Nursing ProcessThe 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. In addition, urine ketone levels are measured, because the patient with type 1 diabetes may have ketones in the urine.

Patients diagnosed with type 1 diabetes are assessed for signs of DKA, including ketonuria, Kussmaul respirations, orthostatic hypotension, and lethargy. The patient is asked about symptoms of DKA, such as nausea, vomiting, and abdominal pain. Laboratory values are monitored for metabolic acidosis (ie, decreased pH and decreased bicarbonate level) and for electrolyte imbalance. Patients diagnosed with type 2 diabetes are assessed for signs of HHNS, including hypotension, altered sensorium, seizures, and decreased skin turgor. Laboratory values are monitored for hyperosmolality and electrolyte imbalance.

If the patient exhibits signs and symptoms of DKA or HHNS, nursing care first focuses on treatment of these acute complications, as outlined earlier. Once 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

Visual deficits (the patient is asked to read numbers or words on the insulin syringe, menu, newspaper, or written teaching materials)

Deficits in motor coordination (the patient is observed eating or performing other tasks or handling a syringe or finger-lancing device)

Neurologic 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

Low literacy level (may be evaluated while assessing for visual deficits by having the patient read from teaching materials)

Limited financial resources or lack of health insurance

Presence or absence of family support

Typical daily schedule (the patient is asked about timing and number of usual daily meals, work and exercise schedule, plans for travel)

The patient's emotional status is assessed by observing his or her general demeanor (eg, withdrawn, anxious) and body language (eg, avoids eye contact). The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any misconceptions or misinformation regarding diabetes. Coping skills are assessed by asking how the patient has dealt with difficult situations in the past.

DiagnosisNursing DiagnosesBased on the assessment data, major nursing diagnoses may include the following:

Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalance of insulin, food, and physical activity

Deficient knowledge about diabetes self-care skills/information

Potential self-care deficit related to physical impairments or social factors

Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications

Collaborative Problems/Potential ComplicationsBased on assessment data, potential complications may include the following:

Fluid overload, pulmonary edema, and heart failure Hypokalemia

Hyperglycemia and ketoacidosis

Hypoglycemia

Cerebral edema

Planning and GoalsThe major 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 anxiety, and absence of complications.

Nursing Interventions

Maintaining Fluid and Electrolyte BalanceIntake and output are measured. IV fluids and electrolytes are administered as prescribed, and oral fluid intake is encouraged when it is permitted. Laboratory values of serum electrolytes (especially sodium and potassium) are monitored. Vital 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 (ECG rhythm strips).

Improving Nutritional IntakeMeal planning is implemented, with the control of glucose as the primary goal. Planning must take into consideration the patient's lifestyle, cultural background, activity level, and food preferences. An 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. Arrangements may be made with the dietitian for extra snacks before increased physical activity. It 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.

Reducing AnxietyThe nurse provides emotional support and sets aside time to talk with the patient who wishes to express feelings, cry, or ask questions about the new diagnosis. Any misconceptions the patient or family may have regarding diabetes are dispelled (see Table 41-7). 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-injection or lancing a finger for glucose monitoring is performed for the first time, anxiety will decrease. Positive reinforcement is given for the self-care behaviors attempted, even if the technique is not yet completely mastered.

Improving Self-CareAs previously discussed, patient teaching is the major strategy used to prepare patients for self-care. Special equipment may be needed for instruction on diabetes survival skills, such as a magnifying glass for insulin preparation or an injection-aid device for insulin injection. Low-literacy information and literature in other languages can be obtained from the ADA. Families are also taught so that they can assist in diabetes management; for example, they can prefill syringes or monitor the patient's blood glucose level. The diabetes educator is consulted regarding various blood glucose monitors and other equipment for use by patients with physical impairments. The patient is assisted in identifying community resources for education and supplies as needed. Other 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 adjusted accordingly.

Monitoring and Managing Potential Complications

Fluid Overload

Fluid overload can occur because of the administration of a large volume of fluid at a rapid rate, which is often required to treat patients with DKA or HHNS. This risk is increased in elderly patients and in those with preexisting 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 frequent intervals. Central venous pressure monitoring and hemodynamic monitoring

may be initiated to provide additional measures of fluid status. Physical examination 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 IV and other fluid intake, along with urine output measurements.

HypokalemiaAs previously described, hypokalemia is a potential complication during the treatment of DKA as potassium is lost from body stores. Low serum potassium levels may result from rehydration, increased urinary excretion of potassium, and movement of potassium from the extracellular fluid into the cells with insulin administration. Prevention of hypokalemia includes cautious replacement of potassium; 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, ECG, and serum potassium levels is essential.

