Therapeutic schools allow patients to improve. Education of patients with chronic noncommunicable diseases in outpatient practice
Progress in healthcare Improving medical care for patients with chronic diseases - Introduction of high-tech methods of treatment (new diagnostic tools, new drugs, invasive methods) Increasing life expectancy Improving the quality of life Occupational and social rehabilitation
Progress in health care High-tech methods of treatment - are most effective when combined with changes in the patient's lifestyle - require new knowledge and skills from the doctor and patient - efficiency allows you to better motivate the patient to change lifestyle
Therapeutic education Therapeutic education is an effective way to improve the care of patients with chronic diseases Therapeutic education can be carried out in the form of joint work of the patient, nurse, attending physician The main share of therapeutic education is communication between the patient and the nurse
Therapeutic education is the organized work of medical personnel aimed at changing the behavior of a patient with a chronic disease. The main resource for changing the organization of the work of nurses is the training of specialists - nursing managers.
Requirements for nursing managers Understanding the essence of therapeutic education, its effectiveness and limitations Knowledge of the basic principles of organizing and conducting therapeutic education Knowledge of the peculiarities of the pedagogy of therapeutic education Ability to plan patient education Possession of the skills to search for the necessary information
Requirements for nursing managers Understanding the objectives and nature of the control of therapeutic education of patients and the ability to plan and monitor the effectiveness of training The ability to transfer their knowledge and skills to nursing staff The ability to organize teamwork in therapeutic education
The structure of the course of study Theoretical training: The essence and principles of therapeutic training Independent work: planning therapeutic training Practice: conducting therapeutic training Patient needs and organization of work with patients
Theoretical foundations of the TOP Teaching 4th year students - 5 lectures and 5 seminars Learning objectives - requirements for nursing managers Understanding the essence of therapeutic education, its effectiveness and limitations Knowledge of the basic principles of organizing and conducting therapeutic education Knowledge of the peculiarities of the pedagogy of therapeutic education Ability to plan patient education Possession of the skills to search for the necessary information
"Nurse - organizer of the TOP" - independent work First semester of the 5th year Learning objectives - requirements for nursing managers Understanding the essence of therapeutic education, its effectiveness and limitations Knowledge of the basic principles of organizing and conducting therapeutic education Knowledge of the peculiarities of the pedagogy of therapeutic education Ability to plan patient education Skills search for the necessary information
"Nurse - organizer of the TOP" - independent work The student's task is to draw up a plan of the TOP on the chosen topic. Diseases - diabetes mellitus, ischemic heart disease, hypertension, bronchial asthma, post-resection syndromes ... The choice of topic depends on the experience of previous work
"Nurse - organizer of the TOP" - independent work Structured training plan Theme of the lesson Definition of the target group and its set Patients' needs Objectives of the lesson Lesson plan - knowledge, skills, formation of motivation Teaching methods Effectiveness control
Patient needs and organization of work with patients First semester of the 5th year - Training based on the Nizhny Novgorod Diabetes League Determination of the needs of patients with chronic diseases using the example of diabetes Patient needs in the training program
Learning outcomes One graduate of students who have completed the course of study The second graduate of students is undergoing work practice Students are involved in teaching children with diabetes and their parents in DiaNN courses and the school for teaching patients with diabetes mellitus
Department of Polyclinic Therapy and General Medical Practice
PATIENT TRAINING
WITH CHRONIC
NON-INFECTIOUS
DISEASES IN
OUTPATIENT PRACTICE
Lecture
Head department, professor
N.K. Gorshunova
According to WHO, 80% of diseases
population have chronic
flow.
For most of them
proven and
reasonable therapeutic
measures to slow down
disease progression and
prevent their exacerbation.
However, the prescribed treatment
less than 50% correctly applied
patients. The relevance of patient education
Patients do not own
necessary knowledge for
everyday
"managing" their
illness and are unaware
responsibility for
the state of your health.
Application of modern
treatment methods required
deep understanding
mechanism of their action, because
they are quite complex and
sometimes dangerous. Relevance of training
patients
Patient education is an integral part
arsenal of therapy for many chronic
diseases: arterial
hypertension, diabetes mellitus, CHF,
obesity, etc.
Treatment outcomes are directly related
from the behavior of the patient: he must
follow doctor's instructions
necessary knowledge and skills
to take independent
medical decisions,
be motivated.
Learning objectives
developing patient skillsself-government over their
chronic illness with
aiming to turn it into
active participant in the treatment
process,
preparing the patient for daily
use of new effective
technologies for the treatment of chronic
diseases.
awareness raising
patients about the disease and its
risk factors;
increased responsibility
patients for the preservation of their
health;
formation of rational and
active relationship of the patient
illness, motivation
wellness, commitment to
treatment and implementation
doctor's recommendations.
MAIN OBJECTIVES OF EDUCATION OF PATIENTS WITH CHRONIC NON-COMMUNICABLE DISEASES
the development of patients' skills andself-monitoring skills
health, first aid
assistance in cases of exacerbations and crises;
developing patient skills
self-correction of behavioral factors
risk (nutrition, physical activity,
stress management, avoidance of harmful
habits);
formation in patients of practical
skills in developing an individual
recovery.
Conditions for effective implementation of patient education
Development of training programs forvarious chronic
diseases or specific forms
their currents.
Preparation of methodological
provision and demonstration
teaching aids.
Training of teaching staff
(doctors, nurses).
arterial hypertension -
School of health for patients witharterial hypertension is included in the industry classifier
(OK) "Complex and complex
medical services" (SKMU)
91500.09.0002-2001 (Order of the Ministry of Health of the Russian Federation No. 268 dated
07/16/2001 "The system of standardization in
healthcare of the Russian Federation") and
has code 04.015.01 (04 - medical
prevention services; 015 cardiology; 01 - School for patients with
AG as a type of service). School of health for patients with
arterial hypertension - organizational
form of preventive group and
individual counseling.
arterial hypertension - medical
preventive service (i.e. has
independent complete meaning and
certain value).
School of health for patients with
arterial hypertension - aimed at
prevention of complications of the disease,
timely treatment, recovery.
School AG - new information and motivational technologies
Targetpromote
raising
patient adherence to treatment
create motivation for conservation and
increased responsibility for health
as for personal property
ensure the quality of preventive
help
population
in
process
implementation
preventive
focus in the work of GPs (SV)
Essential Structural Elements for Organizing an AG School
qualified personnel inperforming complex and
for educational activities
patient education;
provision of conditions for
effective functioning
schools (room, methodical
and educational materials
tonometers).
Forms of study:
individual conversations with a doctor,group cycle classes,
review lectures,
study by patients
popular literature
for arterial hypertension,
showing videos, etc.
a significant increase in the frequency of reaching
target blood pressure,
obese,
a significant decrease in the number of patients with
moderate and severe
hypercholesterolemia,
significant reduction in the number of smokers.
