Nursing Process

The Patient Newly Diagnosed With Diabetes Mellitus

Assessment
The history and physical assessment focus on the signs and symptoms of prolonged
hyperglycemia and on physical, social, and emotional factors that may affect the patient's
ability to learn and perform diabetes self-care activities. The patient is asked to describe
symptoms that preceded the diagnosis of diabetes, such as polyuria, polydipsia,
polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing
ulcers. Blood glucose levels are measured in patients with either type 1 or type 2
diabetes. n addition, urine ketone levels are measured, because the patient with type 1
diabetes may have ketones in the urine.
!atients diagnosed with type 1 diabetes are assessed for signs of "#$, including
ketonuria, #ussmaul respirations, orthostatic hypotension, and lethargy. The patient is
asked about symptoms of "#$, such as nausea, vomiting, and abdominal pain.
%aboratory values are monitored for metabolic acidosis &ie, decreased p' and decreased
bicarbonate level( and for electrolyte imbalance. !atients diagnosed with type 2 diabetes
are assessed for signs of '')*, including hypotension, altered sensorium, sei+ures, and
decreased skin turgor. %aboratory values are monitored for hyperosmolality and
electrolyte imbalance.
f the patient e,hibits signs and symptoms of "#$ or '')*, nursing care first focuses
on treatment of these acute complications, as outlined earlier. -nce these complications
are resolving, nursing care then focuses on long-term management of diabetes, as
discussed in this section.
Then the patient is assessed for physical factors that may impair his or her ability to learn
or perform self-care skills, such as
.isual deficits &the patient is asked to read numbers or words on the insulin
syringe, menu, newspaper, or written teaching materials(
"eficits in motor coordination &the patient is observed eating or performing other
tasks or handling a syringe or finger-lancing device(
)eurologic deficits caused by stroke, other neurologic disorders, or other
disabling conditions, from the history in the chart &the patient is assessed for
aphasia or decreased ability to follow simple commands(
The nurse evaluates the patient's social situation for factors that may influence the
diabetes treatment and education plan, such as
%ow literacy level &may be evaluated while assessing for visual deficits by having
the patient read from teaching materials(
%imited financial resources or lack of health insurance
!resence or absence of family support
Typical daily schedule &the patient is asked about timing and number of usual
daily meals, work and e,ercise schedule, plans for travel(
The patient's emotional status is assessed by observing his or her general demeanor &eg,
withdrawn, an,ious( and body language &eg, avoids eye contact(. The patient is asked
about ma/or concerns and fears about diabetes0 this allows the nurse to assess for any
misconceptions or misinformation regarding diabetes. 1oping skills are assessed by
asking how the patient has dealt with difficult situations in the past.
Diagnosis
Nursing Diagnoses
Based on the assessment data, ma/or nursing diagnoses may include the following2
3isk for fluid volume deficit related to polyuria and dehydration
mbalanced nutrition related to imbalance of insulin, food, and physical activity
"eficient knowledge about diabetes self-care skills4information
!otential self-care deficit related to physical impairments or social factors
$n,iety related to loss of control, fear of inability to manage diabetes,
misinformation related to diabetes, fear of diabetes complications
Collaborative Problems/Potential Complications
Based on assessment data, potential complications may include the following2
5luid overload, pulmonary edema, and heart failure
'ypokalemia
'yperglycemia and ketoacidosis
'ypoglycemia
1erebral edema
Planning and Goals
The ma/or goals for the patient may include maintenance of fluid and electrolyte balance,
optimal control of blood glucose levels, reversal of weight loss, ability to perform
diabetes survival skills and self-care activities, decreased an,iety, and absence of
complications.
