1

The Technical Working Group

The Technical Working Group is a multidisciplinary group composed of representatives from the 4

implementing partners of the CVD Program and other relevant stakeholders. The Technical Working Group

met in 6 workshops in 2010 to finalize the 4-party Memorandum of Understanding, draft the city

proclamation declaring the city‘s observation of the World Heart Day, develop the CVD Program including

its systems (health care delivery, referral system and monitoring system), review all the CVD program tools

(information, education and implementation tools) and develop the basic training for the primary health

care providers. The meetings of the Technical Working Group was facilitated and supported by Handicap

International‘s CVD Project team.

Technical Working Group Members:

Dr. Anabelle Yumang - NCD Coordinator – Department of Health – CHD Davao Region

Dr. Josephine Villafuerte- City Health Officer – Davao City

Dr. Julinda Acosta– CVD Program Medical Coordinator, District Health Officer – City Health Office

Ms. Chona Dazon RN-CVD Program Nurse Coordinator – City Health Office

Dr. Maribel Camelotes- District Health Officer – Calinan District – City Health Office

Ms. Ma. Teresa Ng RND- Nutrition Officer – City Health Office

Ms. Leah Flor Suelan RN - Public Health Nurse – Talomo North – City Health Office

Ms. Trinidad Yambao RN - Public Health Nurse – City Health Office

Ms. Nelia Sarona -Public Health Midwife-Talomo North District– City Health Office

Ms. Alice Jaen- Public Health Midwife-Barangay Lapu-Lapu – City Health Office

Ms. Vilma Ong - Public Health Midwife–City Health Office

Ms. Florencia Cayon -PEO IV-City Planning and Development Office

Dr. Suzette Q. Alegarbes – Head—Mindanao Diabetes Center – Southern Philippines Medical Center

Dr. Ryan Lonzaga –Chief Resident -Surgery Department – Southern Philippines Medical Center

Dr. Raymund Darius Liberato -Chief Resident -Internal Medicine- Southern Philippines Medical Center

Ms. Ma. Elena Zapanta RN-Diabetes Nurse Educator-Mindanao Diabetes Center –

Southern Philippines Medical Center

Ms. Vivien Bayacag RND-Nutritionist – Dietitian–Mindanao Diabetes Center –

Southern Philippines Medical Center

Ms. Nonnah Vee Macasaet RN—Wound Care Nurse – Wound and Ostomy Care Unit –

Southern Philippines Medical Center

Ms. Imelda Mallorca –Psychologist - Wellness Center - Southern Philippines Medical Center

Ms. Chona Serra PTRP-Program Coordinator – Physical Rehabilitation - Davao Jubilee Foundation

Dr. Ivy Boyose Nolasco—Handicap International

Mr. Richard Erick Caballero RN—Handicap International

Handicap International CVD Project Team

Ms. Ivy Boyose-Nolasco—Project Manager

Ms. Mary Ann S. Cabigon—Admin and Finance

Mr. Richard Erick Caballero—Health Capacity Building Officer

Mr. Erolle Linus Miranda—Communication Officer

Mr. Rudy Calonia—Organizational Development Officer

Ms. Aprilyn Balaquit—Peer Support Officer

Ms. Evisa Jean Caro—Training Assistant

Ms. Eva Diana Baldoza—Logistics Assistant

Mr. Anthony Barcelon—General Services

2

Table of Contents

CONTENT Page

I History of the CVD Program 5

II Training Design 6

III Introduction 9

Integrated NCD Prevention and Control Program 10

IV Module 1: CVD Overview: Risk Factors, Signs & Symptoms, Pathophysiology

Diabetes mellitus 14

Diabetes and Cardiovascular Disease 17

Risk Factors of Diabetes and Cardiovascular Disease 18

Pathophysiology 19

Signs and Symptoms of Diabetes and Cardiovascular Disease 20

Complication of Diabetes 21

V Module 2: Screening, Diagnosis and Monitoring

Definition of Terms 24

Screening of Diabetes and CVD Risks

Risk factors for Screening 25

Algorithm for Diabetes Screening and Diagnosis for Adults 26

Diabetes Risk Assessment 27

Cardiovascular Event Risk Assessment 28

Diagnosis of Diabetes and Hypertension 29

Biochemical Tests for Screening and Diagnosis of Diabetes 30

Screening and Diagnosis of Hypertension 31

Monitoring of CVD Risks 32

The 7 Monitoring Parameters 33

VI Module 3: Management: Pharmacologic Treatment, Medical Nutrition Therapy

and Lifestyle Interventions

36

Pharmacologic Management of Diabetes 36

Medical Management of Diabetes in Health Centers –DOH Algorithm 38

ADA/EASD Algorithm 39

AACE/ACE Diabetes Algorithm 40

Oral Anti-Diabetic Agents 44

Insulin 46

3 Table of Contents

CONTENT Page

Pharmacologic Management of Hypertension 48

Oral Antihypertensive Drugs 49

Pharmacologic Management of Dyslipidemia 51

Oral Lipid Controlling Agents 52

Medical Nutrition Therapy

Setting Dietary Management Goals 53

WHO Protocol for Counselling on Diet and Physical Activity 54

Basic Nutrition Education Using the Plate Method 55

Using the Food Diary 56

Meal Planning Using the Plate Method 57

Calculating Individualized Dietary Prescription 58

Weight Management 60

Physical Activity and Exercise 64

The Activity Pyramid 69

Tobacco Cessation—WHO: 5A Steps Protocol 72

The Smoker‘s Body 74

VII Module 4: Foot, Wound and Stump Care 78

Foot Care

Foot Complications due to Diabetes 79

Pathways to the Development of Foot Ulcers 81

The 5 Cornerstones of Foot Management 82

Basic Foot Care Practice 83

Appropriate Footwear 84

Identifying the Foot At-risk for Amputations 86

Conducting Foot Care Sessions in Health Centers 87

Foot Risk Assessment 88

Wound Care

Introduction to Wounds 89

Definition and Classification of Wounds 90

Steps in Wound Management 92

Wound Assessment 92

Wound Care 96

Wound Monitoring 98

Stump Care

Importance of Stump Care 100

Proper Residual Limb Positioning 101

Residual Limb Wrapping 102

4

CONTENT Page

Criteria for Artificial Leg Fitting 105

Monitoring of Prosthesis and Stump 105

VIII Module 5: Psychosocial and Behavioral Approaches 108

Professional Attitudes and Behaviors 108

5 C Intervention 109

Behavioral and Psychosocial Interventions in Diabetes: A Conceptual Review

by Mark Peyrot PHD and Richard Rubin PHD

110

IX Module 6: Self-Management Education

Introduction 118

The Health Educator 119

The E.A.S.E Approach 120

Using Patient Education Materials 121

The Diabetes Diary 122

Medical Nutrition Therapy Kit 133

X Module 7: Setting up Services for CVD Risk Management in Primary Health

Centers

Introduction to Team Management 134

CVD Program Tools and Equipment 134

Functions of the Health Care Team 135

Making Health Services Physically Accessible 136

Setting up Health Services for CVD Risk Management in Primary Health Centers 137

Information Dissemination 138

Flow of Services for New Patients 139

Generating the Patient Record 140

Recording in the Patient Registry 144

Flow of Services for Old Patients 147

Referral

Indications for Referral 148

The Referral Form 149

Reporting 151

Barangay Health Station Monthly Statistics 152

XI Module 8: Community Health Workers Training

Training Design 156

Training Documentation 159

Table of Contents

5 History of the CVD Program

Upon completion of all

legal requirements and

securing the

commitment of

partner implementers,

the CVD Program is set for full implementation in

Davao City in 2011. This partnership to implement a

city-wide program in the next 3 years is formalized

through a 4-party Memorandum of Understanding

(MOU) between Handicap International, the City

Government of Davao with the City Health Office as

its implementing arm, Southern Philippines Medical

Center (formerly Davao Medical Center) and the

Department of Health-Center for Health

Development Davao Region.

A technical working group mainly consisting of

representatives of the 4 partners is formed to

spearhead the implementation of the CVD

program. The group met 5 times in 2010 to: plan for

the development of the program including how the

program will be implemented through systems of

health service provider trainings, health care

delivery and referral. A system of program

monitoring is also planned. Handicap International

serves as the coordinating body for the duration of

the MOU and provides both financial and technical

support. The CHO and SPMC will serve as the

implementing agencies while the DOH will provide

technical guidance for the alignment of the

program with current Philippine health programs.

HI‘s functions will be slowly turned over to the 3 other

partners (mainly with the City Health Office) during

the course of the program implementation.

In the next three years 3 major trainings will be

implemented in a progressive manner to increase

the chances for program sustainability namely: 2011

- Basic Training, 2012- Advanced Training and

2013-Training of Trainors.

The creation of the CVD Program is facilitated by

Handicap International through its Cardiovascular

Disease (CVD) Project in the city of Davao. The CVD

Project aims to empower relevant stakeholders

through capacity building to implement integrated

cardiovascular risk management (diabetes and

hypertension as entry-points) and to coordinate their

actions in order to increase access to health

services. The project is implemented with a local

inclusive development approach focusing on the

capacity building of service providers (City Health

Office, and local rehabilitation service providers),

local diabetes support groups and policy makers

(local government units). This is a 4-year project

which follows the 3-year pilot Diabetes Project

implemented from 2006 to2009. It aims to build on

the lessons learned from pilot testing in 10 pioneer

barangays and replicate best health service

delivery practices in the rest of the 182 barangays.

Tools for patient education and health service

delivery developed during the first phase are

improved on for use in the CVD Program. An

important project strategy is the development of a

functional referral system among the health and

rehabilitation service providers for a coordinated

effort to increase access to health care.

6

Training Design

Methodology

Objectives

General:

Primary Health Care Professionals are able to implement integrated CVD risk management (focusing

on diabetes and hypertension) and to coordinate their actions to provide quality health care

services.

Specific: At the end of the four-day training, the following are achieved:

1. Health Care Professionals are able to manage patients with diabetes and hypertension in a

multidisciplinary manner.

2. Health Care Professionals are able to implement the CVD Program and all its sub-activities in the

community level.

3. Health Care Professionals are able to train community health workers to implement the CVD

Program.

Methods take into consideration the adult learning process so lectures are minimal. Participants will be

divided into groups of 4 for most of the activities. Case studies are the main method where 2 patients will

be consistently discussed throughout the training. Facilitators will refer to these cases during their sessions.

These patients will be introduced via a short film. More information about the 2 main characters will be

provided as the training progresses and will be the bases for discussions. Sessions are also activity-based

and will use group discussions, role playing and return demonstrations to maximize participation

eg. actual aerobic exercise during the physical activity part. Training tools will also be maximized to make

the training as visual as possible.

Training Programme

Program Activity / Topic Time Facilitator

DAY 1

Registration Attendees fill up attendance sheet and

training kits will be distributed

8:00 – 9:00 E.J. Caro

Opening

Ceremonies

Opening Prayer

National Anthem

9:00—9:15

Preliminaries Getting to know you activity 9:15—10:15 E.J. Caro

E.D. Baldoza

A. Balaquit

Levelling of Expectations and Presentation

of the training objectives

10:15—10:30 C. Dazon

R.E. Caballero

General Orientation to the

Training Program

10:30—10:45 R.E. Caballero

I. Nolasco

Pretest Examination 10:45 – 11:30 R.E. Caballero

Introduction Overview of the CVD Program

11:30 – 12:15 Dr. J. Acosta

Dr. A. Yumang

C. Dazon

7 Training Design

Training Program

Program Activity / Topic Time Facilitator

DAY 1

Lunch 12:15 – 1:00

Attendance

Check

E.J. Caro

Module 1

CVD Overview: Risk Factors, Signs and

Symptoms and Pathophysiology

1:00—2:30 Dr. S. Alegarbes

Dr. A. Echavia

Dr. J. Acosta

Module 2

Screening, Diagnosis and

Monitoring

2:30 – 5:30 Dr. I. Nolasco

R.E. Caballero

Daily Evaluation Reading assignments maybe given in

preparation for the sessions on the

succeeding day

5:30 – 6:00 C. Dazon

RE Caballero

END OF DAY 1

DAY 2

Breakfast 7:00 – 8:00

Review of Day 1 Knowledge Check

8:00 – 8:30 C. Dazon

RE Caballero

E.J. Caro

Module 3 CVD Management: Pharmacologic

Treatment, MNT and Lifestyle Interventions

Introduction to Diabetes and

Hypertension Management

8:30—8:40

Dr. S. Alegarbes

Dr. A. Echavia

E. Zapanta

V. Bayacag

M.T. Ng Calculating the TER / Diet Prescription 8:40—9:10

Physical Activity and Prescription 9:10—9:30

Case Study and Group Work 9:30—10:00

Discussion of Case Studies 10:00—11:00

Calculation of Own TER 11:00—11:30

Physical Activity 11:30—12:00 V. Javier

Lunch 12:00 – 1:00

Attendance

Check

E.J. Caro

Module 3 cont. Tobacco Cessation Counselling Protocol 1:00—2:00 E. Zapanta

Module 4 CVD Management: Foot, Wound and

Stump Care

Basic Foot Care

2:00 – 3:30

Dr. I. Nolasco

Basic Wound Care 3:30—4:30 N. Macasaet

Stump Care 4:30—5:30 C. Serra

Daily Evaluation Day-end evaluation and reading

assignments

5:30—5:45

C. Dazon

RE Caballero

EJ Caro

END OF DAY 2

8

Training Design

Training Program

DAY 3

Breakfast 7:00 – 8:00

Review of Day 2 Knowledge Check 8:00 – 8:30 C. Dazon

R.E. Caballero

E.J. Caro

Module 5 Psychosocial and Behavioral

Approaches

8:30—10:00 I. Mallorca

E. Zapanta

Module 6

Patient Education

10:00—11:30 R.E. Caballero

Dr. I Nolasco

E. Zapanta

Physical Activity 11:30 – 12:00 V. Javier

Lunch 12:00 – 1:00

Attendance

Check

E. Caro

Module 7 Setting Up Services for CVD Risk

Management in Primary Health Centers

1:00 – 5:00 I. Nolasco

R.E. Caballero

Daily Evaluation Day-end evaluation and reading

assignments

5:00 – 5:30 C. Dazon

R.E. Caballero

E.J. Caro

END OF DAY 3

DAY 4

Breakfast 7:00 – 8:00

Practicum

Diabetes and Heart Day 8:00 – 11:00

C. Dazon

R.E. Caballero

I. Nolasco

Module 8

The Community Health Workers Training

11:00 – 11:30 C. Dazon

R.E. Caballero

Physical Activity 11:30 – 12:00 V. Javier

Lunch 12:00 – 1:00

Attendance

Check

E.J. Caro

Action Planning

and Commitment

Setting

Training Schedules 1:00 – 2:00 R.E. Caballero

C. Dazon

Post test Post Test

Discussion of Post test answers

2:00 – 3:00

3:00—4:00

R.E. Caballero

C. Dazon

Training Evaluation 4:00—4:30 E.J. Caro

Closing Ceremony Awarding of Certificates 4:30 – 5:30 C. Dazon

R.E. Caballero

END OF TRAINING

9

INTRODUCTION

Cardiovascular disease (CVD) is responsible for

one-third of all global deaths. Nearly 85% of the

global mortality and disease burden from CVD is

borne by low- and middle-income countries. The

majority of the estimated 32 million heart attacks

and strokes that occur every year are caused by

one or more cardiovascular risk factors –

hypertension, diabetes, smoking, high levels of

blood lipids, and physical inactivity – and most of

these CVD events are preventable if meaningful

action is taken against these risk factors.

Hypertension is the most prevalent CVD, affecting

at least 600 million people, and is an important

contributor to cardiovascular mortality and mor-

bidity.

Diabetes currently affects more than 250 million

individuals worldwide. This number is expected to

rise to over 333 million by 2025 if we do not do

anything about it. Obesity, changing lifestyles and

dietary practices and aging populations

contributed significantly to a one-third increase in

diabetes during the 1990s, but the greater bulk of

this increase will occur in the Indian and Asian

subcontinents, due to a complex interplay of ge-

netic, environmental and social factors, such as

rural-urban migration and industrialization.

Excess weight – abdominal fat in particular –

increases insulin requirements and compounds the

problem of insensitivity to insulin. Therefore,

disturbing increases in the prevalence of type 2

diabetes reflect the rising prevalence of obesity.

There are particularly disturbing trends in

adolescents – thought to be exacerbated by

decreased exercise and increased calorie and fat

intake. Research has shown that some ethnic

groups are at higher risk than others. Communities

of Asian Indians and people from African origin, for

example, show higher rates of type 2 diabetes and

appear to suffer more in terms of diabetes

complications – such as kidney failure – compared

to Caucasian populations.

Diabetes is a world‘s leading cause of blindness,

end-stage renal disease, and non-traumatic

lower-limb amputations. Furthermore, diabetes is

the 4th leading cause of death by disease around

the world.

People with diabetes are 2- to 4-times more likely

to develop cardiovascular disease than are those

without diabetes. Eight of 10 people with diabetes

will die from a cardiovascular disease.

The devastating complications of diabetes—

blindness, kidney failure, and heart disease—are

imposing an enormous burden on health care

services. In some countries, up to 10% of health

care costs can be attributed to diabetes.

In many settings, the management of hypertension

is sub-optimal, mainly due to barriers related to

patients, health-care providers and the health

system. Furthermore, the management of

cardiovascular risk, compared to treating elevated

blood pressure per se, demands more skills and

better-maintained and better-equipped

facilities.

Regrettably, the prevention of CVD often

focuses on single risk factors such as diabetes or

hypertension rather than on comprehensive

cardiovascular risk. For CVD prevention activities to

achieve the greatest impact a paradigm shift is

required, away from the treatment of risk factors in

isolation, to a comprehensive cardiovascular

risk-management approach. Evidence based,

cost-effective interventions are available for

addressing comprehensive cardiovascular risk,

and the challenge now is to ―use what we know‖,

particularly in low- and middle-income countries.

This calls for resource-sensitive, innovative

strategies.

For CVD prevention activities to

achieve the greatest impact a

paradigm shift is required, away

from the treatment of risk factors in

isolation, to a comprehensive

cardiovascular

risk-management approach.

10

Introduction

Heart disease and stroke continue to be the top

causes of mortality in the Philippines in 2010.

Diabetes mellitus has become the 5th cause from

being the 9th cause of mortality in 2009. A

cross-sectional population based study was

conducted in 2002 among 7044 adults aged 20-65

years old residents of urban and rural areas in Luzon

in the Philippines estimated the crude diabetes

prevalence to 5.1% which represented a 54%

increase over the figure (3.3%) in 1982. This study

reported that diabetes were unknown by one in

three diabetics.

The Philippine Cardiovascular Outcome

Study-Diabetes Mellitus (PHILCOS-DM), a community

-based descriptive cohort study done in 2006, noted

the increasing incidence of pre-diabetes states,

and overt conversion to diabetes in such a short

time interval. Using the newer cut-off level of

100-125mg/dl, the prevalence of impaired fasting

glucose (IFG) is 30% while the prevalence of

impaired glucose tolerance (IGT) is 25%. The 8-years

incidence of diabetes mellitus using fasting blood

glucose (FBG) is 9% and the prevalence is 19%.

WHO projects that the number of diabetics in the

Philippines will increase from 2.8 in 2000 to 7.8 Millions

in 2030. [7] In Davao City, in 2006, diabetes was the

9th cause of death with 274 deaths or 20.1 per

100,000 inhabitants.

90% of Filipinos has one or more of these

6 prevalent risk factors (NNHeS, FNRI 2003)

1. Physical inactivity……60.5%

2. Smoking…….34..8%

3. Hypertension….22.5% (SBP>140 or DBP>90)

4. Hypercholesterolemia …..8.5% (TC>240)

5. Obesity……4.9% (BMI>30)

6. Diabetes…..4.6%n

Current Use of Tobacco Product

Among Adolescents

Both Sexes: 27% (20% in 2003)

Boys: 34% (27% in 2003)

Girls: 14% (13% in 2003)

The Philippines is one of the 23 selected

countries contributing to around 80% of the

total mortality burden attributable to chronic

diseases in developing countries, and 50% of

the total disease burden caused by

non-communicable diseases worldwide

The Philippine Situation

Integrated NCD Prevention and Control Program continued

Vision: Improved quality of life for all Filipinos

Mission: To ensure that quality prevention and con-

trol NCD services are accessible to all,

especially to the vulnerable and at-risk population.

Goal: To reduce mortality and morbidity due to

NCDs

Objectives:

To reduce the exposure of population to risks re-

lated to NCDs primarily smoking, unhealthy diet,

physical inactivity.

To increase the proportion of NCD cases given

appropriate treatment and care

Policy Thrusts

Adoption of an integrated, comprehensive and

community-based response to NCD prevention

and control;

Strengthening health promotion to effect chang-

es that lead to significant reduction in mortality

and morbidity due to NCDs;

Fostering complementary accountabilities in the

implementation of the program.

11 Introduction

Integrated NCD Prevention and Control Program continued

Adoption of an integrated, comprehensive and

community based response to NCD prevention

and control

Focuses on common risk factors cutting across

specific diseases guided by a life course

perspective;

Encompasses the three levels of disease

prevention: primary, secondary and tertiary level

Emphasizes strategies which would benefit entire

population or large packets of population

Integrates across settings; such as health centers,

schools, workplaces and communities

Makes explicit links to other government

programmes, community based organizations

Emphasizes intersectoral action

Health Status Targets

Reduction of mortality from lifestyle-related

diseases:

Heart diseases (from 79.1/100,000)

Vascular diseases (from 63.2/100,000)

COPD (20.8/100,000)

Diabetes mellitus (from 14.1/100,000)

Malignant neoplasm – all form (from

47.7/100,000)

12

Introduction

Notes:

13 Introduction

Notes:

14

Contents:

1. Definition of Diabetes Mellitus

2. Definition of Cardiovascular Disease (CVD)

3. Diabetes Mellitus and CVD

4. Risk Factors of Diabetes Mellitus and CVD

5. Pathophysiology

6. Signs and Symptoms

7. Chronic Complications

8. Misconceptions

Diabetes Mellitus

Module 1

CVD OVERVIEW: RISK FACTORS, SIGNS AND SYMPTOMS,

PATHOPHYSIOLOGY

Diabetes is a chronic condition characterized by

hyperglycemia. It is caused by deficient insulin

production, resistance to insulin action or a

combination of both. Knowledge of the relationship

between glucose, insulin and counter-regulatory

hormones and glucose homeostasis is important in

understanding these defects and how they result in

abnormal glucose and fat metabolism.

Normal Glucose Metabolism For proper management of diabetes, it is important

that we understand normal metabolic mechanisms

and what happens in diabetes because it facilitates

our understanding of key areas of intervention.

The human body needs energy for its survival and it

is Adenosine triphosphate (ATP) that serves as the

fuel that maintains the integrity as well as the normal

processes that ensure survival. In order to generate

ATP, we need its main substrate, which is glucose.

The normal process of glucose metabolism is

controlled by a negative feedback system. After

food is ingested intestinal absorption and chemical

breakdown of carbohydrates, proteins and fats lead

to serum blood glucose elevation. The increase in

blood glucose stimulates the beta cells to release

insulin. Serum insulin levels begin to rise within

minutes after a meal, reach a peak in about 3 – 5

minutes, and then gradually reach a baseline level

in 2 – 3 hours.