Criteria for the effectiveness of patient education in school
a significant decrease in the number of patients,abusing fatty, carbohydrate and
salty food.
a significant decrease in the number of patients with
hypochondriacal and depressive
manifestations with high levels of stress
taking antihypertensive drugs,
downgrading of the dispensary observation group
patient.
Important Conditions for Keeping Patient Knowledge and Skills Up to Date
Recommended frequency of classes - 1-2 timesper week in an outpatient clinic
institution or 3-5 times a week in
day hospital,
Recommended number of patients per
group - 10-12 people.
Recommended repetition rate
training - 2 times a year.
Keeping a diary is required
main functional indicators.
Accounting and reporting documentation of the patient's schools
Patient registration log,students at the School of Health.
Accounting for patients studying at the School of Health,
carried out in a separate journal for each
type of School (indicating the patient's full name, age,
contact phone number, dates of classes,
presence marks).
Outpatient medical record
making records of the start of schooling
health, dates and topics of each lesson,
certified by a medical professional,
conducting the lesson.
The mark on the front side of the medical card according to
completion of the learning cycle
Health school option for patients with arterial hypertension
The full cycle consists of 5 lessons of 90 minutes,dedicated to the main most important
problems of hypertension control.
Lesson 1. Arterial hypertension: how to recognize it?
Lesson 2. Arterial hypertension: what contributes to it
development?
Arterial hypertension: how to do it right
measure blood pressure?
Lesson 3.
Lesson 4. Methods for the prevention of arterial
hypertension.
Lesson 5. Arterial hypertension: when and to whom
Should medicines help?
Lesson 1. "Arterial hypertension: how to recognize it?".
explain that arterialhypertension is chronic
progressive disease (primary
symptoms of which are headache,
nosebleeds, fatigue,
performance decline as
the result of increased blood pressure), and the task
learn to control the patient
its course in order to prevent
occurrence of crises.
Target:
Lesson 2. "Arterial hypertension: what contributes to its development?".
Purpose: to give an ideaabout risk factors
development of hypertension and create
patients motivation
to overcome them.
Lesson 3. "Hypertension: how to measure blood pressure correctly?".
Purpose: to teach the rulesand methodology
measurements
arterial
pressure.
Features of measuring blood pressure in the elderly
With age, there is thickening andthickening of the wall of the brachial artery.
palpated even when
cuff pressure over
intra-arterial.
To achieve compression of the rigid
arteries require a higher
pressure level in the cuff, in
resulting in a false
overestimation of the level of blood pressure
("pseudohypertension, Osler's sign").
To recognize this error,
palpation to determine blood pressure
forearm.
If there is a difference between systolic blood pressure,
certain palpation and
auscultatory more than 15 mm Hg. Art., for
calculation of true blood pressure in a patient
required from the measured value
subtract 10-30 mHg. Art.
Lesson 4. "Methods for the prevention of arterial hypertension."
Purpose: to teach patients how tonon-drug treatment and
compliance with recommendations for
healthy lifestyle (no
sedentary lifestyle increased physical
activity - and bad habits,
diet food)
Lesson 5. "Arterial hypertension: when and to whom should medications come to the rescue?"
Purpose: to teach patientstake it right
antihypertensive drugs
with counseling for
necessary with the attending
doctor.
The purpose of "ASTMA-SCHOOL"
Assistance to the sickbronchial asthma based
new principles of organization
treatment and observation.
In the medical complex of patients
asthma introduces a learning factor,
which will allow the patient
actively participate in your own
treatment and control
diseases.
Conditions for organizing a school of bronchial asthma
qualified personnel inin accordance with the requirements for
performing complex and
comprehensive medical services;
institution has a license
for educational
training activities
patients;
provision of conditions for
efficient
functioning of the school
(room, methodical
materials and asthma kits).
Asthma - set
includes the necessaryaccessories
for
control
patient's condition:
spacer to ensure efficient and
peak flowmeter to control your condition
nebulizer for emergency
safe use of dosed
aerosol inhalers,
and assessment of lung function as under
doctor's guidance, and independently in
at home,
treatment of exacerbations of bronchial asthma.
OBJECTIVES OF "ASTTHA-SCHOOL"
Achievement and establishmentcontrol of disease symptoms.
Prevention of exacerbations and
complications of the disease.
Maintaining the quality of life
sick.
Prevention of side effects
from drugs used for
treatment, as well as irreversible
complications of the disease itself
decrease in morbidity
mortality and disability.
Factors affecting the effectiveness of teaching in asthma schools
trusting relationship betweenhealthcare workers and patients
(mutual understanding and empathy, ability to
convince and explain, etc.);
simplicity and accessibility of recommendations and their
realism for specific patients,
availability of written instructions and memos,
patient diary, forms and methods
education, premises, furnishings and
equipment of the premises where
training, etc.). Forms of study:
individual conversations with
doctor,
group cycle classes,
review lectures,
study by patients
popular literature
for bronchial asthma,
showing videos, etc.
Asthma School Program
Keeping a diary of self-control.Training in the right way
medicines.
Learning how to use
inhaler
Peak flowmetry training.
Orientation training during asthma
/zonal assessment: green, yellow,
red/.
Teaching proper nutrition.
Physical rehabilitation: curative
gymnastics, breathing exercises,
dosed walking, classes on
simulators, massage, hardening.
Option "Asthma School"
Number of patients in a group of 10-12 peopleCycle - 5 lessons of 1-1.5 hours
Two times per week "What
bronchial asthma?"
First lesson:
Purpose: to explain that bronchial
asthma is a chronic disease
and the task of the patient is to learn
control its flow
not to allow
the occurrence of exacerbations. Second lesson:
"Peakflowmetry. Asthma and Allergies »
Purpose: to teach patients how to use
personal peak flow meter
daily and weekly diaries; to give
block of available information about
allergies, methods of its diagnosis with
active participation of the patient
prevention and treatment of allergies. Third lesson:
"Treatment
chronic inflammation
with bronchial
asthma"
Purpose: to teach patients
right
use
anti-inflammatory
drugs. Fourth session:
"Non-pharmacological methods
corrections"
Purpose: to create in patients
motivation for training
respiratory muscles,
teach them how to
correct breathing. Fifth session:
"Self-help with exacerbation
bronchial asthma"
Purpose: to teach patients to recognize
exacerbation of bronchial asthma,
stop asthma attacks
varying severity.
THE SYSTEM OF COLOR ZONES FOR A PATIENT WITH BRONCHIAL ASTHMA
"It's all right" - the disease is goodcontrolled, PEF - 80-100% of
the best / due indicator for the patient,
daily deviation<20%. Ни ночных, ни
There are usually no daytime asthma attacks.
Supportive therapy is indicated.
"Warning" - "zone of alarm" asthma symptoms (cyclic or acyclic),
nocturnal attacks of coughing or choking. PEF - 6080%, daily deviation 20 -30%. Therapy
should be strengthened.
"Anxiety!" - a sharp deterioration! – symptoms
asthma at rest, frequent attacks of prolonged
character, the interictal period is preserved.
