Welfare-Friendly Practices in Farming - 741 Words

Siegford et al. (2008) write about the need for farmers to introduce up-to-date improved livestock practices into their farming. Livestock and poultry producers face a tremendous amount of pressure from the public to introduce environmental standards and welfare-friendly practices into their farming. Farmers, in response, often go beyond the demands and expectations in order to meet consumers requests. However, Siegford et al (2008)show through various examples that animal welfare and environmental stewardship may be projects that have opposite objectives. One example is the high fiber diets of pasture-based dairy and beef cattle that although profiting the cattle only produce higher methane emissions. Lower emissions would be produced by a different kind of diet, namely by .. but this would not be good for the animal. In some parts of the world too, grazing is liberally allowed for animals and, in fact, is the accepted practice. Unfortunately, grazing spreads nitrate cotnaitmntion of land and land water. Thirdly, unconfined animal production iincreases land emission particularity since excreta is left unchecked. There is less opportunity to trap and treat the emissions since there is greater space for the animals. With these and other examples, Siegford et al. (2008) show how, although consumers demand coupling of environmental concern with excellent animal husbandry and practices of animal welfare, the objective of both can conflict one with the other. Even feedingShow MoreRelatedAnalysis Of Hayden Farr. Trader Joe s Organic Sumatra Coffee Commodity Chain1671 Words   |  7 Pagesacidity, and a rustic flavor with hints of cocoa, tobacco, and cedar. The beans are roasted to a medium-dark color and emits bold and earthy flavors which one could describe as distinct and full-bodied. Trader Joe’s prides itself in being an eco-friendly and human rights conscious firm in terms of the products they purchase for its numerous specialty grocery stores scattered across the U.S. By only purchasing Fair Trade certified Sumatran coffee at or above market value, Trader Joe’s ensures thatRead MoreOrganic Food : A Popular Trend Among Americans1342 Words   |  6 Pages$35.1 billion dollars, an 11.5% increase compared to the previous year (Market Analysis). Consumers seem to believe that organic foods have more health benefits, such as nutritional value, environmental benefits, and also take account for animal welfare. So what is the truth about organic food and why is it becoming so popular? It seems as though while organic food maybe the better choice, most consumers do not have a clear understanding on what organic food actually is and what it means. 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This community has a diverse population of professionals on different fields such as consulting, transportation, organic farming, and construction. TheRead MoreAgriculture Reform Act984 Words   |  4 PagesThe 1960s pushed farming to a new low. â€Å"federal agriculture policy continued to curtail surplus production and raise farm incomes, but it placed greater emphasis on guaranteeing low food prices† (Miller, 2011). Farmers were competing with other farms just to keep their farms and homes. The government implemented additional programs l ike the use of food stamps and the free school lunch programs, which further deemphasized the necessity for production for the farmers. 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This report is based on the case study ‘Walmart: Love, Earth ®Ã¢â‚¬â„¢ which identifies key points which are the criticism faced by the multinational corporation (MNC), business practices that are/were unethical and which ethical theories did/ do they violate and why do MNCs like Walmart address their social and environmental i mpacts. The case study is very important as it outlines the way the MNC works and the different types ofRead MoreAnimal Welfare And Relative Welfare4014 Words   |  17 Pages Organic Animal Welfare By Jason Hubing University of Wisconsin River Falls ANSC 115 Animal Welfare Dr. Kurt Vogel Scientific Journal Report #2 12/16/2014 Introduction Much can be said about animal welfare, many aspects are relatively new. New topics and avenues of potential research are constantly surfacing. For starters, one idea I’m going to attempt to tackle is an ethical one. Subjective at best in my opinion, it usually doesn’t warrant serious scientific research. The

Poverty Porn Promoting The Popular Stereotype - 2116 Words

Poverty Porn: Promoting the popular stereotype More often than not, poverty is represented in the general narrative that labels poverty as the same for every single individual in the situation and fails to address the complexity of poverty. This is especially true in the film Slumdog Millionaire. Starring Dev Patel, Slumdog Millionaire is the story of Jamal Malik, an eighteen year old, uneducated, orphan from the slums of Mumbai. Jamal Malik is one question away from winning 20 million rupees on India’s Kaun Banega Crorepati? (equivalent to America’s Who Wants to Be a Millionaire?). But when the show breaks for the night, the police arrest him with the allegation of cheating. Desperate to prove his innocence, Jamal tells the story of his life in the slums, where he and his brother grew up, of their adventures together on the road, of vicious encounters with local gangs, and of Latika, the girl he loved and lost. Each chapter of Jamal’s increasingly layered story, reveals where he learned the answers to the sh ow’s seemingly impossible questions. The film won a total of eight Oscars in 2009, out of the ten it was nominated for. The film also won 5 Critic’s Choice Awards and 4 Golden Globes. Set in the year of 2006, the novel based film explores a â€Å"different† perspective of India. However, director Danny Boyle, paints a selective portrait of Mumbai, ignoring the middle class and only involving the aspects of the lives of those who belong to the lower socioeconomic class of