Insulin is released in a biphasic manner. A first-phase

release of stored insulin occurs in 3 – 5 minutes, and

then a second-phase release begins after about 2

minutes and continues until the stimulus stops.

Glucose is then either utilized by the different organ

cells or is transported to the liver and muscles to be

stored as glycogen (glycogenesis). Just as a rise in

blood glucose levels stimulates the release of insulin,

a low blood glucose level inhibits the release of

insulin.

In addition to intestinal absorption of food-derived

glucose the other major source of plasma glucose is

the liver. The contribution of the liver to plasma

glucose concentration is through two important

mechanisms:

Is a chronic illness that requires

continuing medical care, on-going patient self-management

education

and support

to prevent acute complications and to reduce the risk of long-term

complications.

American Diabetes Association Definition

15 Module 1

Normal Blood Glucose and Insulin Patterns throughout the Day with Food Intake

Glycogenolysis- breaking down of glycogen

stores into glucose

Gluconeogenesis- formation of glucose from non

-glucose precursors

In the fasted state, glycogen is broken down into

glucose and released into the plasma, to meet the

energy requirements of the body. This supply is rather

limited, so that if fasting is extended, and glycogen

stores have been depleted, gluconeogenesis then

occurs.

The end-products of the breakdown of

carbohydrates (lactate and pyruvate), fats

(glycerol), and proteins (amino acids) serve as pre-

cursors of gluconeogenesis. Other substrates include

lactate released from muscles during anaerobic gly-

colysis, and glycerol from adipose tissue mobilization

of stored triglycerides.

The muscles also utilize glycogen for immediate

energy needs but glycogenolysis in the

muscle only provides for the energy needs of that

organ and the amounts produced are not enough

for circulation to other parts of the body. The next

sources of energy are free fatty acids (FFA’s) once

carbohydrate sources of glucose have been used

up.

Fat is stored in adipose tissue as triglycerides (TG)

and it contains the highest energy value among

ingested foods. Lipolysis refers to the break down of

TGs into glycerol and free fatty acids (FFA). Only

odd-chained FFAs such as propionate can directly

contribute to net gluconeogenesis (formation of

glucose). Glucose stored as fats are then used up by

other organs and peripheral tissues of the body while

glucose from carbohydrate sources are then

shunted or mobilized for the use of the brain which is

a vital organ for survival.

Amino acids from tissue protein (mostly muscle

proteins) are the most important substrates for

gluconeogenesis in the fasting state. Almost all ami-

no acids resulting from breakdown of muscle protein

(except leucine) are available for gluconeogenesis.

Role of Insulin Energy intake exceeds the energy requirements of

the body during the fed state (anabolic phase) and

the rise in plasma glucose concentration stimulates

the release of insulin, a hormone that regulates

glucose levels. Insulin facilitates the uptake of

glucose into the cells of most tissues:

16

In the liver – insulin decreases glucose

production by:

facilitating glycolysis and glucose uptake

inhibiting glycogen breakdown and

gluconeogenesis

increasing transformation of FFA to triglycerides

increasing free amino acid transport across

hepatocytes (liver cells)

In adipose tissues – insulin increases circulating

free fatty acids in the blood by inhibiting their

breakdown (lypolysis)

In muscles – insulin facilitates glucose and free

amino acid transport across cells

All insulin-sensitive organs – insulin facilitates

glucose uptake

Types of Diabetes

In Type 1 diabetes, the destruction of the

insulin-producing beta cells is usually an

autoimmune process in people with a genetic

susceptibility. The trigger for type 1 diabetes is not

fully understood but in about 95% of people with the

condition, it is organ-specific resulting in

pancreatic islet cell destruction.

Type 2 diabetes arises from the combination of

insulin resistance followed by impaired insulin

secretion leading to decreased glucose uptake in

peripheral tissues, and increased hepatic glucose

output.

There is a natural loss of beta-cell function as we

age – approximately 1% per year. In people with

type 2 diabetes, this loss is accelerated to 7% per

year. Insulin requirements increase as part of the

normal aging process. The aging process also results

in the loss of beta cells.Blood glucose levels will rise

when insulin requirements exceed insulin production.

This is known as ‗primary failure‘. In some people this

does not occur until very late in life.

However, other people are born with insensitivity to

insulin and their pancreas produce more insulin than

usual in an effort to overcome this insensitivity.

In the early stages of insulin insensitivity, levels of

insulin in the blood become excessively high

(hyperinsulinaemia). Eventually the beta cells

become ‗exhausted‘ and the amount of insulin

produced decreases.

The loss of beta-cells, relative insulin deficiency, and

elevated blood glucose levels occur at an early

stage of life. Some of the excess glucose is taken up

by fat cells or by the liver and converted to

triglycerides. The storage of these triglycerides in the

liver leads to the ‗fatty liver‘ associated with insulin

insensitivity.

In a nutshell, the basic pathophysiology in type 2

diabetes is the interplay of two mechanisms: beta

cell dysfunction and insulin resistance.

Gestational Diabetes (GDM) is defined as any

degree of glucose intolerance with onset or first

recognition during pregnancy. The definition

applies whether insulin or only diet modification is

used for treatment and whether or not the condition

persists after pregnancy.

Module 1

Definition of Diabetes continued

Slides current until 2008

Diagnosis and typesCurriculum Module II-1

Slide 22 of 48

Age (years)

Endogenous insulin

Insulin requirements

Beta-cell loss

Insulin insensitivity

Hyper-insulinaemia

The natural history of type 2 diabetes

Insulin requirements with age

17 Module 1

Diabetes and Cardiovascular Disease

Diabetes is a heart

disease equivalent.

18

Module 1

Risk Factors of Diabetes and Cardiovascular Disease

Controlling individual

cardiovascular risk factors is

effective in preventing or slowing

CVD in people with diabetes.

Prevention of CVD is the most effective way of

combating the CVD epidemic in the resource poor

nations. Knowledge of modifiable risk factors

(smoking, lack of exercise, obesity and

consumption of fatty foods) for heart diseases has

been identified important for behaviour change to

occur and is often targeted by prevention

programs.

Abdominal obesity, commonly known as belly

fat or clinically as central obesity, is the

accumulation of abdominal fat or visceral fat

resulting in an increase in waist size. There is a

strong correlation between central obesity

cardiovascular disease.

Visceral fat, also known as organ fat or intra-

abdominal fat, is located inside the peritoneal

cavity, packed in between internal organs and

torso, as opposed to subcutaneous fat which is

found underneath the skin, and intramuscular

fat which is found interspersed in skeletal muscle.

Visceral fat is composed of several adipose depots

including mesenteric, epididymal white adipose

tissue (EWAT) and perirenal fat. An excess

of visceral fat is known as central obesity, the "pot

belly" or "beer belly" effect, in which the abdomen

protrudes excessively. This body type is also known

as "apple shaped", as opposed to "pear shaped",

in which fat is deposited on the hips and buttocks.

Major Modifiable Risk Factors

High Blood Pressure—major risk for heart attack and the

most important risk factor or stroke

Diabetes Mellitus—major risk for coronary heart disease

and stroke

Abnormal blood lipids—high total cholesterol, LDL

Cholesterol and triglyceride levels, and low levels of HDL

cholesterol increase the risk of coronary heart disease

and ischemic stroke.

Tobacco Use—increases risk of cardiovascular disease

especially in people who started young, and heavy

smokers. Passive smoking an additional risk.

Physical Inactivity—Increases risk of heart disease and

stroke by 50%.

Obesity—major risk of coronary heart disease and

diabetes.

Unhealthy diets—low fruit and vegetable intake is

estimated to cause about 31% of coronary heart disease

and 11% of stroke worldwide; high saturated fat intake

increases the the risk of heart disease and stroke through

its effect on blood lipids and thrombosis.

Other Modifiable Risk Factors

Low Socioeconomic status—consistent inverse

relationship with risk of heart disease and stroke.

Psychosocial stress—chronic life stress, social isolation

and anxiety increases the risk of heat disease and stroke

Alcohol use—1 to 2 drinks per day may lead to a 30%

reduction in heart disease, but heavy drinking damages

the heart muscles

Non-Modifiable Risk Factors

Advancing Age—most powerful independent risk factor

for cardiovascular disease; risk of stroke doubles every

decade after 55.

Heredity or Family History—Increase risk if a first-degree

blood relative has had coronary heart disease or stroke

before the age of 55 years (for male relative) or 65 years

(for a female relative)

Gender—Higher rates of coronary heart disease among

men compared to women in premenopausal age; risk

of stroke is similar to men and women.

Source: The Atlas of Heart Disease and Stroke. WHO and

Center for Disease Control and Prevention

19 Module 1

Pathophysiology

20

Module 1

Often diabetes goes undiagnosed because many

of its symptoms seem so harmless. Early detection of

diabetes symptoms and treatment can decrease

the chance of developing the complications of

diabetes. Some diabetes symptoms include:

1. Frequent urination (Polyuria)

2. Excessive thirst (Polydipsia)

3. Extreme hunger (Polyphagia)

4. Unusual weight loss

5. Increased fatigue

6. Irritability

7. Blurry vision

The first symptoms of diabetes are related to the

direct effects of high blood sugar levels. When the

blood sugar level rises above 160 to 180 mg/dL,

glucose passes into the urine. When the level rises

even higher, the kidneys excrete additional water

together with the large amounts of glucose lost.

Because the kidneys produce excessive urine, a

person with diabetes urinates large volumes

frequently (polyuria). The excessive urination creates

abnormal thirst (polydipsia).

People with diabetes are unable to process many of

the calories in the foods they eat. Thus, they may

lose weight even though they eat an apparently

appropriate or even excessive amount of food. Los-

ing sugar and water in the urine and the accompa-

nying dehydration also contributes to weight loss. To

compensate, the person often feels excessively hun-

gry (polyphagia).

Other symptoms include blurred vision, drowsiness,

nausea, and decreased endurance during exercise.

The body is inefficient and sometimes unable to use

glucose for fuel. The body switches over to

metabolizing fat, partially or completely, as a fuel

source. This process requires the body to use more

energy. The end result is feeling fatigued or

constantly tired.

In addition, people whose diabetes is poorly

controlled are more susceptible to infections.

Because of the severity of insulin deficiency,

people with type I diabetes almost always lose

weight before undergoing treatment. Most people

with type II diabetes don't lose weight.

In people with type I diabetes, the symptoms begin

abruptly and may progress rapidly to a

condition called diabetic ketoacidosis. Despite high

levels of sugar in the blood, most cells can't use

sugar without insulin; thus, they turn to other sources

of energy. Fat cells begin to break down,

producing ketones, toxic chemical compounds that

can make the blood acidic (ketoacidosis).

The initial symptoms of diabetic ketoacidosis include

excessive thirst and urination, weight loss, nausea,

vomiting, fatigue, and--particularly in children--

abdominal pain. Breathing tends to become deep

and rapid as the body attempts to correct the

blood's acidity. The person's breath smells like nail

polish remover. Without treatment, diabetic ke-

toacidosis can progress to coma, sometimes within

a few hours.

People with Type 1 diabetes can develop

ketoacidosis even after starting insulin treatment if

they miss an insulin injection or become stressed by

an infection, an accident, or a serious medical

condition.

People with type II diabetes may not have any

symptoms for years or decades. When insulin

deficiency progresses, symptoms may develop.

Increased urination and thirst are mild at first and

gradually worsen over weeks or months.

Ketoacidosis is rare. If the blood sugar

level becomes very high (often exceeding 1,000

mg/dL)--usually as the result of some superimposed

stress such as an infection or drugs--the person may

develop severe dehydration, which may lead to

mental confusion, drowsiness, seizures, and a

condition called nonketotic hyperglycemic-

hyperosmolarcoma.

Signs and Symptoms of Diabetes and Cardiovascular Disease

21 Module 1

Complications of Diabetes

Acute complications Acute complications occur suddenly and may

be the first manifestation of diabetes in a person

who does not know that he is diabetic. The acute

complications of diabetes may also happen

when insulin therapy is suddenly withdrawn, or

when infection, surgery or other stressful events

occur. The two acute complications of diabetes

mellitus are diabetic ketoacidosis and

hyperosmolar non-ketotic diabetic coma.

Long term complications The long-term diabetes mellitus

complications occur within 10-15 years from the

onset of diabetes. The increase of blood sugar

level produces changes throughout the body.

The thickening and narrowing of blood vessels is

accelerated in a person with diabetes. This may

eventually lead to a stroke or heart attack. Aside

from changes in the blood vessels, diabetes may

cause loss of vision (retinopathy), decrease in

sensation (neuropathy), and renal failure

(nephropathy).

Diabetes is caused by excessive sugar intake

Diabetes is caused mainly by stress

Diabetes means no sugar altogether

Diabetic diet

Diabetic patients cannot exercise or perform

strenuous work

Diabetics should not undergo surgical procedures

Diabetes can be cured

Once blood glucose is normal, medications may

be discontinued

Medications of DM should be stopped during

other illness

DM medications should be stopped on the day of

blood glucose testing

Medications prescribed for diabetes can harm the

kidneys

Food supplements are alternatives to prescribed

medications

Insulin is addictive

When insulin is prescribed, it means that the

patient is already dying

Insulin and hemodialysis can lead to death

Misconceptions ( Mga maling pagtuo)

22

Module 1

Notes:

23 Module 1

Notes:

24

Contents:

Definition of terms.

Screening of Diabetes and CVD Risks

Algorithm for Diabetes Screening and

Diagnosis for Adults

Diabetes Risk Assessment

Cardiovascular Event Risk Assessment

Diagnosis of Diabetes and Hypertension

Biochemical Tests for Screening and Diag-

nosis of Diabetes.

Screening and Diagnosis of Hypertension.

Monitoring of CVD Risks

The 7 monitoring parameters

Requesting for Biochemical Tests

Module 2

SCREENING, DIAGNOSIS AND MONITORING

Definition of Terms

The diagnostic procedure must be

done properly and diagnosis fully

established since the consequences

for the individual is considerable and

lifelong.

Diabetes mellitus describes a metabolic disorder of multiple etiology characterized by chronic

hyperglycemia, with disturbances of carbohydrate, fat and protein metabolism resulting from

defects in insulin secretion, insulin action, or both. Severe hyperglycemia detected under conditions of

acute infection, traumatic, circulatory or other stress may be transitory and should not in itself be

regarded as diagnostic of diabetes.

Normoglycemia

Since there are insufficient data to accurately define normal glucose levels, the term ―normoglycemia‖

should be used for glucose levels associated with low risk of developing diabetes or cardiovascular

disease, that is levels below those used to define prediabetes.

Prediabetes

Prediabetes is a state of intermediate hyperglycemia not meeting the diagnostic criteria of

diabetes but is higher than normoglycemia. It is not a clinical entity but is a risk factor for future diabetes

and/or adverse outcomes such as premature mortality and cardiovascular disease. There are two forms of

intermediate hyperglycemia: impaired fasting glycemia (IFG) and impaired glucose tolerance (IGT).

Metabolic Syndrome

The clustering of hyperglycemia, obesity, dyslipidemia and hypertension has been labeled the

metabolic syndrome, dysmetabolic syndrome or insulin resistance. This clustering indicates common

etiological factors. Its clinical importance is its high cardiovascular risk association. Recognition of these

features in people with type 2 diabetes indicates the need for aggressive CVD risk reduction which

includes lifestyle intervention strategies and pharmacologic treatment.

25

Screening of Diabetes and CVD Risks

Screening deals with the identification of risk

factors for initiating interventions focusing on

modifiable risk factors. It is usually performed on

asymptomatic individuals to de able to identify

diabetes, hypertension and other risk factors at an

early stage for the prevention of cardiovascular

diseases.

Diabetes, hypertension and dyslipidemia are

independent risk factors for CVD, however, the

chances of a CVD event increases with more risk

factors. Diabetes and CVDs also share other risk

factors . Risk factors of diabetes are divided into

modifiable and non-modifiable risk factors:

Modifiable Risk Factors: BMI of ≥ 23

Abdominal obesity with waist circumference of

≥ 90 cm for males and ≥ 80 cm for females

Prediabetes (refer to Table 1 on page 9)

Hypertension ( ≥ 140/90 mmHg )

Increased triglyceride levels ( > 250 mg/dl or 2.82

mmol/l)

Low HDL cholesterol level ( < 35 mg/dl or 0.09

mmol/l)

Sedentary Lifestyle

Cigarette Smoking

Alcohol Drinking

Non-modifiable Risk Factors: ≥ 35 years of Age

Parent or sibling diagnosed with diabetes

Previous gestational diabetes

Female gender

History of giving birth to an infant with a birth

weight of > 9 pounds (4.0 kg )

Cardiovascular disease

Polycystic ovarian syndrome

Small for gestational age (SGA), intrauterine

growth retardation (IUGR) or large for

gestational age at birth

Risk Factors for Type 2 Diabetes in Children Only children who have risk factors for the

development of type 2 diabetes need to undergo

biochemical testing.

Screening is initiated in obese children with:

A body mass index (BMI) of greater than the

85th percentile for age and sex

Weight greater than 120% of ideal for height

Plus any 2 of the following risk factors are present:

Family history of Type 2 diabetes in a first or

second degree relative

Ethnic background of African-American,

Hispanic, American Indian, Asian, or Pacific

Islander origin

Signs of insulin resistance

Presence of conditions associated with insulin

resistance: e.g., acanthosis nigricans,

polycystic ovary syndrome, high blood pressure,

and blood fat disorders.

When should you screen?

Started at 10 years old and repeated every 3 years if

test result is normal

How should you screen? Fasting blood sugar

Module 2

The IDF Consensus Worldwide Definition of the Metabolic Syndrome

Characteristics Values

Central Obesity Waist Circumference :

≥ 90cm for males and ≥ 80 cm for females Note: If BMI is > 30 kg/m², then central obesity can be assumed, and waist circumference does not need to be measured

Plus any two of the following

Raised triglycerides ≥ 1.7 mmol/L (150 mg/dl) or specific treatment for this lipid abnormality

Reduced HDL-cholesterol < 0.9 mmol/L (40 mg/dl) in males

< 1.1 mmol/L ( 50 md/dl) in female

or specific treatment for this lipid abnormality

Raised blood pressure ≥ 130mmHg systolic or ≥ 85 mmHg diastolic or treatment of previously diagnosed hypertension

Raised fasting blood sugar FBS of ≥ 5.6 mmol/L (100mg/dl) or previously diagnosed with type 2 diabetes

Source: Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical Targets and Treatments. International Diabetes Institute:Melbourne, Australia, 2005.

26

Module 2

Algorithm for Diabetes Screening and Diagnosis for Adults

Initiate prevention interventions and

advice repeat FBS/OGTT every year

Risk Factor Identification

Risk Factor

Present

Administer Risk Assessment Questionnaire

Yes No

No Screening

With Symptoms

Yes No

Request for RBS or FBS or OGTT

Risk Factors Identified

High Risk

Yes No

Repeat Risk Questionnaire after

3 years

Request for

Biochemical Testing (FBS or OGTT)

Prediabetes Normoglycemia Diabetes

Request for FBS or OGTT on a subsequent day

Prediabetes Normoglycemia Diabetes

Initiate diabetes management

Initiate prevention interventions and advice repeat FBS/OGTT every year

Diagnostic Criteria

for Diabetes

Test mmol/L mg/dl

OGTT ≥ 11.1 ≥ 200

FBS ≥ 7.0 ≥ 126

RBS ≥ 11.1 ≥ 200

HbA1c ≥ 6.5%

Levels of Glycemia (Plasma venous values)

in mmol/L

Level of Glycemia OGTT FBS

Normoglycemia < 7.8 < 5.6

Prediabetes—IGT 7.8—11.0 < 7

Prediabetes –IFG < 7.8 5.6—6.9

Diabetes ≥11.1 ≥ 7.0

27 Module 2

Diabetes Risk Assessment

Screening tests for type 2 diabetes include a combination of risk assessment questionnaires and

biochemical tests. Primary screening for potential type 2 diabetes is done using a non-invasive risk-factor

based screening questionnaire to limit the proportion of the population that needs to undergo

diagnostic glucose measurement as a second step. Questionnaires are also less labor intensive and more

acceptable to patients than biochemical tests.

Diabetes Self Assessment Questionnaire developed for the CVD Program. This will be distributed among households

to encourage persons at-risk of developing diabetes to go for diabetes screening in health centers.

28

Module 2

Cardiovascular Event Risk Assessment

29 Module 2

Cardiovascular Event Risk Assessment continued

The Cardiovascular Event Risk Assessment form is

developed based on the World Health

Organization / International Society of Hypertension

(WHO/ISH) colored Risk Prediction Charts. It

combined the assessment of 5 risk factors to

determine the risk of a CVD event.

The 5 risk factors assessed are:

1. Diabetes

2. Gender

3. Smoking Status

4. Age

5. Systolic Blood Pressure

Risk prediction and the accompanying

recommendations can be used by health care

professionals to match the intensity of risk factor

management with the likelihood of cardiovascular

events.

The assessment form can be used to explain to

patients the likely impact of interventions on their

individual risk of developing cardiovascular disease.

This approach may motivate patients to change

their behavior. The use of risk assessment charts or

forms will help health care professionals to focus

their limited time on those who will benefit from their

services the most.

Diagnosis of Diabetes and Hypertension

Diagnosis confirms the existence of risk factors like

diabetes and hypertension after the screening

process or if an individual exhibits signs and

symptoms.

In diagnosing diabetes, the clinician must feel

confident that the diagnosis is fully established since

the consequences for the individual are

considerable and lifelong. In the absence of a more

specific biological marker to define diabetes, the

measurement of glucose in blood remains the basis

of the diagnostic criteria.

The clinical diagnosis of diabetes is often prompted

by symptoms such as increased thirst and urine

volume, recurrent infections, unexplained weight

loss and, in severe cases, drowsiness and coma; high

levels of glycosuria are usually present. A single

blood glucose estimation in excess of the diagnostic

values (refer to Biochemical Tests) establishes the

diagnosis in such cases.

The diagnosis of diabetes in an asymptomatic

patient on the other hand should never be made on

the basis of a single abnormal blood glucose value.

At least one additional plasma/blood glucose test

with a value in the diabetic range is essential.

Diagnostic Criteria for Prediabetes and Diabetes by OGTT, FPG and HbA1c

30

Module 2

Biochemical Tests for Screening and Diagnosis of Diabetes

TYPES OF BLOOD SAMPLES FOR BIOCHEMICAL TESTS:

Venous Plasma Glucose

Venous plasma glucose should be the standard method for measuring and reporting glucose

concentrations in blood. This can be done via Oral Glucose Tolerance Test, Fasting Blood Sugar or

Random Blood Sugar in established laboratories.

Capillary Blood Glucose

Ideally for self-monitoring of diagnosed diabetes

patients using a portable blood glucose meter.

However in recognition of the widespread use of

capillary sampling, especially in under-

resourced settings where there is no access to

venous plasma glucose testing determination of

Capillary Blood Glucose using a portable blood

glucose meter can be done provided that it is

determined in the fasting state. This is an indirect

way of determining Fasting Plasma Glucose

(FPG) or FBS since fasting values for venous and capillary plasma glucose are identical.

If glucose values fall on prediabetes or diabetes levels, OGTT or FBS should be recommended on a

subsequent day to establish diagnosis.

TYPES OF TESTS:

Oral Glucose Tolerance Test (OGTT)

OGTT should be recommended first (if acceptable to the patient) before alternative tests are

considered for the screening of diabetes.