PEF<60%. Немедленно обратиться к врачу!
Criteria for the effectiveness of training in the school of a patient with AD
significant reduction in the number of exacerbationsand nocturnal asthma attacks
an increase in the number of patients, regularly
controlling individual PSV with
keeping peak flow diaries and
symptoms,
reduction in the number of cases of temporary
disability and hospitalization
downgrading of the dispensary group
patient observation.
School of patients with CHF
Organizationlearning process
schools and
her relationship
participants are built
on the basis of a single
teams, and in the center
attention - the patient.
Classes are held in
clinic and
home.
Patients with CHF, their relatives need
good information andtraining, including
recommendations for correction
diet, lifestyle,
physical activity, mode
drug therapy,
acquisition of the necessary
self-control skills
heart symptoms
insufficiency with management
diary. Medical recommendations
it is desirable to give not in the directive
form the need for hard
limitations of habits and image
the life of the patient, but in the form
joint search for ways
greater independence
from disease and conservation
quality of life.
School of patients with CHF
Patients do not drop outfamiliar environment that
allows them to apply
acquired knowledge and skills in
Everyday life.
Training in conditions
clinics are designed for
patients with II FC CHF.
School of patients with CHF
To conduct schools withpatients with III-IV FC CHF
should be connected
specially trained
nurses.
Their task is to provide
psychological support and
necessary assistance for
compliance with medical
recommendations received at
inpatient treatment. Alternative
form of submission
patient with CHF
necessary information and
execution control
prescribed
recommendations distance learning with
using
information
newsletters, brochures,
videos and
videos, participation in
work of webinars on
Internet sites. One of the important elements
organization of school activities
CHF that determines success
its implementation, - a meeting of the doctor with
relatives of patients
who need to be told
about all the problems with CHF.
Monitoring the clinical condition of patients trained at the CHF school
carry out twoways:
directly - inspection
patient's doctor or
receptionist or
at home;
remotely during
phone calls
(communication via e-mail)
email, skype). Specially held
research has revealed that
use of telephone
(electronic) reminders
doctor about the need
fulfillment of the prescribed
recommendations in the first
months after discharge
patients from the hospital
significantly reduced the frequency
readmissions
compared to the group
patients with
traditional approach to
treatment.
Conclusion
Patient education inschools, successfully
held on
outpatient stage -
efficient technology
flow control
disease and improvement
quality of life of patients
and their relatives.
The introduction of schools for patients with arterial hypertension into real practice allows, within one year, to obtain significant medical and socio-economic efficiency of this new organizational and functional model of preventive activities. There is evidence that as a result of patient education and the formation of a partnership between the doctor and the patient in the treatment process, the frequency of achieving the target level of blood pressure in patients doubled (from 21% to 48%). The number of patients with obesity significantly decreased (by 5.4%), with moderate and severe hypercholesterolemia (by 39%), and the number of smokers decreased (by 52%).
Significantly reduced the number of patients abusing fats, carbohydrates and salt. The proportion of patients with hypochondriacal and depressive manifestations, with a high level of stress, has decreased. Patients' attitudes and attitudes towards health have changed significantly: patients' motivation to implement preventive recommendations has improved; the number of patients who consider the actions of medical personnel ineffective has decreased; the economic factor has ceased to be considered the main obstacle to the implementation of the doctor's recommendations for recovery.
Organization of Health Schools
in the primary health care system
An analysis of the health indicators of the population of the Chelyabinsk region revealed that chronic non-communicable diseases (cardiovascular, oncological) form the main cause of supermortality and premature mortality of the population. It is these diseases that are associated with lifestyle and risk factors (smoking, unhealthy diet, low physical activity, diabetes mellitus, arterial hypertension, stress, etc.), which have an extremely high prevalence among residents of the Chelyabinsk region.
A study of human rights to health promotion and disease prevention, conducted on a representative sample of the population of the Chelyabinsk region in 2001-2002, showed that 82.6% of respondents would like to improve their health status. Determining those responsible for their own health, 80% indicated themselves, 13% - health workers. At the same time, 85% of respondents believed that health authorities should pay more attention to disease prevention and health promotion.
Under these conditions, the role of a medical worker in the issues of teaching patients a healthy lifestyle, disease prevention (primary, secondary, tertiary) is increasing. Most chronic diseases cannot currently be cured, but it is possible to actually control and prevent complications, which can significantly prolong the life of patients and improve its quality. However, it is not possible to successfully control a chronic disease, even with the maximum use of the arsenal of modern medicine, but without the active participation of the patient, is not possible.
The creation of Schools of Health in the system of primary health care can contribute to the solution of these tasks. Education at the School of Health is defined as helping patients acquire and maintain the skills they need to manage their lives as much as possible in the setting of a chronic disease, or during certain periods of life (pregnancy, feeding a newborn). This is a medical and educational process, which is a full-fledged area of health, an integral and continuous part of patient management. Therapeutic education is patient-centered, designed to help patients and their families understand their disease/condition, treat effectively, lead a healthy lifestyle, learn to take care of themselves, and collaborate with healthcare professionals. All this ultimately leads to an improvement in the quality of life of the patient. Health schools should enhance the therapeutic effect of the traditional professional treatment of chronic diseases through patient education and contribute to:
To improve the quality and increase the life expectancy of patients;
In reducing the personal costs of patients associated with the disease;
In reducing the material costs of medical institutions and society as a whole for medical care for patients.
Curricula for Schools of Health should be based on:
On active learning and strengthening the patient's ability to plan and develop their own lifelong learning;
Based on ideas about the health, needs and problems of the patient;
On the active partnership of the health worker and the patient in health management;
On the cooperation of patients with each other.
Core learning topics are common to many chronic diseases and include: the causes of the disease; explanation of some aspects of the pathological process and associated symptoms; classification of the severity and severity of the disease, since the validity of treatment is closely related to these issues; treatment, list of drugs indicated for this patient, basic concepts of therapy, side effects of drugs; disease complications and worsening symptoms; what can happen with the progression of the disease and insufficient treatment; practical skills for monitoring the condition (measurement of blood pressure, body mass index, glucometry, peak flowmetry); recommendations for a healthy lifestyle: diet, physical activity, giving up bad habits, principles for reducing the effects of stress.
In the implementation of such programs, along with medical workers, the media, heads of enterprises, the administration of a district or city should take part.
The health school should be conducted by health professionals who have the skills to educate patients. Training in these programs should be part of the continuing education of health professionals and can be included in the basic medical education of physicians, nurses and other health professionals.
The School of Health is a special form of work with the sick, and medical professionals conducting Schools of Health should be able to:
Adapt your professional behavior to patients and their diseases;
Empathize with patients when communicating;
Recognize the needs of patients;
Take into account the capabilities of patients, the decline in cognitive functions that exists in chronic patients;
Take into account the emotional state of patients;
Intelligibly tell patients about their disease and methods of treatment;
Help patients manage their lifestyle;
Advise patients on how to manage various factors that may interfere with the treatment process;
Evaluate the learning process in terms of therapeutic outcomes (clinical, psychological, social, economic impact);
Periodically evaluate and correct teaching methods at the School of Health.