Drawing and Recording by Lens

Drawing and Recording by Lens-Based Media Essay â€Å"A photograph is static because it has stopped time. A drawing is static but it encompasses time. † John Berger People have been drawing since the dawn of humanity, as evidenced in early cave drawings and wall frescos. The development of paper had a major impact on the way that drawing was recorded and distributed. In 1826, the invention of the camera had a profound effect on the world, providing a new way of recording information. In this essay, I will discuss and compare the acts of recording through drawing the human eye† and cameras the mechanical eye, drawing on images from periods of time since the early cameras of the nineteenth century. Specifically, I have chosen three periods that relate to human conflicts; the Crimean War, the Vietnam War and the recent war in Iraq. Through these three periods I will explore the developments in technology, and in processes and philosophy of the acts of recording, both by drawing and by lens based media. We begin our discussion in the 1850s, when for the first time we can compare the acts of recording by drawing and photography The Crimean war artist, William Simpson was respected as bringing the reality of war to the British people. He went to the Crimean war and; â€Å"he reported faithfully, sometimes disapprovingly on what he saw He preferred accuracy to drama, spirit to extravagance† (Lipscomb, 1999) His famous painting â€Å"The Charge of the Light Brigade† (figure 1) was undoubtedly a sustained study, bringing together a number of sketches of the event to provide a full image for the viewer. Conversely, Crimean war photographer Rogar Fenton never captured battles, explosions, and the blood and tears that is a moving image of war The first practical photographic method, daguerreotype, had a process too slow to capture a moving image; it needed to focus for a longer period on an unmoving object. But Michelle Bogre tells us that â€Å"If action happened too fast for them to be able record it, they resorted to finding or staging events that symbolically replicated what they had really seen† (2011,19-20) This seems true of Fenton, in his famous photograph â€Å"The Valley of The Shadow of Death† (Figure 2) Arriving at the battlefield months after the battle was over, he took two images of the scene; one with, and one without cannonballs, â€Å"Photo historians suspect that he and his assistants scattered the all-important cannonballs†, (Bogre, 2011, 20) Phillip Bounds suggests that â€Å"unlike other means of communicating, which represent events or things across an appreciable stretch of time, the camera records a single instant in complete isolation from the temporal continuum to which it belongs† (Bounds, 2011). â€Å"The Valley of the Shadow of Death† appears very static, as we cannot see evidence of war, such as explosions, army, fighting. We just see the landscape and without close scrutiny for the cannonballs, it has no meaning and context. It is a frozen moment which at best captures the aftermath of war. Perhaps it best described by Barthes: â€Å"photography is a new sort of hallucination: false on the level of perception, true on the level of time† (Vanvolsem, 2005, 51,) William Simpson, however, draws what he sees while at war, but then brings his canvas home to continue and complete his painting, â€Å"The Charge of the Light Brigade†. The results are more dramatic as the picture includes many details (white explosive, postural angles, fighting, and weather) to convey a sense of movement, and therefore to encompass time. By the twentieth century, technology had advanced; the camera is able to accurately capture faster. In later twentieth century conflict, the photographer was able to capture events and scenes of war as they were happening. For both artist and photographer there are a number of choices to be made in recording. Berger suggests: â€Å"The photographer’s way of seeing is reflected in his choice of subject. The painter’s way of seeing is reconstituted by the marks he makes on the canvas or paper† (1972, 10). The artist has options of mark-making, choice of colour, and medium. Take, for example, â€Å"Vietnam! † by Antonio Frasconi (figure 3). Nelson Mandela EssayMaimon says of the visual of the camera obscura, â€Å"it remains always the same, and for this reason appears more perfect, (2011, 965). Opton’s portraits of Iraq service personnel (Nagy Stocke 2012) try â€Å"to apply some provocative structure to a real moment in time. † (Nagy Stocke, 2012) Opton states â€Å"I guess I want the public to see the impact of war on a young person’s face† (Nagy Stocke, 2012) Clearly, Opton is striving for empathy from the viewer, echoing Berger: â€Å"We never look at just one thing; we are always looking at the relation between things and ourselves† (1972, 9). In both photography and drawing, the human element is vital; the camera is a tool; there is still a person making choices. While Dziga Vritov claims that the camera is â€Å"A mechanical eye. I, the machine, show you a world the way only I can see it† (Berger,1972) Berger argues the opposite: â€Å"Photographs are not, as is often assumed, mechanical records. Every time we look at photographs, we are aware, however slightly, of the photographer selecting that sight from an infinity of other possible sights† (Berger, 1972,10) In conclusion, we see that since the invention of the camera, the practice of photography has undergone massive changes, while the practice of drawing remains very much the same. The emergence of modern photography has opened the world visually on a scale that drawing was not able to achieve. While we relied on artists to record information accurately and relay it to the people, modern technology enables everyone to record and share through lens based media. But while most people are able to use cameras, the skills involved in drawing are still rare, and this elevates drawing for me into a more special realm. Moreover, the modern artist not only records, but interprets what they see, and this is seen in the emergence of abstract art. Our modern culture demands instant images, and photojournalists get well paid for timely images, whereas artists seem less in demand. It raises the question of the future; will photography continue as the dominant act of recording, or will there be a re-emergence of drawing? Perhaps the combination of drawing and photography with digital manipulation will prove to be the most popular means of recording? Bibliography: BERGER, John, 1980. About Looking, London: Writers and Readers. BERGER, John. 1972. Ways of Seeing. London: BBC/Penguin. BOGRE, Michelle. 