WHO recommends it as the standard test to define glycemic status.

OGTT should be the first choice for diagnosis in asymptomatic people since FBS alone fails to

diagnose approximately 30% of cases of previously undiagnosed diabetes

Intermediate hyperglycemia (prediabetes) and asymptomatic type 2 diabetes are best diagnosed

by this test because it determines both fasting and 2-hour plasma glucose values.

Fasting Blood Sugar (FBS)

Less commonly known as Fasting Plasma Glucose (FPG)

Requires 8-10 hours of fasting

It is more convenient to patients, more reproducible, less costly, and easier to administer than OGTT.

It should also be noted that FPG does not detect patients with Impaired Glucose Tolerance (IGT) a

form of prediabetes detected by OGTT.

If FBS is opted as initial screening test for non-pregnant adults an OGTT may be considered in patients

with Impaired Fasting Glycemia (IFG) a form of prediabetes detected by FBS. This is to better define

the risk of diabetes.

Random Blood Sugar (RBS)

Testing of blood sugar anytime of the day.

Can be used aside from FBS to establish diagnosis of those with symptoms.

HbA1c Test (NGSP-certified)

The American Diabetes Association in its Standards of Medical Care in Diabetes 2010 added A1c of

≥ 6.5% as another criterion for the diagnosis of diabetes.

HbA1c is the combination of glucose and adult hemoglobin (HbA). The amount of adult hemoglobin-

that becomes glycated to form HbA1c is directly related to the average concentration of glucose in

the blood. In the normal person, about 3–6% of HbA is glycated; in persons with diabetes, the

percentage of HbA1c may double or even triple depending upon the degree of hyperglycemia.

With normalization of bloodsugar in the diabetic , HbA 1c values will gradually approach normal

levels .

Conversion of Plasma Glucose Values

From Conventional (mg/dl) to SI units (mmol/L)

multiply by 0.05555

eg. 200 mg/dl x 0.0555 = 11.1 mmol/L

From SI units (mmol/L) to conventional units

multiply by 18.02

eg. 7.0 mmol/L x 18.02 = 126 mg/dl

31 Module 2

Screening and Diagnosis of Hypertension

Conditions for blood pressure measurement

Participants should refrain from smoking and drinking coffee in the morning prior to BP measurement.

Allow fifteen minutes of rest prior to blood pressure measurements.

The participant should sit straight with both feet flat on the floor arm at slightly more than 90 degree angle

on the elbow rest with crease in elbow level with the heart.

Blood pressure measurement procedure

1. BP will be measured preferably using a

digital or aneroid blood pressure

monitor . The measurer should refer to

the product manual on the operation

and calibration of the apparatus.

2. Position the arm by exposing the upper

arm, the elbow slightly flexed, the

forearm with the palm facing upward

and supported by the elbow rest.

3. Apply the cuff 1 inch above the

antecubital fossa.

4. BP will be measured twice on both arms

with at least a 1 minute interval between

measurements.

5. If the first two measurements in the same

arm will differ by 5mmHg or more, a third

measurement will be taken.

6. The average of the measurements per

arm will be calculated.

7. Record the results.

8. The higher average will be the reported

blood pressure.

Correct Position for Blood Pressure Measurement

Interpretation Systolic

Blood Pressure

Diastolic

Blood Pressure

Those not taking anti-hypertensive medications

Normal < 120 mmHg < 80 mmHg

Pre-hypertension 120 to139 mmHg 80 to 89 mmHg

Stage 1 Hypertension 140 to 159 mmHg 90 to 99 mmHg

Stage 2 Hypertension 160 mmHg or higher 100 mmHg or higher

Those taking anti-hypertensive medications

Hypertension Controlled < 130 mmHg < 80 mmHg

Hypertension Not Controlled 130 mmHg or higher 80 mmHg or higher

Interpretation of Blood Pressure Readings:

32

Module 2

Monitoring of CVD Risks

The overriding goal for diabetes management is to

lower all glucose parameters to as near to normal as

safely possible. These goals provide a framework for

initiating and monitoring clinical management.

However, targets should be individualized. All

improvements are beneficial whether or not a

target is reached.

Key Concepts in Setting Glycemic Goals

1. HbA1c is the primary target for glycemic control.

2. The goal of diabetes therapy should be to

achieve glycemic status as near to normal as

safely possible in all three measures of glycemic

control ( HbA1c, fasting premeal and postmeal

plasma glucose).

3. Certain populations (children, pregnant women,

and elderly) require special considerations.

4. More stringent glycemic goals (eg. A1c of <6%)

may further reduce complications at the cost of

increased risk of hypoglycemia.

5. Less intensive glycemic goals may be indicated

in patients with severe or frequent

hypoglycemia.

6. Postprandial glucose may be targeted if A1c

goals are not met despite reaching pre-prandial

glucose goals.

Self Monitoring of Blood Glucose (SMBG)

Self monitoring of blood glucose using a glucose

meter is currently the optimal method for assessing

plasma glucose levels. It allows people with

diabetes and the diabetes management team to

obtain and use information about ―real-time‖

plasma glucose levels to facilitate timely

intervention to achieve and maintain near-normal

blood glucose levels.

Frequency

The frequency of monitoring will depend upon

available resources, either to the individual or the

community concerned. Extra tests should be

performed during illness or prior to strenuous

activity.

Quality Control

Self monitoring technique should be checked once

or twice per year by the physician or healthcare

team. Quality control of tests is essential, particularly

if results are inconsistent with HbA1c or clinical state.

Other Parameters

Blood or urine ketone tests should be

performed during illness or when blood glucose is >

20 mmol/L (. 360 mg.dl)

Screening of Complications

Retinopathy and Blindness

Refer to ophthalmologist for a comprehensive,

dilated eye examination at the time of diagnosis.

Assess visual acuity every 1-2 years

More frequent examinations are required if

retinopathy is detected;

Mild Non-proliferative diabetic retinopathy

- every 6-12 months

More severe retinopathy — every 3-6 months

Nephropathy

Screening should be performed annually

The minimum requirement is to dipstick the urine

for protein that will detect overt proteinuria.

The simplest test for micro-albuminuria is a

urinary albumin:creatinine ratio.

If levels are abnormal the test should be

repeated within 3 months to confirm the

diagnosis.

Serum creatinine should be measured annually.

Diabetic Foot

Foot screening should be performed annually in

all patients with diabetes.

Risk of neuropathic foot ulceration is most easily

detected using a 5.07/10 g Semmes Weistein

monofilament.

Palpation of foot pulses (dorsalis pedis and

posterior tibial) is the simplest means of

identifying peripheral arterial disease.

Check for skin cracks, infection, state of nails,

callus, deformities and suitability of footwear

during each visit

Capillary blood glucose testing using a

portable blood glucose meter

33 Module 2

Monitoring of CVD Risks continued

The 7 Monitoring Parameters

Monitoring Parameters Target Value Frequency

1 Blood Sugar HbA1c < 6.5 % Every 3-6 months

Fasting / Pre-meal

(Capillary)

< 5.6 mmol/L Done daily.

Frequency

depends if on

insulin and the

degree of blood

sugar control.

2-hour post meal

(Capillary)

< 7.8 mmol/L

2 Blood Pressure < 130/80 mmHg Every visit

3 Cholesterol LDL Cholesterol < 2.5 mmol/L

(<97 mg/dl)

Once a year

Triglyceride < 1.5 mmol/L

(<133 mg/dl)

Once a year

HDL Cholesterol > 1.0 mmol/L

(>39 mg/dl)

Once a year

Total Cholesterol ≤ 4.5 mmol/L

(≤ 174 md/dl)

Once a year

4 Urine Albumin Negative Once a year

5 Smoking Status No Every visit

6 Waist Circumference < 80 cm—Females

< 90 cm—Males

Depending on

weight loss goals

7 Foot Risk O or if with ulcer (3)

for the ulcer to heal

and foot risk main-

tained (0-2)

Depending on

foot risk

category

Requesting for

Biochemical Tests

Use this laboratory

request form to

request for biochemical

tests. Check the

desired test

accordingly. At the

back are instructions for

the patients before

going for testing. Do

not forget to read out

loud to the patients the

instructions on the back

and encircle the type

of test.

34

Module 2

Notes:

35 Module 2

Notes:

36

Contents:

Introduction

Pharmacologic Management of Diabetes

Pharmacologic Management of Hypertension

Pharmacologic Management of Dyslipidemia

Dietary Management

Weight Management

Physical Activity and Exercise

Tobacco Smoking Cessation

Introduction

Module 3

MANAGEMENT: PHARMACOLOGIC TREATMENT,

MEDICAL NUTRITION THERAPY AND LIFESTYLE INTERVENTIONS

The ultimate goal of management is to improve quality of life and productivity of people with

CVD risks like diabetes by: early diagnosis, prevention of complications, prevention of premature death,

promotion of self-care practices and reduction of personal, family and societal burden of disease.

The successful establishment of the health care team and infrastructure to support it is critical for

the achievement of these goals. This includes provision of education for health-care professionals and for

people with CVD risks.

Essential Components of Care

The care of a person with CVD risks like diabetes and hypertension does not only mean

pharmacologic management. Equally important is the simultaneous application of non-pharmacologic

interventions– dietary, physical activity, education and psychosocial support to:

Control Hyperglycemia

Treat hypertension and dyslipidemia

Prevent and treat complications (microvascular and macrovascular)

Initial Evaluation

On the patient’s first visit after a diagnosis is confirmed, a complete medical evaluation should be

performed to:

1. Classify the patient.

2. Detect complications.

3. Assist in formulating a management plan.

4. Provide a basis for continuing care.

If the patient is previously diagnosed with diabetes and/or hypertension, the evaluation should

review the previous treatment and the past and present degrees of glycemic and/or blood pressure

control.

The care of a person with CVD

risks like diabetes does not only

mean pharmacologic

management. Equally important is

the simultaneous application of

non-pharmacologic interventions.

Pharmacologic Management of Diabetes

Pharmacologic treatment of hyperglycemia uses two types of drugs which address the underlying

metabolic abnormalities: oral anti-diabetic agents (OADs) and insulin. The following are general principles

of pharmacologic therapy:

Prediabetes

For individuals with IFG, IGT or both, health care providers should first actively counsel patients to maintain

normal weight and exercise regularly. Because of potential side effects and cost, there is insufficient

37 Module 3

Pharmacologic Management of Diabetes continued

evidence to support the use of drug therapy as a

substitute for, or routinely used in addition to, lifestyle

modification to prevent diabetes.

Initiation of OAD

Metformin therapy should be initiated ( if there are

no contraindications) concurrent with lifestyle

intervention at diagnosis. This is the first step in

treating new-onset type 2 diabetes. Metformin

should be titrated to its maximally effective dose

over 1-2 months as tolerated.

Monotherapy vs Combination Therapy

If lifestyle intervention and maximal tolerated dose

of metformin fail to achieve or sustain glycemic

goals, another medication should be added within 2

to 3 months of the initiation of therapy or at any time

when the A1c goal is not achieved.

Combination therapy options include:

Metformin + Secretagogue ( sulfonylurea or

meglitinide )

Metformin + Thiazolidinedione

Metformin + Secretagogue + Thiazolidinedione

Secretagogue + Thiazolidinedione

Secretagogue + α-glucosidase inhibitor

OAD in Children

Patients who are not ill at diagnosis can be

managed initially with medical nutrition therapy and

exercise, but most will eventually require drug

therapy. Although insulin is the only drug approved

for treatment of diabetes in children pediatric

diabetologists use oral agents for children with type

2 diabetes. If pharmacologic therapy is indicated

and if insulin is not available the first oral agent used

is metformin.

OAD in Pregnancy

No oral agent should be used in pregnancy.

If a patient becomes pregnant or if a pregnant

patient develops diabetes it is best to refer for

initiation of insulin therapy.

Initiation of Insulin

If lifestyle, metformin, and a second medication do

not result in goal glycemia, the next step should be

to start, then intensify insulin therapy. Insulin can be

titrated rapidly and is associated with greatest

likelihood of returning blood glucose rapidly to

target levels. After symptoms are relieved, oral

agents can often be added and it may be possible

to withdraw insulin, if preferred.

Indications for the Use of Insulin in Type 2 Diabetes:

1. Fasting Blood Sugar of > 13.9 mmol/l

( 250 mg/dl )

2. Random Blood Sugar of > 16.7 mmol/l

( 300 mg/dl)

3. HbA1c of > 10%

4. Presence of ketonuria

5. Symtomatic diabetes with polyuria, polydipsia

and weight loss

6. Failure to meet glycemic targets with OHAs

7. Presence of contraindications to OHAs

8. Hyperglycemic emergency

9. Pregnancy

10.Peri-operative period especially major or

emergency surgery

11.Other medical conditions requiring tight

glycemic control

12.Organ failure (eg. Renal, liver, heart )

Guidelines for Commencing Insulin:

1. Continue oral hypoglycemic agents

2. Start with intermediate acting / long-acting

insulin at bedtime

3. Initial dose of 0.2 units / kg

4. Monitor premeal glucose ( fasting plasma

glucose-FPG )

5. Aim for FPG of 4-8 mmol/L (72-144 mg/dl),

individualize

6. Adjust insulin by 2-4 units every 3-4 days until FPG

target is met. Proceed to twice-daily insulin if

daytime blood sugars or HbA1c are elevated,

and nocturnal hypoglycemia is occurring.

Insulin Dosage:

The correct dose of insulin is that which achieves the

best attainable glycemic control without causing

obvious hypoglycemic problems.

For Children and Adolescents:

Partial remission phase < 0.5 IU/kg/day

Prepubertal children 0.7—1.0 IU/kg/day

Puberty 1-2 U/kg/day

For Adults

Adult 0.5—1 U/kg/day

38

Module 3

Medical Management of Diabetes at Health Centers

Source: Department of Health, Republic of the Philippines. Prevention and Control of Chronic, Lifestyle-Related

Noncommunicable Diseases in the Philippines Manual of Operations. 2009

39 Module 3

The goal of all interventions is to achieve and maintain glycemic levels within or as close as possible to

the normoglycemic range

Lifestyle intervention and metformin should be considered as the first step in the treatment of new-onset

type 2 diabetes

Reinforce lifestyle interventions at every visit. Check A1C every 3 months until A1C is <7% and then at

least every 6 months

For patients with type 2 diabetes who do not meet glycemic goal after 2 to 3 months with metformin and

lifestyle intervention alone, adding basal insulin can be considered as one option

Insulin analogs with longer nonpeaking profiles have a low rate of hypoglycemia

Initiate basal insulin with 10 units or 0.2 units/kg, and titrate until fasting levels are consistently within target

range

40

Module 3

41 Module 3

42

Notes:

Module 3

43 Module 3

Notes:

44

Oral Anti-Diabetic Agents General Information

CLASS Primary Action

Site of Action

Adverse Effects

Contra- indications

Sulfonylurea

insulin secretion (insulin secretagogue)

Sulfonylurea receptors in pancreatic beta islet cells

Hypoglycemia (++1st gen & + 2nd gen) Weight Gain

Renal Insufficiency Liver Diseases Known Hypersensitivity

Meglitinides

insulin secretion

(insulin secretagogue)

Receptors

in pancreatic beta islet cells

Hypoglycemia

Weight Gain

Liver Diseases

Known Hypersensitivity

a-Glucosidase Inhibitors

carbohydrate absorption

Small Intestine

Gastrointestinal Symptoms

Renal Insufficiency Liver Diseases Inflammatory Bowel Disease Known Hypersensitivity

Biguanides

Hepatic Glucose production

Unknown Gastrointestinal Symptoms Lactic Acidosis

Renal Insufficiency Liver diseases Alcoholism Congestive Heart Failure Known Hypersensitivity

Thiazolidinediones Insulin sensitivity

Peripheral glucose uptake

PPARg

receptors in insulin-sensitive tissues

Weight Gain

Edema Congestive Heart Failure

Liver Disease

Alcoholism Congestive Heart Failure Known Hypersensitivity

DPP-4 Inhibitors

Inhibits degradation of DPP IV Incretin enhancers to increase insulin secretion and suppress glucagon secretion

Small Intestines Uncommon: hypo-glycemia, GI symp-toms, peripheral edema nasopharyngitis, headache

Known hypersensitivity Type 1 DM, diabetic ketoacidosis

CLASS Types Indications

Time-Action Profile (hours)

Onset

Peak Level

Duration

Sulfonylurea

1st Generation Chlorpropramide Tolbutamide Acetohexamide 2nd Generation Glipizide Gliclazide Glyburide or Glibenclamide Glimepiride

Difficult to control diabetes or with poor compliance Older Diabetics Older Diabetics Younger Diabetics

0.5 4-5 1

2-4

4

1-3 6-12 2-6

2-3

60

12-24 24

12- 24

16-24

Meglitinides

Repaglinide Nateglinide

Postprandial Hyperglycemia

0.25-0.5

0.3

1 1

4-6

1-4

a-Glucosidase Inhibitors

Acarbose Voglibose

Postprandial Hyperglycemia

1

0.25

1-2

1-1.5

4

Biguanides

Metformin Overweight patients with insulin resistance

2-3 7-12

Module 3

45 Module 3

Oral Anti-Diabetic Agents Preparations and Dosages

CLASS Types Indications

Time-Action Profile (hours)

Onset

Peak Level

Duration

Thiazolidinediones Pioglitazone Insulin Resistance 1 1-2

DPP-4 Inhibitors

Sitagliptin Vildagliptin Saxagliptin

Fasting and post-prandial hyperglycemia

1-4

1.7—2.5

2-4

24

12

24

Note: For drug preparations, daily doses and maximum dose of different types of drugs please consult product inserts, the Philippine Drug Formulary, PPD or PIMS.

CLASS Types Preparation

(tablets) Initial Daily Dose

Maximum Dose

(mg/day)

Sulfonylurea

Chlorpropramide Tolbutamide Glipizide Gliclazide Glyburide or Glibenclamide Glimepiride

250 mg 500 mg 2.5,5,10 mg 80 mg 5 mg 1,2,3 mg

250 mg OD a.m. 2.5mg OD for elderly 30 mins AC 80 mg BID-TID 30 mins AC 2.5-5 mg OD 1-2 mg OD

100-500 mg 40 mg 40-320 mg 20mg 8 mg OD

Meglitinides

Repaglinide Nateglinide

0.5,1,2 mg 0.5 – 2 mg tab BID-QID 15 minutes before meals 120 mg TID, 60 mg TID in elderly 15 minutes before meals

0.5-16 mg 120 mg TID

a-Glucosidase Inhibitors

Acarbose Voglibose

50 & 100 mg 200 , 300 mcg

25 mg tab TID after first mouthful of food 200-300 mcg tab TID after first mouthful of food 25 mg tab TID afetr first mouthful of food

100 mg TID 600-900 mcg 100 mg TID

Biguanides

Metformin 500 & 850 mg

500 mg BID or 850 mg OD Taken AC

Maximum 3 grams

Thiazolidinediones Pioglitazone 15 & 30 mg 15 mg OD-BID 30 mg tab OD

45 md OD

DPP-4 Inhibitors Sitagliptin Vildagliptin Saxagliptin

25,50 & 100 mg 50 mg 2.5 & 5 mg

100 mg OD mono or combination 50 mg OD—moderate renal insuffi-ciency 25 mg OD—end-stage renal disease Can be taken without meals 50 mg OD to BID 5 mg OD mono or in combination 2.5 mg OD—renal impairment/end stage renal disease

Abbreviations: OD – once a day, BID- twice a day, TID- Three times a day, QID- four times a day, AC- before meals

Note: For drug preparations, daily doses and maximum dose of different types of drugs please consult product inserts, PPD or PIMS.

46

Module 3

Various Insulin Formulations

Classification Description / Recommendations Type

Action Profile

Onset (hrs)

Peak (hrs)

Duration (hrs)

Rapid Acting Analogues

Can be given immediately before meals because there is

evidence that the rapid action not only reduces postprandial hyperglycemis but that postprandial and nocturnal hypoglycemia may also be reduced.

Offer the useful option of being given after food to toddlers

who are reluctant to eat.

Give a quicker effect than regular insulin when treating

hyperglycemia, with or without ketosis, including sick days.

Most often used as prandial or snack boluses in combination

with longer acting insulins given twice or more times daily.

Most often used in insulin pumps.

ALL CHILDREN SHOULD HAVE SOLUBLE OR RAPID ACTING

INSULIN AVAILABLE FOR CRISIS MANAGEMENT.

Lispro Aspart Glulisine

0.15-0.35 1-3 3-5

Short Acting Used as an essential component of most daily replacement

regimens either: in combination with intermediate acting insulin in a twice-daily regimen as pre-meal bolus injections in basal-bolus regimens (20-30 min before meals) together with intermediate acting insulin twice daily or a basal analogue given once or twice a day.

Regular insulins are best suited for intravenous therapy.

Rapid-acting insulins can also be given IV. However the effect is not superior to that of regular insulin and it is more expensive.

Soluble insulin is used in the following crisis situations:

diabetic ketoacidosis control of diabetes during surgical procedures hyperglycemic episodes at home (eg. During intercurrent illness)

Regular/ Soluble

0.5 -1 2-4 5-8

Intermediate Acting

Suitable for twice-daily regimens and for pre-bed dosage in

basal-bolus regimens

Isophane insulins are extensively used in children, mainly

because of their suitability for mixing with soluble or rapid-acting insulins in the same syringe, vial or cartridge without interaction

WHEN REGULAR INSULIN IS MIXED WITH LENTE

PREPARATIONS IT REACTS WITH EXCESS ZINC, BLUNTING ITS SHORT-ACTING PROPERTIES.

Isophane NPH

2-4 4-12 12-24

IZS/lente 3-4 6-15 18-24

Semilente 1-2 4-10 8-16

Long Acting Designed to have a duration of action of more than 24

hours to meet basal insulin requirements and therefore could be used in basal-bolus injection regimens. Their action profile in children appears to be extremely variable and they may have to be injected twice daily to meet basal insulin requirements.

Ultralente Ultratard

4-8 12-24 20-30

Basal Analogues

Show a more predictable insulin effect with less day-to-day

variation compared with NPH insulin

More expensive

Have not been formally approved for children younger than

6 years old

Glargine 2-4 none 24

Detemir 1-2 6-12 20-24

Pre-mixed Fixed ratio mixtures of premeal and basal insulins. Although they remove potential errors in drawing up insulin, they remove the flexibility offered by separate adjustment of the two types

50% NPH + 50% regular, 70% NPA + 30% aspart 70% NPH + 30% regular, 75% NPL + 25% lispro

Source: International Society for Pediatric and Adolescent Diabetes, "ISPAD Clinical Practice Consensus Guidelines 2006-2007." Pediatric Diabetes Vol. 72006-2007 28 Nov 2007 <www.ispad.org>.