Health professionals trained in therapeutic education programs are becoming an important resource and should be encouraged to engage in individual and group health education work in Schools of Health.
The medical worker helps the patient to understand the essence of what is happening, shows the connection between his behavior and the danger to health, the need to follow the recommendations for treatment and maintaining a healthy lifestyle to prevent complications. Knowledge is an important but not sufficient incentive to change one's behavior. For each person, the reason and motivation for change is individual, and the doctor should try to help in finding the motive. The patient himself must choose those risk factors that he must influence. Giving up bad habits right away is an overwhelming task for many. The doctor is obliged to advise the patient what problems he needs to deal with in the first place. Lifestyle change goals should be realistic, clearly defined, time-bound and measurable.
In the process of conducting the School of Health, a medical worker must:
To learn and adapt to the patient's ideas about health, chronic disease and its treatment;
Adapt the training to the level of preparedness, past experience and understanding of the patient;
Consider the patient's readiness to perceive information;
Practice active listening to the patient;
Involve him in the learning process;
Encourage personal goal setting and self-assessment;
Identify the patient's ways of coping with their illness and treatment;
Assess the patient's skills and behavior based on the patient's personal experience;
Explain and instruct the patient about the prescribed treatment;
Educate to cope with the difficulties associated with the patient's compliance with the diet;
Identify barriers to effective long-term treatment and care;
Model and solve various problem situations;
Preside over a group discussion of treatment management issues, a group discussion;
Individually conduct supportive conversations with the patient;
Assess the extent to which the patient understands the explanations and instructions about the prescribed treatment.
The role of the patient in the treatment of a chronic disease cannot be limited to passive obedience to medical prescriptions. He must be an active, responsible participant in the therapeutic process.
Among the psychological influences on the effectiveness of training, a factor that can be called "readiness for changes in behavior" plays a significant role. In 1983 - 86 years. I. Prochaska and C. Di Clemente substantiated the so-called "spiral model" of the process of behavior change. Its main concept is the substantiation of the staging of changes in the behavior of a person who is trying to give up certain addictions or switch to a different, healthier lifestyle. According to this model, the process of change consists of several stages:
1. Indifference.
The patient does not realize that his behavior is problematic, harmful to health and avoids discussion of this problem, the possibilities of change.
2. Consider change.
The patient begins to think about the possible consequences of his behavior. He admits that his lifestyle is not correct, and this largely determines the state of his health. This stage involves an active search for information and is characterized by a high preoccupation with misbehavior.
3. Prepare for change.
The patient begins to realize the problem, thinks about specific action plans, overcoming difficulties and obstacles. The stage ends with a decision, which is characterized by the patient's firm intention to change his behavior.
4. Stage of action.
The patient modifies his behavior associated with the disease: changes habits, monitors control parameters, participates in the treatment process.
5. Maintaining behavior adequate to the disease.
This is the final stage of the process in which self-control becomes more or less stable. The process of change comes to an end when a maximum of confidence is developed in one's ability to withstand a breakdown in treatment.
It should be borne in mind that in the process of behavior change, relapse is typical, i.e. return to the previous, "wrong" behavior, which can happen at any of the listed stages. Relapse does not mean the end of the process. Most patients who experience such an episode are re-introduced into the process of change as they a person who at least once experienced doubts and considered the need to change his lifestyle, still inevitably returns to this.
These data are directly related to the education of patients, tk. the actual behavior of patients corresponds to the listed stages, and the patient cannot enter each subsequent stage without going through all the previous ones. Most patients are in the contemplative or indifference stage, and education can facilitate the process of "moving" up the spiral.
Sometimes the patient himself finds an incentive to change behavior. However, if there is no such incentive, there is no need to insist. The views of the patient must be respected. If the patient flatly refuses to take responsibility for his health, he should be given the opportunity to remain in this position. After all, the doctor is just an assistant, not a nanny.
Organization of the School of Health in a medical institution
1. Issuance of an order for a medical institution, which specifies the conditions for the organization of the School of Health, the procedure for work, the training program, the duration of training, technical equipment, and determines: the person responsible for organizing the activities of the School of Health in the institution, the doctors-lecturers responsible for training, paramedical workers.
2. Information about the School of Health should be presented in the form of an announcement at the reception of the polyclinic, if possible, covered in the media.
3. Equipment of a separate study room:
3.1. Special equipment necessary for conducting classes at the School of Health on a specific pathology: tonometers, spirometers, peak flow meters, glucometers, scales, centimeter tapes, gymnastic rugs, board, chalk, exercise therapy equipment, overhead first aid kit, TV, VCR.
3.2. Visual aids for patients: dummies, posters, booklets, memos, brochures, videos.
4. When conducting Schools of Health, unified programs (or training modules of programs) approved by the Ministry of Health and Social Development of the Russian Federation, the Ministry of Health of the Chelyabinsk Region, the educational and medical commission and the Academic Council of medical academies of higher professional and additional professional education are used.
4.2 The program of the School of Maternity was approved by the order of the Ministry of Health of the Russian Federation dated February 10, 2003 N 50 "On the improvement of obstetric and gynecological care in outpatient clinics" (Appendix 3).
5. A doctor / paramedic conducting classes at the School of Health must have a specialist certificate or a state-issued certificate of thematic improvement. For classes, you can attract specialists in dietetics, physiotherapy exercises (doctors, nursing staff).
6. Organization of classes at the School of Health:
The duration of patient education is usually 1 to 2 months;
Duration of classes 1 - 1.5 hours;
Classes can be held in hospitals around the clock and day stay, in the clinic, at the feldsher-obstetric station;
Time of the lesson: the second half of the day, for the convenience of working patients, compliance with the medical and protective regimen for people who are on inpatient treatment;
Class structure:
20 - 30% - lecture material;
30 - 50% - practical training;
20 - 30% - answers to questions, discussion, discussion;
10% - individual consultation.
Therapeutic patient education as a tool for chronic disease control
Therapeutic training. one
The role of the healthcare worker. 3
The role of the patient. 4
Patient schools. 5
Learning objectives. 5
Factors affecting the effectiveness and efficiency of therapeutic education in the "Schools of Patients". 6
Behavior rehearsal methodology components: Modeling, coaching and reinforcement. 7
Self-observation diary (behavioral). eight
Examples of sessions with patients. nine
SESSION TOPIC: "METABOLIC CONTROL" "COMPLICATIONS OF DIABETES MELLITUS". nine
THE TOPIC OF THE LESSON: "NUTRITION PLANNING IN TYPE 1 DIABETES MELLITUS". fourteen
Examples of tasks for patients. 20
Evaluation of the quality of therapeutic education in the School for Patients. 21
List of schools for patients in accordance with OK NKMU.. 21
Methods of informing and motivating. 22
From the book of Lozovoy V.V. "Prevention of addictions: school, family." - Yekaterinburg, Publishing House of the Ural State University, 2000. 22
Algorithm for informational and motivating communication. 26
How to deal with objections: 29
FOCUS GROUP.. 32
DISCUSSION. 37
BRAINSTORM. 41
SIMULATION.. 46
Therapeutic training
According to WHO, 80% of diseases are chronic. With most of them, therapeutic measures have been developed (proven and justified) that allow slowing down the progression of the pathology and preventing its exacerbation. However, less than 50% of patients correctly carry out the prescribed treatment. It was found that patients do not have the necessary knowledge for the daily "management" of their disease and do not realize their responsibility for this. And modern methods of treatment today require understanding, because they are quite complex and sometimes dangerous.