Nursing nterventions
Maintaining !luid and "lectrolyte #alance
ntake and output are measured. . fluids and electrolytes are administered as prescribed,
and oral fluid intake is encouraged when it is permitted. %aboratory values of serum
electrolytes &especially sodium and potassium( are monitored. .ital signs are monitored
hourly for signs of dehydration &tachycardia, orthostatic hypotension( along with
assessment of breath sounds, level of consciousness, presence of edema, and cardiac
status &617 rhythm strips(.
mproving Nutritional nta$e
8eal planning is implemented, with the control of glucose as the primary goal. !lanning
must take into consideration the patient's lifestyle, cultural background, activity level, and
food preferences. $n appropriate caloric intake allows the patient to achieve and maintain
the desired body weight. The patient is encouraged to eat full meals and snacks as
prescribed in the diet prescription. $rrangements may be made with the dietitian for e,tra
snacks before increased physical activity. t is important for the nurse to ensure that
insulin orders are altered as needed to correspond to delays in eating caused by diagnostic
and other procedures that affect timing of meals.
%educing An&iety
The nurse provides emotional support and sets aside time to talk with the patient who
wishes to e,press feelings, cry, or ask 9uestions about the new diagnosis. $ny
misconceptions the patient or family may have regarding diabetes are dispelled &see Table
:1-;(. The patient and family are assisted to focus on learning self-care behaviors. The
patient is encouraged to perform the skills that he or she fears most and must be reassured
that once a skill such as self-in/ection or lancing a finger for glucose monitoring is
performed for the first time, an,iety will decrease. !ositive reinforcement is given for the
self-care behaviors attempted, even if the techni9ue is not yet completely mastered.
mproving 'el()Care
$s previously discussed, patient teaching is the ma/or strategy used to prepare patients
for self-care. *pecial e9uipment may be needed for instruction on diabetes survival skills,
such as a magnifying glass for insulin preparation or an in/ection-aid device for insulin
in/ection. %ow-literacy information and literature in other languages can be obtained from
the $"$. 5amilies are also taught so that they can assist in diabetes management0 for
e,ample, they can prefill syringes or monitor the patient's blood glucose level. The
diabetes educator is consulted regarding various blood glucose monitors and other
e9uipment for use by patients with physical impairments. The patient is assisted in
identifying community resources for education and supplies as needed. -ther members of
the health care team are informed about variations in the timing of meals and the work
schedule &eg, if the patient works at night or in the evenings and sleeps during the day( so
that the diabetes treatment regimen can be ad/usted accordingly.
Monitoring and Managing Potential Complications
!luid *verload
5luid overload can occur because of the administration of a large volume of fluid at a
rapid rate, which is often re9uired to treat patients with "#$ or '')*. This risk is
increased in elderly patients and in those with pree,isting cardiac or renal disease. To
avoid fluid overload and resulting heart failure and pulmonary edema, the nurse monitors
the patient closely during treatment by measuring vital signs and intake and output at
fre9uent intervals. 1entral venous pressure monitoring and hemodynamic monitoring
may be initiated to provide additional measures of fluid status. !hysical e,amination
focuses on assessment of cardiac rate and rhythm, breath sounds, venous distention, skin
turgor, and urine output. The nurse monitors fluid intake and keeps careful records of .
and other fluid intake, along with urine output measurements.
+ypo$alemia
$s previously described, hypokalemia is a potential complication during the treatment of
"#$ as potassium is lost from body stores. %ow serum potassium levels may result from
rehydration, increased urinary e,cretion of potassium, and movement of potassium from
the e,tracellular fluid into the cells with insulin administration. !revention of
hypokalemia includes cautious replacement of potassium0 however, before its
administration, it is important to ensure that a patient's kidneys are functioning. Because
of the adverse effects of hypokalemia on cardiac function, monitoring of the cardiac rate,
cardiac rhythm, 617, and serum potassium levels is essential.
+yperglycemia and ,etoacidosis
$lthough the hyperglycemia and ketoacidosis that may have led to the new diagnosis of
diabetes may be resolved, patients are at risk for their subse9uent recurrence. Therefore,
blood glucose levels and urine ketones are monitored, and medications &insulin, oral
antidiabetic agents( are administered as prescribed. The nurse monitors the concentrations
of blood glucose and urine ketones and reports any value out of the target range. .
insulin and . fluids may need to be administered again.