Hyperglycemia and Ketoacidosis

Although the hyperglycemia and ketoacidosis that may have led to the new diagnosis of diabetes may be resolved, patients are at risk for their subsequent 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. IV insulin and IV fluids may need to be administered again.

Hypoglycemia

Hypoglycemia may occur if the patient skips or delays meals, does not follow the prescribed meal plan, or greatly increases the amount of exercise without modifying food intake and insulin. In addition, hospitalized patients or outpatients who fast in preparation for diagnostic testing are at risk for hypoglycemia. Juice, 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. If 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 Edema

Although the cause of cerebral edema is unknown, rapid correction of hyperglycemia, resulting in fluid shifts, is thought to be the cause. Cerebral edema, which occurs more often in children than in adults, can be prevented by gradual reduction in the blood glucose level (ADA, 2004h). An hourly flow sheet is used to enable close monitoring of the blood glucose level, serum electrolyte levels, urine output, mental status, and

neurologic signs. Precautions are taken to minimize activities that could increase intracranial pressure.

Promoting Home and Community-Based CareTeaching Patients Self-CareThe patient is taught survival skills, including treatment modalities (diet, insulin administration, monitoring of blood glucose, and, for type 1 diabetes, monitoring of urine ketones); recognition, treatment, and prevention of acute complications (hypoglycemia and hyperglycemia); practical information (where to obtain supplies, when to call the physician); and simple pathophysiology that the patient will understand. If 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 (Chart 41-10).

Continuing Care

Follow-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. Referral 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. Patients who are newly diagnosed with diabetes are also reminded about the importance of participating in other health promotion activities and health screening. Chart 41-11 is a checklist of self-care skills.

EvaluationExpected Patient OutcomesExpected patient outcomes may include the following:

Achieves fluid and electrolyte balanceo Demonstrates intake and output balance

o Exhibits electrolyte values within normal limits

o Exhibits vital signs that remain stable, with resolution of orthostatic hypotension and tachycardia

Achieves metabolic balance

o Avoids extremes of glucose levels (hypoglycemia or hyperglycemia)

o Exhibits glucose levels within target range with minimal episodes of hypoglycemia

o Recognizes and treats hypoglycemia appropriately

o Demonstrates rapid resolution of hypoglycemic episodes

o Avoids further weight loss (if applicable) and begins to approach desired weight

Demonstrates/verbalizes diabetes survival skills.

o Defines diabetes as a condition in which high blood glucose levels are present

o States normal and target blood glucose ranges

o Identifies factors that cause the blood glucose level to fall (insulin, exercise, some oral antidiabetic medications)

o Identifies factors that cause the blood glucose level to rise (food, illness, stress, and infections)

o Describes the major treatment modalities: nutrition therapy, exercise, monitoring, medication, education

o Demonstrates proper technique for drawing up and injecting insulin (including mixing two types of insulin, if necessary)

o States dose and timing of injections, peak action, duration, and adverse effects of insulin

o States dose, timing, peak action, and duration of prescribed oral antidiabetic agents

o Verbalizes plan for rotating insulin injection sites

o Verbalizes understanding of food group classifications (depending on system used)

o Verbalizes appropriate schedule for eating snacks and meals; orders appropriate foods on menus; identifies foods that may be substituted for one another on the meal plan

o Demonstrates proper technique for monitoring blood glucose, including using finger-lancing device; obtaining a drop of blood; applying blood properly to strip; obtaining value of blood glucose; and recording blood glucose value. Also, is able to calibrate and clean meter, change batteries, identify alarms and warnings on meter, and use control solutions to validate strips.

o Demonstrates proper technique for disposal of lancets and needles used for blood glucose monitoring and insulin injections (ie, discarding them into sharps container)

o Demonstrates proper technique for urine ketone testing (for patients with type 1 diabetes) and verbalizes appropriate times to assess for ketones (when ill or when blood glucose test results are repeatedly and inexplicably greater than 250 to 300 mg/dL [13.8 to 16.6 mmol/L])

o Identifies community, outpatient resources for obtaining further diabetes education

o Identifies acute complications (hypoglycemia and hyperglycemia)

o Verbalizes 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 (seizures and coma)

o Identifies appropriate treatment of hypoglycemia, including 15 g simple carbohydrate (eg, two to four glucose tablets, 4 to 6 oz juice or soda, 2 to 3 teaspoons sugar, 6 to 10 hard candies) followed by a snack of protein and carbohydrate (eg, cheese and crackers or milk) or by a regularly scheduled meal