Therapeutic education is designed to develop in patients the skills of self-management of their specific chronic disease and differs from previous forms of medical education of patients in its focus on becoming an active participant in the treatment process and inclusion in the standards of care. Therapeutic education in Health Schools for patients with various pathologies is reflected in the order of the Ministry of Health of the Russian Federation dated July 16, 2001 No. 269 “On the introduction of the industry standard “Complex and comprehensive medical services”.
Therapeutic education of patients is an integral part of the arsenal of therapy for many chronic diseases: arterial hypertension, diabetes mellitus, obesity, etc.
The results of treatment directly depend on the behavior of the patient: he must follow the instructions of the doctor, have the necessary knowledge and skills to make independent decisions of a medical nature, and be motivated. And this, in turn, requires special training of patients with the participation of medical professionals.
Therapeutic training of patients is considered as a continuous process integrated into the medical care system, including education, psychological support, cooperation between the patient and the medical worker in matters of optimal management of the patient's life and disease. WHO working group report, 1998). The Report of the WHO working group names the diseases and conditions for which they should be used. These are diabetes mellitus, arterial hypertension, and coronary heart disease, obesity, and decreased vision and blindness, kidney failure, dialysis, organ transplants, conditions after limb amputations, osteoporosis, depression.
Fundamentals of Therapeutic Patient Education (TEP) :
The patient must learn the skills to optimally manage their life with the disease;
learning is a continuous process that must be integrated into the health care system;
TEP includes information, "self-help" training and psychological support related to the disease and prescribed treatment;
TOP helps patients and their families achieve better interactions with healthcare professionals and a better quality of life.
The role of the patient
The role of the patient in the treatment of a chronic disease cannot be limited to passive obedience to medical prescriptions. He must be an active, responsible participant in the therapeutic process. Among the psychological influences on the effectiveness of training, a factor that can be called "readiness for changes in behavior" plays a significant role. In 1983 - 86 years. I. Prochaska and C. Di Clemente substantiated the so-called "spiral model" of the process of behavior change. Its main concept is the substantiation of the staging of changes in the behavior of a person who is trying to give up certain addictions or switch to a different, healthier lifestyle. According to this model, the process of change consists of several stages:
Indifference.
The patient does not realize that his behavior is problematic, harmful to health and avoids discussion of this problem, the possibilities of change.
Thinking about change.
The patient begins to think about the possible consequences of his behavior. He admits that his lifestyle is not correct, and this largely determines the standing of his health. This stage involves an active search for information and is characterized by a high preoccupation with misbehavior.
Preparing for change.
The patient begins to realize the problem, thinks about specific action plans, overcoming difficulties and obstacles. The stage ends with a decision, which is characterized by the patient's firm intention to change his behavior.
Action stage.
The patient modifies his behavior associated with the disease: changes habits, monitors control parameters, participates in the treatment process.
Maintaining behavior appropriate to the disease.
This is the final stage of the process in which self-control becomes more or less stable. The process of change comes to an end when a maximum of confidence is developed in one's ability to withstand a breakdown in treatment.
It should be borne in mind that in the process of behavior change, relapse is typical, i.e. return to the previous, "wrong" behavior, which can happen at any of the listed stages. Relapse does not mean the end of the process. Most patients who experience such an episode are re-introduced into the process of change as they a person who at least once experienced doubts and considered the need to change his lifestyle, still inevitably returns to this.
These data are directly related to the education of patients, tk. the actual behavior of patients corresponds to the listed stages, and the patient cannot enter each subsequent stage without going through all the previous ones. Sometimes the patient himself finds an incentive to change behavior. Most patients are in the contemplative or indifference stage, and education can facilitate the process of "moving" up the spiral.
Patient schools
Therapeutic patient education can be carried out in the form of so-called "Schools of Patients" (SHP).
From a formal point of view ShP is a medical preventive technology based on a combination of individual and group effects on patients and aimed at increasing their level of knowledge, awareness and practical skills in the rational treatment of a particular disease, increasing the accuracy of the patient's implementation of the prescribed treatment regimen to prevent complications of the disease, improve prognosis and improving the quality of life
Learning objectives
The objectives of training in Schools of Patients are:
ü increasing patient awareness, and the goal is not to fill the vacuum of knowledge, but to progressively change the patient's ideas about the disease and its treatment, leading to a change in behavior, to the true ability to manage the treatment of the disease in active alliance with the doctor;
ü ensuring the quality and completeness of the implementation of medical recommendations;
ü increased adherence to the implementation of medical prescriptions;
ü motivating the patient to change behavior, habits, attitudes towards his disease in favor of an active approach.
ü developing self-control skills
As a result, the patient must acquire the skills to manage the course of the disease and the treatment process in active cooperation with the doctor.
One of the goals of TOP- the formation of motivation and new psychological attitudes so that they can take on most of the responsibility for the competent, independent treatment of their disease, i.e. change in their disease-related behavior.
Therefore, the focus of training programs should be strictly practical, consistent with the principle of "reasonable sufficiency".
You should not delve into the details of biochemistry, pathogenesis, medical terminology. They are affected insofar as they are directly related to treatment.
Patient education has nothing to do with mere lecturing. After all, when giving a lecture, a specialist does not receive direct information about whether students achieve learning goals, there is no feedback from patients, lectures are usually accompanied by passivity and emotional disengagement of students. In teaching patients to ensure cognitive, emotional and behavioral activity, it is better to use interactive teaching methods (brainstorming, role modeling, training).
Duration of training.
Single, intensive, one- or two-week programs have only a limited effect. Thus, the training system should be aimed at providing long-term motivation, updating and consolidating knowledge and skills, that is, training should be a permanent component of long-term treatment.
Basic forms of education- group (groups of no more than 7-10 people, which is much more effective than individual training when working with adult patients) and individual (more often used for children, as well as for newly diagnosed diseases or diseases in pregnant women)
Examples of sessions with patients
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TOPIC: "METABOLIC CONTROL" "COMPLICATIONS OF DIABETES MELLITUS"
1. PURPOSE OF THE LESSON: to motivate patients to conduct
self-control of carbohydrate metabolism.