+ypoglycemia
'ypoglycemia may occur if the patient skips or delays meals, does not follow the
prescribed meal plan, or greatly increases the amount of e,ercise without modifying food
intake and insulin. n addition, hospitali+ed patients or outpatients who fast in preparation
for diagnostic testing are at risk for hypoglycemia. <uice, milk, or glucose tablets are used
for treatment of hypoglycemia. The patient is encouraged to eat full meals and snacks as
prescribed in the meal plan. f hypoglycemia is a recurring problem, the total therapeutic
regimen should be reevaluated.
Because of the risk of hypoglycemia, especially with intensive insulin regimens, it is
important for the nurse to review with the patient the signs and symptoms, possible
causes, and measures for prevention and treatment of hypoglycemia. The nurse should
stress to the patient and family the importance of having information on diabetes at home
for reference.
Cerebral "dema
$lthough the cause of cerebral edema is unknown, rapid correction of hyperglycemia,
resulting in fluid shifts, is thought to be the cause. 1erebral edema, which occurs more
often in children than in adults, can be prevented by gradual reduction in the blood
glucose level &$"$, 2==:h(. $n hourly flow sheet is used to enable close monitoring of
the blood glucose level, serum electrolyte levels, urine output, mental status, and
neurologic signs. !recautions are taken to minimi+e activities that could increase
intracranial pressure.
Promoting +ome and Community)#ased Care
Teaching Patients 'el()Care
The patient is taught survival skills, including treatment modalities &diet, insulin
administration, monitoring of blood glucose, and, for type 1 diabetes, monitoring of urine
ketones(0 recognition, treatment, and prevention of acute complications &hypoglycemia
and hyperglycemia(0 practical information &where to obtain supplies, when to call the
physician(0 and simple pathophysiology that the patient will understand. f the patient has
signs of long-term diabetes complications at the time of diagnosis of diabetes, teaching
about relevant preventive behaviors &eg, foot care, eye care( is appropriate at this time
&1hart :1-1=(.
Continuing Care
5ollow-up education is arranged with a home care nurse and dietitian or an outpatient
diabetes education center. This is particularly important for patients who have had
difficulty coping with the diagnosis, patients who have limitations that may affect their
ability to learn or to carry out the management plan, and patients who are without any
family or social supports. 3eferral to social services and community resources &eg,
centers for the visually impaired( may be needed, depending on the patient's financial
circumstances and physical limitations. The importance of self-monitoring and of
monitoring and follow-up by primary health care providers is reinforced, and the patient
is reminded about the importance of keeping follow-up appointments. !atients who are
newly diagnosed with diabetes are also reminded about the importance of participating in
other health promotion activities and health screening. 1hart :1-11 is a checklist of self-
care skills.
"valuation
"&pected Patient *utcomes
6,pected patient outcomes may include the following2
$chieves fluid and electrolyte balance
o "emonstrates intake and output balance
o 6,hibits electrolyte values within normal limits
o 6,hibits vital signs that remain stable, with resolution of orthostatic
hypotension and tachycardia
$chieves metabolic balance
o $voids e,tremes of glucose levels &hypoglycemia or hyperglycemia(
o 6,hibits glucose levels within target range with minimal episodes of
hypoglycemia
o 3ecogni+es and treats hypoglycemia appropriately
o "emonstrates rapid resolution of hypoglycemic episodes
o $voids further weight loss &if applicable( and begins to approach desired
weight
"emonstrates4verbali+es diabetes survival skills.