o States potential causes of hypoglycemia (too much insulin, delayed or decreased food intake, increased physical activity) and verbalizes preventive behaviors, such as frequent monitoring of blood glucose when daily schedule is changed and eating a snack before exercise

o Verbalizes importance of wearing or carrying medical identification and carrying a source of simple carbohydrate at all times

o Verbalizes symptoms of prolonged hyperglycemia (increased thirst and urination)

o Verbalizes rules for sick day management

o Describes where to purchase and store insulin, syringes, and glucose monitoring supplies

o Identifies appropriate circumstances for calling the physician (when ill, when glucose levels repeatedly exceed a certain level [per physician guidelines], or when skin wounds fail to heal) and also identifies name of physician (or other health care team member) and 24-hour phone number

Absence of complications

o Exhibits normal cardiac rate and rhythm and normal breath sounds

o Exhibits no jugular venous distention

o Exhibits blood glucose and urine ketone levels within target range

o Exhibits no manifestations of hypoglycemia or hyperglycemia

o Shows improved mental status without signs of cerebral edema

Chart 41-10: Patient EducationFoot Care Tips

1. Take care of your diabetes.o Work with your health care team to keep your blood glucose level within a

normal range.

2. Inspect your feet every day.

o Look at your bare feet every day for cuts, blisters, red spots, and swelling.

o Use a mirror to check the bottoms of your feet or ask a family member for help if you have trouble seeing.

o Check for changes in temperature.

3. Wash your feet every day.

o Wash your feet in warm, not hot, water.

o Dry your feet well. Be sure to dry between the toes.

o Do not soak your feet.

o Do not check water temperature with your feet; use a thermometer or elbow.

4. Keep the skin soft and smooth.

o Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes.

5. Smooth corns and calluses gently.

o Use a pumice stone to smooth corns and calluses.

6. 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.

7. Wear shoes and socks at all times.

o Never walk barefoot.

o Wear comfortable shoes that fit well and protect your feet.

o Feel inside your shoes before putting them on each time to make sure the lining is smooth and there are no objects inside.

8. Protect your feet from hot and cold.

o Wear shoes at the beach or on hot pavement.

o Wear socks at night if your feet get cold.

9. Keep the blood flowing to your feet.

o Put your feet up when sitting.

o Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day.

o Do not cross your legs for long periods of time.

o Do not smoke.

10. Check with your health care provider.

o Have your health care provider check your bare feet and find out whether you are likely to have serious foot problems. Remember that you may not feel the pain of an injury.

o Call 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 Follow your health care provider's advice about foot care.

o Do not self-medicate or use home remedies or over-the-counter agents to treat foot problems.

Nursing ProcessThe Patient With Diabetes as a Secondary Diagnosis

Patients with diabetes frequently seek medical attention for problems not directly related to blood glucose control. However, during the course of treatment for the primary medical diagnosis, blood glucose control may worsen. In addition, the only opportunity for some patients with diabetes to update their knowledge about diabetes self-care and prevention of complications may be during hospitalization. Therefore, it is important for nurses caring for patients with diabetes to focus attention on the diabetes as well as the primary health issue. Furthermore, control of blood glucose levels is important, because hyperglycemia impairs resistance to certain infections and impedes wound healing.

Assessment

Assessment 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. In 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. In addition, the patient is asked about use of alternative and complementary therapies; studies have demonstrated that patients with diabetes are twice as likely as other patients to use these therapies, some of which may be harmful (Egede, Ye & Zheng, 2002).Assessment for hypoglycemia and hyperglycemia involves frequent blood glucose monitoring (usually prescribed before meals and at bedtime) and monitoring for signs and symptoms of hypoglycemia or prolonged hyperglycemia (including DKA or HHNS), as described previously.Careful assessment of the skin, especially at pressure points and on the lower extremities, 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. Deep tendon reflexes are assessed.The nurse should assess the patient's diabetes self-care skills as soon as possible to determine whether further diabetes teaching is required. The nurse observes the patient preparing and injecting the insulin, monitoring blood glucose, and performing foot care. (Simply questioning 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 questioning 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. In addition, the patient is asked the date of his or her last eye examination (including dilation of the pupils). It is also important to assess the patient's use of preventive health measures, including annual influenza vaccination (flu shot), date of the most recent pneumonia vaccination (ADA, 2004k), and daily dose of aspirin (unless contraindicated) (ADA, 2004a).

