I work on a med-surg unit with plenty of diabetic patients. Most are noncompliant with high A1Cs and are always demanding cookies.
I try to find a balance. Last week I had a 400 pound patient demanding multiple snacks outside of his diet. He had a wound that wasn't healing and I explained to him that high blood sugar levels could interfere with the healing process. He still demanded that I give him whatever he wanted. I managed to convince him to meet me in the middle and have one of what he wanted instead of two of everything and covered his carbs and blood sugar.
So question: when a diabetic patient demands sweets, has high blood sugars and isn't NPO or clear liquids for a procedure, do you just continue to give them all the snacks they want? Or do you insist that if they want to be noncompliant with the hospital diet that they must get their own treats?
We need to move beyond using "education" as a crutch to avoid dealing with the patients real issues related to life-long carbohydrate restrictions.
Wholeheartedly agree. Could probably talk about this subject with you ad nauseam as I am a diet and lifestyle blood glucose maintainer as well. My endocrinologist is progressive and holistically research oriented and her advice to me was interesting and almost counter-intuitive. (this was years ago) After getting to know me (she's a family friend), she told me to forget about carbs as my objective and to focus on my stress levels. She advised me to ditch the strenuous cardio exercise I was doing and try a yoga practice. She had me read Sandra Cabot's work about liver cleansing.
Once I started to focus on the effects of stress and learning the breathing and mindfulness techniques of yoga, my AC1 started to normalize. I'm still pretty amazed at how I had these blind spots in my understanding for my own treatment plan, I didn't seem to be able to see myself clearly enough to know that carbs and exercise weren't the only thing driving up my glucose, high levels of sympathetic nervous system activity and low levels of parasympathetic nervous system activity were possibly creating an unbalanced feedback loop and the roller coaster effect of glucose. This is my personal experience.
I'd love to see more research in this area. Personally and professionally.
I educate to cover myself, not because I believe the patient is unaware. I know they've heard it millions of times before. I know they don't care or want my opinion. Life-long issues need to be dealt with as an outpatient and the patient has to want to deal with them. I don't have time for that in acute care.
True, you don't have time in acute care. But you are assuming that they do not want to deal with them. At some point we need to address WHY a person is non-complient. What have they tried. What was working, what wasn't, etc. It is a process with a lot of failures. It's hard enough dealing with it, worse dealing with those who all ready think crap about the patient.
I educate to cover myself, not because I believe the patient is unaware. I know they've heard it millions of times before. I know they don't care or want my opinion. Life-long issues need to be dealt with as an outpatient and the patient has to want to deal with them. I don't have time for that in acute care.
I understand that and sympathize with the limitations that accompany a short-term inpatient visit. But you can "cover yourself" with a very brief question or two to the patient to verify that a lack of knowledge is not the problem. There is no need for time-consuming education.
You could then use the extra gained by skipping the education to ask the patient why he/she is non-compliant. He/she may just tell you. Even if they don't tell you, you could explore whether or not they have anyone in the lives and/or on their healthcare team that they can talk to about their struggles with the carb limitations. You could recommend that they explore those issues after this hospitalization is over. You might be able to make an actual referral to someone who could help them.
As this is a common problem ... you could/should express your need as a staff nurse to have resources available for such patients. And resources for you to help provide appropriate care for such patients. If it is a regular problem for you and your colleagues, you should have training and resources to respond to such patients appropriately.
Wholeheartedly agree. Could probably talk about this subject with you ad nauseam as I am a diet and lifestyle blood glucose maintainer as well.
It's nice to meet you, defying.gravity. I wish there was more discussion of patients like us in the literature (and how to meet our needs). I am fortunate to have a PCP who knew me well enough to give some "freedom" when I was first diagnosed -- and a wellness coach here at work who is similarly flexible. But I see almost nothing in the nursing literature about how to help those of us who choose to make long-term lifestyle changes instead of relying on meds for glucose control.
I guess we don't make a profit for a pharmaceutical company ... so we are not worth paying attention to.
@llg- What else can you do as a floor nurse besides education? ..
See post #50 above. I added some more thought there. If you don't feel qualified to discuss/address the real reasons your patients are non-compliant, then you have identified an important learning need for YOURSELF. Get educated on how to have those conversations with your patients. Ask for an inservice on the topic or talk with the diabetes educator.
This would be a good project for an advanced student project ... or for a practice committee to take on for the benefit of your unit. It would be a great quality improvement project or research study, too. Get knowledgable people together and review the literature and make a list of the common reasons people are non-compliant and suggest ways to help them while on your unit.