o "efines diabetes as a condition in which high blood glucose levels are
present
o *tates normal and target blood glucose ranges
o dentifies factors that cause the blood glucose level to fall &insulin,
e,ercise, some oral antidiabetic medications(
o dentifies factors that cause the blood glucose level to rise &food, illness,
stress, and infections(
o "escribes the ma/or treatment modalities2 nutrition therapy, e,ercise,
monitoring, medication, education
o "emonstrates proper techni9ue for drawing up and in/ecting insulin
&including mi,ing two types of insulin, if necessary(
o *tates dose and timing of in/ections, peak action, duration, and adverse
effects of insulin
o *tates dose, timing, peak action, and duration of prescribed oral
antidiabetic agents
o .erbali+es plan for rotating insulin in/ection sites
o .erbali+es understanding of food group classifications &depending on
system used(
o .erbali+es appropriate schedule for eating snacks and meals0 orders
appropriate foods on menus0 identifies foods that may be substituted for
one another on the meal plan
o "emonstrates proper techni9ue for monitoring blood glucose, including
using finger-lancing device0 obtaining a drop of blood0 applying blood
properly to strip0 obtaining value of blood glucose0 and recording blood
glucose value. $lso, is able to calibrate and clean meter, change batteries,
identify alarms and warnings on meter, and use control solutions to
validate strips.
o "emonstrates proper techni9ue for disposal of lancets and needles used for
blood glucose monitoring and insulin in/ections &ie, discarding them into
sharps container(
o "emonstrates proper techni9ue for urine ketone testing &for patients with
type 1 diabetes( and verbali+es appropriate times to assess for ketones
&when ill or when blood glucose test results are repeatedly and
ine,plicably greater than 2>= to ?== mg4d% @1?.A to 1B.B mmol4%C(
o dentifies community, outpatient resources for obtaining further diabetes
education
o dentifies acute complications &hypoglycemia and hyperglycemia(
o .erbali+es symptoms of hypoglycemia &shakiness, sweating, headache,
hunger, numbness or tingling of lips or fingers, weakness, fatigue,
difficulty concentrating, change of mood( and dangers of untreated
hypoglycemia &sei+ures and coma(
o dentifies appropriate treatment of hypoglycemia, including 1> g simple
carbohydrate &eg, two to four glucose tablets, : to B o+ /uice or soda, 2 to ?
teaspoons sugar, B to 1= hard candies( followed by a snack of protein and
carbohydrate &eg, cheese and crackers or milk( or by a regularly scheduled
meal
o *tates potential causes of hypoglycemia &too much insulin, delayed or
decreased food intake, increased physical activity( and verbali+es
preventive behaviors, such as fre9uent monitoring of blood glucose when
daily schedule is changed and eating a snack before e,ercise
o .erbali+es importance of wearing or carrying medical identification and
carrying a source of simple carbohydrate at all times
o .erbali+es symptoms of prolonged hyperglycemia &increased thirst and
urination(
o .erbali+es rules for sick day management
o "escribes where to purchase and store insulin, syringes, and glucose
monitoring supplies
o dentifies appropriate circumstances for calling the physician &when ill,
when glucose levels repeatedly e,ceed a certain level @per physician
guidelinesC, or when skin wounds fail to heal( and also identifies name of
physician &or other health care team member( and 2:-hour phone number
$bsence of complications
o 6,hibits normal cardiac rate and rhythm and normal breath sounds
o 6,hibits no /ugular venous distention
o 6,hibits blood glucose and urine ketone levels within target range
o 6,hibits no manifestations of hypoglycemia or hyperglycemia
o *hows improved mental status without signs of cerebral edema
Chart -.)./0 Patient "ducation
!oot Care Tips
1. Take care of your diabetes.
o Dork with your health care team to keep your blood glucose level within a
normal range.
2. nspect your feet every day.
o %ook at your bare feet every day for cuts, blisters, red spots, and swelling.
o Ese a mirror to check the bottoms of your feet or ask a family member for
help if you have trouble seeing.
o 1heck for changes in temperature.
?. Dash your feet every day.
o Dash your feet in warm, not hot, water.
o "ry your feet well. Be sure to dry between the toes.
o "o not soak your feet.
o "o not check water temperature with your feet0 use a thermometer or
elbow.