2. OBJECTIVES OF THE LESSON:
2.1. Teach patients:
2.1.1. Independently determine the level of sugar in the blood and in
urine by express methods using a glucometer and visually
test strips.
2.1.2. How to record the results of self-control in a diary.
2.1.3. How to correctly evaluate the results based on the results
adequacy of insulin therapy.
2.2. Provide patients with general information about complications
diabetes mellitus and measures to prevent their occurrence.
3. LESSON PLAN:
3.1. What is carbohydrate metabolism control:
3.1.1. What is the purpose of monitoring blood sugar levels?
blood throughout the day.
3.1.2. What indicators of glycemia are considered "normal"; to which
blood sugar levels should be aimed at.
3.1.3. At what time should the sugar content in
blood to assess the adequacy of the insulin regimen and dose
insulin.
3.1.4. The value of determining sugar in urine; is it possible to judge
compensation of carbohydrate metabolism according to the daily content of sugar in the urine.
3.1.5. What is a "fresh" or "half hour" urine sample; for what
determine the sugar content in a half-hour portion of urine.
3.1.6. What is acetone; when to determine the reaction of urine to
acetone; How often should the sugar content be measured?
blood, if there is a positive reaction of urine to acetone.
3.1.7. What is "glycated" hemoglobin; what are his indicators
3.2. Acquaintance with the "Diary of a diabetic".
3.3. "Good" metabolic control is the most effective measure
to prevent diabetic complications.
3.4. Solution of situational problems on the topic: "EXCHANGE CONTROL
SUBSTANCES".
4. REQUIRED MATERIAL FOR THE LESSON:
1. Orange methodical cards on the topic "Control
metabolism" - 25 pcs.
2. Board, chalk.
3. Visual aids:
- "Blood sugar measurement".
4. Devices-glucometers and test strips for monitoring blood sugar.
5. Lancets for taking blood for analysis.
6. Clock with a second hand.
7. Diary of a diabetic for the registration of tests.
8. Test strips to determine the reaction of urine to sugar content
and the presence of acetone.
9. Situational tasks on the topic "Metabolism control" - 8 pcs.
COMPLICATIONS OF DIABETES MELLITUS 2.0:
1. Methodological yellow cards on the topic "Complications" - 15
2. Visual aids:
- "Foot care in diabetes";
- Control examinations in diabetes mellitus.
3. Tuning fork.
5. AFTER THE EXERCISE, THE PATIENT SHOULD KNOW:
At what time should blood sugar be measured in order to
correctly assess the adequacy of the regimen of insulin therapy and the dose of insulin;
When it is necessary to determine the reaction of urine to acetone;
How often do you need to monitor glycated hemoglobin;
Causes of complications in diabetes mellitus;
Maintaining a "good" blood sugar level is the most
an effective measure to prevent diabetic complications.
6. AT THE END OF LESSONS, THE PATIENT SHOULD BE ABLE TO:
It is technically correct to take blood from a finger for
determining the content of sugar in the blood;
Self-determine with a glucometer and visual
Self-determine content using test strips
sugar in the urine;
Keep a diabetic diary;
Evaluate the results of analyzes during the day from the point
view of the adequacy of the regimen of insulin therapy and the dose of insulin;
Assess the indicators of glycated hemoglobin;
- take care of your feet.
REPEAT the material of the lesson "WHAT IS DIABETES?" for the following
main questions:
1) What blood sugar levels are considered normal?
diabetic?
3) What will happen to a patient with IDDM if he does not
insulin injections?
4) What is acetone and when does acetone appear in urine?
ASK: Why should a diabetic's blood sugar levels
be well regulated?
LISTEN to patients' responses.
FIX wrong answers.
ADDITION:
1. A good metabolic state helps to avoid
occurrence of diabetic complications.
2. With a "bad" state of metabolism in a diabetic, more often
infectious diseases occur and become more severe.
UNDERLINE: “feeling good” does not always mean
"good" diabetes control!
WRITE on the board:
"INDICATORS OF BLOOD SUGAR DURING THE DAY IN A DIABETIC"
80 - 140 mg /% (4.4 mmol - 7.7 mmol) - this should be strived for;
80 - 180 mg /% (4.4 mmol - 9.9 mmol) - this is the range
which you can reach around 140 mg/% (7.7 mmol) - great if
You have achieved such results.
ADDITION: blood sugar readings to be
to avoid is 200 mg/% (11 mmol) and above. If such indicators
are recorded more often than normal, the threat of
diabetic complications are significantly increased.
ASK: do you feel the sugar content in
LISTEN to patients' responses.
DEMONSTRATE the visual aid "Blood Sugar".
SPECIFY: You may feel a change in your condition
only when the blood sugar level is either too high or
too low, i.e. in extreme cases. However, you won't notice
no change in how you feel if your blood sugar is
200 mg/% or 280 mg/%. If you don't "react" to leveling up
sugar in your blood, you may develop a serious emergency
"ketoacidosis"!
UNDERLINE: remember that maintaining normal or close to
normal blood sugar is the most reliable measure of
prevention of diabetic complications! That's why
it is so important to constantly measure the level of sugar in the blood!
ASK: how do you measure blood sugar when
help of "visual" test strips?
LISTEN to patients' responses.
EXPLAIN: based on the visual aid "Measuring the content
blood sugar levels as follows:
1. Prepare the necessary materials, including suitable
Light source.
2. Inject with a lancet into the lateral surface of the terminal phalanx 4
or 3 fingers.
3. Squeeze a large drop of blood onto the test strip.
4. Immediately look at the clock and note this time.
5. After 60 seconds, blot the drop of blood on the test strip well.
6. After another 60 seconds, compare the color of the test strip with the color
scale (compare between two nearby shades).
ASK: at what time should blood sugar be measured during
LISTEN to patients' responses.
WRITE on the board:
In the morning on an empty stomach;
In the afternoon before dinner;
Evening before dinner;
At night before bed.
DISCUSS:
1. What do you evaluate in this way?
2. How important are these measurements?
UNDERLINE: there is a rule: "THE SUGAR FIRST SHOULD BE CHECKED
BLOOD, THEN INJECT INSULIN, AND THEN EAT.
You solve the problem: how much short-type insulin should be injected
Actions - You need to know your blood sugar!
ADDITION: if you register normal content indicators
blood sugar - it means that the dose of insulin administered earlier was
"sufficient" for the absorption of sugar by cells.
ASK: What do you prick your finger with to get a drop of blood?
DISCUSS the different types of finger prick lancets.
ASK: where do you inject to get a drop of blood for
UNDERLINE: not at the tip of the finger, but at the lateral surface 3 or 4
finger. You can make an injection in the tip of the ear. By no means do
kick in the toes!
ASK: is pre-disinfection required?
ANSWER: not required. But you need to wash your hands first.
ASK: How many times can the same lancet be used?
ANSWER: 1 time.
ASK: Are you already familiar with blood sugar test strips?
DISCUSS what is written on the test strip vial?