For example, you might make a selection of lower-carb -- yet appealing/yummy -- snacks available on your unit. You might simply listen as they discuss their stress and struggles to stay compliant. Sometimes, it helps the patient to "talk it through" and once they have gotten the chance to verbalize it to a supportive listener and "get it all out", they might make a healthier choice. You can encourage them to seek support on an outpatient patients and maybe even recommend someone they can talk to while hospitalized. All of these things would be more helpful than repeating information they have heard 100 times before and already know.
Okay, of course there should be something available for medication that can't be taken on an empty stomach or when someone is hypoglycemic. When I have a patient who is NPO all day I still get them to order food and then I just hold it until after the procedure. I really meant snacks for the purpose of snacking, or trying to beat the record for the most graham crackers eaten in one day.
Honestly, I have never had that. People who have brought in tons of outside junk but never people who use our small sampling as a grazing station. I did have one dementia patient who swore she didn't get dinner who ate 3 sets of graham crackers...and was telling me how good they were. I work nightshift, and if someone doesn't let us know at the very beginning of shift that they missed a meal, we are scrambling to find something because even the late menu stops at 9:30. Dementia patients and patients who English isn't their first language are often the ones most likely to miss a meal and not tell anyone about it until bedtime.
I find that as you dig deeper in most non-compliant people, you can find the real reason they are "non-compliant". Quite often it is grief, depression, and anxiety. They are afraid to die and through eating they find comfort and a sense of denial..."see, I ate that and didn't die"...it is also how people show love so the family members bring in the bad choices because they know it brings "joy" to that person that is hospitalized and sick. If you take some time to talk to your patients...many of those with chronic conditions have some pretty sad life stories...often not related to their conditions. I spend a lot of time "normalizing" psychiatric meds and doctors in hopes that some of my patients will go get that part of their life treated when they walk out without feeling "crazy" for seeking help in that direction of medicine. I suspect that a lot of chronic pain could be reduced with talk therapy and psychiatric medications if for no other reason that it helps establish a stronger base for "coping". My worst non-compliant patient never said it outright, but after spending hours each shift changing dressings...it came out that she had a really hard time making decisions concerning her health since her husband died. She depended on her son to help her but he only wanted to make his mom "happy" and it was easier to agree with her crazy logic than stand up to her. Grief is a powerful force. Don't underestimate its power even if the spouse died "years" ago. May you never have to understand what I am saying but try to learn to hear with your heart when educating a patient.
As for the snacks, a fancy granola bar or fresh fruit isn't going to settle an upset stomach or raise the blood sugars quickly. They aren't there to be "snacks" but rather part of their treatment.
... We need to move beyond using "education" as a crutch to avoid dealing with the patients real issues related to life-long carbohydrate restrictions.
What llg said. Food is much more than nutrition. It is culture, nurture, anger management and much more. Not saying it should be, just that it is. Learning to change eating patterns is not an easy task. And wait, there's more! Diabetes management requires more work than a non-diabetic can imagine. Try sticking yourself with a lancet before and after every meal and doing the rest of the rigamarole. Remember how you felt when you failed at something you really wanted to do and then try to imagine what it would be like to fail at something you never, ever wanted to do... manage diabetes. As one woman with juvenile diabetes for 35 years said to me, "Every diabetic will, at some point, give up and take a holiday."
One more thing. I really dislike the term "noncompliant." That term refers to failure or refusal to comply with a law, regulation, or term of a contract. The NANDA nursing diagnosis of "noncompliance" specifically states in pertinent part that noncompliance is failure to comply with an agreed upon therapeutic plan. Sadly,many diabetics have not reached the point of agreement. They are still in the earlier stages of grief: denial, anger, bargaining.
Yeah, I work in LTC/SNF...mostly it's I'm sorry I cannot provide you with that item, or we don't have whatever they are asking of, it's not in your diet or educate on blood sugars and infection, depending on the patient and their diagnoses. MANY, almost all are non-compliant and they families are total enablers. When I do see some compliant diabetics, their sugars may still be high due to high stress and/or infection. Several patients eat candy bars, drink soda, etc. Many families still bring in their family member whatever they ask for.
What really bugs me, is when other patients/varies other patients family members are trying to nice and get the person a snack or soda when they ask...WITHOUT asking staff members. Or the patient that is on thickened liquids and un-controlled diabetic and people are giving them soda. Very frustrating.
