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Diabetes Mellitus


Diabetes Mellitus Definition: metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin – PowerPoint PPT presentation

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Title: Diabetes Mellitus

Diabetes Mellitus
  • Definition metabolic disorder characterized by
    hyperglycemia due to an absolute or relative lack
    of insulin or to a cellular resistance to insulin
  • Major classifications
  • 1. Type 1 Diabetes
  • 2. Type 2 Diabetes

Diabetes Mellitus
  • Impact on health of American population
  • 1. Sixth leading cause of death due to
    cardiovascular effects resulting in
    atherosclerosis, coronary artery disease, and
  • 2. Leading cause of end stage renal failure
  • 3. Major cause of blindness
  • 4. Most frequent cause of non-traumatic

Diabetes Mellitus
  • 5. Diabetes affects estimated 15.7 million people
    (10.3 million are diagnosed 5.4 million are
  • 6. Increasing prevalence of Type 2 Diabetes in
    older adults and minority groups (African
    American, American Indian and Hispanic
  • 7. Estimated 11 of older U. S. population (65
    74) have diabetes

Diabetes Mellitus
  • Diabetes Type 1
  • Definition
  • 1. Metabolic condition in which the beta cells of
    pancreas no longer produce insulin characterized
    by hyperglycemia, breakdown of body fats and
    protein and development of ketosis
  • 2. Accounts for 5 10 of cases of diabetes
    most often occurs in childhood or adolescence
  • 3. Formerly called Juvenile-onset diabetes or
    insulin-dependent diabetes (IDDM)

Diabetes Mellitus
  • Pathophysiology
  • 1. Autoimmune reaction in which the beta cells
    that produce insulin are destroyed
  • 2. Alpha cells produce excess glucagons causing
  • Risk Factors
  • 1. Genetic predisposition for increased
    susceptibility HLA linkage
  • 2. Environmental triggers stimulate an autoimmune
  • a. Viral infections (mumps, rubella,
    coxsackievirus B4)
  • b. Chemical toxins

Diabetes Mellitus
  • Manifestations
  • Process of beta cell destruction occurs slowly
    hyperglycemia occurs when 80 90 is destroyed
    often trigger stressor event (e. g. illness)

Diabetes Mellitus
  • 2. Hyperglycemia leads to
  • a. Polyuria (hyperglycemia acts as osmotic
  • b. Glycosuria (renal threshold for glucose 180
  • c. Polydipsia (thirst from dehydration from
  • d. Polyphagia (hunger and eats more since cell
    cannot utilize glucose)
  • e. Weight loss (body breaking down fat and
    protein to restore energy source
  • f. Malaise and fatigue (from decrease in energy)
  • g. Blurred vision (swelling of lenses from
    osmotic effects)

Diabetes Mellitus
  • Diagnosis
  • Patient is symptomatic plus
  • Casual plasma glucose (non-fasting) is 200 mg/dl
  • Fasting plasma glucose of 126 mg/dl or higher OR
  • Two hour plasma glucose level of 200 mg/dl or
    greater during an oral glucose tolerance test

Diabetes Mellitus
  • Diabetic Ketoacidosis (DKA)
  • 1. Results from breakdown of fat and
    overproduction of ketones by the liver and loss
    of bicarbonate
  • Occurs when Diabetes Type 1 is undiagnosed or
    known diabetic has increased energy needs, when
    under physical or emotional stress or fails to
    take insulin
  • Mortality as high as 14
  • 3. Pathophysiology
  • a. Hypersomolarity (hyperglycemia, dehydration)
  • b. Metabolic acidosis (accumulation of ketones)
  • c. Fluid and electrolyte imbalance (from osmotic

Diabetes Mellitus
  • Diagnostic tests
  • a. Blood glucose greater than 250 mg/dL
  • b. Blood pH less than 7.3
  • c. Blood bicarbonate less than 15 mEq/L
  • d. Ketones present in blood
  • e. Ketones and glucose present in urine
  • f. Electrolyte abnormalities (Na, K, Cl)
  • G. serum osmolality lt 350 mosm/kg (normal

Diabetes Mellitus
  • DKA
  • Signs and symptoms
  • Kussmals respirations
  • Blow off carbon dioxide to reverse acidosis
  • Fruity breath
  • Nausea/ abdominal pain
  • Dehydration
  • Lethargy
  • Coma
  • Polydipsia, polyuria, polyphagia