47 Module 3

Insulin Regimen

Regimen Indications Recommendations

Basal Insulin + oral agents

When oral agents fail to achieve the target glycemic control

Continue oral agents at same dose Add single, evening insulin dose 10 U or 0.15-0.2 u/kg/day

NPH (bedtime) 70/30 (evening meal) Glargine (bedtime or with evening meal)

Titrate dose weekly according to fasting SMBG* (FPG) Increase by 4U if FPG> 140 mg/dl Increase by 2U if FPG = 120 -140 mg/dl

Treat to target ( usually <120 mg/dl) Reduce morning oral agent dosage if daytime hypoglycemia

occurs

Two Insulin injections + Oral agents

When FPG is acceptable but HbA1c is 7% or if evening NPH or 70/30 dose is large (>50 u) and targets are still not achieved

Oral agent options: Stop Sulfonylurea Continue Metformin for weight control Continue glitazone for glycemic stability Insulin options: NPH bedtime + morning NPH + regular/aspart/lispro with

evening meal 70/30 (evening meal) + 70/30 morning Glargine + regular/aspart/lispro to main meal

Basal-Bolus

When HbA1c is >7% on 2 injections

Oral agent options: Continue Metformin for weight control Continue glitazone for glycemic stability Insulin options: Bedtime NPH and morning NPH + regular/aspart/lispro with each

meal Glargine + regular/aspart/lispro with each significant meal

Monotherapy Start at 0.5 – 1.0 unit/kg/day May start at low, fixed dose of intermediate acting insulin

(15-20 in AM and 5-10 at HS)

Options: NPH or Premixed twice a day Single morning or bedtime NPH

Increase by 10-20% once or twice a week If dose reaches >40-50 units give 2/3 total in AM and 1/3 total in PM. When requirement reaches 1-1.5 u/kg may do any of the

following: Shift to multiple injections when necessary Add insulin sensitizers (Met, TZD) Increase dose to break state of insulin resistance

Mixed split Conventional insulin therapy

PREBREAKFAST with HN, H70/30 or R/N PRESUPPER with HN, H70/30 or R/N

Premixed Convenient method for taking 2 types of insulin. Eliminated errors inherent in the multi-step procedure of

self-mixing

Multiple components

Conventional insulin therapy Multiple doses of short acting insulin + 1-2 doses of intermediate

or long acting insulin

48

Pharmacologic Management of Hypertension

Adapted from: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and the

Treatment of High Blood Pressure. The NHLBI JNC 7 Express. NIH Publication No. 03-5233, May 2003

No drug therapy

Treat conditions

accordingly; some may warrant use of

antihypertensives

Start Monotherapy

Start Combination

Therapy

Consider: First line Antihypertensives

Ace inhibitor Angiotensin Receptor Blocker Thiazide Type Diuretics Beta blocker Calcium Channel Blocker

refer to Next Page

Use combination of First Line antihypertensives if

with complications and with high risk conditions

BP Target not reached

Drug elicits no response or has

intolerable side effects

Drug is tolerable but elicits insufficient clinical

response

Replace with drug from a different class

Add drug from a different class

BP Target not reached

Continue adding other drugs / refer to hypertension specialist

BP Target reached Follow-up every

3-6 months

Patient with Diabetes

Assess Blood Pressure

Abnormal SBP ≥ 120 mmHg DBP ≥ 80 mmHg

Pre-Hypertension SBP=120-139 mmHg DBP=80-89 mmHg

Stage 1 SBP=140-159 mmHg DBP=90-99 mmHg

Stage 2 SBP ≥ 160 mmHg DBP ≥ 100 mmHg

Initiate Lifestyle

Modification

Target: SBP < 130 mmHg DBP < 80 mmHG

Complications

and high risk conditions

NO YES

With Complications

YES NO

Module 3

49 Module 3

Oral Antihypertensive Drugs

Drug Indications Contraindications Time Action Profile

Onset of Action (h)

Time of Peak (h)

Duration (h)

ACE Inhibitors

Captopril

Hypertension Heart failure Acute and post-MI Left Ventricular

Dysfunction Diabetic nephropathy

Idiopathic or hereditary

angioedema Bilateral renal artery ste-

nosis Pregnancy (2nd & 3rd

trimester) Hypersensitivity

1-1.5 1-1.5 6-12

Enalapril 1 4-6 24

Lisinopril 1 7 24

Moexipril 1-2 3-6 24

Quinapril 1 2-6 18-24

Ramipril 1-2 3-6 24

Trandolapril 2-4 4-10 24

Angiotensin II Receptor

Antagonist

Losartan

Hypertension with or

without concurrent use of thiazide diuretics

Diabetic nephropathy

Hypersensitivity Primary

hyperaldosteronism Bilateral renal artery ste-

nosis Pregnancy (2nd & 3rd

trimester)

6

6

24

Irbesartan

Telmisartan

Diuretics

Hydrochlorothiazide

Edema, mild to moderate hypertension (hydrochlorothiazide)

Edema, hypertension, congestive heart failure (furosemide)

Edema and ascites associated with CHF, liver cirrhosis, or nephritic syndrome, essential hypertension, hypokalemia, primary aldosteronisn (K+ diuretics)

Anuria Hepatic coma Severe electrolyte

depletion, imbalance Hypersensitivity Pregnancy, lactation Hypokalemia (furosemide) Hyperkalemia

(spironolactone) Hyperuricemia/ Gout Severe or progressive renal

insufficiency Clients receiving potassium

supplements, amiloride, or triamterene (spironolactone)

2

4-6

6-12

Furosemide 1 1-2 6-8

Bumetanide 30-60 mins 1-2 4-6

Amiloride hcl 2 6-10 24

Triamterene 2-4 6-8 7-9

Spironolactone 1-2 days 2-3 days

Beta Blockers

Atenolol Hypertension Angina pectoris Acute and post-MI Congestive heart failure Arrhythmias

Sinus bradycardia Peripheral arterial

occlusive disease 2nd and 3rd degree heart

block Cardiogenic shock Pulmonary edema Bronchial asthma

0.25

1-1.5

6-12

Metoprolol 1 2-4 24

Propranolol 0.5 1-1.5 3-5

Calcium Channel Blockers

Amlodipine

Angina pectoris Mild to moderate

hypertension Supraventricular

tachyarrhythmias

Hypersensitivity Left ventricular

dysfunction Hypotension Cardiogenic shock Sick sinus syndrome 2° & 3° AV block Atrial flutter or fibrillation Pregnancy Acute MI Pulmonary congestion

Felodipine

Verapamil 2 6-8

Diltiazem 0.5-1 2-3 6-11

50

Oral Antihypertensive Drugs continued

Notes:

Drug Indications Contraindications Time Action Profile

Onset of Action (h)

Time of Peak (h)

Duration (h)

Alpha and Beta Blockers

Carvedilol

Hypertension Angina Congestive heart failure Myocardial infarction (MI)

Bronchial asthma or COPD Cardiogenic shock Hypersensitivity Overt cardiac failure 2° & 3° AV block Sick sinus syndrome Severe hepatic dysfunction

1 4-7 24

Centrally-acting adrenergic block-

er

Methydopa

Moderate to severe hypertension

Resistant cases of hyperten-sion complicated by stroke, CAD, or nitrogen retention

Hypertensive crisis Impaired renal function Renal hypertension

Hypersensitivity Mild hypertension Active hepatic disease

7-12 4-6 12-24

Direct Vasodilators

Hydralazine

Essential hypertension Drug of choice for eclamp-

sia Reduce afterload of CHF Severe aortic insufficiency

after valve replacement

Coronary artery disease Angina pectoris Advanced renal disease Rheumatic heart disease Chronic glomerulonephritis

45 min 1-2 3-8

Module 3

51 Module 3

Pharmacologic Management of Dyslipidemia

Use NICOTINIC ACID or

FIBRATES

Use FIBRATES Use STATINS

Monitor Lipid Profile

Every 3-6 months

Diagnosed with Dyslipidemia NO

Monitor Lipid Profile

Annually

Person with Diabetes

For LDL For Triglycerides For HDL

YES

Manage

Initial Treatment: Non-Pharmacologic interventions

1. Improve blood glucose control 2. Reduce saturated fat intake 3. Ensure regular moderate exercise 4. Reduce weight if indicated 5. Avoid alcohol intake if triglyceride is elevated 6. Discourage smoking

Add pharmacotherapy if above interventions are unsuccessful

after 6 months

Specifications:

Statins should be used in all those with previous CVD, irrespective of current lipid levels, with the aim of achiev-

ing LDL < 2.5 mmol/L.

For those without CVD and > 40 years of age, statins should be used if LDL ≥ 2.5 mmol/L or if total cholesterol ≥

4.5 mmol/L. For those < 40 years old, statins should be considered if other cardiovascular risk factors (hypertension, smoking, microalbuminuria, family history of premature CVD) are also present.

Once LDL targets are achieved, fibrates should be considered if triglycerides are ≥ 1.5 mmol/L or HDL ≤ 1.1

mmol/L.

Triglyceride lowering agents should be used if triglycerides are > 4.5 mmol/L to prevent pancreatitis.

Consideration should be given to the use of other lipid-lowering drugs (e.g. ezetemibe, sustained release

nicotinic acid, concentrated omega 3 fatty acids) in those who fail to reach lipid targets or who are intolerant of conventional drugs.

All patients with abnormal lipid levels should have intensified lifestyle interventions.

Source : 1. Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical

Targets and Treatments. International Diabetes Institute:Melbourne, Australia, 2005. 2. International Diabetes Federation and World Diabetes Foundation. Type 2 Diabetes Clinical Practice Guidelines for Sub-saharan

Africa. IDF Africa Region Task Force on Type 2 Diabetes Clinical Practice Guideline. July 2006.

52

Oral Lipid-Controlling Agents

Drug Indications Contraindications Dosing Informaton

Initial Dose Dosage Range

Regimen

HMG-CoA Reductase Inhibitors

Atorvastatin

First line for LDL Maybe added to non-

pharmacologic therapies for hyperlipidemia

Coronary artery disease and concomitant hypercholesterolemia

Active liver disease Unexplained elevations of

serum transaminases Hypersensitivity Pregnancy and lactation

10-20 mg

10-80

mg OD

Fluvastatin 20-40 mg 20-80 mg OD

Lovastatin 20 mg 10-80 mg OD

Pravastatin 40 mg 10-80 mg OD

Simvastatin 20-40 mg 5-80 mg OD

Fibric Acid Derivatives

Gemfibrozil

triglycerides Increases HDL cholesterol

Gallbladder disease Hepatic disease Hypersensitivity Primary biliary cirrhosis Renal disease

Coadministration of genfibrozil and cerivastatin

1200 mg divided twice daily

Fenofibrate Starting doses: Hypocholesterolemia— 160 mg OD Hypertryglyceridemia– 54-160 mg/day With Rrenal impairment– 54 mg/day

Fenofibrate, micronized

67-201 mg/day taken with food

Nicotinic Acid Niacin

triglycerides LDL HDL

Hypersensitivity Active liver disease Active peptic ulcer disease Arterial bleeding Uncontrolled hyperglycemia

100 mg 1-6 g TID

Niacin extended release 500 mg 1-2 g OD

Notes:

Module 3

53 Module 3

Setting Dietary Management Goals

Screening or Diagnosis of Diabetes

Patient with Diabetes

With Prediabetes

Assess patient’s nutritional status according to the following: Patient’s diet history

Anthropometric Measurements

Glucose , lipids and metabolic profile

Clinical findings

Determine BMI and Waist Circumference

Overweight or Central Obesity?

Consider weight loss by: total caloric intake by 250-500 kcal physical activity Refer to Weight Management Algorithm

Determine: Glucose levels (if controlled) through

self monitoring or HbA1c levels Lipids

No Yes

No

YesNo

Persistently

high glucose?

Elevated Lipids?

Recommend balanced varied meal plan

with lots of fiber Refer to physician for further assessment

Recommend less saturated fat intake and more monosaturated fat

Yes

Yes

Determine patient’s food choices and eating habits

Nutrient abnormalities Yes

Nutrient deficient: incorporate food items rich in the needed nutrient and

modify diet prescription. Nutrient excess: identify and lessen

intake of food items rich in nutrients found in excess, and modify diet prescription.

Yes

Recommend the basic Filipino Pyramid Food

Guide And Weight Management

Algorithm if overweight or

obese

Follow Dietary Mgt. recommendations

No

No

No

Source: An Evidence-Based Approach to

Diabetes Management for Health Care

Professionals ( A Learning Module Series),

First Edition.

54

Module 3

WHO Protocol for Counseling on Diet and Physical Activity

Source: World Health Organization CVD Risk Management Package for Low and Medium Resource Settings 2002

55 Module 3

Basic Nutrition Education Using the Idaho Plate Method

56

Module 3

Using the Food Diary

The food diary is a tool to document a

patient’s actual food intake based on the Idaho

plate method. This can be used by the health

care team especially the Nutritionist-Dietitian for:

1. Meal planning—so that meals can be based

on actual food that are available and the

patient can afford.

2. Monitoring—if the actual prescribed diet is

practiced by patients.

57 Module 3

Meal Planning Using the Plate Method

Actual meals can also be planned using the plate method for easy understanding by patients. Nutritionists

can place the actual menu on the designated portions of the plate. The corresponding amount of the

food is also placed. A 1-week sample meal plan can be made per patient as a food reference.

58

Calculate the patient’s Desirable Body Weight (DBW)

Tannhauser’s (Broca) Method:

[ Height (cm) – 100] – 10% of difference= DBW in kg (eg. [165cm-100] – 6.5 = 58.5 kg)

Get the Total Energy Requirement (TER)

DBW in kg x Energy requirement based on physical activity

If the patient is a driver: (eg. 58.5 x 35 = 2048 kcal or 2050 kcal)

Determine the carbohydrate, protein and fat percentage

distribution of the TER. Consider the health and

nutritional status of the patient.

Eg. Carbohydrates 60%

Protein 20% Fat 20%

Note: No single ―diabetic diet‖ is appropriate for the

general population of patients with diabetes. Such patients have different needs depending on their nutritional and health status, physical activity and lifestyle. A short method of diet computation is based on the prescribed caloric contributions of carbohydrates, proteins and fats distributed as: CARBOHYDRATE = 55-70% ( 60% - normal diet ) PROTEINS = 10-20% ( 20% - normal diet ) FATS = 20-30% ( 20% - normal diet )

Translate the percent distribution into kilocalories.

Eg. 2050 x 0.60 = 1230 kcal CHO (Carbohydrates)

2050 x 0.20 = 410 kcal CHON (Proteins) 2050 x 0.20 = 410 kcal FATS

Convert calories into GRAMS.

Eg. 1230 kcal / 4 = 307.5 g CHO (Carbohydrates)

410 kcal / 4 = 102.5 g CHON (Proteins) 410 kcal / 9 = 45.5 g FATS

Plan a menu distributing the serving portions for values at breakfast, lunch and dinner MEAL PLANNING BY THE

NUTRITIONIST-DIETITIAN

Diet Prescription

TER : 2050 kcal

Carbohydrates= 310 g

Proteins = 100 g

Fat = 45 g

Refer to the following tools for meal planning:

1. Food Exchange list by FNRI and DOST

2. Nutritional Guidelines 3. Food Pyramid

For simplicity and practicality of the diet prescription, round off calories to the: Nearest 50 for calories Nearest 5 for proteins, fats, & carbohydrate

Table 5. Energy Requirement Based on Physical Activity

Classification Description kcal/kg

DWB/day

Bed rest Hospital patients 27.5

Sedentary Mostly sitting 30

Light Tailor, nurse, physician, driver 35

Moderate Carpenter, painter, housework 40

Heavy Swimming, lumberman 45 Source: Food Exchange Lists For Meal Planning Food and Nutrition Research Institute and Department of Science and Technology.

Source: An Evidence-Based

Approach to Diabetes

Management for Health Care

Professionals ( A Learning Module

Series), First Edition.

Calculating Individualized Dietary Prescription

Module 3

59 Module 3

Practice Diet Prescription

Carbohydrates Carbohydrate should approximate 55-70% of calories/day.

Total carbohydrate content rather than type should be considered.

When added to monounsaturated fats, carbohydrates should make up 70% of total calories/day.

25-50 grams of carbohydrates from fiber per day may be given.

Sucrose need not be restricted and could be substituted as carbohydrate as long as total energy

requirement (TER) is not exceeded. However sucrose should be eaten in the context of a healthy diet.

Non caloric sweeteners are acceptable within prescribed levels.

Sugar alcohols may be used with caution and should not be taken in amounts of >10g/day.

Fructose consumption should be limited to 60g/day for a patient with a daily caloric requirement of

2000.

Proteins

Should approximate 10-20% of calories/day

If patient has good glucose control, there is no need to decrease amount of protein intake.

In cases where hyperglycemia is present, protein intake may be > 0.8 g/kg of body weight

but no more than 1g/kg BW per day.

If patient has renal problems, protein intake should not be less than 40g per day, and can be as much

as 0.6—0.8 g/kg BW/day (10-15% of TER).

If the patient has cardiovascular risk factors, replace animal-sourced protein with plant sources.

If source of protein has limited amino acids, complementing proteins should be added.

Fats

Should approximate 20-30% of calories/day

Saturated fat, trans fatty acids should be < 7% of TER

Dietary cholesterol should be < 200mg/day

Polyunsaturated fatty acids should be 10% of TER.

Monounsaturated fatty acids should be >10-15% of TER.

Use mono- and polyunsaturated fats in place of saturated fat

60

Weight Management

The achievement of a normal weight is often unrealistic and does not have to be the ultimate goal of a

weight reduction strategy. Moderate weight loss can have significant benefits. Long term goals for weight

management include:

1. Reduction of excess weight by 5-6 kg or 10% of the initial body weight

2. Maintenance of BMI < 23 kg/m²

3. Any reduction of blood pressure

4. Any reduction of blood glucose

5. Any improvement of glycemic control

6. Any reduction of the modifiable risk factors

Before initiating weight loss management patients should have a full medical assessment to evaluate the

following:

1. Presence of co-morbidities such as diabetes, hypertension and dyslipidemia. These should be

managed accordingly.

2. Age older than 40 years, or who have a history of heart disease, a cardiovascular examination

may be necessary prior to exercise prescription.

3. Secondary causes of obesity including Cushing’s syndrome, hypogonadism and

hypothryoidism that should be referred to specialists and managed accordingly.

4. Symptomatic complications of severe obesity such as obstructive sleep apnea, osteoarthritis,

reflux esophagitis, gravitational edema should be treated actively regardless of whether the

patient is losing weight.

Classification of Weight by BMI in Adult Asians

Classification of Weight by BMI in Adult Asians and Co-morbidities risk associated with the combination of BMI and Waist Circumference

Classification BMI Risk of co-morbidities

Waist circumference

< 90 cm men ≥ 90 cm men

< 80 cm women ≥ 80 cm women

Underweight < 18.5 Low (but increased risk to oth-er clinical problems)

Average

Normal Range 18.5 – 22.9 Average Increased

Overweight ≥ 23

At risk 23 – 24.9 Increased Moderate

Obese I 25 – 29.9 Moderate Severe

Obese II ≥ 30 Severe Very Severe

Source: International Diabetes Institute, World Health Organization-WPRO, International Association for the Study of Obesity, International Obesity Task Force, The Asia-Pacific Perspective: Redefining Obesity and its Treatment. Australia: Health Communications Australia Pty Limited, 2000.

Module 3

61 Module 3

Weight Management Algorithm

Determine patient’s BMI + Waist Circumference related health risk

TREATMENT ACCORDING TO RISK

Monitor for 3-6 months

Weight loss of >5kg or 5-10% of initial BW?

No

Yes Successful

Failure

Reassess and redefine treatment

Adequate weight loss?

Yes

Refer

Continue, maintain and

prevent weight gain

FOLLOW-UP

Yes

Yes

Treat risk factors before starting weight

management or refer to specialist

Overweight or obese?

Weight Problem Suspect

Measure BMI and re-view dietary history

No

Measure WC

No

Normal

Central Obesity?

Yes

CLASSIFYING PATIENTS WORK-UP FOR CAUSES OF OBESITY

Treat with appropriate disease therapy or refer to specialist

Yes

No

No

Offer weight

management

Presence of exclusion criteria

for weight management?

Presence of co-morbidities?

Risk factors?

No

Advice patient to at least address risk fac-tors and prevent fur-

ther weight gain

Monitor twice a year

Patient ready to start the pro-

gram?

Yes

Yes No

PREPARATION

Determine TSH / FT4

Determine Serum

Cortisol (done between

8-10 am)

Yes

Yes

No Refer to Specialist Yes

No

Check for plasma glucose, BP, sleep

apnea, venous stasis, car-diac disease

Hypothyroid signs and

symptoms?

Cushing’s signs

and symptoms?

No

Elevated?

Elevated?

EVALUATION OF CO-MORBIDITIES

Moderate

Severe

Very severe

Yes

Yes

Yes

No

No

No

Extremely severe

Yes

Increase physical activity Lifestyle change

LOW CALORIE DIET

Increase physical activity Lifestyle change Low calorie diet

PHARMACOTHERAPY

Increase physical activity Lifestyle change

Pharmacotherapy VERY LOW CALORIE DIET

Increase physical activity Lifestyle change

Pharmacotherapy Very low calorie diet

REFER FOR SURGERY Recommendation from the Philippine Association for the Study of Overweight and Obesity (PASOO). CPM 7th Edition.

62

Weight Management

Module 3

Conversion of kilocalories to grams

For Carbohydrates (CHO) divide by 4

For Proteins (CHON) divide by 4

For Fats divide by 9

Determining the Body Mass Index

BMI = Weight (kg) or Weight (kg)

Height (m)² Height (m) x Height (m)

Determining Significant Weight Loss

% weight loss = usual weight—actual weight x 100 %

Usual weight

Interpretation Duration Significant weight loss % Severe Weight loss %

1 week 1-2 > 2

1 month 5 > 5

3 months 7.5 > 7.5

6 months 10 > 10

Formulas

63 Module 3

Notes:

64

Physical Activity and Exercise

Before starting an exercise program, a patient has to be screened for presence of risk factors in which

exercises may be contraindicated. Patients are screened and evaluated for these contraindications to

prevent potential complications of exercise. It is for this reason that exercise prescriptions are best done in

consultation with exercise specialists.

Exercise Prescription An appropriate exercise prescription formulates a person’s physical activity program that suits the present

physical condition and status (refer to page 16). Parameters of the exercise prescription are:

Intensity - Amount of exertion done in terms of Target heart rate and perceived exertion.

Target Heart Rate should be 50 – 70% of the maximum heart rate (moderate physical activity)

For the Middle aged – start at 50-60% of maximum heart rate

For 50 years old and above – start at 40-50% of maximum heart rate

For Weight loss – 60-75% of maximum heart rate for 20-30 minutes

75-85% of maximum heart rate should be reserved for a training goal

The objective measurement of the heart rate must be balanced with the subjective perception

of how hard one feels when exercising. There is a need to observe and listen to the body’s

breathing, leg and arm fatigue or a general feeling of being tired. If these are felt there is a need

to slow down and seek appropriate consultation.

Duration - How long a certain physical activity is done.

High intensity exercises should only last for a short period of time. Persons with diabetes should avoid

longer exercise sessions because they result to greater decrease in blood glucose levels. The

recommended duration is a total of ―30 minutes of moderate physical activity on most days of the

week.‖

Frequency - How often an exercise program is done.

As a general rule, short duration activities must be done with more frequency to achieve desired

effects. On the contrary, heavy activities (70% of HRmax) must be done less frequently to avoid

fatigue. The recommended frequency is: 3 non-consecutive days in a week.

Obese patients may need to exercise 6-7 days a week.

Patients on insulin may exercise everyday to decrease difficulty in balancing insulin and caloric

needs

Timing - Time of the day an exercise is done.

Generally, the schedule for exercising depends on convenience. However, patients who are taking

anti-diabetic medications should avoid exercising during peak drug absorption as it may lead to

hypoglycemia during and after the exercise.

Type - Kind of physical activity done.