I know too many diabetics personally, I guess. It doesn't bother me when they ask for stuff outside their diet. I have no problem saying no and if they want anything other than what the doc ordered, they have to provide it themselves. Then the family member troops in with grocery bags.
I remind them that they are here for healing and that high glucose levels hinder that. I tell them that diabetes kills by inches, and it starts with eyes and toes then moves on to kidneys. After that, if they don't care, then I don't worry about it. They've made their informed decision and I've tried.
I may request a case management consult so they can get some sort of psych or endocrine services outside of the hospital, or I'll ask for a diabetes education consult if they seem to want to change, but that's as far as I go. I'm not a psychiatrist nor a counselor and I don't pretend to be.
It's their life, not mine, and they can ruin or save it as they see fit.
It's nice to meet you, defying.gravity. I wish there was more discussion of patients like us in the literature (and how to meet our needs). I am fortunate to have a PCP who knew me well enough to give some "freedom" when I was first diagnosed -- and a wellness coach here at work who is similarly flexible. But I see almost nothing in the nursing literature about how to help those of us who choose to make long-term lifestyle changes instead of relying on meds for glucose control.
I guess we don't make a profit for a pharmaceutical company ... so we are not worth paying attention to.
Nice to meet you, too, Ilg. I couldn't agree with you more about wishing there was more discussion about successful diet/lifestyle treatment. I can see your point about the funding source for the studies ... trying to get funding for research studies that don't involve medication treatment isn't the easiest task.
Funny that you worked with a wellness coach, I did the same. I hired a holistic health coach for 6 months to work with in holding me accountable and helping me with some areas where I was weak. I pretty much transformed my health habits during those 6 months, it was pretty intense.
I juice daily now. Green juice with kale, ginger, lemon, celery. Never would have even thought of that, but the ginger has properties that seems to help me with glucose levels. I use my vitamix regularly. I learned how to make meals that are delicious and healthy. I became quite the health food nut after my time with the health coach, not because it was another "type A" to do list for me, but because I started to change my entire attitude towards my own health. A lot of what the health coach worked with me on was slowing down and giving myself permission to care about making the best decisions for my own health. When I first started the program I thought the whole thing was a little corny and far fetched, it went against my "nursing" nature. I wanted objectives, treatment plans and clear cut goals. Instead we worked on slowing down, being more flexible, and enjoying my health ... lol ... When a "type A" slows down it's pretty funny to watch. But, the results were and are incredible, so I have to say that my coach knew what he was talking about, at least with me .... it changed my view of diabetes, no doubt.
I don't advocate that in my nursing practice because that's not my role as a nurse, but I do offer some insights if they make sense to any patient I work with.
I'd love to see the nursing literature reflect those like us, I really would. It's painful for me to see those who don't understand or know that lifestyle change and diet change and attitude change really can make such a huge difference in health.
What llg said. Food is much more than nutrition. It is culture, nurture, anger management and much more. Not saying it should be, just that it is. Learning to change eating patterns is not an easy task. And wait, there's more! Diabetes management requires more work than a non-diabetic can imagine. Try sticking yourself with a lancet before and after every meal and doing the rest of the rigamarole. Remember how you felt when you failed at something you really wanted to do and then try to imagine what it would be like to fail at something you never, ever wanted to do... manage diabetes. As one woman with juvenile diabetes for 35 years said to me, "Every diabetic will, at some point, give up and take a holiday."
defying.gravity
35 Posts
Wholeheartedly agree. Could probably talk about this subject with you ad nauseam as I am a diet and lifestyle blood glucose maintainer as well. My endocrinologist is progressive and holistically research oriented and her advice to me was interesting and almost counter-intuitive. (this was years ago) After getting to know me (she's a family friend), she told me to forget about carbs as my objective and to focus on my stress levels. She advised me to ditch the strenuous cardio exercise I was doing and try a yoga practice. She had me read Sandra Cabot's work about liver cleansing.
Once I started to focus on the effects of stress and learning the breathing and mindfulness techniques of yoga, my AC1 started to normalize. I'm still pretty amazed at how I had these blind spots in my understanding for my own treatment plan, I didn't seem to be able to see myself clearly enough to know that carbs and exercise weren't the only thing driving up my glucose, high levels of sympathetic nervous system activity and low levels of parasympathetic nervous system activity were possibly creating an unbalanced feedback loop and the roller coaster effect of glucose. This is my personal experience.
I'd love to see more research in this area. Personally and professionally.
Thanks for bringing up some really great points.