2011. Photography as activism: images for social change, Oxford: Focal Press. BOUNDS, Philip. 2011. ‘Beyond Ways of Seeing – The Media Criticism of John Berger’ Available at: http://www.fifth-estate-online.co.uk/2p=40 GOMPERTZ, Will. 2012. ‘David Hockney – why art has become â€Å"less†Ã¢â‚¬â„¢. Available at: http://www.bbc.co.uk/news/entertainment-arts16578438 HOCKNEY, David. 1984. Hockney’s Photographs. London: Arts Council of Great Britain. HOCKNEY, David. 2001. Secret Knowledge: rediscovering the lost techniques of the old masters, London: Thames Hudson. KONSTANTINIDOU, Christina. 2008, The spectacle of suffering and death: the photographic representation of war in Greek newspaper, Visual Communication, 7 (2) LIPSCOMB, Adanan.1999. ‘William Simpson â€Å"Pierre of Pictorel Coneapondent’, Available at: http://www.victorian.org/painting/simpson/bio.html, MAIMON, Vered. 2011. On the singularity of early photography: William Henry Fox Talbots Botaniel Images, Art History: Journal of the Association of art Historians, 24 (5) VANVOLSEM, Martin. 2005. Hinting at on experience of time is still photography, Journal of Visual Art Practice, 4 (1)

Teaching Plan Diabetes Mellitus free essay sample

According to the Centers for Disease Control and Prevention (CDC, 2011), 25. 8 million Americans, 8. 3 percent of the population, have diabetes and nearly 27 percent of those 26 million Americans, are undiagnosed. In 2010, the CDC reported nearly 2 million Americans aged 20 years and older were diagnosed with diabetes. Diabetic education is an important part of helping those with diabetes effectively manage the disease and prevent complications. Statistics from the CDC show that poorly managed diabetes is the leading of non-traumatic lower limb amputations in the United States . Patients with diabetes are at greater risk for serious complications with their feet than those who do not have diabetes. Implementing a diabetic foot care program for those patients receiving home health services can reach an often-overlooked at-risk diabetic population . The home health nurse has the perfect opportunity to implement a foot care regimen and reinforce the importance of proper foot care with her diabetic patients and their families/caregiver. We will write a custom essay sample on Teaching Plan Diabetes Mellitus or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page This teaching plan is a prevention plan designed to reinforce good foot care practices for a diabetic patient who needs a refresher on proper foot care or the newly diagnosed diabetic patient. The content is suitable for anyone who is age 18 or older with at least an eighth-grade education, and who can read/write English or Spanish. Any family members or caregivers should be present to learn proper foot care in case the patient becomes unable to practice proper foot care at some point in the future. Family members and caregivers are also excellent sources of support and positive reinforcement. Goal The goal of this teaching plan is to motivate the diabetic patient to engage in proper foot care, which can avoid serious complications. Patients with diabetes often do not recognize the how important it is to take care of their feet. Objectives Following a one-hour teaching session, the diabetic patient will be able to: 1. Recognize two ways diabetes can affect the feet (cognitive). 2. Describe two ways to keep the blood vessels healthy (cognitive). 3. Recognize the signs/symptoms that indicate an infection (cognitive). 4. Describe proper footwear (cognitive). 5. Recognize when to visit the doctor for foot care (cognitive). 6. Demonstrate proper foot care (psychomotor). a. Perform visual inspection of the feet b. Demonstrate proper foot cleansing c. Demonstrate proper toenail trimming d. Demonstrate proper application of lotion 7. Verbalize feelings of confidence in performing daily foot care to prevent foot complications (affective). 8. Verbalize any issues or concerns related to maintaining proper foot care, for examples, costs associated with proper footwear (affective). 9. Display continued interest in maintaining proper foot care (affective). The objectives of this program are learner-centered behavioral objectives, they place the emphasis on what the learner is expected to accomplish, have specific learning outcomes, and are observable . The teaching plan incorporates objectives from all three learning domains: cognitive, affective, and psychomotor. They follow the guidelines established by the ADA for Diabetes Self-Management Education for creating â€Å"action-oriented, behavioral goals and objectives† . Because of the difficult lifestyle changes associated with diabetic, it is important to include affective behavioral objectives to help the diabetic patient develop their own intrinsic motivations to change. Objective 9 is a long-term objective that the home care nurse evaluates at each subsequent home visit. Content The content of the teaching plan utilizes the diabetic foot care interactive tutorial from the Patient Education Institute, available at MedlinePlus, a service of the U. S. National Library of Medicine, National Institutes of Health, http://www. nlm. nih. gov/medlineplus/tutorials/. The content is available