Provided that there are no contraindications, the choice of activity is completely based on per-

sonal preference. The patient must be involved in planning the program so that he/she could

choose activities that are of interest and therefore avoid boredom. Frequently, exercises consist

of a combination of aerobic and anaerobic exercises

It is also equally important to start with a 20-30 minute warm-up of low intensity aerobic and stat-

ic stretching activities and end the exercise with a 10-15 minute cool down gradually slowing

down the intensity of activity.

Module 3

Sources 1. International Diabetes Federation and World Diabetes Foundation. Type 2 Diabetes Clinical Practice Guidelines for Sub-saharan Africa.

IDF Africa Region Task Force on Type 2 Diabetes Clinical Practice Guideline. July 2006.

2. American Diabetes Association. Standards of Medical Care in Diabetes-2007. Diabetes Care. Volume 30, Supplement 1, January 2007.

65 Module 3

Patient diagnosed with Diabetes Mellitus or Prediabetes

Exercise

Presence of Complications ?

Screening for complications

No

Pharmacologic Stress Test c/o

cardiologist

Yes

YesNo

Proliferative Retinopathy

Cardiovascular Disease

Vascular/Orthopedic Peripheral Neuropathy

LOW IMPACT ACTIVITY

Do stress test/ETT before exercise prescription

LOW IMPACT ACTIVITY With one or more of

the following risk factors ?

1. Hypertension 2. Smoking 3. Hyperlipidemia 4. Family History

of CVD

Identification of Risk Factors

Yes LOW IMPACT ACTIVITY

Determine Age

≥ 35 years old

No

Yes

MODERATE PHYSICAL ACTIVITY

Stress Test is recommended before vigorous physical

activity

No

MODERATE OR VIGOROUS PHYSICAL ACTIVITY

Source: An Evidence-Based Approach to Diabetes Management for Health Care Professionals (A Learning Module Series), First Edition. Adapted from Texas Diabetes Council.

Screening and exercise risk assessment (Identification of Contraindications)

Refer to Appendix 4 on page 34

3. Department of Health Philippines, University of the Philippines Manila., A Training Manual for Health Workers on Promoting Healthy Lifestyles.

Manila Philippines: Publications Unit of WHO-WPRO, 2003.

4. Johnson and Johnson, An Evidence-Based Approach to Type 2 Diabetes Management for Health Care Professionals A Learning Module

Series. First Edition. 2003.

5. Food and Nutrition Research Institute and Department of Science and Technology, Food Exchange List for Meal Planning. 3rd Revision.

Philippines: Philippine Information Agency, 1996.

6. Asia-Pacific Type 2 Diabetes Policy Group and International Diabetes Federation Western Pacific Region, Type 2 Diabetes Practical Targets

and Treatments. International Diabetes Institute:Melbourne, Australia, 2005

7. International Diabetes Institute, World Health Organization-WPRO, International Association for the Study of Obesity, International Obesity

Task Force, The Asia-Pacific Perspective: Redefining Obesity and its Treatment. Australia: Health Communications Australia Pty Limited,

2000.

Physical Activity Prescription

FITT-D Frequency

Intensity

Type

Timing

Duration

66

Selected Physical Activities Defined by Level of Intensity

Light Activity Less than 3.0 METs

(<3.5kCal/min)

Moderate Activity 3.0 to 6.0 METs (3.5-7kCal/min)

Vigorous Activity Greater than 6.0 METs

(> 7 kCal/min) Walking casually , < 3 mph In the house or yard

Window shopping

Walking at a moderate or brisk pace, 3-4.5 mph on a level surface, inside or outside, such as To class, work or store

For pleasure

As a break from work Walking downstairs or down a hill Racewalking, < 5mph Hiking Roller skating, leisurely pace

Racewalking and aerobic walking, 5 mph or faster Jogging or running Walking and climbing briskly up a hill Marching rapidly (military ) Mountain climbing, rock climbing, rapelling

Roller skating, fast pace

Bicycling, < 5 mph Stationary bicycling, using very light effort

Bicycling 5-9 mph, level terrain Stationary bicycling, using moderate effort

Bicycling, > 10mph , or bicycling on steep uphill terrain Stationary bicycling, using vigorous effort

Stretching exercises, slow warmup

Calisthenics, light gymnastics General home exercises, light or moderate effort, getting up and down from the floor Jumping on a trampoline

Calisthenics, push-ups, vigorous effort Karate, judo, tae kwondo, jujitsu Jumping rope Performing jumping jacks

Boxing, punching bag Boxing, in the ring, sparring Wrestling, competitive

Ballroom dancing, very slowly Ballroom dancing Folk dancing Modern dancing, disco, Ballet

Professional ballroom dancing, energetically Folk dancing, energetically

Table tennis or Ping-pong, leisurely

Table tennis, competitive Tennis, doubles

Tennis, singles Wheelchair tennis

Golf, riding a powered golf cart Golf, driving range Playing miniature golf

Golf, wheeling or carrying clubs

Playing catch, football or baseball Throwing a baseball

Softball, fast or slow pitch Basketball, shooting baskets Coaching children or adult sports

Most competitive sports Football game Basketball game

Wheelchair basketball Soccer, Rugby, Kickball

Volleyball, recreational Volleyball, competitive Beach volleyball, on sand court

Billiards Darts Pistol or rifle target practice Throwing a Frisbee Bowling, or lawn bowling

Badminton Fencing Archery (non hunting) Playing Frisbee Juggling

Handball, general or team Racquetball

Swimming, floating Swimming, recreational Treading water, slowly ,moderate ef-fort Aquatic aerobics Diving, springboard or platform

Water skiing Snorkeling Surfing, board or body

Swimming, steady paced laps Synchronized swimming Treading water, fast vigorous efforts Water jogging

Water basketball Scuba diving

Boating, powerboat Yachting

Paddle boating Canoeing or rowing a boat, at < 4 mph Sailing, recreational or competition Kayaking, on a lake, calm water

Canoeing or rowing, 4 or more mph Kayaking, in whitewater rapids

Module 3

67 Module 3

Light Activity Less than 3.0 METs

(<3.5kCal/min)

Moderate Activity 3.0 to 6.0 METs (3.5-7kCal/min)

Vigorous Activity Greater than 6.0 METs

(> 7 kCal/min)

Sitting and playing a board game or video game Sitting while reading, writing, color-ing, painting, using a computer

Playing on school playground equipment, moving about, swinging, or climbing Skateboarding Roller-skating or in-line skating, leisurely pace

Jumping rope Running Skipping Performing jumping jacks Roller-skating or in-line skating, fast pace

Sitting and playing most musical instruments

Playing instruments while actively moving; playing in a marching band; playing guitar or drums in a rock band

Twirling a baton in marching band Singing while actively moving about- as on stage or in church

Playing heavy musical instrument while actively running in a marching band

Gardening and yard work: weeding while sitting or kneeling, pruning Using a riding mower or driving a tractor on firm ground

Gardening and yard work: raking the lawn, digging, hoeing, light shoveling (< 10 lbs/min), weeding while standing or bending Planting trees, trimming shrubs and trees, hauling branches, stacking wood Pushing a power lawn mower

Gardening and yard work: heavy or rapid shoveling (> 10 lbs/min), digging ditches, or carrying heavy loads Felling trees, carrying large logs, swinging an ax, hand- splitting logs, or climbing and trimming trees Pushing a non motorized lawn

Light housework: dusting, sweep-ing floors, making beds, cooking or serving food, washing dishes, folding and putting away laundry , sewing Most other household tasks done while sitting or standing

Moderate housework: scrubbing the floor or bathtub while on hands or knees, hanging laundry on a clothesline, sweeping an outdoor area, washing windows, moving light furniture, walking and putting household items away , carrying water or firewood General household tasks requiring considerable effort

Heavy housework: moving or pushing heavy furniture (75 lbs or more), carrying household items weighing 25 lbs or more up a flight of stairs, or shovel-ing coal in a stove Standing, walking, or walking down a flight of stairs carrying objects weighing 50 lbs or more

Sitting and playing with children Child care: dressing, bathing, feeding or occasionally lifting young children

Actively playing with children: walking, climbing, running Walking while carrying a child < 50 lbs Walking while pushing or pulling a child

in a stroller or an adult in a wheelchair Carrying a child weighing < 25 lbs up a flight of stairs Child care: handling uncooperative young children (chasing, dressing) or handling several young children at one time Bathing and dressing an adult

Vigorously playing with children: run-ning longer distances or playing strenuous games with children Carrying an adult or a child weighing 25 lbs or more up a

flight of stairs Standing or walking while carrying an adult or a child weighing 50 lbs or more

Light home repair: wiring, plumb-ing, or repairing appliances

Home repair: cleaning gutters, refinishing furniture, sanding floors with power sander, or laying or removing car-pet or tiles General home construction

work: roofing, painting inside or outside the house, wall papering, scraping, plastering, remodeling

Home repair or construction: very hard physical labor, standing or carry-ing heavy loads of 50 lbs or more, taking heavy loads of 25 lbs or > up a flight of stairs or ladder

( e.g. carrying roofing materials to the roof), or concrete or masonry work.

Workshop carpentry Outdoor carpentry, sawing wood with power saw

Hand-sawing hardwoods

Light automobile repair Motorcycle or bicycle repair

Automobile bodywork Hand washing and waxing a car

Pushing a disabled car

68

Contraindications to Exercise Participation

Cardio-Pulmonary Renal Others

Absolute Contraindications

Abnormal ECG readings Unstable angina pectoris Abnormal heart rhythm Severe symptomatic aortic stenosis Abnormal dilatation Heart infections Presence of atherosclerosis Sudden blockage of pulmonary arteries

Acute or inadequate controlled kidney failure

Untreated high-risk diabetic retinopathy Recent significant retinal hemorrhage. Infections

Relative Contraindications

Uncontrolled hypertension with resting blood pressure of >200mmHg systolic or >110 mmHg diastolic

Severe autonomic neuropathy with exertional hypotension.

Functional abnormalities of the heart Other forms of outflow tract obstruction Abnormal heart rate Abnormal impulse conduction dilatation in any of the heart chambers

electrolyte abnormalities (eg. Hypokalemia, hypomagnesemia)

FBS of > 300mg/dl or > 250 mg/dl with urinary ketone bodies.

Hypoglycemia Uncontrolled metabolic disease (eg. Thyrotoxicosis, myxedema) Chronic infectious disease (eg. Hepatitis, TB, AIDS) Neuromuscular, musculoskeletal, or

rheumatoid disorders that are aggravated by exercise Complicated pregnancy

Cardiovascular Microvascular Metabolic Musculoskeletal

Cardiac dysfunction abnormal rhythm due to ischemia

Very high or low blood pressure during exercise

Decrease of blood pressure when changing body position

Bleeding of the retina Increased protein in urine

(proteinuria) Aggravation of lesions

Worsening of hyperglycemia (high blood glucose) and increase in ketone formation

Hypoglycemia (low blood glucose) in patients maintained on diabetes drugs

Foot ulcers Bone and muscle injuries Joint diseases Eye injuries

Aerobic Anaerobic

Uses large group of muscles in rhythmic motion for an extended period of time

Short burst of energy, quick or of very high intensity

Uses oxygen as muscles burn a greater percent of fat for fuel Burns mostly glycogen and glucose for fuel.

Improves cardiovascular conditioning and overall physical fitness

Minimal conditioning benefits for the cardiorespiratory system

Improves muscle efficiency and tone Improves muscle strength and spped of activity

Helps lose fat weight Builds muscle tissue, ineffective for fat loss

Examples: Walking, jogging, cycling, dancing, skating, rope skipping

Examples: Weight lifting, sprinting, calisthenics (push-ups, sit-ups), resistance training programs

Short term effects usually not felt in healty adults especially if done in low intensities and volumes

May cause orthopedic and vascular problems, may also be bad for patients with poor metabolic control, and those with active proliferative

Source: Johnson and Johnson, An Evidence-Based Approach to Type 2 Diabetes Management for Health Care Professionals A Learning Module Series. First Edition. 2003.

Module 3

Complications of Exercise in Type 2 Diabetes

Two Basic Types of Exercise

69 Module 3

The Activity Pyramid

Computing Target Heart Rate (THR )

First, determine maximum heart rate (HRmax) by:

Short method: HRmax= 220 — age in years Best-Fit Formula: HRmax= 210 — 50% of age — 5% of body weight (lbs) + 4 (if male only)

Then compute for the Target Heart Rate based on the intensity of exercise desired

Intensity Target Heart Rate (THR)

Light / very light < 50% of HRmax

Moderate 50—70% of HRmax

Vigorous >70% of HRmax

70

Notes:

Module 3

71 Module 3

Notes:

72

Module 3

WHO: 5A Steps Protocal for Tobacco Cessation Counselling

73 Module 3

Key statistics

Every seven seconds, someone in the world dies from a tobacco-related illness.

The annual death toll of more than five million could rise to more than eight million by 2030 unless

urgent action is taken to control the tobacco epidemic.

One in five tobacco-related deaths occurs in the Western Pacific.

Tobacco kills up to half of its users.

Smokers are exposed to over 4000 toxic substances in cigarette smoke. Over 25 of these are known

human carcinogens.

Tobacco causes over 40 diseases, many of them fatal or disabling. Smoking is responsible for over 90%

of all cases of lung cancer, 75% of chronic bronchitis and emphysema cases and nearly 25% of cases

of ischemic heart disease. Chewing tobacco causes a significant proportion of oral cancer

More than 80% of the world's one billion smokers live in low- and middle-income countries.

Total consumption of tobacco products is increasing globally, though it is decreasing in some

high-income and upper middle-income countries.

Leading cause of death, illness and impoverishment

Tobacco use is one of the biggest public health threats the world has ever faced. It kills more than five

million people a year – an average of one person every six seconds – and accounts for one in 10 adult

deaths. Up to half of current users will eventually die of a tobacco-related disease.

More than 80% of the one billion smokers worldwide live in low- and middle-income countries, where the

burden of tobacco-related illness and death is heaviest.

Tobacco users who die prematurely deprive their families of income, raise the cost of health care and

hinder economic development.

In some countries, children from poor households are frequently employed in tobacco farming to provide

family income. These children are especially vulnerable to "green tobacco sickness", which is caused by

the nicotine that is absorbed through the skin from the handling of wet tobacco leaves.

Gradual killer

Because there is a lag of several years between when people start using tobacco and when their health

suffers, the epidemic of tobacco-related disease and death has just begun. Tobacco caused 100 million

deaths in the 20th century.

If current trends continue, it will cause up to one billion deaths in the 21st century. Unchecked, tobacco-

related deaths will increase to more than eight million per year by 2030. More than 80% of those deaths will

be in low- and middle-income countries.

Surveillance is key

Good monitoring tracks the size and character of the epidemic and indicates how best to tailor policies.

Two-thirds of countries – more than four in five of them low- and middle-income – do not have even mini-

mal information about tobacco use.

Second-hand smoke kills

Second-hand smoke is the smoke that fills restaurants, offices or other enclosed spaces when people burn

tobacco products such as cigarettes, bidis and water pipes. There is no safe level of second-hand tobac-

co smoke.

74

Module 3

75 Module 3

76

Notes:

Module 3

77 Module 3

Notes:

78

Contents:

Foot Care

Importance of foot care

Foot complications due to diabetes

Pathways to the development of foot ulcers

The 5 cornerstones of foot management

Basic foot care practices

Appropriate footwear

Identifying the Foot At-risk for Amputation

Conducting Foot care sessions in health centers

Wound Care

Introduction to wounds

Definition and classification of wounds

Wound assessment

Wound care

Wound Monitoring

Stump Care

Definition of amputation.

Levels of amputation common to diabetes.

Importance of stump care.

Proper residual limb positioning

Stump skin care.

Proper stump bandaging

Criteria for Artificial Leg Fitting

Referring patients for prosthetic device acquisition

Patient follow-up and monitoring Importance of Foot Care

Module 4

FOOT, WOUND AND STUMP CARE

―Every 30 seconds someone

loses a lower limb due to

diabetes in the world.‖

Kada 30 segundo usa ka tao ang maputlan

ug tiil sa tibuok kalibutan tungod sa diabetes

International Diabetes Federation

Diabetic foot problems are common, very

expensive and life-threatening. However, diabetic

foot problems are often not perceived as

important by both the patient and the health care

provider.

Every year, more than 1 million people undergo a

lower limb amputation due to diabetes. With the

rising incidence of diabetes, the number of

amputations may increase.

Foot care then is an integral part of diabetes

management. Persons with diabetes should be

able to practice basic foot care to prevent the

occurrence of foot ulcers that may lead to

amputations.

It is the role of health care providers to both

routinely check patients’ feet and teach persons

with diabetes how to take care of their feet.

Know the numbers…………

70% Up to 70% of all lower-leg amputations

are performed on people with diabetes.

70% Up to 70% of people who undergo a

lower extremity amputation die within 5 years

of amputation.

4 million Approximately 4 million people

develop a new diabetic foot ulcer every year.

85% Up to 85% of amputations are preceded

by an ulcer and are therefore preventable.

49-85% A multidisciplinary approach to

diabetic foot care has been shown to bring

about a 49-85% reduction in amputation rates.

50% Up to 50% of people with type 2 diabetes

have significant neuropathy and at-risk feet

79 Module 4

The most important causes of diabetic foot ulcers are

neuropathy or nerve damage and peripheral arterial

disease or damage to blood vessels of the feet.

Diabetic foot lesions frequently result from two or more risk

factors occurring together. In the majority of cases,

diabetic peripheral neuropathy plays a central role. Up to

50% of people with type 2 diabetes have neuropathy and

at-risk feet. Neuropathy leads to an insensitive and

sometimes deformed foot, often with abnormal walking

pattern. In people with neuropathy, minor trauma—caused

for example by ill-fitting shoes, walking barefoot or an

acute injury—can precipitate a chronic ulcer.

Loss of sensation, foot deformities, and limited joint mobility

can result in abnormal biomechanical loading of the foot.

Thickened skin (callus) forms as a result. This leads to a

further increase of the abnormal loading and often,

subcutaneous hemorrhage.

Whatever the primary cause, the patient continues walking

on the insensitive foot, impairing subsequent healing.

Peripheral vascular disease, usually in conjunction with

minor trauma, may result in a painful, purely ischemic foot

ulcer. However, in patients with both neuropathy and

ischemia(neuro-ischemic ulcer), symptoms may be absent

despite severe peripheral ischemia.

There are 3 main types of neuropathy seen in diabetes:

1. Autonomic (heart and blood vessels, digestive

system, urinary tract, sex organs, sweat glands, eyes)

2. Sensory (sensation)

3. Motor (movement)

Symptoms of nerve damage may include:

1. Numbness, tingling, or pain in the toes, feet, legs,

hands, arms, and fingers

2. Wasting/atrophy of the muscles of the feet or hands

3. Indigestion, nausea, or vomiting

4. Diarrhea or constipation

5. Dizziness or faintness due to a drop in blood pressure

after standing or sitting up

6. Problems with urination

7. Erectile dysfunction in men or vaginal dryness in women

8. Weakness

Risk factors for developing neuropathy are:

Age – persons diagnosed with diabetes later in life have

a far greater risk of developing neuropathies related to

diabetes mellitus.

Sex – the risk for men to develop neuropathies is far

greater than for women diagnosed with diabetes

mellitus.

Foot Complications due to Diabetes

Subcutaneous hemorrhage

Callus formation

Breakdown of skin

Deep foot infection with

osteomyelitis

80

Module 4

Foot Complications due to Diabetes continued

Glycemic (blood sugar) control – if the blood sugar

levels are not controlled it drastically increases the risk

of neuropathies.

Length of diabetes – the longer the persons has been

diagnosed with diabetes, the greater the risk of

developing neuropathies – especially autonomic

High Cholesterol – the increased LDL levels have been

shown to damage the smaller blood vessels that feed

the nervous system.

Smoking – the effects of nicotine and other

carcinogens in tobacco have been shown to harden

and impair blood flow to the lower extremities and

damage the nervous system.

The following are consequences of neuropathy:

Loss of motor nerve function causes weakening of the

intrinsic foot muscles causing distal muscle atrophy.

This imbalance produces changes in foot structure

and gait. Common foot deformities include:

Claw toes

Hammer toes

Mallet Toe

The resulting deformity and limited range of motion

contribute to increased mechanical stress on

corresponding areas of the foot.

Charcot Foot / Diabetic Osteoneuropathy—– is a

progressive degenerative condition that affects the

joints in the feet. It is associated with nerve damage

that decreases the ability to sense stimuli, including

pain, and decreases muscular reflexes that control

movement. As a result, the joints in the feet are

subjected to repeated trauma and injury, causing

progressive damage to the ligaments, cartilage, and

bones. This results to a permanent deformity where the

foot becomes large, broad and flat if not treated or

managed.

Acute and Chronic infection – result from impaired

ability of the body to heal the affected area – usually

in the foot – osteomylelitis.

Other opportunistic infections and complications of

neuropathy:

1. Urinary tract infection

2. Sexual dysfunction

3. Digestive problems

4. Increased or decrease in sweating – due to

autonomic neuropathy

Early symptoms of diabetic foot

Charcot Foot

Common foot deformities due to neuropathy

81 Module 4

Pathways to the Development of Foot Ulcers

Mellitus

82

Module 4

The 5 Cornerstones of Foot Management-IDF-International Consensus on the Diabetic Foot

Education for patients, family, and health care providers

Education, presented in a structured and organized manner, plays an important role in the prevention of

foot problems. People with diabetes should learn how to recognize potential foot problems and be aware

of the steps they need to take in response. It is essential to evaluate whether the person with diabetes has

understood the messages, is motivated to act, and has sufficient self-care skills. Items that must be

covered when instructing a high-risk patient include:

1. Daily feet inspection including areas between the toes and the need for another person with

skills to inspect the feet, should the people with diabetes be unable to do so.

2. Regular washing of feet with careful drying, especially between the toes.

3. Water temperature for washing—always below 37ºC.

4. Not to use heater or hot water bottle to warm your feet.

5. Use lubricating oils or lotions for dry skin but not between the toes.

6. Not to use chemical agents or plasters to remove corns and calluses.

7. Corns and calluses should be cut by a health care provider.

8. Avoidance of walking barefoot indoors or outdoors and of wearing shoes without socks.

9. Daily inspection and palpation of the inside of the shoes.

10. Not to wear tight shoes/socks or shoes/socks without rough edges and uneven seams.

11. Change socks daily.

12. Never wear tight or knee-high socks.

13. Cutting nails straight across.

14. Ensure that the feet are examined regularly by a health

care provider.

15. Notify the health care provider at once if a blister, cut, scratch or sore has developed.

Appropriate footwear

Inappropriate footwear is a major cause of ulceration. Appropriate footwear should be used both indoors

and outdoors, and should be adapted to the altered biomechanics and deformities. This is essential for

prevention.

Identification of the at-risk foot

People with high risk for future ulceration can be identified with simple foot examination. Following

examination of the feet, each patient can be assigned a risk category which should guide subsequent

management. People with high risk for future ulceration can be identified with simple foot risk assessment

tools like the 10g Semmes-Weinstein Monofilament and tuning fork.

Regular Inspection and Examination

All people with diabetes should be examined once a year for potential foot problems. Patient with

demonstrated risk factor (s) should be examined more often (every 1-6 months). Health care providers

must make a habit of inspecting the feet of people with diabetes during every visit to the health center for

early detection of wounds. Persons with diabetes must also check their feet daily before going to bed. The

patient’s feet should be examined with the patient lying down and standing up, and their shoes and socks

should also be inspected.