Color scale;
Shelf life;
Test control program number.
DISCUSS visual material (various test strips).
UNDERLINE: In most cases, blood sugar measurements
are carried out 3-4 times a day before meals and at bedtime.
It is important that you record your performance in a special diary. This is
will help you to correctly "orient" in various situations.
DISTRIBUTE AND DISCUSS "Diary of a diabetic".
ASK: what are the benefits of regularly measuring sugar
blood and entering them in a diary?
REPLY:
1. Help yourself.
2. Help the attending physician.
DEMONSTRATE with one of the patients how
PRACTICAL SKILLS: all patients self-measure sugar
ENTRY of the received results of control in diaries.
UNDERLINE: From now on, you will always be in parallel
with the measurement of blood sugar with a glucometer, which
will be conducted by the teacher, independently control the level
blood sugar by changing the color of the test strips (on the "eye"). We will
compare the findings and discuss. Small differences are not
are of particular importance. Most importantly, the sugar content in
Your blood has always been within normal limits!
DISCUSS blood glucose meters. If you
learned to visually "read" blood sugar indicators and you do not have
discrepancies with the results of the analysis on the device, then your diagnosis
accurate enough. Glucometers versus visual analysis,
of course, give greater measurement accuracy. But at the same time, it is impossible
eliminate technical interference. You need to rely on
own measurements!
ASK: what other methods of self-monitoring do you
LISTEN to patients' responses.
DISCUSS various assays to determine the sugar content in
ASK: for what purpose do you examine the sugar content in
"accumulated" urine for the whole day? How informative is the measurement
LISTEN to patients' responses.
SPECIFY: This analysis shows "daily loss" of sugar
organism. But measuring the sugar content in urine collected over a
day, does not give you exact data on the period of time when
excretion of sugar into the urine due to a deficiency of insulin in
body, i.e. You will not be able to estimate at what time of the day you "do not
enough insulin to maintain normal blood sugar levels
REPORT: more informative measurement of sugar in the urine,
collected in a few hours, for example: from morning to lunch, from lunch to
supper. The results of this study make it possible to evaluate
"sufficiency" of the dose of "food" insulin for absorption by cells
carbohydrates received in breakfast, lunch or dinner.
ADDITION: "loss" of sugar in the urine during the night (i.e.
examination of the sugar content in the early morning urine) will indicate
You "correct" dosage of "evening" long-term insulin
actions.
ASK: what portion of urine should be tested for the content
sugar to get an idea of your blood sugar levels
a certain point in time?
SPECIFY "fresh" (half-hourly) portion of urine!
ASK: what does the term "fresh" urine mean?
EXPLAIN: this is the portion of urine "entered" into the bladder for
a short period of time for 15 - 30 minutes. For this
research is needed:
1. "Free" the bladder.
2. After 15` - 30` again collect urine and examine it for
REPORT how to correctly assess the results of the study
"fresh" portion of urine:
If in the "fresh" portion of urine sugar is not determined, then the level
it in the blood does not exceed the "renal" threshold, i.e. 10 mmol/l.
ASK: So when do you expect sugar to show up in your urine?
LISTEN to patients' responses.
SPECIFY when the "kidney" threshold for sugar is exceeded!
SPECIFY: In most diabetics, the "renal" threshold for
penetration of sugar into the urine is the blood sugar content of 9 - 10
EMPHASIZE that only at a "normal" renal threshold can
use this assay to "indirectly" monitor blood sugar levels
SPECIFY: You can test your "kidney"
threshold. To do this, it is necessary to repeatedly examine the level of sugar in
blood 1 - 1.5 hours after a meal (i.e. during the hours of maximum
results you will conclude "when" (at what level of sugar in
blood) you have sugar in your urine.
DISCUSS Urine Response Test Strips
it has sugar in it.
SPECIFY: must be specified:
date of manufacture;
exposure time;
Color scale.
DISTRIBUTE to all patients a pack of blood sugar test strips
DISCUSS how to assess the color change of a test strip in
according to the control color standard.
DEMONSTRATE how the color of the test strip changes according to
the presence of sugar in the liquid. For this:
Dip the test strip into a glass of water with dissolved
a piece of sugar;
Shake the strip;
Wait 2 minutes;
Check the color change on the color scale.
ASK with a test strip to measure the sugar content in
sweet water solution of any of the patients.
CHECK if the patient evaluates the result correctly.
SPECIFY: If there is no sugar in the urine or it contains up to
0.5% check the color change of the strip along the top of the color
scales. From 1% to 5% - check the result on the bottom of the color
ASK: when should you check your urine for
the presence of acetone?
LISTEN to patients' responses.
ADDITION: if blood sugar levels are higher than
240 mg /% (12.9 mmol) in repeated studies. Especially important
this analysis if there are clinical signs of an increase
ASK: How do you monitor urine for acetone?
LISTEN to patients' responses.
EXPLAIN:
1. Substitute the test strip under the stream of urine.
2. Shake.
3. After 1 minute, compare the color change of the scale on the strip with
control standard.
ADDITION: "negative" reaction is called - the absence
color changes. "Positive" is a reaction when there is
stripe color change. (During the explanation, urine control is carried out
any of the patients.)
ASK what glycated hemoglobin values mean
(HbAl and HbAlc)?
LISTEN to patients' responses.
SPECIFY: Al and Alc glycated hemoglobin levels are
indicators of long-term control of blood sugar (for the last 2 - 3
UNDERLINE: you should ask your doctor about the upper limit of normal
the research methodology used in your laboratory, because there are
different normative ranges for these indicators.
REPORT: Have you had a
"good" diabetes control if HbAl is between 8% and 9% or HbAlc
From 6% to 7%.
UNDERLINE: You must pay attention to the level
glycated hemoglobin Al was measured every 8 - 12 weeks.
OFFER patients to solve situational problems on the topic of the lesson.
DISCUSS patients' responses.