Diabetes Mellitus
  • Treatment
  • a. Requires immediate medical attention and
    usually admission to hospital
  • B .Frequent measurement of blood glucose and
    treat according to glucose levels with regular
    insulin (mild ketosis, subcutaneous route severe
    ketosis with intravenous insulin administration)
  • c. Restore fluid balance initially 0.9 saline
    at 500 1000 mL/hr. regulate fluids according
    to client status when blood glucose is 250 mg/dL
    add dextrose to intravenous solutions

Diabetes Mellitus
  • DKA
  • d.Correct electrolyte imbalance client often is
    initially hyperkalemic
  • As patient is rehydrated and potassium in pushed
    back into the cell they become hypokalemic
  • Monitor K levels
  • e. Monitor cardiac rhythm since hypokalemia puts
    client at risk for dysrrhythmias
  • f. Treat underlying condition precipitating DKA
  • G. Acidosis is corrected with fluid and insulin
    therapy and rarely needs bicarb

Diabetes Mellitus
  • Diabetes Type 2
  • A. Definition condition of fasting hyperglycemia
    occurring despite availability of bodys own
  • B. Was known as non-insulin dependent diabetes
    or adult onset diabetes
  • Both are misnomers, it can be found in children
    and type II DM may require insulin

Diabetes Mellitus
  • Pathophysiology
  • 1. Sufficient insulin production to prevent DKA
    but insufficient to lower blood glucose through
    uptake of glucose by muscle and fat cells
  • 2. Cellular resistance to insulin increased by
    obesity, inactivity, illness, age, some

Diabetes Mellitus
  • Risk Factors
  • 1. History of diabetes in parents or siblings no
  • 2. Obesity (especially of upper body)
  • 3. Physical inactivity
  • 4. Race/ethnicity African American, Hispanic,
    or American Indian origin
  • 5. Women history of gestational diabetes,
    polycystic ovary syndrome, delivered baby with
    birth weight gt 9 pounds
  • 6. Clients with hypertension HDL cholesterol lt
    35 mg/dL, and/or triglyceride level gt 250 mg/dl.

Diabetes Mellitus
  • Syndrome X or Metabolic Syndrome
  • Chronic, low grade inflammatory process
  • Gives rise to diabetes type 2, ischemic heart
    disease, left ventricular hypertrophy
  • Group of disorders with insulin resistance as the
    main feature
  • Includes
  • Obesity especially around the waist and abdomen
  • Low levels of physical activity
  • High blood pressure
  • Increased blood cholesterol (high LDL, low HDL,
    high triglycerides

Diabetes Mellitus
  • Manifestations
  • 1. Client usually unaware of diabetes
  • a. Discovers diabetes when seeking health care
    for another concern
  • b. Most cases arent diagnosed for 5-6 years
    after the development of the disease
  • c. Usually does not experience weight loss

Diabetes Mellitus
  • 2. Possible symptoms or concerns
  • a. Hyperglycemia (not as severe as with Type 1)
  • b. Polyuria
  • c. Polydipsia
  • d. Blurred vision
  • e. Fatigue
  • f. Paresthesias (numbness in extremities)
  • g. Skin Infections

Diabetes Mellitus
  • Hypersomolar Hyperglycemic Nonketotic Syndrome
  • 1. Potential complication of Diabetes Type 2
  • Life threatening medical emergency, high
    mortality rate, as high as 50
  • Enough insulin is secreted to prevent ketosis,
    but not enough to prevent hyperglycemia
  • High blood sugar causes an extreme diuresis with
    severe electrolyte and fluid loss

  • Characterized by
  • Plasma osmolarity 340 mOsm/l or greater- normal
  • Blood glucose severely elevated, 800-1000
  • Altered level of consciousness

Diabetes Mellitus
  • 4. Precipitating factors
  • a. Infection (most common)
  • pneumonia
  • b. Therapeutic agent or procedure
  • c. Acute or chronic illness
  • MI
  • Stroke
  • Pancreatitis
  • pregnancy
  • 5. Slow onset 1 14 days

Diabetes Mellitus
  • Pathophysiology
  • a. Hyperglycemia leads to increased urine output
    and dehydration
  • b. Kidneys retain glucose glucose and sodium
  • c. Severe hyperosmolar state develops leading to
    brain cell shrinkage
  • Manifestations
  • a. Altered level of consciousness (lethargy to
  • b. Neurological deficits hyperthermia, motor and
    sensory impairment, seizures
  • c. Dehydration dry skin and mucous membranes,
    extreme thirst, tachycardia, polyuria, hypotension

Diabetes Mellitus
  • Treatment
  • a. Usually admitted to intensive care unit of
    hospital for care since client is in
    life-threatening condition unresponsive, may be
    on ventilator, has nasogastric suction
  • b. Correct fluid and electrolyte imbalances
    giving isotonic or colloid solutions and correct
    potassium deficits
  • c. Lower glucose with regular insulin until
    glucose level drops to 250 mg/dL
  • Monitor for renal failure
  • d. Treat underlying condition

Diabetes Mellitus
  • Complications of Diabetes
  • A. Alterations in blood sugars hyperglycemia and
  • B. Macrocirculation (large blood vessels)
  • 1. Atherosclerosis occurs more frequently,
    earlier in diabetics
  • 2. Involves coronary, peripheral, and cerebral
  • C. Microcirculation (small blood vessels)
  • 1. Affects basement membrane of small blood
    vessels and capillaries
  • 2. Involves tissues affecting eyes and kidneys
  • D. Prevention of complications
  • 1. Managing diabetes
  • 2. Lowering risk factors for conditions
  • 3. Routine screening for complications
  • 4. Implementing early treatment

Diabetes Mellitus
  • Complications of Diabetes Alterations in blood
  • A. Hyperglycemia high blood sugar
  • 1.DKA (mainly associated with Diabetes Type 1)
  • 2.HHS (mainly associated with Diabetes Type 2)
  • 3.Dawn phenomenon rise in blood sugar between 4
    am and 8 am, not associated with hypoglycemia
  • Glucose released from the liver in the early AM
    secondary to growth hormones
  • Altering the time and dose of the insulin (NPH or
    Ultralente) by 2-3 units stabilizes the blood

Diabetes Mellitus
  • 4. Somogyi effect combination of hypoglycemia
    during night with a rebound morning hyperglycemia
    that may lead to insulin resistance for 12 to 48

Diabetes Mellitus
  • B. Hypoglycemia (insulin reaction, insulin shock,
    the lows) low blood sugar
  • 1.Mismatch between insulin dose, carbohydrate
    availability and exercise
  • 2.May be affected by intake of alcohol, certain

Diabetes Mellitus
  • Specific manifestations
  • a. Cool, clammy skin
  • b. Rapid heartbeat
  • c. Hunger
  • d. Nervousness, tremor
  • e. Faintness, dizziness
  • f. Unsteady gait, slurred and/or incoherent
  • g. Vision changes
  • h. Seizures, coma
  • 5. Severe hypoglycemia can result in death
  • 6. Clients taking medications, such as
    beta-adrenergic blockers may not experience
    manifestations associated with autonomic nervous
  • 7. Hypoglycemia unawareness clients with
    Diabetes Type 1 for 4 or 5 years or more may
    develop severe hypoglycemia without symptoms
    which can delay treatment

Diabetes Mellitus
  • Treatment for mild hypoglycemia
  • a. Immediate treatment client should take 15 gm
    of rapid-acting sugar (half cup of fruit juice 8
    oz of skim milk, 3 glucose tablets, 3 life savers
  • b. 15/15 rule wait 15 minutes and monitor blood
    glucose if still low, client should eat another
    15 gm of sugar
  • c. Continue until blood glucose level has
    returned to normal
  • d. Client should contact medical care provider if
    hypoglycemia occurs more that 2 or 3 times per

Diabetes Mellitus
  • Treatment for severe hypoglycemia is often
  • a. Client is unresponsive, has seizures, or has
    altered behavior blood glucose level is less
    than 50 mg/dL
  • b. If client is conscious and alert, administer
    15 gm of sugar
  • c. If client is not alert, administer
  • 1. 25 50 solution of glucose intravenously,
    followed by infusion of 5 dextrose in water
  • 2. Glucagon 1 mg by subcutaneous, intramuscular,
    or intravenous route follow with oral or
    intravenous carbohydrate
  • d. Monitor client response physically and also
    blood glucose level

Diabetes Mellitus
  • Complications Affecting Cardiovascular System,
    Vision, and Kidney Function
  • A. Coronary Artery Disease
  • 1. Major risk of myocardial infarction in Type 2
  • Increased chance of having a silent MI and
    delaying medical treatment
  • 2. Most common cause of death for diabetics (40
  • 3. Diabetics more likely to develop Congestive
    Heart Failure

Diabetes Mellitus
  • B. Hypertension
  • 1. Affects 20 60 of all diabetics
  • 2. Increases risk for retinopathy, nephropathy

Diabetes Mellitus
  • C. Stroke
  • Type 2 diabetics are 2 6 times more likely to
    have stroke as well as Transient Ischemic Attacks
    (TIA) or mini stroke

Diabetes Mellitus
  • D. Peripheral Vascular Disease
  • 1. Increased risk for Types 1 and 2 diabetics
  • 2. Development of arterial occlusion and
    thrombosis resulting in gangrene
  • 3. Gangrene from diabetes most common cause of
    non-traumatic lower limb amputation

Diabetic Foot Ulcer
Diabetes Mellitus
  • Diabetic Retinopathy
  • 1. Definition
  • a. Retinal changes related to diabetes
  • Hemorrhage, swelling, decreased vision
  • b. Leads to retinal ischemia and breakdown of
    blood-retinal barrier
  • 2. Leading cause of blindness ages 25 74
  • a. Affects almost all Type 1 diabetics after 20
  • b. Affects 60 of Type 2 diabetics
  • Diabetics should be screened for retinopathy and
    receive treatment (laser photocoagulation
    surgery) to prevent vision loss
  • Should be sent immediately to ophthalmologist
    upon diagnosis because may already have damage
  • 4. Diabetics also have increased risk for
    cataract development

Diabetes Mellitus
  • Diabetic Nephropathy
  • 1. Definition glomerular changes in kidneys of
    diabetics leading to impaired renal function
  • 2. First indicator microalbuminuria
  • 3. Diabetics without treatment go on to develop
    hypertension, edema, progressive renal
  • a. In type 1 diabetics, 10 15 years
  • b. May occur soon after diagnosis with type 2
    diabetes since many are undiagnosed for years
  • 4. Most common cause of end-stage renal failure
    in U.S.
  • 5. Kimmelstiel-Wilson syndrome
    glomerulosclerosis associated with diabetes

Diabetes Mellitus
  • Male erectile dysfunction
  • Half of all diabetic men have erectile

Diabetes Mellitus
  • Collaborative Care
  • A. Based on research from 10-year study of Type 1
    diabetics conducted by NIH focus is on keeping
    blood glucose levels as close to normal by active
    management interventions complications were
    reduced by 60
  • B. Treatment interventions are maintained through
  • 1. Medications
  • 2. Dietary management
  • 3. Exercise
  • C. Management of diabetes with pancreatic
    transplant, pancreatic cell or Beta cell
    transplant is in investigative stage

Diabetes Mellitus
  • Other Complications from Diabetes
  • A. Increased susceptibility to infection
  • 1. Predisposition is combined effect of other
  • 2. Normal inflammatory response is diminished
  • 3. Slower than normal healing
  • B. Periodontal disease
  • C. Foot ulcers and infections predisposition is
    combined effect of other complications

Diabetes Mellitus
  • Diagnostic tests to monitor diabetes management
  • 1. Fasting Blood Glucose (normal 70 110 mg/dL)
  • 2. Glycosylated hemoglobin (c) (Hemoglobin A1C)
  • a. Considered elevated if values above 7
  • b. Blood test analyzes excess glucose attached to
    hemoglobin. Since rbc lives about 120 days gives
    an average of the blood glucose over previous 2
    to 3 months
  • Not a fasting test, can be drawn any time of the
  • of glycated (glucose attached) hemoglobin
    measures how much glucose has been in the
    bloodstream for the past 3 months
  • )

Diabetes Mellitus
  • 3. Urine glucose and ketone levels (part of
    routine urinalysis)
  • a. Glucose in urine indicates hyperglycemia
    (renal threshold is usually 180 mg/dL)
  • b. Presence of ketones indicates fat breakdown,
    indicator of DKA ketones may be present if
    person not eating
  • 4. Urine albumin (part of routine urinalysis)
  • a. If albumin present, indicates need for workup
    for nephropathy
  • b. Typical order is creatinine clearance testing

Diabetes Mellitus
  • 5. Cholesterol and Triglyceride levels
  • a. Recommendations
  • 1. LDL lt 100 mg/dl
  • 2. HDL gt 45 mg/dL
  • 3. Triglycerides lt 150 mg/dL
  • b. Monitor risk for atherosclerosis and
    cardiovascular complications
  • 6. Serum electrolytes in clients with DKA or HHNS

Diabetes Mellitus
  • Medications
  • A. Insulin
  • 1. Sources standard practice is use of human
    insulin prepared by alteration of pork insulin or
    recombinant DNA therapy
  • 2. Clients who need insulin as therapy
  • a. All type 1 diabetics since their bodies
    essentially no longer produce insulin
  • b. Some Type 2 diabetics, if oral medications are
    not adequate for control (both oral medications
    and insulin may be needed)
  • c. Diabetics enduring stressor situations such as
    surgery, corticosteroid therapy, infections,
    treatment for DKA, HHNS
  • d. Women with gestational diabetes who are not
    adequately controlled with diet
  • e. Some clients receiving high caloric feedings
    including tube feedings or parenteral nutrition

Diabetes Mellitus
  • Injection sites
  • Abdominal areas is the most preferred because of
    rapid absorption
  • Do not aspirate insulin injections
  • Administration covered in the lab

Diabetes Mellitus
Diabetes Injection Sites
Diabetes Mellitus
  • When rapid acting or short acting insulin is
    mixed with longer acting insulin, draw the short
    acting insulin into the syringe first.
  • Prevents contamination of the shorter acting
    insulin with the longer acting insulin
  • Draw up clear, then cloudy
  • Insuling glargine (Lantus) should not be mixed
    with any other insulin

Diabetes Mellitus
  • Mixing insulin

Diabetes Mellitus
  • Alternative insulin administration
  • Insulin pump
  • Continuous subcutaneous infusion of a basal dose
    with increases at meal times
  • Implanted pumps
  • Implanted into the peritoneal cavity
  • Inhaled insulin
  • Under development

Insulin Pump
Internal Insulin Pump
Diabetes Mellitus
  • Oral Hypoglycemic Agents
  • 1. Used to treat Diabetes Type 2
  • 2. Client must also maintain prescribed diet and
    exercise program monitor blood glucose levels
  • 3. Not used with pregnant or lactating women
  • 4. Several different oral hypoglycemic agents and
    insulin may be prescribed for the client
  • 5. Specific drug interactions may affect the
    blood glucose levels
  • 6. Must have some functioning beta cells

Diabetes Mellitus
  • Classifications and action
  • a. Sulfonylureas
  • 1. Action Stimulates pancreatic cells to secrete
    more insulin and increases sensitivity of
    peripheral tissues to insulin
  • 2. Used to treat non-obese Type 2 diabetics
  • 3. Example Glipizide (Glucotrol), Chlorpropamide
    (Diabinese), Tolazamide (Tolinase)

Diabetes Mellitus
  • b. Meglitinides
  • 1. Action stimulates pancreatic cells to secret
    more insulin
  • 2. Taken just before meals, rapid onset, limited
    duration of action
  • 3. Major adverse effects is hypoglycemia
  • 4. Used in non-obese diabetics
  • 5. Example Repaglinide (Prandin), Nateglinide

Diabetes Mellitus
  • c. Biguanides
  • 1. Action decreases overproduction of glucose by
    liver and makes insulin more effective in
    peripheral tissues
  • 2. Used in obese diabetics
  • 3. Does not stimulate insulin release
  • 4. Metabolized by the kidney, do not use with
    renal patients
  • 5. Example Metformin (Glucophage

Diabetes Mellitus
  • d. Alpha-glucoside Inhibitors
  • 1. Action Slow carbohydrate digestion and delay
    rate of glucose absorption
  • 2. Take with first bite of the meal or 15 min.
  • 3. Adjunct to diet to decrease blood glucose
  • 4. Example Acarbose (Precose), Miglitol