Treatment of Non-ulcerative Pathology

In high-risk patients, callus, and nail and skin pathology should be treated regularly, preferably by a

trained foot care specialist. If possible, foot deformities should be treated non-surgically (eg. with an

orthosis)

There are 5 key elements of foot management:

1. Education for patients, family, and health care providers.

2. Appropriate footwear

3. Identification of the at-risk foot

4. Regular inspection and examination of the at-risk foot.

5. Treatment of non-ulcerative pathology

85% of amputations can be

prevented by simple foot care.

83 Module 4

Basic Foot Care Practices

84

Module 4

Appropriate Footwear

Shoe-related trauma is the most frequent event precipitating an ulcer. It is therefore important to explain

the benefits of good footwear choice and selection.

General Criteria for Footwear Selection

Criteria for shoe selection should include the amount of walking, activity type and environment they

will most often be worn in.

Ideally the shoes should provide support for the foot structure without applying excessive pressure on

any part of the foot

The shoe should be a comfortable fit, not too tight, or loose.

The shoes should comfortably fit the largest foot (often one foot is slightly larger than the other)

In low risk levels most feet can be accommodated in commercially available shoes

In High risk feet it is often necessary to have special ―extra‖ depth shoes or shoes made up to fit the

foot and the deformity present. A soft shoe is preferred. The shoe should be wide enough to prevent

pressure on the metatarsal heads and on the dorsum of the foot. Ideally there should be a soft

innersole in the shoe which is easily removable for modification or cleaning

Buying new shoes:

The shoes should be measured and fitted in the afternoon

Wear new shoes two hours at a time to prevent blisters.

Fashion vs. the Foot

Fashion and foot care have very seldom been complimentary. Affects of the feet are usually felt in later

life. Most common problems are related to the heel heights and the narrow shape and size of the toe box

Footwear Modifications

It is often possible to do limited modifications to existing shoes for pressure relief. This should be done

preferably on new or fairly new shoes. It involves removing the sole of the shoe and modifications to the

inside and soles of the shoe. Most common practice in Diabetic Foot care is the use of Rocker Soles.

Toe Only Rocker Sole

Provides relief at toe off by

placing weight bearing and

forces more proximal in the

foot, away from ulcers in the

great toe or metatarsal

region

Heel to toe Rocker Sole

Used to provide relief for pressure on

the heel and the metatarsal region of

the foot. Allows a normal rolling gait

action

Double Rocker Sole

The ―W‖ shape alleviates

pressure from the arch area –

used often in Charcot Foot

85 Module 4

Anatomy of the Appropriate Shoe

The heel should provide

support and stability to

the heel of the foot

Deep toe box to allow

space for the toes There

should be about ½ to 1cm

space to the front of the

shoe from the furthest toe.

Lace up shoes, or Velcro

closure shoes are preferred.

The shoes should be

closed at the heel for

better fit and stability

Heel height should not

exceed 2 inches (5cm)

Seamless, smooth inner

and outer lining.

With padded insole

for cushioning

The sole of the shoe should

be firm and provide

support for walking over

uneven terrain

Sandals should NOT be the type that goes between toes, but

rather the type that goes over the top of the foot

The internal width of the shoe should

be equal to the width of the foot.

86

Module 4

Identifying the Foot At-Risk for Amputation

Neuropathic foot characteristics:

1. Dry skin, fissures, cracks

2. Deformities such as claw feet, helix valgus,

hammer toes, flat foot and pes cavus

3. Callus

4. Abnormally shaped foot

5. Plantar neuropathic ulcer on bony prominences

6. Prominent veins on dorsum of the foot

7. Nail pathologies

8. Limited joint mobility

Neuropathic foot with peripheral vascular disease:

1. Loss of peripheral pulsation 2. Loss of hair on dorsum

3. Dark, dusky skin

4. Feet turning red in dependent positions

5. Neuro-ischemic ulcer

Infected Foot:

1. Discharge from foot

2. Maceration

3. Reddish skin with swelling

Dry, cracked skin

Plantar neupathic ulcer on

bony prominence

Nail pathologies such as fungal infection

Abnormally shaped foot (charcot foot)

with neuropathic ulcer at the midfoot

Neuro-ischemic ulcer with discharge

Maceration between toes

We need to detect neuropathy and

peripheral arterial disease at its early

stage to help people with diabetes

avoid amputations.

Source: Step-by-Step Project instructional video with academic support from

the International Diabetes Federation Consultative Section on the Diabetic

Foot, International Working Group on the Diabetic Foot, Muhimbili University

College of Health Sciences Dar es Salaam Tanzania, Diabetic Foot Society of

India with funding from the World Diabetes Foundation,

87 Module 4

Step 1: Introduction

1. Explain to the patient the importance of foot

examination

2. Explain that a simple painless examination will

be done to assess the risk for amputation.

3. It is best to conduct the examination with the

patient lying down.

Step 2: Conduct the foot examination

1. Look at the dorsum of the feet and palpate

2. Look for growth of hair at the medial border of

the dorsum.

3. Look at the medial and lateral borders.

4. Feel the back of the foot at the heel.

5. Observe the tip of the toes.

6. Look in between toes.

7. Observe the nails.

8. Look at the plantar part of the foot and feel for

bony prominences

9. Palpate for peripheral pulses at the dorsalis

pedis and posterior tibial

10. Feel the temperature of the skin and look for

any swelling

11. Check for mobility of toes especially the great

toe.

12. Test for protective sensation using a 10 gram

Semmes-Weinstein monofilament

Step 3: Assess foot risk

1. Fill up the Foot Risk Assessment Form (page 88)

2. Assign a risk category.

3. Advice the timing of follow-up check-up.

Step 4: Conduct an education session

1. Educate patient on basic foot care using the

Diabetes Diary or the foot care poster.

2. Examine the patient’s footwear including the

socks and advice accordingly. Point out

protective features of the patient’s shoes or

advice appropriate footwear.

Step 5: Further management:

1. If with callus—remove or refer

2. If with ulcer—treat accordingly or refer

3. Recommend offloading methods such as bed

rest, use of walker or crutches and appropriate

footwear. (refer to stump care if patient was

amputated)

Step 6: Schedule the next visit

Do not forget to encourage the patient to continue

visiting the health center.

Conducting Foot Care Sessions in Health Centers

Sensory foot examination using the

10g Semmes-Weinstein monofilament

1. Examination should be carried out in a

quiet and relaxed setting. First apply the

monofilament on the patient’s hands (or

elbow or forehead) so that he or she knows

what to expect.

2. The patient must not be able to see where

the examiner applies the filament. Test the

sites indicated in the foot risk assessment

form.

3. Apply the monofilament perpendicular to

the skin surface.

4. Apply sufficient force to cause the filament

to bend or buckle.

Palpating the dorsalis pedis artery

Palpating the posterior tibial artery

Make it a habit to look at the

patient’s feet during every

health center visit.

88

Module 4

Foot Risk Assessment

5. The total time for skin contact and removal of the filament

should be approximately 2 seconds.

6. Apply the filament along the perimeter of, not on, an ulcer site,

callus, scar or necrotic tissue.

7. Do not allow the monofilament to slide across the skin or make

repetitive contact at the test site.

8. Press the filament to the skin and ask the patient whether they

feel the pressure applied (yes/no) and next where they feel the

pressure (left foot/right foot)

9. Repeat this application twice at the same site, but alternate this

with at least one ―mock‖ application in which no filament is

applied (total three questions per site)

10. Protective sensation is present at each site if the patient

correctly answers two out of three applications. Protective

sensation is absent with two out of three incorrect answers—the

patient is then considered to be at risk for ulcerations.

11. Encourage the patients during testing by giving positive feed-

back.

12. The healthcare provider should be aware of the possible loss of

buckling force of the monofilament if used for too long a period

of time.

89 Module 4

WOUNDS are any breaks in the skin. It can result from a planned event, such as surgery, or from an

unexpected event, such trauma or exposure to pressure, heat, sun or chemicals.

Introduction to Wounds

Our skin is composed of three layers:

1. Epidermis is the outer layer of the skin that

you can see. Lacking blood vessels, the

epidemis gets oxygen and nutrients from

the lower layers. It continually creates new

skin cells to replace dead cells on the

surface. The epidermis also produces

melanin which gives the skin its color.

2. Dermis is the middle skin layer. It contains

many cells and structures including hair

follicles, nerves, blood vessels and oil and

sweat glands.

3. Hypodermis or subcutaneous tissue is the

third or bottom layer of the skin. It is made

up of fat and and connective tissue that

contains larger nerves and blood vessels.

The depth of the subcutaneous tissue varies from

person to person.

Wound Healing

Wound healing is a complex process

during which the skin is repaired. It involves

inflammation, re-epithelialization,

blood vessel and connective tissue

formation subsequent degradation and

resynthesis of extra-cellular membranes.

Injury initiates the rapid onset of a vigorous,

multicellular wound healing reaction,

which then gradually, during following

weeks or months, proceeds towards a

rather acellular scar.

When a wound fails to heal, it results in a

chronic, nonhealing ulcer. Recurrency rate

of a chronic leg ulcer is high. Leg ulcers are

a common problem of the elderly. The

most common causes of leg ulcers is

chronic venous insufficiency, arterial

disease and diabetic neuropathy. Other

causes include vasculitis, malignancies and

bacterial infections.

90

Module 4

Definition and Classification of Wounds

Ulcers are classified into:

1. Pressure Ulcers

2. Venous stasis ulcers

3. Arterial Ulcers

4. Neuropathic ulcers

PRESSURE ULCERS are local areas of tissue trauma

over soft tissue where pressure has compressed

one area of tissue between a bony prominence

and any external surface for a prolonged period.

Characteristics of pressure ulcers:

Location: most often over bony prominences,

but may be over soft tissue.

Size: may be any size or depth

Edema: often present in early stages

Pain: Stage I and Stage II most common.

Stage: I,II,III,IV OR unstageable if wound base

cannot be visualized.

Exudates: With or without

Periwound Skin: often involved with edema,

induration (hardening) ,temperature, pain,

itching, and coloration changes

Wound Edges: varies, may have undermining,

tunneling, hypergranulation

2007 Staging System for Pressure Ulcers ( NPUAP)

Stage I: Intact skin with non-blanchable redness of

a localized area usually over a bony prominence.

The area may be painful, firm, soft, warmer,or

cooler as compared to adjacent tissue.

Stage II: Partial thickness loss of dermis presenting

as a shallow open ulcer with a red pink wound

bed, without slough. May also present as an intact

or open ruptured serum-filled blister.

Stage III: Full thickness tissue loss. Subcutaneous fat

may be visible but bone, tendon, or muscle are

not exposed.may include undermining and

tunneling.

Stage IV: Full thickness tissue loss with exposed

bone, tendon, or muscle. Slough or eschar may be

present on some parts of the wound bed.

Unstageable: Full thickness tissue loss in which the

base of the ulcer is covered by slough yellow, tan,

gray,green,or brown)and/or eschar ( tan,brown,or

black) in the wound bed.

Staging of Pressure Ulcers

Sta

ge

1

Sta

ge

2

Sta

ge

3

Sta

ge

4

Un

stag

ea

ble

91 Module 4

Definition and Classification of Wounds continued

VENOUS STASIS ULCERS may be partial or full

thickness loss (usually partial) as a result of chronic

venous insufficiency and/or venous hypertension.

Characteristics of venous stasis ulcers:

Location: Usually occurs in the gaiter area-

medial aspect of the lower leg.

Size: Large although may start small.

Wound edges: diffuse, flat, and sloping

although the wound is usually shallow and may

be beefy red in color.

Pain:

ARTERIAL ULCERS occur as a result of arterial

insufficiency therefore causing cellular ischemia.

Also called ischemic ulcers.

Characteristics of arterial ulcers:

Small craters with well defined borders with a

―punched out‖ appearance.

Location: On a toe or at a traumatic injury site.

Edema: localized if present.

Wound edges: sharp and well defined

Wound Base: devoid of healthy granulation

tissue

Periwound skin: most often pale and mottled.

Pain: (+)nocturnal pain, during rest( rest pain)

NEUROPATHIC ULCERS are caused by trauma,

pressure, peripheral neuropathy, peripheral arterial

disease and infection

Characteristics of neuropathic ulcers:

Location: plantar surface of the foot.

Size: often very small with even, well-defined

edges

Surrounding skin: often dry with fissures and

callus formation

Common orthopedic changes: plantar flexion

contractures, hammertoes, or Charcot foot.

Pain: painless

MIXED VENOUS AND ARTERIAL ULCERS are

ulcers caused by both venous and arterial disease.

The majority of patients diagnosed with mixed

venous ulcers have ulcers of venous origin and

develop arterial insufficiency over time.

NEURO-ISCHEMIC ULCERS take longer to heal

and are more likely to lead to amputation. The

patient’s vascular status is the strongest predictor

of healing rate and outcome.

Venous Stasis Ulcer

Arterial Ulcer

Neuropathic Ulcer

Understanding the underlying cause

of an ulcer and its classification is

important in ulcer management.

92

Module 4

Steps in Wound Management

Drainage Descriptors

This chart provides terminology that you can

use to describe the color and consistency of

wound drainage.

Description Color and Consistency

Serous Clear or light yellow

Thin and watery

Sanguinous Red (with fresh blood)

Thin

Sero-

sanguinous

Pink to light red

Thin, watery

Purulent Creamy yellow, green, white or

tan

Thick and opaque

Steps in wound management:

1. Assess your patient and the wound

2. Treat underlying pathology and the wound

3. Monitor the wound to evaluate the effect of the

treatment.

If the wound is healing as expected, continue the

treatment as planned. If not, adjust treatment

according to the reassessment.

ASSESS

TREAT MONITOR

Wound Assessment

ASSESS THE PATIENT Full medical history e.g. diseases such as:

- Diabetes

- Vascular diseases

- Immune compromise

- Connective tissue disorders

- Allergies

Medication

Nutritional status

Lifestyle -tobacco/alcohol habits

Impaired mobility

Psychological/psychiatric problems

Quality of Life

ASSESS THE WOUND Location

Drainage (color, consistency, amount)

Wound Bed

Size

Depth and tunnel measurement

Color and texture

Moisture

Odor

Margins and surrounding skin condition

Pain

Drainage

Is drainage well contained, is it oozing?

Is the dressing saturated or dry?

How much drainage is there? Scant, moderate,

large

Color and consistency of drainage?

Size

Wound length is the longest distance across the

open area regardless of the orientation. The width is

simply the longest distance across the wound at

right angle to the length. Also note the area of

reddened, intact skin and white, macerated skin.

These areas would be measured and recorded as

surrounding erythema and maceration—not as part

of the wound itself.

93 Module 4

Wound Assessment continued

Check the wound and the skin only

after they have been cleaned.

Flushing the wound bed with

normal saline solution is the best

method of cleaning diabetic foot

ulcer.

Depth and Tunnel Measurement

Use a cotton-tipped swab. Gently insert the swab

into the deepest portion of the wound and then

carefully mark the stick where it meets the edge

of the skin. Remove the swab and measure the

distance from your mark to the end to determine

depth. Measure tunnels or sinus tracts as you

would the depth. Use a cotton-tipped swab or

palpate with a gloved finger (if the tunnel is

large).

Depth is reported as :

Partial Thickness— involve only the

epidermis or extend into the dermis but not

through it.

Full Thickness—extend through the dermis into

the tissue beneath and may expose adipose

tissue, muscle or bone. These wounds heal by

granulation and contraction which require

more body resources and more time than the

healing of partial thickness wounds.

Measuring wound size

Length

Wid

th

Partial Thickness Wound

Full Thickness Wound

94

Module 4

Wound Assessment continued

Color and Texture

Wounds can be also classified by the color of the

wound bed. Wound color helps you determine

whether debridement is appropriate.

Black—be alarmed. This signals necrosis (tissue

death). Eschar (dead, avascular tissue) covers

the wound, slowing the healing process and

providing microorganisms with a site in which

to proliferate. When eschar covers a wound,

assessment is deferred until eschar is removed.

Typically debridement is indicated. However

ulcers caused by ischemia and uninfected

heel ulcers are exceptions.

Yellow—beware. A yellow color may be a film

of fibrin on the tissue. Fibrin is a sticky

substance that normally acts as a glue in tissue

rebuilding. However, if the wound is unhealthy

or too dry, fibrin builds up into a layer that

can’t be rinsed off and may require

debridement.

Red—you’re ahead. The wound bed is healthy

and normal healing is underway. When a

wound begins to heal, a layer of pale, pink

granulation tissue covers the wound bed. As

this layer thickens, it becomes beefy red.

The texture of the wound bed provides just as

much information about the wound and healing

as its color. If you note very smooth red tissue in a

partial-thickness wound, its most likely the dermis.

In full-thickness wound, its probably muscle tissue—

not granulation tissue. Healthy granulation tissue

has a soft, bumpy appearance.

Moisture

The wound bed must be moist—but not overly

moist. Moisture allows cells and chemicals needed

for healing to move about the wound surface.

Describe wound beds as dry or moist.

Odor

If kept clean, a non-infected wound usually

produces little, if any, odor (one exception is the

odor normally present under a hydrocolloid

dressing that develops as a by-product of the

degradation process.) A newly detected odor

might be a sign of infection.

Types of Wound Bed Color

95 Module 4

Margins and Surrounding skin

Check for induration (hardness) and the color of

the skin around the wound. This can alert you to

impending problems that can impede healing:

White skin indicates maceration or too much

moisture, and signals the need for a

protective barrier around the wound and a

more absorbent dressing

Red skin can indicate inflammation, injury

(for example tape burn, excessive pressure,

chemical exposure) or infection.

Purple skin can indicate bruising, one sign of

trauma.

Pain

Note not only pain associated with the injury itself

but also pain associated with healing and with

therapies employed to promote healing. Ask the

following:

Where is the pain located?

How long does it last?

How often does it occur?

What does the pain feel like?

What relieves the pain? What makes it worse?

How would you rate your pain from the scale

of 1 to 10 with 10 representing the worse pain.

Wound Assessment continued

Wound Assessment and Monitoring Tool

Assessment Parameters Initial Assessment

Date:

First Follow-up visit

Date:

Second Follow-up visit

Date

Location

Drainage

Wound Bed

1 Size

2 Depth and tunnel

3 Color and texture

4 Moisture

5 Odor

Margins and surrounding skin

Pain

Type of wound? Stage?

Presence of infection

Others

Management

How should I clean?

Dressing? Compression?

Antimicrobials?

Offloading? Footwear?

Referral? To whom?

Date of next visit?

Others:

96

Module 4

Wound Care

Basic wound care centers on cleaning and dressing

the wound. The goal of wound cleaning is to remove

debris and contaminants from the wound without

damaging healthy tissue. The wound should be

cleaned initially; repeat cleaning as needed or

before a new dressing is applied.

The basic purpose of dressing is to provide an

optimal environment in which the body can heal

itself. Functions of the wound dressing include:

1. Protecting the wound from contamination or

trauma

2. Providing compression if bleeding or swelling is

anticipated.

3. Applying medications

4. Absorbing drainage or debrided necrotic tissue

5. Filling or packing the wound

6. Protecting the skin surrounding the wound.

Cleaning the wound Flushing the wound bed with normal saline solution is

the best method of cleaning diabetic foot ulcer.

Sterile normal saline provides a moist environment,

promotes granulation tissue formation, and causes

minimal fluid shifts in healthy adults.

Most commercial wound cleaners are somewhat

toxic to cells in the wound bed, and their use can

slow healing. Use clean, warm water and mild soap

to clean the surrounding skin.

Debridement Wound healing can’t take place until necrotic tissue

is removed. Necrotic tissue may present as moist

yellow or gray tissue that’s separating from viable

tissue. It this moist tissue becomes dry, it presents as

thick, hard, leathery black eschar. Areas of necrotic

tissue may mask underlying fluid collections or

abscesses. Although debridement can be painful, it

is necessary to prevent infection and promote

healing.

Types of debridement are:

Sharp—use of cutting tool such as scalpel,

scissors or a laser.

Autolytic—use of moisture retentive dressings to

cover the wound bed. Necrotic tissue is then

dissolved through self-digestion of enzymes in

the wound fluid. If the wound is infected, this

method is not the treatment of choice. Although

this takes longer than other methods, it isn’t

painful, it’s easy to do, and its appropriate for

patients who can’t tolerate any other method.

Chemical—a selective method using enzymatic

agents applied topically to areas of necrotic

tissue only. Stop using enzymes when the wound

is clean with red granulation tissue.

Mechanical—includes wet-to-dry dressings,

irrigation and hydrotherapy.

Wound Irrigation Use sterile water or sterile normal saline solution.

Irrigation cleans tissues and flushes cell debris and

drainage from an open wound. It also helps prevent

premature surface healing over an abscess pocket

or an infected tract. After irrigation, pack open

wounds to absorb additional drainage.

Attach a 19G needle or catheter to a 35-ml piston

syringe. This setup delivers an irrigation pressure of 8

psi which is effective in cleaning the wound and

reducing the risk of trauma and wound infection.

Avoid forcing the needle or catheter into the wound

to prevent tissue damage. Make sure the solution

flows from the clean to the dirty area of the wound

to prevent contamination of clean tissue.

Continue until the solution returns clear. Keep the

patient positioned to allow further wound drainage.

Clean the area around the wound and apply

dressing.

Wound Dressings Moist wound therapy speeds healing in diabetic

foot ulcers. Dressing that maintain the necessary

wound environment include:

Alginates

Transparent films

Foams

Hydrocolloids

Hydrogels

Collagen-based dressings

Composites (combination of the other dressings)

Choice of dressing depends on the condition of the

ulcer. Diabetic foot ulcers tends to produce low to

moderate drainage. However, if the wound bed is

dry, its needs a dressing that adds moisture.

With any wound, healing is promoted by

keeping the wound moist, clean and free

from debris. The cardinal rule is to keep

moist tissue moist and dry tissue dry.

97 Module 4

Gauze dressing

Made of absorptive cotton or synthetic fabric,

gauze dressings are permeable to water, water

vapor and oxygen and may be impregnated with

hydrogel or another agent. When uncertain about

which dressing to use, you may apply gauze

dressing moistened in saline solution until a wound

specialist recommends definitive treatment.

Hydrocolloid dressing

Adhesive. Moldable wafers made of a

carbohydrate-based material and usually have

waterproof backings. They’re impermeable to

oxygen, water, and water vapor, and most have

some absorptive properties.

Transparent film dressing

Clear, adherent and non-absorptive. These

polymer-based dressings are permeable to

oxygen and water vapor but not to water. Their

transparency allows visual inspection. Because they

can’t absorb drainage, they’re used on partial-

thickness wounds with minimal exudate.

Alginate dressing

Made from seaweed, are nonwoven, absorptive

dressings available as soft white sterile pads or ropes.

They absorb excessive exudate and may be used

on infected wounds. As these dressings absorb

exudate, they turn into a gel that keeps the wound

bed moist and promotes healing. When exudate is

no longer excessive, switch to another type of

dressing.

Foam dressing

Spongelike polymer dressings that may be

impregnated or coated with other materials.

Somewhat absorptive, they may be adherent. These

dressings promote moist wound healing and are

useful when a nonadherent surface is desired.

Hydrogel dressing

Water-based and nonadherent, polymer-based

dressings that have some absorptive properties.

