Newly diagnosed diabetes in the acute setting: through the lens of a diabetes educator

By: Olivia Heinz

Through my clinical rotation at Meritus Health in Hagerstown, MD, I have learned an immense amount of new information on type 2 diabetes mellitus. The registered dietitians at Meritus work closely with Crystal Allison, the certified diabetes care and education specialist (CDCES). Crystal is a registered nurse with a master’s degree in Nursing Leadership and Management. Registered nurses, advanced practice nurses, registered dietitian nutritionists, pharmacists, physicians and other healthcare professionals can get certified to become a CDCES. Due to the extreme prevalence of diabetes, especially in America, it is essential to have qualified diabetes educators.

In the acute care setting, the diabetes educators and dietitians work together when managing patients with diabetes mellitus. Diabetes is a multifaceted disease, and treatment and dietary approaches vary tremendously among patients. Oftentimes, the dietitian screens patients for high blood glucose levels and is in charge of dietary interventions. The diabetes educator provides education and guidance for patients who are newly diagnosed with diabetes, including pump and insulin education. The dietitian and diabetes educators then work together to monitor the patient and any needs for additional education.

I had the opportunity to shadow Crystal during an educational session for a patient with newly diagnosed type 2 diabetes. This was an amazing learning experience, as Crystal is an extremely detail-oriented healthcare professional. She provided the patient with a lot of new information, education and guidance. Crystal explained to me that her sessions vary tremendously depending on the status of the patient. It is important for her to first assess the patient’s previous knowledge of diabetes, talk through any symptoms the patient has been experiencing, explain side effects of hyperglycemia and hypoglycemia, discuss carbohydrates and diet, discuss physical activity and finally discuss medication.

Her approaches to sessions with patients depend mostly on their willingness to make behavioral changes, as well as their engagement with the information she is providing. The patient that we saw together had previously made lifestyle changes and had lost a significant amount of weight through dietary changes and increased physical activity. This patient was very engaged during the session and was receptive to any and all information that Crystal provided. I had not anticipated a session of 45 minutes in length, but Crystal pulled up a chair to the patient’s bedside and got to work. The patient asked many questions regarding diet, caffeine intake and insulin usage. She answered all of his questions and together they set a couple of goals that appeared appropriate given his previous lifestyle changes. She also informed him of the free diabetes classes that the hospital offers.

After shadowing this session, I had not only witnessed exceptional delivery of patient-centered diabetes education, but I had also witnessed excellent bedside manner and rapport-building skills. One aspect of motivational interviewing that I have struggled with throughout the internship and my undergraduate nutrition counseling experience has been providing affirmations. In the examples that I have read, affirmations oftentimes seem forced and awkward. Crystal provided her patient with affirmations in an extremely casual manner, applauding him for the changes that he had already made while pivoting the conversation to additional approaches and meeting the patient at a middle ground.

Below is a video that I took of some of Crystal’s props for visual learners. Crystal created the tubes seen in the video out of tomato paste to simulate the blood at different HbA1c levels. HbA1c is a blood test that is used to help diagnose and monitor individuals with diabetes. It refers to the amount of glucose and hemoglobin molecules joined together in the body at a given time. Hemoglobin is the protein in red blood cells that carries oxygen around the body.  The higher the A1C level, the greater the risk of developing complications, such as problems with your eyes or kidneys. 

People with untreated or unmanaged diabetes are at an extremely high risk for poor circulation throughout their bodies. Crystal wanted a simple way to show that as blood sugar goes up, blood flow is impeded because the elasticity of blood vessels decreases and they narrow. The first tube resembles the blood at an HbA1c of 5.1%, which is normal. The second tube resembles the blood at an HbA1c of 8.5%, which would lead to the diagnosis of diabetes. The third tube resembles the blood at an HbA1c of 15.5%, which is abnormally high. Her catchphrase is “Diabetes? Not really a big deal. It only impacts the organs with blood vessels.”

This pivotal experience allowed me to see a lot of diabetes materials and many skills in action, which I plan to use with clients in the future. I look forward to learning more about the complexities of diabetes through the rest of the internship and my future career.

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