in three different formats: (a) an interactive tutorial with questions, (b) a self-playing tutorial without question, and (c) a text summary of the tutorial in a downloadable PDF file. The tutorials give the user the option to have the displayed text narrated, which is appropriate for use with visually impaired and auditory learners. The content reviewed for health literacy, supports the National Standards for Diabetes Self-Education . This teaching plan focuses on the interactive tutorial with questions. The plan can be delivered using the printed text summary. Health literacy is important to consider when choosing because patient education materials because studies have shown that an individual’s functional health literacy is usually lower than their general literacy. The U. S. Department of Health and Human Services defines health literacy as the ability of the individual to understand health information to make knowledgeable decisions about their care. This program considers health literacy by using plain language, a minimum amount of words supplemented with pictures, and presenting the information in a logical sequence, so that each section of the program builds upon the previous section. This allows the diabetic patient to internalize the knowledge acquired and apply it to future concepts, promoting independence and self-efficacy. The content of the program centers on positive behaviors and is not condescending in tone when narration is used. Time Allotment The teaching plan will take approximately one-hour to complete and consists of: (a) 35-minute interactive computer tutorial, (b) 15-minute patient demonstration of foot inspection and washing, and (c) 10-minute wrap-up session. Patient Assessment At the beginning of the home visit, the nurse asks the patient if she can assess the condition of the diabetic patient’s feet and review proper foot care with them. Asking permission gives the patient a sense of control over the situation and answers to the questions can help the nurse assess readiness to learn. To assess readiness to learn, the nurse will assess such things, as the patient’s present health condition, emotional state, and environment, all factors that can affect a diabetic patient’s ability to learn . The nurse should also assess the patient’s ability to complete foot care tasks independently. If the patient is unable to complete any task independently, a family member or caregiver should be present. The nurse will have to assess their readiness to learn, as well. If the patient is not receptive, now might not be the right for a learning session or this patient may prefer to learn on their own . If the nurse determines the patient is not ready or prefers self-instruction, she asks permission to leave information on proper foot care. The nurse can follow-up with a similar interaction at the next visit to see if the diabetic patient has any questions or concerns regarding the material and see if the patient is ready to participate in a learning session. Interactive Computer Tutorial – 35 Minutes The interactive tutorial gives the diabetic patient the necessary knowledge to meet Objective 1 through Objective 5, and enhances their ability to complete Objective 6 during the 15-minute demonstration return demonstration of proper foot care. The entire teaching plan supports Objective 7 and Objective 8. As necessary, a family member or caregiver should take part in the learning. All participants are given a copy of the text summary prior to starting the tutorial. If they are tactile learners, they can take notes, underline, highlight, etc. , as they view the tutorial. The tutorial consists of 72 slides and takes approximately 30 minutes to complete. There are questions peppered throughout the tutorial, which provide immediate feedback to the diabetic patient and nurse. The nurse will explain to the other participants that the patient should answer the questions on their own. The first 27 slides set the stage for the learner, providing them with an overview of how and why feet are important, especially to a diabetic patient, before presenting information on prevention and proper foot care. The diabetic patient has to know why foot care is important to them and what the consequences are if they do not protect their feet in order to participate in preventative health behaviors . Slides 28 through 66 discuss prevention measures, foot care, footwear, how to prevent injuries, and the importance of regular checkups. The last five slides provide a summary of the important concepts learned. All of the slides contain a combination of words and pictures relevant to the discussion. Introduction. The Introduction provides the diabetic patient with a short overview of what the tutorial will cover. The first slide states an honest, straightforward fact, â€Å"Patients with diabetes are more likely than others to have problems with their feet. These problems can lead to dangerous infections of the foot† . Denial is common among patients with chronic illnesses so it is important to provide them with facts, no fluff, no medical jargon – just the important points (Lowenstein, et al. , 2009). The goal of the tutorial, how to recognize and treat foot problems to avoid serious complications is stated on the second slide. A Healthy Foot. This section provides the diabetic patient with a simple description of how healthy feet support the body, absorb pressure from the body, prevent infections from entering the foot, and most importantly, feel pain. Giving the diabetic patient a description of what a healthy foot does will help them grasp the next concept, how diabetes adversely affects the feet. Diabetes the Feet. These slides describe two ways diabetes can affect the feet: (a) nerve damage, and (b) narrowing of the blood vessels. The slides on nerve damage discuss how diabetic neuropathy decreases sensation to the feet and can cause feelings of numbness and tingling. Decreased sensation can prevent the diabetic patient from realizing they have a cut or blister on their feet. Numbness in the feet can affect balance and standing possibly leading to painless fractures or flattened arches. Flattened arches may cause blisters from unusual pressure points. The slides on damaged blood vessels explain how narrowed blood vessels lead to poor circulation in the feet and causes impaired healing of foot injuries, which could lead to gangrene and amputation. The section ends with three True/False questions (see Appendix A). If the patient gets a question wrong, the question appears again for them answer. They cannot move forward in the tutorial until they select the correct answer. Prevention. The most important prevention method is controlling blood sugar. This is on the first slide in the prevention section. A simple concept, yet many diabetic patients do not understand the importance of monitoring and controlling their blood sugar levels (Lowenstein, et al. , 2009). This slide is about reinforcing that message. The next slide discusses four other things diabetic patients can do to protect their feet (a) proper foot care, (b) proper footwear, (c) preventing injury, and (d) getting regular check-ups. While many people receive diabetic education, many fail to maintain proper foot care; diabetic patients report wearing inappropriate shoes and walking barefoot, and improper nail care despite education . This section ends with two True/False questions (See Appendix A). Foot Care. Proper foot care is important for preventing complications. Daily foot inspections are important way for a diabetic patient to prevent complications before they start. Foot inspections help the diabetic patient identify small problems and address them before they become serious. The first slide in this section stresses the importance of daily foot inspection. The next slide explains how to inspect the foot and to use a mirror if you cannot see the soles of the feet. The next three slides explain how to wash and dry the feet and apply lotion. A True/False question (see Appendix A) applying lotion is presented. The next three slides provide information on trimming toenails and signs of ingrown toenails, which need to be reported to the nurse or doctor. A True/False question about trimming the nails is next. The section continues with a slide discussing corns and calluses and the importance of talking to the doctor about them. Patients should not attempt to remove corns or calluses on their own. A True/False question (see Appendix A) on corns and calluses concludes this section. Before moving to the next session, the nurse will explain to the patient they should inspect their feet every day around the same time so that it becomes part of their daily routine. She should also stress that foot cleansing is performed daily, but does not need to be a separate activity, it can be done in the shower or while bathing. The water should be warm, not hot and the patient should test it with their hand or elbow. Toenails are trimmed before applying lotion so the patient is able to hold their toes without their fingers slipping. Footwear. Many of us probably do not think much about the shoes (or socks) we put on our feet, but for the diabetic patient, improper footwear (and socks) can lead to serious complications. The first slide tells the diabetic patient that the right shoes and socks can keep their feet healthy. The next three slides discuss proper and improper shoes and socks. Proper shoes are ones that allow the toes room to move. Improper shoes are tight, pointed or high-heeled shoes. Open toe or open-back shoes leave the foot exposed and increase the risk for injury. Socks should be clean and comfortable with no bumps (pressure sore) or tight elastic (circulation). This section ends with a multiple-choice question (see Appendix A) about circulation. The question builds upon information presented at the beginning of the tutorial. Integrating this question in the context of footwear helps the patient establish a connection between the two concepts. Requiring them to recall previous learning refreshes the information and increases probability of retention (Lowenstein, et al. , 2009). Before beginning the next session, the nurse should let the patient know that if they have Medicare Part B insurance, it may cover the some of the costs for special shoes or inserts. Preventing Injury. These slides provide the diabetic patient with important tips for preventing injuries to the foot: (a) never walk barefoot, (b) check the inside of shoes each time for small objects or torn linings that can create pressure points, (c) avoid contact with hot water or surfaces, and (d) avoid exposure to the sun and wear sunscreen. This section ends with a True/False question (see Appendix A) on nerves. Like the previous section, the question builds upon previously learned information and helps the patient establish a relationship between the two. The nurse will tell the patient they should keep a pair of slippers next to their bed to prevent them from walking barefoot when they get out of bed in the morning. Regular Checkups. The first two slides indicate the diabetic patient should see their doctor or podiatrist regularly (podiatrist is defined for the diabetic patient) and to have the doctor check their feet. The next slide is a reminder for the diabetic patient that a doctor should care for and remove corns or calluses. The next two slides stress the importance of catching foot problems early so they can be treated early. Untreated infections can lead to severe infections that can spread to the bone and may require surgery. These slides reinforce previous learning, integrating the information with the importance of seeing a doctor. This section ends with a True/False question (see Appendix A) about infections, again integrating information learned previously within the context of regular checkups. The nurse should remind the patient it is important for them to schedule regular visits to the doctor and to keep those appointments. Summary. The four slides in this section summarize the key points the diabetic patient should take away from the tutorial. The most important aspect of prevention is maintaining proper blood sugar levels and good foot hygiene. The last slide emphasizes that management of diabetes and good foot hygiene is dependent on the diabetic patient. Evaluation. Evaluation is accomplished with a process evaluation. The tutorial questions provide immediate feedback to the diabetic patient and the nurse. This allows both the diabetic patient and the nurse to assess learning throughout the program. Either the nurse or diabetic patient can make adjustments, such as repeating a section, or stopping the tutorial to provide further explanation . This method ensures the patient is meeting the objectives as they progress through the tutorial. Demonstration of Proper Foot Care – 15 minutes The nurse should give the patient a minute or two to let the information gel as she sets up the supplies for the foot care demonstration. If the patient’s range of motion or visual acuity does not allow them to inspect or clean their feet, a family member or caregiver will perform the inspection and cleaning. If the nurse determined from the assessment the toenails can be safely trimmed by the patient (or participant), she will also include nail trimming in the foot cleansing demonstration. When the nurse is ready for the demonstration, she will ask the patient to remove their shoes and socks while she removes the shoe and sock from one of her feet. To begin the demonstration, the nurse will explain what she is looking for: cuts, sores, red spots, swelling, lack of sensation, and anything that does not look right. Then she will examine the top and bottom (with mirror) of her foot and inspect the area between her toes while she explains what she is doing. The patient should return demonstrate on both feet and explain what they are doing. The nurse will observe: (a) how carefully the patient examines the tops and bottoms of their feet, (b) if they use a mirror when they cannot the bottoms of their feet, and (c) if they inspect between all their toes. The next part of the demonstration is proper foot cleansing. The nurse will do a mock demonstration on proper foot care and then observe the patient perform actual foot cleansing, drying, nail trimming on one nail (as necessary), and moisturizing. She will observe the following: (a) how the patient tests the water in the basin prior to putting their feet in, (b) how the patient dries the feet, (c) how the patient trims the toenail, and (d) if the patient puts lotion between the toes. While the patient is performing both skills, the nurse should refrain from asking any questions that require cognitive or affective responses because they interfere with psychomotor learning. Questions related to these domains should be presented before or after the demonstration. Evaluation. Evaluation of foot inspection and cleansing is based on instructor observation (see Appendix B). The nurse will assess the diabetic patient’s affective domain (Objectives 7 and 8) at the end of the demonstration by asking the patient to verbalize how confident they feel about performing foot care and if they have any concerns about proper foot care, for example, the costs associated with proper footwear. Wrap-Up – 10 minutes The nurse will review patient the To Do List (see Appendix C) and the list of Foot Care Tips (see Appendix D) that encourages them to continue practicing proper foot care. These lists are included in the booklet from the U. S. Department of Health and Human Service, National Diabetes Education Program , â€Å"Take Care of Your Feet for a Lifetime,† that the nurse will leave with the patient. This booklet, reviewed for health literacy, is an excellent reference tool for the diabetic patient after the education session. Method of Instruction There are three methods of instruction included in this teaching plan, self-instruction, one-on-one, and demonstration return demonstration. All three of these instruction methods are appropriate for one-on-one use and provide for immediate feedback. The interactive tutorial combines self-instruction with one-on-one instruction to enhance the learning process. The nurse and diabetic patient view the tutorial together, but the diabetic patient controls the movement among the slides, allowing them to progress at their own pace. The nurse is there to provide guidance and answer any questions. Both self-instruction and one-on-one instruction can be paced to meet the diabetic patient’s needs and both methods provide the opportunity for immediate feedback. One-on-one teaches in all the behavioral domains and is suitable for those with low literacy, a disadvantage with self-instruction. Self-instruction teaches in the cognitive and psychomotor domains. The tutorial complements the psychomotor learning process by introducing the patient to the steps for proper foot care before the demonstration return demonstration portion of the teaching session. Demonstration of proper foot care uses demonstration return demonstration, which is appropriate for learning in the psychomotor domain. By this time in the teaching session, the diabetic patient should feel comfortable with the nurse and not feel like the nurse is testing them on the return demonstration . The return demonstration by the diabetic patient happens right after the demonstration by the nurse also reduces the diabetic patient’s anxiety. Resources The interactive tutorial requires a computer and internet connection. Many homes today have computers and internet access. Some home health and public health agency nurses carry company laptops with internet access. The content can also be delivered using the printed text summary, which is the same information found in the tutorial. The hand-out is six pages long. The leave-behind booklet from NDEP can downloaded and printed by the general public or up to 10 copies can be ordered free from the NDEP website http://ndep. nih. gov/publications/PublicationDetail. aspx? PubId=67. Additional packages of 10 (up to 100 copies) can be order for two-dollars each. The patient should provide the basin, soap, lotion, mirror, nail clippers, emery board, and towel. The nurse should have these tools as wells, in case the patient does not have the appropriate tools. If the patient does not have the appropriate tools, they should be encouraged to obtain them. Summary The following concepts were considered when selecting this tutorial: Cost-effective and up-to-date evidence-based quality information from a reliable source. Narration for use with visually impaired and auditory learners. Content is appropriate for low-literacy patients. Adult learners are independent and self-directed learners, but they appreciate (even need) structure and direction . The tutorial allows for nurse- patient interaction providing that structure and direction. Gives the diabetic patient control over the learning process empowers them to learn (Lowenstein et al. , 2009). There are three other tutorials presented in a similar format available on the Medline website: an introduction to diabetes, eye complications, and meal planning. This gives the nurse a set of tools to help her patient manage diabetes. Why recreate the wheel when appropriate instructional materials are already available . This teaching plan will provide the diabetic patient with the necessary knowledge and tools to motivate self-directed behavioral changes towards proper foot care. Motivation, learning and behavior are inextricably linked. People tend to be intrinsically motivated; if the motivation to learn is not there, then the behavioral changes will not occur . References Bastable, S. (2008). Nurse as educator: Principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett. Center for Disease Control and Prevention. (2011). National diabetes fact sheet, 2011. Retrieved from Center for Disease Control and Prevention: http://www. cdc. gov/diabetes/pubs/factsheet11. htm Corbett, C. F. (2003). A randomized pilot study of improving foot care in home health patients with diabetes. The Diabetes Educator, 29(2), 273-282. doi:DOI: 10. 1177/014572170302900218 Funnell, M. M. , Brown, T. L. , Childs, B. P. , Haas, L. B. , Hosey, G. M. , Jensen, B. , . . . Weiss, M. A. (2010, January). National Standards for Diabetes Self-Education. Diabetes Care, 33(Supplement_1), S89-S96. doi:10. 2337/dc-S089 Lowenstein, A. J. , Foord, L. , Romano, J. C. (2009). Teaching strategies for health education and health promotion. Working with patients, families, and communities. Sudbury, MA: Jones and Bartlett Publishers. Neder, S. , Nadash, P. (2003). Individulized education can improve foot care for patients with diabetes. Research briefs. Home Healthcare Nurse, 21(12), 837-840. Retrieved from http://journals. lww. com/homehealthcarenurseonline/Fulltext/2003/12000/Individualized_Education_Can_Improve_Foot_Care_for. 13. aspx The Patient Education Institute. (2013). Diabetes Foot Care. Retrieved from MedlinePlus: http://www. nlm. nih. gov/medlineplus/tutorials/diabetesfootcare/htm/index. htm U. S. Department of Health and Human Services. (2013, April 10). Health Literacy. Retrieved from Health. gov: http://www. health. gov/communication/literacy/ U. S. Department of Health and Human Services, National Diabetes Education Program. (2012). Take care of your feet for a lifetime. A booklet for people with diabetes. (NIH Publication No. 12-4285. NDEP-4). Retrieved from http://ndep. nih. gov/publications/PublicationDetail. aspx? PubId=67 Appendix A Questions in the Tutorial Diabetes the Feet 1. People with diabetes who have damaged nerves in their feet are less likely to feel injury to their feet than people without diabetes. True or False. True Answer Correct. Because nerves carry the feeling of pain, people with damaged nerves in their feet are less likely to feel injury to their feet. False Answer Incorrect. Nerves carry the feeling of pain. People with damaged nerves in their feet are less likely to feel injury to feel injury. 2. People with diabetes are more likely to have narrow blood vessels than people without diabetes. True or False. True Answer Correct. Diabetes affects the blood vessels throughout the body, however, the blood vessels of the feet, kidneys, and eyes are especially vulnerable. False Answer Incorrect. Patients with diabetic are more likely to have narrow blood vessels than people without diabetes. 3. All diabetic patients with diabetes will have foot problems. True or False. True Answer Incorrect. Not all patients with diabetes will experience foot problems. Good hygiene and successful control of diabetes can delay or prevent these problems. False Answer Correct. Not all patients with diabetes will experience foot problems. Good hygiene and successful control of diabetes can delay or prevent these problems. Prevention 1. To keep their feet healthy, patients with diabetes should avoid walking. True or False. True Answer Incorrect. Exercising, such as walking is important for controlling diabetes and keeping the blood vessels healthy. The healthier the blood vessels, the less likely foot problems will appear. Use sensible footwear! False Answer Correct. Exercising helps keep the blood vessels of the body healthy, which leads to healthier feet. Use sensible footwear! 2. Stopping smoking can help prevent or delay foot complications. True or False. True Answer Correct. Smoking can reduce the blood flow to the feet. This makes it difficult for the feet to receive the nutrients and oxygen they need for health and healing. False Answer Incorrect. Smoking can reduce the blood flow to the feet. Foot Care 1. It is preferable to avoid putting lotion between the toes. True or False. True Answer Correct. It is preferable to avoid putting lotion between the toes. The excessive moisture that may result can be a breeding ground for infections. False Answer Incorrect. It is better to keep the area between the toes dry. 2. Patients with diabetes can cut off corns and calluses on their own. True or False. True Answer Incorrect. Patients with diabetes should not cut the calluses and corns on their own. They should ask their healthcare provider to help. False Answer Correct. 