They’re available as a gel in a tube, as flexible

sheets, and as saturated gauze packing strips. They

may have a cooling effect, which eases pain, and

are used when the wound needs moisture.

Compression Ascertain the underlying disease, e.g. venous /

arterial. A venous leg ulcer should be treated with

graduated compression therapy, whereas an

arterial ulcer cannot be treated with compression. If

the leg ulcer is arterial, always refer to a specialist.

Topical Antimicrobials Routine wound cleaning handles most of the

surface microbial population. However, applying a

topical antimicrobials directly to the wound bed

can help control microorganisms in the wound bed

and improve healing. Commonly used topical

antibiotics include:

1. Bacitracin

2. Metronidazole

3. Mupirocin

4. Silver sulfadiazine

Off-loading Relieving pressure from plantar tissues is the

cornerstone of diabetic neuropathy treatment as

well as prevention for those patients at risk for

recurrent breakdown. Off-loading is particularly

important because patients with diabetic

neuropathy can no longer feel the growing

discomfort that precedes tissue damage.

Non surgical off-loading techniques include:

1. Therapeutic footwear, possibly with rocker soles

2. Custom orthotics like shoe inserts

3. Walking casts

4. Use of crutches or wheelchair

5. Bed rest

Wound Care continued

Dressings for Diabetic Foot Ulcers

Type of Ulcer Recommended Dressing

Dry Ulcer Hydrogel

Wet Ulcer Alginate

Foam

Collagen

Necrotic Ulcer Hydrogel

Hydrocolloid

Shallow Ulcer Transparent film

Hydrocolloid

Tunneling or

deep ulcer

Alginate ropes (wet ulcers)

Hydrogel impregnated gauze (for

dry ulcers)

Infected ulcer Iodosorb (a gel that cleans the

wound by absorbing fluid,

exudate, and bacteria)

Acticoat or Arglaes (products

with antimicrobial component)

Bleeding ulcer Alginate

98

Module 4

Wound Monitoring

The next step is to monitor the patient throughout the healing process, periodically reassessing his

status and documenting progress to full healing. Your initial assessment sets the benchmark for

subsequent monitoring and reassessment activities. A series of assessments becomes a moving

picture illustrating the dynamic aspects of the healing process.

Recognizing Failure to Thrive

Sign Cause Intervention

Wound Bed

Too Dry Exposure of tissue and cells

normally in a moist environment

to air

Inadequate hydration

Add moisture regularly

Use a dressing that maintains moisture

such as hydrocolloid or hydrogel dressing

No change in size and

depth for 2 weeks

Pressure or trauma to the area

Poor nutrition, poor circulation,

inadequate hydration, or

medications

Poor control of blood sugar

Inadequate pain control

Infection

Reassess the patient for local or systemic

problems that impair wound healing, and

intervene as necessary

Increase in size or depth Debridement

Ischemia due to excess pressure

or poor circulation

Infection

If debridement of necrotic tissue is being

done, no intervention is necessary.

Poor circulation may not be resolvable,

but consider adding warmth to the area

and administering a vasodilator or

antiplatelet medication

Necrosis Ischemia Perform debridement if the remaining

living tissue has adequate circulation

Increase in drainage or

change of drainage

color from clear to

purulent

Infection

Autolytic or enzymatic

debridement

No intervention is necessary if caused by

autolytic or enzymatic debridement.

Increase in drainage or change of

drainage color is expected because of

the breakdown of dead tissue.

If debridement is not the cause, assess

the wound for infection

Tunneling Pressure over bony

prominences

Presence of foreign body

Deep infection

Protect the area from pressure using off-

loading measures

Irrigate and inspect the tunnel as careful-

ly as possible for a hidden suture or lefto-

ver bit of dressing material

If the tunnel doesn’t shorten in length

each week, thoroughly clean and obtain

a tissue biopsy for infection and, with a

chronic wound, for possible malignancy

Proper documentation of the wound assessment is important. The information that you

have in the initial assessment plays an important role in wound monitoring. It serves as a

benchmark for wound healing.

99 Module 4

Wound Monitoring continued

Recognizing Failure to Thrive continued

Sign Cause Intervention

Wound Edges

Red, hot skin, tenderness,

and induration

Inflammation due to excess

pressure or infection

If pressure relief doesn’t solve the

inflammation within 24 hours, topical

antimicrobial therapy may be indicated.

White skin (maceration) Excess moisture Protect the skin with pertrolatum ointment

or barrier wipe.

Use a more absorptive dressing

Rolled skin edges Too-dry wound bed Use moisture-retentive dressing

If rolling is not resolved in 1 week,

debridement of the edges may be

necessary.

Undermining or ecchy-

mosis or surrounding skin

(loose or bruised skin edg-

es)

Excess shearing force to the

area

Initiate measures to protect the area,

especially during patient transfers.

Factors that Affect Healing include:

1. Nutrition

2. Oxygenation

3. Infection

4. Age

5. Chronic Health Conditions

6. Medications

7. Smoking

Nutrition

Proper nutrition is the most important factor

affecting wound healing. Protein is critical for

wounds to heal properly. It is needed to form

collagen during the proliferation phase. In fact, a

person needs to double the recommended dietary

allowance of protein before tissue even begins to

heal. Aside from protein, collagen synthesis requires

zinc, carbohydrates, fats, vitamins A and C, iron and

copper.

Oxygenation

Healing depends on regular supple of oxygen.

Possible causes of inadequate blood flow to the

area of the wound include pressure, arterial

occlusion, or prolonged vasoconstriction associated

with peripheral vascular disease and atherosclerosis.

Other possible causes of low blood oxygenation

include: anemia, chronic obstructive pulmonary

disease, hypothermia or hyperthermia, etc.

Infection

Infection can be systemic or localized. A systemic

infection increases the patient’s metabolism and

thus consumes body fluids, nutrients and oxygen. A

localized infection in the wound itself is more

common. When the inflammatory phase lingers,

wound healing is delayed and the metabolic

by-products of bacterial ingestion accumulate in

the wound. This build-up interferes with the

formation of new blood vessels and the synthesis of

collagen.

Age

Skin changes that occur with aging cause healing

time to be prolonged in elderly patients. It is usually

complicated by other problems associated with

aging, such as poor nutrition and hydration, the

presence of a chronic condition, or the use of

multiple medications.

Chronic Health Conditions

Diabetes, atherosclerosis, respiratory problems and

malignancies can increase the risk of wounds and

interfere with systemic and peripheral oxygenation

and nutrition.

100

Module 4

Introduction to Stump Care

Levels of Amputation

Above the Knee Amputation (AKA)

Transfemoral amputation

amputation through the femur, under level of

greater trochanter

Below the Knee Amputation (BKA)

Transtibial amputation

amputation through the tibia and fibula

Syme’s Amputation

Trans-ankle amputation

Through ankle-transection tibia and fibula

above articular surfaces, through ankle joint

Partial Foot Amputation

Transmetatarsal, metatarso-phalangeal,

phalangeal amputation

removal of part of the foot, below the ankle

Importance of Stump Care To prevent secondary complications like

contractures, ulcerations and infections

To prepare the stump for prosthesis acquisition

Components of proper stump care:

1. Proper residual limb positioning

2. Stump skin care

3. Proper stump bandaging

Stump Skin Care

Wash stump at least once a day with

lukewarm water & a mild soap

Wash stump, usually, at night to minimize

swelling

Treat any minor irritations or problems on the

stump immediately

Bandaging

Action of wrapping a material around a body

part

Decrease swelling & edema

Transfemoral Amputation

Transtibial Amputation

Syme’s Amputation

101 Module 4

Proper Residual Limb Positioning

Extend hip and knee when lying down

Neutral hip rotation with no abduction

Extend knee when in bed

Extend knee when sitting

Do…….

102

Module 4

Transtibial Residual Limb Wrapping

103 Module 4

Transtibial Residual Limb Wrapping continued

1. Begin by placing a double-length 4-in. elastic bandage above the kneecap.

2. Wrap around once to secure the bandage comfortably, but not too tightly.

3. Continue the bandage around the back, and cross to corner D.

4. Bring the bandage around corner D, and cross upward in a direction toward B.

5. Continue around the back toward A.

6. Wrap the bandage across and down to corner C.

7. Continue to wrap around the end and cover corner D.

8. Move upward and across the front towardB.

9. Continue to move across the back and down toward corner D.

10. Move upward and across the front toward B.

11. Continue to move across the back toward A.

12. Move down and across the front toward corner C.

13. Continue to wrap across the end and cover corner D.

14. Move up and across the front toward B.

15. Continue across the back, and move down and across the front toward corner C.

16. Move around corner C toward corner D and continue up and across the front toward B. This is

the figure-of-8 pattern guide.

17. Continue with the figure-of-8 pattern, and move the bandage higher on the residual limb until

completely covered in a figure-8-pattern. Remember to apply less pressure as you move up.

Complete the wrap by anchoring it with tape

Transfemoral Residual Limb Wrapping

PART 1

1. Begin by placing a double-length 6-in. elastic bandage at letter D, and cross down to

corner B. Note that the pressure should be uniform throughout part 1 (Nos. 1 to 8) of the wrapping

procedure.

2. Continue the bandage around corner C, and cross the front up toward A

3. Wrap around the waist, with the thigh extended, and then back toward A

4. Continue around the back of the thigh toward D.

5. Cross to A, and wrap the uppermost part of the inner aspect of the thigh.

6. Again, wrap the bandage around the waist to A and then around the back of the thigh to D,

and cover the upper inner part of the thigh again.

7. Return toward A, wrap the bandage down and across the back to corner C, and then again

return toward A.

8. Wrap around the back, and anchor with tape. This completes part 1 with the 6-in. bandage.

PART 2

1. Begin by placing a double-length 4-in. elastic bandage on the residual limb between the

corners A and B. Wrap diagonally around corners B and C.

2. Cross upward toward A, and anchor the wrap. 11, continue around the back and down to

corner C.

3. Wrap upward and across to A and then around the back toward D.

4. Continue down and across to cover cornersB and C.

5. Continue upward and across to A This is the figure-of-8 pattern guide.

6. Wrap around the back toward D.

7. Continue down, and wrap corners b and C, but wrap slightly higher than the previous time

around. Continue wrapping higher on the residual limb until the figure-of-8 bandage is

completed.

8. Remember to apply less pressure as you move up. Complete the wrap by anchoring it with tape.

Note that the angle between the figure 8s should be 80 to 90 degrees at the crossover point to

avoid a tourniquet effect.

104

Module 4

Transfemoral Residual Limb Wrapping continued

105 Module 4

Criteria for Artificial Leg Fitting

Prosthetic Device Refer to DJF If the answers

are in this column

1. Are you regularly using your prosthesis? Yes No

2. How is the prosthesis fitting? Good Not Good

3. How is the prosthesis functioning? Good Not Good

4. Are you satisfied with the fit of the prosthesis? Yes No

5. Are you satisfied with the function of the prosthesis? Yes No

Do you feel it necessary for the technician to check-

up your prosthesis?

No Yes

Stump

Are you experiencing any problems with your stump? No Yes

If there are wounds, blisters or signs of infection on the stump refer to district health center

doctor or nurse for medical management before referring to Davao Jubilee Foundation.

Monitoring of Prosthesis and Stump

Use this simple monitoring tool modified from the Davao Jubilee Foundation Patient Monitoring and

Follow-up sheet to assess patients with prosthesis.

6 months after amputation- minimum period prior to fitting

Good physical and mental state condition

Good mobility/strength

No wound, contracture, and infections

Free, good scar

Controlled Blood Pressure

Controlled Blood Sugar

Davao Jubilee Foundation

Address: Sitio Escuela, Catalunan

Grande, Davao City in-front of

Barangay Hall

Telephone Number: 2971398

Referring to Davao Jubilee Foundation for

Artificial Leg Acquisition

PAYING PATIENTS:

Refer to any Rehabilitation Medicine Doctor for Prosthetic

prescription then proceed to Davao Jubilee Center

INDIGENT PATIENTS:

Call Davao Jubilee Center every Thursday morning for free

consultation services

References

1. International Working Group in the Diabetic Foot/Consultative Section of the International Diabetes

Federation, International Consensus on the Diabetic Foot and Practical Guidelines on the Management and

Prevention of the Diabetic Foot. International Working Group on the Diabetic Foot. 2007.

2. Wound Care made Incredibly Easy. Lippincott, Williams and Wilkins: United States of America, 2003.

106

Module 4

Notes:

107 Module 4

Notes:

108

Module 5

PSYCHOSOCIAL AND BEHAVIORAL APPROACHES

Psychological Reactions to the Diagnosis

of DIABETES

Denial ―No! Not Me!‖

Fear ―What if....‖

Anxiety ― How will I live?‖

Depression ―Life has no meaning anymore‖

Anger ―I hate you!‖

Bargaining ― Not now.‖

Hope ―When I get cured ―

Acceptance ― I can die anytime ‖

Other Psychological & Psychiatric Problems

Persons with Diabetes May Suffer

Eating Disorders

Phobia

Obsessive Compulsive Disorder

Alcohol And Drug Dependence

Panic Disorder

Self-care issues—Regimen acceptance &

adherence

Emotional issues Diabetes related distress &

depression

Types of Coping

Problem-focused Coping–Strategies that are

appropriate for problems that can be directly

remedied

Emotion-focused Coping- Strategies appropriate

for problems that cannot be directly remedied.

5 C’s Behavior Change Intervention

Constructing a problem Start with the patients’ problem

Specify the problem

Collaborative Goal Setting Translate patient’s self-management and

behavior change intentions into goals

Collaborative Problem-solving Problem – solving ABILITY is associated with

improved health outcomes

Problem-solving INTERVENTIONS are often

effective in improving health outcomes.

Identify barriers to goal attainment

Cognitions (belief that treatments are not

effective)

Emotions (Lack of self-efficacy)

Social networks (Lack of Support)

Resources (Lack of time or money)

Physical Environment (Lack of facilities)

Contracting for Change Patients should be encouraged to keep a

record of successes and lapses and reasons why

each occurred.

Continuing Support Patients should be prepared to handle relapse

and re-establish self-care regimen

Contents:

Psychological Reactions to the Diagnosis

of Diabetes

Types of Coping

5 C’s Behavioral Change Intervention

Professional Attitudes and Behavior

Asking questions and helping

patients to work through their issues

can enable diabetes care providers

to improve outcomes with relatively

little consumption of resources.

109 Module 5

Professional Attitudes And Behaviors

Traditional

Medical Model

Empowering

Person – Centered Model

Diabetes is a physical illness Diabetes is a biopsychosocial illness

Relationship of provider and patient is

authoritarian based on provider exper-

tise

Relationship of provider and patient is

democratic and based on shared ex-

pertise

Problems and learning needs are usual-

ly identified by professionals

Problems and learning needs are usual-

ly identified by patient

Professional is viewed as a problem

solver and caregiver, i.e., professional is

responsible for diagnnosis, treatment,

and outcome

Patient is viewed as problem-solver &

caregiver i.e., professional acts as a re-

source & both share responsibility for

treatment and outcome

Goal is compliance Goal is to enable patients to make in-

formed choice.

Behavioral strategies are used to in-

crease compliance with recommend-

ed treatment.

Behavioral strategies are used to help

patients change behavior of their

choosing.

Lack of compliance is viewed as failure

by the provider or patient .

Lack of good achievement is viewed as

feedback & used to modify goals &

strategies

Emotional Support Interventions

Health Consequences of Emotional problems:

poorer self-care

poorer metabolic outcomes

morbidity

mortality

functional limitations

poorer quality of life

All Clinicians Should Be Able to:

1. Identify patients who are suffering from diabetes-

related distress.

2. Apply effective treatments to relieve diabetes-

related distress.

3. Identify patients who are suffering from

psychiatric disorders.

4. Refer patients for specialized mental health care

when appropriate.

Identifying Diabetes Distress

Ask the following questions:

Are you having trouble accepting your

diabetes?

Do you feel overwhelmed or burned out by the

demands of diab. Management?

Do you get the support you need from your

family?

Do you worry about getting diabetes

complications?

Primary Intervention:

Cognitive Behavior Therapy

Goal

Address lack of self-confidence

Unrealistic expectations

Lack of Motivation to change behavior

Identifying psychiatric disorders

Ask the following questions:

During the past 2 weeks, have you felt down,

depressed or hopeless?

During the past 2 weeks, have you lost interest or

pleasure in doing things?

110

111 Module 5

112

Module 5

113 Module 5

114

Module 5

115 Module 5

116

Module 5

Notes:

117 Module 5

Notes:

118

Module 6

SELF-MANAGEMENT EDUCATION

Diabetes Education

It is a means of attaining health promotion

It allows the individual to gain knowledge, correct

attitude, behavior and practices for health im-

provement

An integral part of patient care and self-

management

Why education and self-management?

The first step is to educate in order to facilitate

informed decision making. Although many people

with type 2 diabetes do not view their condition as

serious, it needs to be acknowledged and

understood that complications occur with all types

of diabetes.

Diabetes is largely managed by the person with the

condition on a day-to-day basis. Thus, caring for

diabetes is a personal responsibility.

What is the difference between education and

behavioural change? The two are not distinct

entities, but rather overlap to a great degree.

We can think of education as the body of

information, skills and technologies that a person

with diabetes needs to learn. As discussed in the

teaching and learning module, how they learn will

have an impact on whether or not behavioural

changes follow. In this module we will discuss how to

help people take the steps to behavioural change

once they have the necessary knowledge.

Patient Education

planned learning experience using a combination

of methods, such as teaching, counseling and

behaviour modification techniques, which influence

knowledge and health behavior.

Patient education entails more than just teaching or

learning. It involves a combination of techniques

and methods, all of which are aimed at increasing

knowledge, skills and confidence in order to make

appropriate healthy choices and establish new

habits.

Patient-centered Education

Interventions are more effective when they:

Are tailored to people’s preferences

Are tailored to a people’s socio-cultural

environment

Actively engage people in goal-setting

Incorporate coping skills

Provide follow-up support

This is a summary of critical factors for successful

educational interventions. Adult learners generally

have preferences about how they learn best and

the topics they want to address. Information needs

to be culturally relevant and appropriate.

One of the critical factors in ensuring success is the

ongoing nature of self-management and

professional support.

Education is not a one-time event that will provide

people with all they need to manage diabetes for a

lifetime. Without ongoing support, behaviors return

to pre-intervention levels after about six months.

Health Education

Consists of learning experiences that promote

behavior change conducive to good health.

Provides tools for developing physical,

emotional, spiritual and sound mental health.

Contents:

Introduction to Self-Management Education

The Health Educator

The E.A.S.E Approach

Using Patient Education Materials

The Diabetes Diary

The Medical Nutrition Therapy Kit

Introduction

Diabetes is a personal responsibility People with diabetes want information

People with diabetes want to be in

control of their condition

Diabetes needs to be self-managed

Education is more effective when it is

patient-centered

We educate so that our patients can

make informed decisions

119 Module 6

Concept of Health Education

It is a learning process growing out of health

needs, nourished by health knowledge and

producing intelligent constructive and healthful

individual and community action.

It is a means of creating opportunities for the

people to participate and assumes responsibility

for the solution of their own problem in

cooperation with health specialist and

educators.

Principles of Health Education

1. Health education is a teamwork endeavor.

It is everybody’s business.

2. Health education must be an integral part of all

health planning.

3. All health workers need to be trained and make

use of educational methods, approaches and

media.

4. Health education is concerned with the

changes in the knowledge, attitude and feelings

and behavior of the people.

5. Health education program must be built on

already existing structures. Preliminary survey of

what has been done and what needs to be

done is required.

6. Program should be based on clearly stated

goals.

7. Health education is concerned with working with

rather than for the people.

8. Needs and interest of the people should be

considered.

9. All communities, no matter how small, have an

organizational structure on which to build on.

10.Secure the coordination and cooperation of

people and existing organizations.

11.Start with simple educational measures or

projects most likely to succeed in a short time to

gain people’s confidence.

12.Start with project in a pilot area than on a

wide-scale basis.

13.A fundamental faith and belief in people’s

ability to contribute to the solution of their own

problems is essential for effective and lasting

health education.

Philosophy of Health Education

The focus of health education is on people and on

action. In general, it aims to persuade people to

adopt and sustain healthful life practices, to use

judiciously and wisely the health services available

to them and to make their own decisions, both

individually and collectively, to improve their health

status and environment.

The facilitator or implementer of health education

Initiator of the process whereby people learn to

improve their health attitude and habits and to

work together for the improvement of health

condition of the family, community and the

nation.

Qualities of a Health Educator

Efficient – plans with the people, organizes,

conducts, directs health education activities

according to the needs of the people.

Communicator – provides participant with clear

and relevant information.

Active listener – hears what is being said and

what’s behind the words.

Keen observer – keeps an eye on the

proceedings, processes and participants’

behavior.

Systematic – knows how to put in sequence or

logical order the parts of the session.

Creative/resourceful – uses available materials,

involves participants

Analytical – a critical thinker

Tactful – brings about issues in smooth, subtle

manner.

Knowledgeable – imparts relevant, updated and

sufficient input

Open – invites ideas, suggestions, criticisms,

involves people in decision making.

With sense of humor – knows how to place a touch

of humor to keep audience alive.

Change agent – involves participants actively in

assuming the responsibility for his own learning.

The Health Educator

120

The E.A.S.E Approach

Module 6

The E.A.S.E Approach is….. A tip for diabetes educators to guide him/her

during the counselling session be it individual or

group

An easy way to deliver an education process

A tool that is easy to remember

Establish rapport

Make friends with the patient. As we all know,

effective learning can only take place when we

have gained the patient’s trust and

acceptance.

It starts with being genuinely interested about

the person.

listen actively when he/she speaks.

remember to make eye contact.

respect his/her beliefs and opinions and be

sensitive to his/her emotions and needs.

In the course of your conversation, try to learn

the following things about the patient:

1. Who is this patient as a person?

2. What is his/her psychological needs?

3. Is there a significant other to help her through

the learning process?

4. Are there barriers to learning?

5. Can he/she afford to live with this disease?

6. What parts of the health system will she utilize?

7. What referral will she require?

8. Which member of the health care team is

needed at this time or will be required later?

Assess the patient’s needs

This involves finding out:

What he/she has been told about his/her illness

What does the person know?

how does he/she learn?

How ready is he/she to learn?

What are the barriers?

Patient’s NEEDS

N—Nutrition

E—Exercise

E—Education

D—drugs: oral anti-hyperglycemic agents & Insulin

S—Self–monitoring; Self–care; Special

Consideration; Stress Management; Smoking

Cessation

Suggested questions?

What has the doctor told you?

What does having diabetes mean to you?

How do you feel about having diabetes?

What do you know about diabetes?

Strategize your learning approaches based on the

patient’s needs

Once you have assessed your patients learning

needs, you can develop an education plan that

fit his/her needs.

The plan must be developed together with the

patient, and if possible with the spouse or

significant other.

In teaching patients about diabetes

management, encourage participation and

create an environment in which the patient can

freely ask questions and express opinions.

Topics can be classified into three main groups:

The needs to know are the essential

information that the patient needs to survive.

These include medication, diet, self-monitoring

and motivation. These are the absolutely

essential information that a patient needs to

leave you care safety.

The wants to know are the things that patients

ask about. They may not be the most

important things to you, but if the patient asks

you something and you cut them off, you will

lose your patient’s trust and they will no longer

hear anything else you say.