TOPIC: "MEAL PLANNING FOR TYPE 1 DIABETES"
ESSENTIAL NUTRIENTS 1.0 CHARACTERISTICS OF HYDROCARBON FOOD FOOD 2.0 MEAL PLAN 3.0 FOOD EQUIVALENT REPLACEMENT 4.0 EATING OUTSIDE 5.0 2. OBJECTIVES OF THE LESSON: 2.1. Teach the patient how to create an individual menu that is balanced in caloric content and biological value. 2.2. Teach the patient an equivalent replacement of carbohydrate-containing products, taking into account the quantity and quality of carbohydrates included in them (dietary or carbohydrate units), as well as the content of dietary fiber in the product. 2.3. Teach the patient to eat "out of the house". 3. LESSON PLAN: 3.1. To acquaint the patient with the characteristics of food products in terms of the content of essential nutrients in them. 3.2. Explain to the patient how to calculate the physiological energy requirement, in the main food ingredients, how to calculate the sugar value of food. 3.3. Familiarize the patient with the concept of the glycemic effect of food. 3.4. Explain to the patient what factors affect the glycemic effect of food. 3.5. Explain to the patient what dietary fibers are, their importance in the processes of digestion and metabolism. How to make a menu enriched with dietary fiber. 3.6. Explain the need to eat at a certain time. 3.7. Explain to the patient what an equivalent product substitution is, how to use the equivalent product substitution tables. 3.8. Practical work on the preparation of an individual menu for each patient. 3.9. Solving situational problems in nutrition planning. 4. MATERIAL NEEDED FOR LESSONS: BASIC NUTRIENTS 1.0 1. Methodological green cards - 6 pcs. 2. Visual aid "Energy value of nutrients". 3. Table of the content of the main nutrients in the daily diet. MEAL PLAN 2.0 1. Methodological green cards - 2 pcs. 2. A set of drawings ("plates") depicting HC-containing products for 1 - 2 HC units. CHARACTERISTICS OF HYDROCARBON-CONTAINING FOOD PRODUCTS 3.0 1. Methodological green cards - 10 pcs. 2. Table of equivalent replacement of carbohydrate-containing products. 3. A set of drawings ("plates") depicting HC-containing products for 1 - 2 HC units. EQUIVALENT REPLACEMENT OF PRODUCTS 4.0 1. Methodological cards of green color - 12 pcs. 2. Table of equivalent replacement of products by bread or carbohydrate units. 3. A set of drawings ("plates") depicting HC-containing products for 1 - 2 HC units. 4. Visual aid "Sugar substitutes". EATING OUTSIDE THE HOME 5.0 1. Methodological green cards - 5 pcs. 2. Table of equivalent replacement of products by carbohydrate or bread units. 3. A set of drawings ("plates") depicting HC-containing products for 1 - 2 HC units. 4. Situational tasks - 18 pcs. 5. AT THE END OF THE LESSON, THE PATIENT SHOULD KNOW: - the importance of diet in the treatment of diabetes mellitus; - what are proteins, fats and carbohydrates and what products can be attributed mainly to protein, fat or carbohydrate; - how to determine the daily amount of calories needed by the patient, depending on age, physical development and physical activity; - how to distribute meals throughout the day; - what is the sugar value of food, "bread unit", "carbohydrate unit"; - what foods can be consumed in excess of the calculated calories; - the importance of dietary fiber in nutrition. 6. AT THE END OF THE LESSON, THE PATIENT SHOULD BE ABLE TO: - using special tables, draw up a nutrition plan for the day and for each meal; - replace one dish with another, taking into account the content of proteins, fats and carbohydrates in it (according to "bread" and "carbohydrate" units), as well as taking into account the content of dietary fiber in the product; - make "your" menu when eating out. BASIC NUTRIENTS 1.1 REPORT: All food products are divided into 3 large groups depending on the predominant content of essential nutrients in them: 1. Carbohydrate-containing, for example: SUGAR, BREAD, CEREALS, FRUITS, POTATOES. 2. PROTEIN containing, for example: FISH, MEAT, EGG. 3. Fat-containing, for example: CREAM AND VEGETABLE OIL, LAD. INVITE patients to give examples of carbohydrate, protein, or fat foods. OFFER patients drawings - "plates" depicting various food products. ASK to categorize the proposed foods as rich in fats, proteins or carbohydrates. SPECT: A person with diabetes can eat the same amount of carbohydrates, protein, and fat as they did before the disease. At the same time, "sweet" carbohydrate-containing foods are excluded and insulin is administered in accordance with the diet! ASK: Which foods have the greatest effect on blood sugar? LISTEN to patients' responses. ADDITION: CARBOHYDRATES mainly affect the increase in blood sugar. However, the SUGAR VALUE of food also depends on the content of PROTEINS in it. To calculate the sugar value of a product, you need to "add" the carbohydrates and 50% of the protein that make up this product. REPORT: In order to determine the amount of essential nutrients in your meal plan, you must first calculate the so-called. ENERGY VALUE of your diet. When calculating the daily calorie intake of a diabetic, the physiological energy costs of the body should be taken into account, allowing you to maintain a normal level of physical and mental performance; for women and men who are not engaged in heavy physical work, respectively, 1800 - 2500 calories (30 - 35 kcal per 1 kg of body weight). Thus, already at the very beginning of nutrition planning, the individual needs of your body are taken into account. SPECIFY: the amount of carbohydrates, as the main energy material, should "cover" 50% of the daily calorie intake, the amount of proteins and fats, respectively, 20% and 30%. ASK, how much energy (calories) do fats, proteins and carbohydrates "give" to the body? REPORT: 1 gram of protein - 4 calories; 1 gram of fat - 9 calories; 1 gram of carbohydrates - 4 calories. DEMONSTRATE the visual aid "Energy value of the main nutrients". ASK patients to calculate their daily calorie intake based on work profile and body weight. ADDITION: if the patient was overweight before diabetes, then the daily calorie calculation is based on the "ideal" weight. At the same time, it is necessary to limit fats and carbohydrates in the diet and include various vegetables in the diet more widely (link to the table "Energy?..."). REPORT: if you have normal blood fat levels with a good metabolism, then you can not limit the fat diet, but give preference to vegetable oils. MEAL PLAN 2.1 REPORT: A diabetic's diet includes 3 main meals (breakfast, lunch and dinner) and 3 additional snacks (2nd breakfast, afternoon snack and "late" dinner). The main meals account for approximately 25% (lunch - 30%) of the daily calorie intake, and additional - 10 - 5% each. ASK patients to calculate the calories, essential nutrients, and sugar value of each of "their" meals (breakfast, lunch, dinner, and snacks). ASK patients to create menus for individual meals (breakfast, lunch, dinner, and "snacks"). DISCUSS patient-composed "breakfasts", "lunches", "dinners" and "snacks". ASK patients to change their meal plan according to their own eating habits. CHARACTERISTICS OF HYDROCARBON-CONTAINING FOOD 3.1 REPORT: Carbohydrates are found in all plant foods, and in animal foods only in milk and dairy products. ADDITION: Carbohydrate foods include both regular "food" sugar and starch. However, sugar is an easily digestible (simple) carbohydrate and therefore, after its consumption, the blood sugar level rises quickly and "highly". Starch refers to "difficult" digestible carbohydrates (complex) - therefore, the blood sugar content after its use rises slowly. ASK patients to give examples of carbohydrate-containing foods that affect blood sugar in different ways. LISTEN to patients' responses. UNDERLINE: when compiling a menu, you need to learn how to interchange carbohydrate-containing foods, taking into account both the content and the type of carbohydrates! REPORT: It is important for a diabetic to distinguish between 2 groups of carbohydrate-containing foods: 1. Which can be ignored when planning meals. 2. Which must be taken into account. ASK: what carbohydrate-containing foods can you ignore? LISTEN to patients' responses. ADDITION: all types of vegetables (except potatoes and sugar beets) you can use in the usual amount and do not count. ASK: which of you eats vegetable dishes willingly? LISTEN to the answers