:. #eep the skin soft and smooth.
o 3ub a thin coat of skin lotion over the tops and bottoms of your feet, but
not between your toes.
>. *mooth corns and calluses gently.
o Ese a pumice stone to smooth corns and calluses.
B. Trim your toenails each week or when needed.
o Trim your toenails straight across and file the edges with an emery board
or nail file.
;. Dear shoes and socks at all times.
o )ever walk barefoot.
o Dear comfortable shoes that fit well and protect your feet.
o 5eel inside your shoes before putting them on each time to make sure the
lining is smooth and there are no ob/ects inside.
A. !rotect your feet from hot and cold.
o Dear shoes at the beach or on hot pavement.
o Dear socks at night if your feet get cold.
F. #eep the blood flowing to your feet.
o !ut your feet up when sitting.
o Diggle your toes and move your ankles up and down for > minutes, 2 or ?
times a day.
o "o not cross your legs for long periods of time.
o "o not smoke.
1=. 1heck with your health care provider.
o 'ave your health care provider check your bare feet and find out whether
you are likely to have serious foot problems. 3emember that you may not
feel the pain of an in/ury.
o 1all your health care provider right away if a cut, sore, blister, or bruise on
your foot does not begin to heal after one day.
o 5ollow your health care provider's advice about foot care.
o "o not self-medicate or use home remedies or over-the-counter agents to
treat foot problems.
Nursing Process
The Patient With Diabetes as a 'econdary Diagnosis
!atients with diabetes fre9uently seek medical attention for problems not directly related
to blood glucose control. 'owever, during the course of treatment for the primary
medical diagnosis, blood glucose control may worsen. n addition, the only opportunity
for some patients with diabetes to update their knowledge about diabetes self-care and
prevention of complications may be during hospitali+ation. Therefore, it is important for
nurses caring for patients with diabetes to focus attention on the diabetes as well as the
primary health issue. 5urthermore, control of blood glucose levels is important, because
hyperglycemia impairs resistance to certain infections and impedes wound healing.
Assessment
$ssessment of patients with diabetes who have a primary problem such as cardiac
disease, renal disease, cerebrovascular disease, peripheral vascular disease, surgery, or
any other type of illness is the same as that for all patients and is described in other
chapters. n addition to nursing assessment for the primary problem, assessment of the
patient with diabetes must also focus on hypoglycemia and hyperglycemia, skin
breakdown, and diabetes self-care skills, including survival skills and measures for
prevention of long-term complications. n addition, the patient is asked about use of
alternative and complementary therapies0 studies have demonstrated that patients with
diabetes are twice as likely as other patients to use these therapies, some of which may be
harmful &6gede, Ge H Iheng, 2==2(.
$ssessment for hypoglycemia and hyperglycemia involves fre9uent blood glucose
monitoring &usually prescribed before meals and at bedtime( and monitoring for signs and
symptoms of hypoglycemia or prolonged hyperglycemia &including "#$ or '')*(, as
described previously.
1areful assessment of the skin, especially at pressure points and on the lower e,tremities,
is important. The skin is assessed for dryness, cracks, skin breakdown, and redness. The
patient is asked about symptoms of neuropathy, such as tingling and pain or numbness of
the feet. "eep tendon refle,es are assessed.
The nurse should assess the patient's diabetes self-care skills as soon as possible to
determine whether further diabetes teaching is re9uired. The nurse observes the patient
preparing and in/ecting the insulin, monitoring blood glucose, and performing foot care.
&*imply 9uestioning the patient about these skills without actually observing performance
of the skills is not sufficient.( The patient's knowledge about diet can be assessed with the
help of a dietitian through direct 9uestioning and review of the patient's menu choices.