If there is something more important to discuss,

you can tell your patient that the subject will

be covered later on, but if they are really

concerned about it, you will discuss it with

them after the current topic.

The nice to know are the topics that may be

interesting and fun, but no one needs them to

survive. Teach people what they need, not

what they enjoy.

Evaluating what the patient has learned

Ask for your patient’s feedback regularly during

the session, in case there are points that need to

be clarified or if he has a different opinion. At the

end of the session, ask your patient to demon-

strate or tell you what he has learned.

•For example, after the session on self monitoring,

you may ask your patient the following:

How will you know if you have low/high blood

sugar?

What will you do if you have low/high blood

sugar?

Show me how to test your blood sugar (allow

patient to demonstrate)

121 Module 6

E. A. S. E. Approach

E - establish rapport

A - assess the patient’s need

S - strategize your learning approaches

based on the patient’s needs

E - evaluate what the patient has learned

Learning does not automatically lead to doing.

Therefore, we must know if the patient will be

able to do things that he/she has learned. If not,

we must know what the barriers are, and what

can be done to overcome them.

The following are the guide questions you might

want to consider:

Do you think you will have difficulty doing

things?

What will make it difficult for you to do

these things?

Can you think of some ways that will help

you do this?

What would be a better way for you to monitor

blood sugar, follow a diet, exercise etc.?

The common wisdom used to be that if you wanted

to save money on educational materials, just check

the trash can in the parking lot. Although health

professionals cannot guarantee that their patients

will use the materials provided, there are some ways

to increase the likelihood that they will benefit from

such resources. Rather than just handing patients a

stack of materials:

Choose one or two items about which the

patient has expressed a particular interest. Let

patients know that you chose these particular

materials because you think they will benefit

from them.

Take the time to highlight one or two key points

or make a handwritten note of something to

which patients should pay particular attention.

This increases the likelihood that patients will

follow through with recommendations in those

areas.

Match materials to patients. Both content and

pictures need to be representative of a patient’s

age, sex, ethnicity, and culture. Patients are

more likely to read something if it looks as if it

applies directly to them.

Match reading levels to patients. Look for

thorough but simply written materials that are

adult in tone.

Pay attention to tone and avoid materials that

have a lot of ―shoulds‖ and ―musts‖ or that

preach or talk down to patients.

Give a few patients you trust several different

handouts or printouts and ask that they give you

their candid opinions. Ask specifically what they

do and do not like about these materials and

whether they found them to be informative and

inspiring.

Make sure that the materials match the

reality of diabetes. Patients struggle with making

changes and dealing with the anger, fear, and

frustration that often go with diabetes. Materials

need to address these issues just as they address

the clinical aspects of diabetes care.

Source: Finding and Using Patient Education Materials, Volume 27,

Number 1, 2009 • Clinical Diabetes, Martha M. Funnell, MS,

RN, CDE

Using Patient Education Materials

122

The Diabetes Diary

1. Given only to persons with diabetes.

2. Persons with diabetes are those diagnosed by a doctor to have

diabetes.

3. One diary is given per patient.

4. The diary is not for sale.

5. An orientation on how to use the diary must be done immediately

after giving the diary.

6. A list of persons with diabetes who are given a copy of the diary

should be maintained at the health center.

7. The diary should be used to record monitoring activities including

results and consultations done before, during or after the Diabetes

and Heart Days.

8. Although the diary records consultations with the physician, it does

not totally substitute hospital, clinic or health center or CVD

Program consultation forms.

9. Data in the diary of the patients are confidential. Avoid showing it

to other patients.

10. The diary contains sections on patient education. These are meant

for self-reading or self-study. Do not remove pages from the diary to

conduct patient education sessions.

The Diabetes Diary

is used for…..

Patient Identification

Patient Education

Patient Monitoring

Patient Recording

Remind the patient to

always bring their diary

during Diabetes and Heart

Days and during

consultation with any health

care provider.

Module 6

The Diabetes Diary

123 Module 6

The Diabetes Diary—Parts to be filled up by Persons with Diabetes

124

Module 6

125 Module 6

The Diabetes Diary - Parts Filled Up by The Health Care Team

126

Module 6

127 Module 6

The Diabetes Diary - Sections for Patient Education

Notes:

128

Module 6

129 Module 6

130

Module 6

131 Module 6

132

Module 6

133 Module 6

Medical Nutrition Therapy Kit

The Medical Nutrition Therapy Kit is designed for use by Nutritionist-Dietitians for one-on-one nutrition

counselling and for group education sessions. It contains the following items:

1. Food models of common local food items like rice, suman (rice roll), loaf bread, pan-de-sal, sweet

potato, chicken, pork, fish, papaya, banana and durian.

2. Table top weighing scale.

3. Measuring cups and spoons

4. 9-inch diameter plate for Plate-method demonstration.

Notes:

134

Contents:

Team Management

Functions of the Health Care Team

Making Health Service Physically Accessible

Setting up services for CVD risk management in

primary health centers

Team Management

Module 7

SETTING UP SERVICES FOR CVD RISK MANAGEMENT IN

PRIMARY HEALTH CENTERS

The management of diabetes and other CVD risk

factors is an active partnership between people

with diabetes and other CVD risks, their family and

their healthcare team. An integration of clinical

care and self-management education is best

provided by a multidisciplinary health care team .

The core health care team consists of the physician,

the nurse, the nutritionist-dietitian and may also

include health workers, lay educators, psychologists,

pharmacists, laboratory technologists, podiatrists.

The Team Approach is….

Patient education (clinical care and self-

management education)

given by a multidisciplinary health care team

with members having different expertise and

responsibilities

working together with persons with diabetes

by constant communication and coordination

to provide continuous, integrated and quality

care.

CVD PROGRAM TOOLS AND EQUIPMENT

Service Tool

Screening ,

Diagnosis and

Monitoring

Diabetes Risk Self-Assessment Form

CVD Risk Assessment Form

Blood glucose meter with strips

HbA1c point-of-care machine

Sphygmomanometer with adult

and pediatric cuff sizes

Stethoscope

Cholesterol meter with strips

Urine strips for proteins and

ketones

Tape Measure

Height Chart and Weighing scale

Foot Care Kit

Monofilament

Hand mirror

Foot Risk Assessment Form

Management HCP Training Manual Containing

Clinical Practice Guidelines

Foot and Wound Care Kit

Medical Nutrition Therapy Kit

Food Models

Table top weighing scale

Measuring cups and spoons

Plate (9-inch diameter)

Index Cards for Patient Records

FNRI Food Exchange list

Referral Form

Laboratory Request Form

Information

and

Education

Diabetes Diary

Diabetes Prevention Flipchart

Patient Education Flipchart

Risk Factors Poster

Signs and Symptoms Poster

Foot Care Poster

Footwear Poster

CVD Program Services Flowchart

Recording Patient Record Form (Folder)

Consultation Form

Patient Registry

Reporting Barangay Report Form

District Laboratory Report Form

District Monitoring Form

Equipment and Facility Requirements

Physical space, equipment and facilities must be

available and conducive to service delivery and

learning and allow members of the diabetes team

to carry out their respective functions.

135 Module 7

Functions of the Health Care Team

PHYSICIAN

(DHO) Center-based

DISTRICT

NURSE/

MIDWIFE Center-based

NUTRITIONIST Center-based

EXTENSION

TEAM Community-

based

PERSON WITH

DIABETES

THE DISTRICT HEALTH OFFICER (DHO)

Leads and coordinates the activities of the

entire health care team

Performs opportunistic primary screening and

initial assessment

Advices screening and diagnostic

procedures

Establishes diagnosis and identifies existing

complications

Provides initial diabetes education and

orientation to team management

Initiates and adjusts pharmacologic therapy

( OAD or insulin )

Prescribes specialized medical nutrition

therapy based on computed caloric

requirements, dietary needs and restrictions

Prescribes specialized physical activity

Initiates the use of patient monitoring tools

(eg. diaries ) and explain its importance

Determines when and where to refer

patients for further assessment or

management

Makes referrals to other specialized health

care providers

THE DISTRICT NURSE OR MIDWIFE

In the absence of the physician, performs

opportunistic primary screening ,advices

screening and diagnostic procedures and

refers to nutritionist for dietary assessment

Performs monitoring procedures (BP, blood

glucose, foot examination)

Assesses patient’s self-management

practices (eg. through patient diary,

interview, etc), identify potential treatment

problems, and discuss with the patient the

ways for improvement

Monitors drug compliance

Discuss concerns and fears with patient and

family and provide patient/ family support

Bring to the physician’s and nutritionist’s

attention any patient concerns relevant to

their roles

Interface with physicians and other diabetes

management team members

Endorses patients to the barangay extension

team for monitoring.

Prepares and updates records and reports

Property custodian of team equipment

THE DISTRICT NUTRITIONIST-DIETITIAN

Assesses patient’s dietary habits

Develops specialized medical nutrition therapy

based on the physician’s prescription

Develops the patient’s meal plan

Provides continuous dietary management and

counseling including monitoring of patient’s BMI

and WC

Provides patient/ family education including

food preparation methods.

THE BARANGAY EXTENSION TEAM

Barangay Health Station In-charge, Barangay

Health Workers, Barangay Nutrition Scholars

Performs risk assessment

Performs Capillary Blood Glucose testing or

recommends FBS for persons at risk for Diabetes

Refers to the physician for diagnosis and

initiation of management

Provides community-based self management

education

Performs monitoring procedures (BP, blood

glucose, waist circumference, foot examination)

Refers persons with suspected complications to

the physician

Administers diabetes education to the general

population and high risk groups

Prepares and updates records and reports

THE PERSON WITH DIABETES

Performs self-management practices

Provides peer education and support.

136

Module 7

Making Health Services Physically Accessible

REMEMBER

RECU Reach

Enter

Circulate

Use

137 Module 7

Setting Up Health Services for CVD Risk Management

in Primary Health Centers

The Diabetes and Heart Day

The Diabetes and Heart Day, operationalizes the knowledge and skills gained from the CVD Program

trainings into services for people in the community.

The Diabetes and Heart Day is……..

Dedicated to screening, management of diabetes and hypertension and health promotion through

patient education

Operated by a multidisciplinary team of health care professionals and community health workers

Designed to be a regular service at the health center level aimed to regularly monitor patients

registered in the CVD Program

Conducted at a place accessible to all

Frequency may vary (eg. once, twice or thrice a month).

Other Ways of Setting Up Health Services

Aside from the Diabetes and Heart Day, the health care team can also opt to schedule different

components of the Diabetes and Heart Day on different days:

Integration of services into regular consultation times by:

Conducting opportunistic screening of diabetes and CVD risks

Medical Consultations done during existing medical consultation schedules

Regular Medical Nutrition Therapy and nutrition counseling is set on another day depending on

Nutritionist Schedule

Regular monitoring of blood sugar by FBS, blood pressure, waist circumference, smoking status and

foot risk category done more frequently by Barangay Health Workers (eg. once a week)

138

Module 7

Information Dissemination

The distribution of this flyer per

household in the barangays and puroks is

the first strategy in informing the

people in the community of the services

available in the health center.

Fill up the appropriate data first before

distributing the flyers such as name of

barangay, venue of the Diabetes and

Heart Days and schedule of services.

Community Health Workers can

facilitate the purok-level distribution of

the flyers to guarantee that this

information reaches the majority of the

population.

Inside this flyer is the Diabetes Self

Assessment Questionnaire. Be sure to explain to one responsible member of the household how to use the

questionnaire and the corresponding recommendations.

139 Module 7

Flow of Services for New Patients

IF patient has ANY of these three conditions:

1. With existing cardiovascular disease and/or

2. Without established CVD with persistently elevated

BP of >160-170/100-105 mmHg and/or

3. Without established CVD but with either one of the

following biochemical test results::

TOTAL CHOLESTEROL LEVEL OF ≤ 8mmol/L

LDL CHOLESTEROL OF ≥ 6 mmol/L

TC/HDL-C of > 8

PATIENT IS ALREADY CONSIDERED HIGH RISK of a very

fatal or non-fatal vascular event Refer to CVD

Screening tool for recommendations.

REGISTRATION

ASSESSMENT Vital signs and BP measurement

Risk Grading based on the criteria on the

left

SCREENING DM Screening

CVD Screening

CONSULTATION Diagnosis

Management

Referral

RECORDING Generation of Patient Record

Recording in the Patient Registry

EDUCATION AND COUNSELLING Diabetes Education

Medical Nutrition Therapy

Give Diabetes Diary

140

Module 7

Generating the Patient Record

Case Number will be generated once the patient is entered in the Patient Registry. The case number is

made up of two parts: the first part is the Barangay Code (refer to page 145) and the second part is

the patient number. Patients will use the same case number every time they visit the health center. The

case number is also written in their Diabetes Diary for identification purposes.

Fill up the patient information accordingly. Assign trained members of your team to fill up different parts

of the patient record. The entire first page can be filled up by trained community health workers or the

Barangay Midwife.

141 Module 7

Generating the Patient Record continued

The second page contains vital information on the patient’s initial visit.

Trained Community Health Workers can fill up the information inside the circle. The BMI (Body Mass

Index) although not part of the 7 monitoring parameters is included as baseline for Medical Nutrition

Therapy purposes. Use the BMI table.

The next parts of this page is filled up by the District Health Officer during the first consultation. A

specially-trained nurse, nutritionist or midwife may do the ASSESSMENT (Review of Systems, History of

Present Illness) and make the Diet and Physical Activity prescription which will be reviewed by the DHO.

142

Module 7

Generating the Patient Record continued

The second and third pages of this folder-type patient record is for recording the 7 monitoring

parameters. If the patient comes once a month regularly for monitoring, this portion will be good for

5-6 years.

Fill the part inside the circle for easy filing and retrieval.

A pocket is provided to hold loose-leaf consultation records, foot risk assessment forms and laboratory

results.

143 Module 7

Generating the Patient Record continued

This loose leaf, back-to-back consultation form is for District Health Officers to document their

management during patient visits.

4 visits can be documented per leaf.

Do not forget to write the patient’s name and case number just in case this gets separated from the

patient’s folder.

Write the date of each consultation. Please write the same information in a simplified manner on the

Diabetes Diary Consultation records.

144

Module 7

Recording in the Patient Registry

Each patient is

assigned just one case

number

Type of test (HbA1c in %, FBS, OGTT in mmol/L)

and Result

A1c 6.4

LDL 3.7

Lipid Type and

Result mmol/L

145 Module 7

146

Module 7

Recording in the Patient Registry

Filling up the Patient Registry:

The first page of the registry can accommodate 10 patients. Ensure that all data are written properly.

Use a black or blue pen when making an entry.

A summary of important indicators is included on the right top portion of this page. Please

accomplish this when 10 patients have been registered in this page for easy data monitoring.

The succeeding pages contain monitoring boxes that is good for at least two years of monthly

monitoring. Note that not all pertinent data found in this page are re-written on the succeeding pages.

Classification of Patients in the Registry:

New—newly registered regardless if newly diagnosed or previously diagnosed (with referral or previous

medical records from other health facility)

Old—patients already registered who regularly visit the health center for monitoring and those

registered on the previous month (regardless if they visit the health center on the current month)

Defaulter—patients who did not visit the health center for 2 consecutive months

Returned after default—registered patients returning to avail of the health services after not coming for

follow-up for at least 2 months.

Trans-in—Transferring patients previously registered in another health center with CVD Risk Management

Services with proper endorsement/referral . The previous case number is disregarded and a new case

number of the current barangay is assigned.

Tran-out—Patients who transfers to another barangay health center with CVD Risk Management

Services. An endorsement note is given to the receiving health center.

Deceased

147 Module 7

Flow of Services for Old Patients (Those coming for follow-up monitoring)

REGISTRATION

• Queuing

• Retrieve Patient Record

ASSESSMENT

• Vital Signs

• 7 Monitoring Parameters

• Record in Patient Record + Diary

CONSULTATION

• Diagnosis

• Management

• Referral

RECORDING

• Update Patient Registry

EDUCATION / COUNSELLING

• Diabetes Education

• Medical Nutrtion Therapy

• Give Diabetes Diary

148

Module 7

Indications for Referral of Patients

CHO to SPMC SPMC to CHO

Medical (Stable) send to Out Patient Department:

Mindanao Diabetes Center or Cardio Clinic

Stable patients are those who are ambulatory and

afebrile with the following conditions:

Uncontrolled blood sugar despite medications

High serum creatinine and other highly abnor-

mal lab results

With concomitant disease such as TB

For further tertiary evaluation and management

Medical (Unstable) send to Emergency Room

Difficulty in breathing

Febrile

Jaundice

Surgical (Stable) send to Out Patient Department

Wound and Ostomy Care Clinic

Stable with non-healing wounds

Surgical (Unstable) send to Emergency Room

Cellulitis

Necrotic Tissue

Abscess

Fever

Afbrile with WBC > 14,000 or < 2,000

Medical

For CVD Risk factor monitoring

Follow-up medications

For follow-up Medical Nutrition Therapy

For Patient education

Surgical

For wound monitoring and dressing

CHO to Davao Jubilee Foundation Davao Jubilee Foundation to CHO

For Prosthesis and orthosis fitting

Physical Therapy

Stump Care and basic education on

proper positioning

Follow-up proper stump bandaging

Monitoring of prosthesis

City Health Office

Southern Philippines Medical Center

Out Patient Department

Emergency

Davao Jubilee

Foundation

149 Module 7

Referral Form

150

Module 7

Referral Form continued

151 Module 7

Reporting

Handicap International

1. Data is first generated at the Barangay Level. Monthly barangay reports will be submitted to the District

Health Office.

2. The District Health Center collates data from all the barangays and submits this data to the City

Health Office.

3. The City Health Office (CHO) collates data from all district health centers and forwards this data to

Handicap International.

4. Handicap International collates data from CHO, Southern Philippines Medical Center and Davao

Jubilee Foundation, and submits reports to the heads of each partner.

Note: Handicap International’s reporting duties will gradually be turned over to the City Health Office

within 1-2 years.

152

Module 7

153 Module 7

154

Module 7

Notes:

155 Module 7

Notes:

156

Module 8

COMMUNITY HEALTH WORKERS TRAINING

Training Design (to be submitted to CHO and HI at least 2 weeks before the training)

Barangay/ District

Session Title: Basic Training for Community Health Workers for the Implementation of the

Cardiovascular Disease Program in Davao City

Target Participants: Number of Barangay Health Workers: __________

Number of Barangay Nutrition Scholars: ________

Number of Facilitators: ________

Venue:

Date and Time: (total of 2 days)

Facilitators

Background:

Diabetes management requires a multidisciplinary approach that involves all members of the health

care team. As such, there is a need to train and capacitate the community health workers, comprised

mainly of Barangay Health Workers (BHWs) and Barangay Nutrition Scholars (BNS) on how to provide

basic services for persons with cardiovascular disease risk factors.

Based on the action plan generated during the Basic Training for Primary Health Care Professionals for

the Implementation of the Cardiovascular Disease Program in Davao City conducted in the 1st Quarter of

2011, the training for the CHWs on the implementation of the CVD Program shall commence beginning

May until September of 2011.

Objectives:

General: Community Health Workers are able to provide basic services for cardiovascular disease risks

as part of a multidisciplinary health care team through the implementation of the CVD Program:

Specific: At the end of the session, Community Health Workers are able to:

1. Conduct information dissemination on the CVD health services offered in the health centers.

2. Perform diabetes self assessment and interpret the results.

3. Instruct others on how to perform a diabetes self assessment.

4. Recommend the next steps based on the result of the diabetes self assessment.

5. Perform CVD Risk Assessment.

6. Recommend the next steps based on the result of the CVD risk assessment.

7. Enumerate the 7 monitoring parameters and state their significance.

8. Perform blood sugar monitoring using a portable blood glucose meter.

9. Performs blood pressure monitoring.

10. Measure waist circumference.

11. Perform foot risk assessment

12. Educate patients on the hazards of smoking.

13. Conduct basic foot care education

14. Enumerate the target values

15. Refer patients to the District Health Office based on the target and actual values of the 7 monitoring

parameters.

157 Module 8

Program Process Date /Time Facilitator/Materials

Opening Registration

Opening Prayer

National Anthem

Introduction Getting to know you activity

Levelling of Expectations and Presentation of the

training objectives

General Orientation to the Training Program

Nature and the objectives of the training

Correct incongruent expectations

Rules and regulations of the training emphasis on

punctuality, attendance and participation

Overview of the CVD Program

Introduction of the 4 partners of the program

Pretest

Module 1

Diabetes Basics

Definition of Diabetes and CVD

Risk Factors

Signs and Symptoms

Basic principles of diagnosis and the importance of

following diagnostic procedures

Enumerate the components of Diabetes/ CVD Risk

Management:

Medications

Proper Nutrition

Physical Activity

Smoking Cessation

Regular Monitoring

Foot Care

Diabetes and CVD Prevention – focus on lifestyle

change

Module 2

Information Dissemination and Screening

Information Dissemination using the flyers

The importance of screening.

Performing DM Self Assessment

Performing CVD Risk Assessment

Module 3 Monitoring

The 7 monitoring parameters and their target values

Blood sugar testing using portable blood glucose

meters

Blood Pressure monitoring

Measuring waist circumference

Performing Foot Risk Assessment

Refer patients to the District Health Office based on

the target and actual values of the 7 monitoring

parameters using the referral form.

158

Module 8

Program Process Date/Time Facilitator/Materials

Module 3

continued

Recording the monitoring results in the following:

Diabetes Diary

Patient Record

Patient Registry

Module 4

Education

Education tools of the CVD Program

1.Diabetes Prevention Flipchart

2.Diabetes Diary

3.Foot Care Poster

The Idaho Plate Method

The Physical Activity Pyramid

Basic foot care education

Smoking cessation education

Diabetes Prevention education

Module 5

Reporting

Reporting system and schedules

How to fill up the Barangay Health Station Monthly

Statistics

Module 6 Diabetes and Heart Day Action Planning

Scheduling

Identifying different stations and corresponding

assignments

Filling up basic information in the following:

1. Diabetes Diary

2. Patient Record

3. Patient Registry

Evaluation Post test

Participants are asked to evaluate the training

program through a formal questionnaire

Participants, at the end of the evaluation, may

speak before the group to express his or her

thoughts about the training

BUDGET REQUEST ( Note: This part will be finalized by Handicap International only)

Item Frequency Total

Venue 2 days

Lunch (PhP ________ per person) ____pax x 2

Snacks (PhP ________ per person) ____pax x 4

Materials : _______pax

TOTAL

Training Design Submitted by:

Name and Signature: _________________________________ Designation: ____________________DHO:_______________

Reviewed by: Name and Signature__________________________ Designation: ______________ - City Health Office

Approved by: Name and Signature__________________________ - Project Manager—Handicap International CVD Project

159 Module 8

Training Documentation (to be submitted to CHO and HI after the training)

Training Title Basic Training for Community Health Workers for the Implementation of the

Cardiovascular Disease Program in Davao City

Barangay:

District:

Date:

Venue:

Total Number of Community Health Workers Trained: _______________

ATTENDANCE:

Name (Participants only) Designation Day 1 Day 2

AM PM AM PM

1.

2.

3.

4.

5.

6.

7.

8.

9.

10

11.

13.

14.

15.

16.

17

18.

19.

20.

Name (Facilitators only)

1.

2.

3.

4.

5.

6.

7.

Submitted by : Name and Signature: ________________________________ Designation: ___________________________

160 Module 8

Notes: