation and later evaluation. It is unlikely that a single health care model for diabetes exists that can be used effectively and efficiently in all settings indeed, the model will take different forms or shapes in different settings. Health planners have to decide whether to pursue a diabetes-specific model of care or to incorporate multiple chronic diseases such as diabetes, hypertension and chronic lung diseases in a common chronic care model. There are salient reasons for pursuing the latter, given the commonality of aspects of care for these conditions, but factors such as the available resources are likely to guide this decision. Regardless of the model selected, changing the value system in which health care is delivered, with the aim of ensuring motivated affirmed health care workers, is perhaps key to equipping or enabling people living with diabetes with the information, motivation and skills to selfmanage their diabetes. There are certain core principles for diabetes care that could be applied across all resource settings [2]. These include establishing: · A comprehensive approach that provides for health promotion to enable prevention and early diagnosis, management of diabetes and complications when they arise and rehabilitation when needed. Where multiple professionals and organizations are involved in primary care, horizontal coordination of care is also important. Establishment of teams whose focus is on delivering and improving the quality of care permits the development of shared goals, defining and clarifying roles, reflecting on how care can be improved and holding each other accountable for decisions. The identification of a team leader may be a major factor in the success of this element. This is at least partly a paradigm shift in the mind of the health worker from the traditional biomedical, technical and sometimes authoritarian model to a biopsychosocial, holistic and participatory model. The evidence base for diabetes is constantly expanding and all resource settings need to look at how they access the latest and ever-changing evidence base. We now discuss how these principles are being incorporated into care for people with diabetes across different resource settings; low and middle income settings such as encountered in most low and middle income countries as well as in high income countries. Finally, how information technology can be embraced and harnessed appropriately in different settings with the goal of supporting these principles is explored. A comprehensive approach Taking a comprehensive approach to diabetes prevention and care implies that polices and activities are put in place to address primary prevention, early diagnosis (including screening if appropriate), management of diabetes and its complications, and rehabilitation for those affected by complications. For example, promoting healthier diets and greater physical activity could involve policies on food production, marketing and taxation, and policies on design of local environments and public transport. The best indication of a comprehensive approach is a national government-led strategy that covers primary prevention through to rehabilitation, with the caveat that the presence of a strategy does not guarantee that it has been implemented. The region with the lowest proportion of countries (30%) with a 986 Models of Diabetes Care Across Different Resource Settings Chapter 58 national diabetes program was sub-Saharan Africa, but even in richer regions, such as Europe, over 20% of responding countries did not have a national diabetes program. Examples of national diabetes programs in countries at opposite ends of the economic spectrum include the program in Cameroon [7] and the National Service Framework for Diabetes in England [8]. Therefore, initiatives aimed at strengthening an approach to diabetes should do this with an integrated model of care and with the goal of strengthening the whole approach to chronic care [9,10]. There is no reason why such an approach could not be used in primary health care [12]. Integrated health care Integrated care for people with diabetes refers to the need to provide care for conditions coexisting with diabetes within the same primary health care service. Within most high income countries, primary health care has been developed to provide a range of services covering most of the needs with people with diabetes, and indeed with other chronic conditions. While this funding enables higher quality care for a specific disease it can weaken the health care system as a whole.
Timed overnight or 24-hour urine collections are only required for research purposes erectile dysfunction pills in india purchase red viagra 200mg with visa. Urine albumin is stable at room temperature; the patient Other microvascular complications Patients with nephropathy are also much more likely to have other microvascular complications erectile dysfunction gnc buy red viagra with a mastercard. Serum creatinine should also be measured annually impotence uk generic 200 mg red viagra with mastercard, using an accredited assay standardized to the recommended isotope dilution mass spectroscopy reference method erectile dysfunction doctor called generic red viagra 200 mg visa. Cystatin C is a naturally circulating protein that is freely filtered by the glomerulus and almost completely reabsorbed and catabolized by tubular cells. The risk of developing diabetic nephropathy is greatly reduced by good blood glucose control. For a 1% (11 mmol/mol) reduction in HbA1c, there was a 37% reduction in the risk of microvascular complications [116]. There is no HbA1c threshold below which risk is not reduced, implying that the lower the HbA1c, the lower the risk of nephropathy [110]. In addition, fewer participants in the intensive group developed hypertension (29. Thus, the beneficial renal effects of intensive glucose therapy extend far beyond the actual period of good control, a phenomenon termed "metabolic memory. Blood pressure control Control of hypertension reduces the risk of developing microalbuminuria. Treatment with captopril and atenolol was equally effective, although the study was not powered to detect differences between treatment modalities [121]. Thus, very prolonged periods of extremely good control may be necessary to reverse renal structural changes, indicated by microalbuminuria or proteinuria. More optimistically, improved management of microalbuminuria may prevent progression to proteinuria. The studies that have been performed were all small, of short duration or did not achieve sufficiently tight glucose control [13,14,126128]. This may be especially beneficial, as the passage of protein across the glomerular filtration barrier may accelerate the progression of nephropathy [134]. The dose should be titrated up to the maximum recommended or tolerated doses, to obtain maximal antiproteinuric effect. Type 2 diabetes Glucose control There is some evidence that improved glucose control delays progression of microalbuminuria. Over 2 years, the proportion of patients developing persistent proteinuria was as follows: high dose irbesartan 5. The proportion of patients becoming normoalbuminuric was 34%, 24% and 21%, respectively. The choice of additional agents should be made on an individual basis, with diuretics and calcium-channel blockers often being appropriate. Questions about the level of protein intake required and compliance with diet were raised. Large variability between patients was seen, so that a 6-month trial of dietary restriction might be appropriate, with only those patients who respond continuing thereafter. After the 8-year randomized trial, participants were followed observationally for a further 5. Twenty four patients in the initially intensively managed group died, compared to 40 in the conventional therapy group (hazard ratio 0. The risk of cardiovascular death and of cardiovascular events was significantly lower in the intensively treated group. Thus, intensive intervention with lifestyle modification and multiple drug combinations had sustained beneficial effects on both cardiovascular and renal outcomes (Table 37. One uncontrolled study suggested HbA1c values fell by approximately 1% (11 mmol/mol) when hemoglobin rose from 10. Thus, more reliance should be placed on self-monitoring of blood glucose and continuous glucose monitoring.
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