The patient is asked about signs and symptoms, treatment, and prevention of
hypoglycemia and hyperglycemia. The patient's knowledge of risk factors for
macrovascular disease, including hypertension, increased lipids, and smoking, is
assessed. n addition, the patient is asked the date of his or her last eye e,amination
&including dilation of the pupils(. t is also important to assess the patient's use of
preventive health measures, including annual influen+a vaccination &flu shot(, date of the
most recent pneumonia vaccination &$"$, 2==:k(, and daily dose of aspirin &unless
contraindicated( &$"$, 2==:a(.
Nursing Diagnoses
Based on the assessment data, ma/or nursing diagnoses may include the following2
mbalanced nutrition related to increase in stress hormones &caused by primary
medical problem( and imbalances in insulin, food, and physical activity
3isk for impaired skin integrity related to immobility and lack of sensation
&caused by neuropathy(
"eficient knowledge about diabetes self-care skills &caused by lack of basic
diabetes education or lack of continuing in-depth diabetes education(
Collaborative Problems/Potential Complications
Based on the assessment data, potential complications may include the following2
nade9uate control of blood glucose levels &hyperglycemia, hypoglycemia(
"#$ and '')*
Planning and Goals
The ma/or goals for the patient may include improved nutritional status, maintenance of
skin integrity &foot care(, ability to perform basic diabetes self-care skills as well as
preventive care for the avoidance of chronic diabetes complications, and absence of
complications.
Nursing nterventions
mproving Nutritional 'tatus
The patient's food intake is planned with the primary goal of glucose control0 however,
the dietary prescription must also consider the primary health problem in addition to
lifestyle, cultural background, activity level, and food preferences. f alterations are
needed in the patient's diet because of the primary health problem &eg, gastrointestinal
problems(, alternative strategies to ensure ade9uate nutritional intake must be
implemented. The patient's nutritional intake is monitored carefully along with blood
glucose, urine ketones, and daily weight.
Maintaining '$in Care
The skin is assessed daily for dryness or breaks. The feet are cleaned with warm water
and soap. 6,cessive soaking of the feet &eg, to the point of wrinkling the skin( is avoided.
The feet are dried thoroughly, especially between the toes, and lotion is applied to the
entire foot e,cept between the toes. 5or patients who are confined to bed &especially
those with a history of neuropathy(, the heels are elevated off the bed with a pillow
placed under the lower legs and the heels resting over the edge of the pillow. $ bed cradle
may be used to keep the bed covers off the feet of the patient with diabetic neuropathy.
"ermal ulcers are treated as indicated and prescribed. The nurse promotes optimal blood
glucose control in the patient with skin breakdown.
Addressing ,nowledge De(icits
'ospital admission of the patient with diabetes provides an ideal opportunity for the
nurse to assess the patient's level of knowledge about diabetes and its management. The
nurse uses this opportunity to assess the patient's understanding of diabetes management,
including blood glucose monitoring, administration of medications &ie, insulin, oral
agents(, meal planning, e,ercise, and strategies to prevent long- and short-term
complications of diabetes. The nurse also assesses the ad/ustment of the patient and
family to diabetes and its management and identifies any misconceptions they have.
Monitoring and Managing Potential Complications
nade9uate control of blood glucose levels may hinder recovery from the primary health
problem. Blood glucose levels are monitored, and insulin is administered as prescribed. t
is important for the nurse to ensure that prescribed insulin dosage is modified as needed
to compensate for changes in the patient's schedule or eating pattern. Treatment is given
for hypoglycemia &with oral glucose( or hyperglycemia &with supplemental regular
insulin no more often than every ? to : hours(. Blood glucose records are assessed for
patterns of hypoglycemia and hyperglycemia at the same time of day, and findings are
reported to the physician for modification in insulin orders. n the patient with prolonged
elevations in blood glucose, laboratory values and the patient's physical condition are
monitored for signs and symptoms of "#$ or '')*.
"evelopment of acute complications of diabetes secondary to inade9uate control of blood
glucose levels may be associated with other health care problems because of changes in
activity level and diet and physiologic alterations related to the primary health problem
itself. Therefore, the patient must be monitored for acute complications &hyperglycemia,
hypoglycemia(, and measures must be implemented for their prevention and early
treatment.