Nursing Diagnoses

Based on the assessment data, major nursing diagnoses may include the following: Imbalanced nutrition related to increase in stress hormones (caused by primary

medical problem) and imbalances in insulin, food, and physical activity Risk for impaired skin integrity related to immobility and lack of sensation

(caused by neuropathy)

Deficient 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 following:

Inadequate control of blood glucose levels (hyperglycemia, hypoglycemia) DKA and HHNS

Planning and GoalsThe major 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 Interventions

Improving Nutritional Status

The patient's food intake is planned with the primary goal of glucose control; however, the dietary prescription must also consider the primary health problem in addition to lifestyle, cultural background, activity level, and food preferences. If alterations are needed in the patient's diet because of the primary health problem (eg, gastrointestinal problems), alternative strategies to ensure adequate nutritional intake must be implemented. The patient's nutritional intake is monitored carefully along with blood glucose, urine ketones, and daily weight.

Maintaining Skin Care

The skin is assessed daily for dryness or breaks. The feet are cleaned with warm water and soap. Excessive 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 except between the toes. For 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. A bed cradle may be used to keep the bed covers off the feet of the patient with diabetic neuropathy. Dermal ulcers are treated as indicated and prescribed. The nurse promotes optimal blood glucose control in the patient with skin breakdown.

Addressing Knowledge Deficits

Hospital 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, exercise, and strategies to prevent long- and short-term complications of diabetes. The nurse also assesses the adjustment of the patient and family to diabetes and its management and identifies any misconceptions they have.

Monitoring and Managing Potential Complications

Inadequate control of blood glucose levels may hinder recovery from the primary health problem. Blood glucose levels are monitored, and insulin is administered as prescribed. It 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 3 to 4 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. In the patient with prolonged elevations in blood glucose, laboratory values and the patient's physical condition are monitored for signs and symptoms of DKA or HHNS.Development of acute complications of diabetes secondary to inadequate 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 Home and Community-Based Care

Teaching Patients Self-CareEven 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. It 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

A patient who is hospitalized for another health problem may require referral for home care for that problem or if gaps in knowledge about self-care are uncovered. In 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 adequacy for self-care and safety.During home care visits, the nurse assesses the patient for signs and symptoms of long-term complications and assesses the patient's and family's techniques in blood glucose monitoring, insulin administration, and food selection. In 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.

Evaluation

Expected Patient OutcomesExpected patient outcomes may include the following:

Achieves optimal control of blood glucoseo Avoids extremes of hypoglycemia and hyperglycemia

o Takes steps to resolve rapidly any hypoglycemic episodes

Maintains skin integrity

o Demonstrates intact skin without dryness and cracking

o Avoids ulcers caused by pressure and neuropathy

Demonstrates/verbalizes diabetes survival skills and preventive care

Understands treatment modalities

o Demonstrates correct technique for administering insulin or oral antidiabetic medications and assessing blood glucose

o Demonstrates appropriate knowledge of diet through proper menu selections and identification of pattern used for selecting foods at home

o Verbalizes signs, appropriate treatment, and prevention of hypoglycemia and hyperglycemia

Demonstrates proper foot care

o Inspects feet (using mirror if necessary to see the bottoms of both feet), including inspection for cracks or fungal infections between toes

o Washes feet with warm water and soap; dries feet thoroughly

o Applies lotion to entire foot except between toes

o Identifies strategies that decrease the risk of foot ulcers, including wearing shoes at all times; using hand or elbow, not foot, to test temperature of bath water; avoiding use of heating pad on feet; avoiding constrictive shoes; wearing new shoes for brief periods only; avoiding home remedies for treatment of corns and calluses; having feet examined at every appointment with the physician or nurse practitioner; and consulting a podiatrist for regular nail care if necessary

Takes steps to prevent eye disease

o Verbalizes need for yearly or more frequent thorough dilated eye examinations by an ophthalmologist (starting at 5 years after diagnosis for type 1 diabetes or the year of diagnosis for type 2 diabetes)

o Verbalizes that retinopathy usually does not cause change in vision until serious damage to the retina has occurred

o States that early laser treatment along with good control of blood glucose and blood pressure may prevent visual loss from retinopathy

o Identifies hypoglycemia and hyperglycemia as two causes of temporary blurred vision

States measures to control macrovascular risk factors

o Smoking cessation

o Limitation of fats and cholesterol

o Control of hypertension

o Exercise

o Regular monitoring of renal function

Reports absence of acute complications

o Maintains blood glucose and urine ketones within normal limits

o Experiences no signs or symptoms of hypoglycemia or hyperglycemia

o Identifies signs and symptoms of hypoglycemia or hyperglycemia

o Reports appearance of symptoms so that treatment can be initiated