Diabetes Mellitus
  • Thizaolidinediones (Glitazones)
  • 1. Action Sensitizes peripheral tissues to
  • 2. Used in obese diabetics
  • 3. Inhibits glucose production
  • 4. Improves sensitivity to insulin in muscle,
    and fat tissue
  • 5. Example Rosiglitazone (Avandia), Pioglitazone

Diabetes Mellitus
  • Patients with Type 2 DM who are obese have
    insulin resistance, they produce enough insulin
  • Should use Glucophage, Actos or Avandia
  • Enhances insulin secretion in tissue, but does
    not increase amount of insulin secreted

Diabetes Mellitus
  • Patients with Type 2 DM who are thin do not
    produce enough insulin, they are not insulin
  • Need sulfonylurea agents like Diabinese,
    Tolinase, Glucotrol, Diabeta

Diabetes Mellitus
  • Role of Diet in Diabetic Management
  • A. Goals for diabetic therapy include
  • 1. Maintain as near-normal blood glucose levels
    as possible with balance of food with medications
  • 2. Obtain optimal serum lipid levels
  • 3. Provide adequate calories to attain or
    maintain reasonable weight

Diabetes Mellitus
  • B. Diet Composition
  • 1. Carbohydrates 60 70 of daily diet
  • Carbohydrates convert quickly to sugars
  • Advice patient to consume a similar amount of
    carbs at each meal
  • Medications can work on a consistent glucose
    response from foods
  • 2. Protein 15 20 of daily diet
  • 3. Fats No more than 10 of total calories from
    saturated fats

Diabetes Mellitus
  • 4. Fiber 20 to 35 grams/day promotes
    intestinal motility and gives feeling of fullness
  • 5. Sodium recommended intake 1000 mg per 1000
  • 6. Sweeteners approved by FDA instead of refined
  • 7. Limited use of alcohol potential hypoglycemic
    effect of insulin and oral hypoglycemics

Diabetes Mellitus
  • Diet
  • Look for more dietary information online at

Diabetes Mellitus
  • Care of diabetic older clients
  • A. 40 of all clients with diabetes are over age
    of 65
  • B. Need to include spouse, members of family in
    teaching who may assist with client meeting
    medical needs
  • C. Diet changes may be difficult to implement
    since client has established eating habits
  • D. Exercise programs may need adjustment to meet
    individuals abilities (such as physical
    limitations from other chronic illnesses)
  • Obesity worsens diabetes
  • Minimum of 30 minutes of moderate exercise like
    walking or swimming most days of the week

Diabetes Mellitus
  • E. Individual reluctance to accept assistance to
    deal with chronic illness, assist with hygiene
  • F. Limited assets for medications, supplies,
  • G. Visual deficits or learning challenges to
    learn insulin administration, blood glucose

Diabetes Mellitus
  • Nursing Care
  • A. Assessment, planning, implementation with
    client according to type and stage of diabetes
  • B. Prevention, assessment and treatment of
    complications through client self-management and
    keeping appointments for medical care
  • C. Client and family teaching for diabetes
  • D. Health promotion includes education of healthy
    life style, lowering risks for developing
    diabetes for all clients
  • E. Blood glucose screening at 3 year intervals
    starting at age 45 for persons in high risk groups

Diabetes Mellitus
  • Common Nursing Diagnoses and Specific Teaching
  • A. Risk for impaired skin integrity Proper foot
  • 1. Daily inspection of feet
  • 2. Checking temperature of any water before
    washing feet
  • 3. Need for lubricating cream after drying but
    not between toes
  • 4. Patients should be followed by a podiatrist
  • 5. Early reporting of any wounds or blisters
  • B. Risk for infection
  • 1. Frequent hand washing
  • 2. Early recognition of signs of infection and
    seeking treatment
  • 3. Meticulous skin care
  • 4. Regular dental examinations and consistent
    oral hygiene care

Diabetes Mellitus
  • C. Risk for injury Prevention of accidents,
    falls and burns
  • D. Sexual dysfunction
  • 1. Effects of high blood sugar on sexual
  • 2. Resources for treatment of impotence, sexual
  • E. Ineffective coping
  • 1. Assisting clients with problem-solving
    strategies for specific concerns

Diabetes Mellitus
  • 2. Providing information about diabetic
    resources, community education programs, and
    support groups
  • 3. Utilizing any client contact as opportunity to
    review coping status and reinforce proper
    diabetes management and complication prevention
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