Promoting +ome and Community)#ased Care
Teaching Patients 'el()Care
6ven if the patient has had diabetes for many years, it is important to assess his or her
knowledge and adherence to the plan of care. t may be necessary to plan and implement
a teaching plan that includes basic information about diabetes, its cause and symptoms,
and acute and chronic complications and their treatment. The nurse asks the patient to
give repeated return demonstrations of skills that were not performed correctly during the
initial assessment. The patient is taught self-care activities for the prevention of long-term
complications, including foot care, eye care, and risk factor management. The nurse also
reminds the patient and family about the importance of health promotion activities and
recommended health screening.
Continuing Care
$ patient who is hospitali+ed for another health problem may re9uire referral for home
care for that problem or if gaps in knowledge about self-care are uncovered. n either
case, the home care nurse can use this opportunity to assess the patient's knowledge about
diabetes management and the patient's and family's ability to carry out that management.
The nurse reinforces the teaching provided in the hospital, clinic, office, or diabetes
education center and assesses the home care environment to determine its ade9uacy for
self-care and safety.
"uring home care visits, the nurse assesses the patient for signs and symptoms of long-
term complications and assesses the patient's and family's techni9ues in blood glucose
monitoring, insulin administration, and food selection. n addition, the patient and family
are reminded of the importance of keeping appointments with health care providers and
participating in health promotion activities as well as recommended health screening.
"valuation
"&pected Patient *utcomes
6,pected patient outcomes may include the following2
$chieves optimal control of blood glucose
o $voids e,tremes of hypoglycemia and hyperglycemia
o Takes steps to resolve rapidly any hypoglycemic episodes
8aintains skin integrity
o "emonstrates intact skin without dryness and cracking
o $voids ulcers caused by pressure and neuropathy
"emonstrates4verbali+es diabetes survival skills and preventive care
Enderstands treatment modalities
o "emonstrates correct techni9ue for administering insulin or oral
antidiabetic medications and assessing blood glucose
o "emonstrates appropriate knowledge of diet through proper menu
selections and identification of pattern used for selecting foods at home
o .erbali+es signs, appropriate treatment, and prevention of hypoglycemia
and hyperglycemia
"emonstrates proper foot care
o nspects feet &using mirror if necessary to see the bottoms of both feet(,
including inspection for cracks or fungal infections between toes
o Dashes feet with warm water and soap0 dries feet thoroughly
o $pplies lotion to entire foot e,cept between toes
o dentifies strategies that decrease the risk of foot ulcers, including wearing
shoes at all times0 using hand or elbow, not foot, to test temperature of
bath water0 avoiding use of heating pad on feet0 avoiding constrictive
shoes0 wearing new shoes for brief periods only0 avoiding home remedies
for treatment of corns and calluses0 having feet e,amined at every
appointment with the physician or nurse practitioner0 and consulting a
podiatrist for regular nail care if necessary
Takes steps to prevent eye disease
o .erbali+es need for yearly or more fre9uent thorough dilated eye
e,aminations by an ophthalmologist &starting at > years after diagnosis for
type 1 diabetes or the year of diagnosis for type 2 diabetes(
o .erbali+es that retinopathy usually does not cause change in vision until
serious damage to the retina has occurred
o *tates that early laser treatment along with good control of blood glucose
and blood pressure may prevent visual loss from retinopathy
o dentifies hypoglycemia and hyperglycemia as two causes of temporary
blurred vision
*tates measures to control macrovascular risk factors
o *moking cessation
o %imitation of fats and cholesterol
o 1ontrol of hypertension
o 6,ercise
o 3egular monitoring of renal function
3eports absence of acute complications
o 8aintains blood glucose and urine ketones within normal limits
o 6,periences no signs or symptoms of hypoglycemia or hyperglycemia
o dentifies signs and symptoms of hypoglycemia or hyperglycemia
o 3eports appearance of symptoms so that treatment can be initiated