3. It is better to trim nails before and not after taking a shower. True or False. True Answer Incorrect. It is preferable to trim nails after soaking them, such as after taking a bath or shower. False Answer Correct. It is preferable to trim nails after soaking them, such as after taking a bath or shower. Footwear 1. Pale and cold feet indicate which of the following? a. Poor Circulation b. Damaged Nerves a. Poor Circulation Correct. Pale and cold feet may mean the feet are not receiving adequate supply of blood. b. Damaged Nerves Incorrect. Pale and cold feet may mean the feet are not receiving adequate supply of blood. Exercise, such as walking, is important for controlling diabetes and keeping the blood vessels healthy. The healthier the blood vessels are, the less likely foot problems will appear. Preventing Injury 1. Frequent tingling or numbness may indicate that the nerves are damaged. True or False. True Answer Correct. Odd feelings of numbness and tingling should be reported to the doctor. They may mean the nerves are damaged. False Answer Incorrect. Frequent of numbness and tingling may mean the nerves of the feet are damaged. Regular Checkups 1. Redness and swelling in the feet with increased heat are signs of an infection. True or False. True Answer Correct. Redness, swelling, increased temperature, fever, and chills are all signs of infections. Call your doctor immediately if you notice any of these signs. False Answer Incorrect. Redness, swelling, increased temperature, fever, and chills are all signs of infections. Call your doctor immediately if you notice any of these signs. Appendix B Foot Care Observation Evaluation Critical Elements YES NO Comments Inspects the tops/bottoms of feet. Uses mirror when appropriate. Inspects between all toes. Tests water with hand or elbow. Gently dries feet and between the toes. Trims toenails before applying lotion Trims toenails straight across, not too far down. Uses an emery board to file the edges, does not cut them with the clippers. Does not apply lotion between the toes Verbalizes feelings of confidence in performing daily foot care Verbalizes any issues related to proper foot care Appendix C To Do List Make plans now to take care of your feet for a lifetime. Check each item when completed. ____ Use the foot care tips on the other side of this page. ____ Put this list where I will see it every day. ____ Get a pair of nail clippers, an emery board, and pumice stone if my doctor tells me to. ____ Buy soft, lightly padded, seamless socks. ____ Buy a pair of shoes that fit well and protect my feet. ____ Place slippers beside my bed to wear when I get out of bed. ____ Get a mirror to help me see the bottoms of my feet. ____ Ask for help from a family member or caregiver if I cannot see my feet. ____ Keep my next doctor’s visit. ____ Ask my doctor if my insurance will cover the cost of special shoes or inserts. ____ Ask my health care team about diabetes services and supplies that may be covered by Medicare or other insurance plans. ____ Ask my doctor or nurse to look at my feet at every visit. ____ Talk with my health care team about safe ways I can be more active each day. ____ Stop smoking. Call 1-800-784-8669 to get help with quitting. ____ Work to manage my diabetes to prevent foot problems. Source: To Do List from The National Diabetes Education Program booklet, â€Å"Take Care of Your Feet for a Lifetime†. Available at http://ndep. nih. gov/publications/PublicationDetail. aspx? PubId=67. Appendix D Foot Care Tips 1. Check your feet every day. Look at your bare feet every day for cuts, blisters, red spots, and swelling. Use a mirror to check the bottoms of your feet or ask a family member for help if you have trouble seeing. 2. Wash your feet every day. Wash your feet in warm, not hot, water every day. Dry your feet. Be sure to dry between the toes. 3. Keep the skin soft and smooth. Rub a thin coat of lotion over the tops and bottoms of your feet, but not between your toes. 4. Smooth corns and calluses gently. If your doctor tells you to, use a pumice stone to gently smooth corns and calluses. Do not use over-the-counter products or sharp objects on corns and calluses. 5. If you can see, reach, and feel your feet, trim your toenails regularly. If you cannot, ask a foot doctor (podiatrist) to trim them for you. Trim your toenails straight across and smooth the corners with an emery board or nail file. 6. Wear shoes and socks at all times. Never walk barefoot. Wear shoes that fit well and protect your feet. Feel inside your shoes before putting them on to make sure the lining is smooth and that there are no objects inside. 7. Protect your feet from hot and cold. Wear shoes at the beach and on hot pavement. Wear socks at night if your feet get cold. Do not test bath water with your feet. Do not use hot water bottles or heating pads on your feet. 8. Keep the blood flowing to your feet. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, two or three times a day. Do not cross your legs for long periods of time. Do not smoke. Call 1-800-QUITNOW (1-800-784-8669). 9. Be active every day. Talk to your health care team about safe ways you can be more active. 10. Check with your health care team. Have your doctor or nurse check your bare feet and tell you if you have foot problems or may get foot problems in the future. Remember that you may not feel the pain of an injury. Call your health care team right away if you find a cut, sore, blister, or bruise on your foot that does not begin to heal after a few days. Follow your health care team’s advice about foot care.