This document discusses diabetes mellitus, including its classification, pathophysiology, clinical features, investigations, management, complications, nursing assessments, and interventions. It describes diabetes as a metabolic disorder characterized by hyperglycemia resulting from defects in insulin production, secretion, or utilization. The two main types discussed are type 1 diabetes, which results from little to no endogenous insulin production, and type 2 diabetes, which involves insulin resistance and deficiency. Management involves diet, exercise, medication including insulin therapy, and treatment/prevention of complications.
A comprehensive presentation on Diabetes Mellitus for undergraduate students from medical /dental/biotechnology /pharmacology education.It describes causes, classification, symptoms ,diagnostic biochemical tests,biochemical changes in metabolism,Management, drugs used for DM .Google images relevant to text are presentation.
What is diabetes mellitus, Epidemiology of diabetes, Diabetes diagnosis, Features of diabetes, WHO classification of Diabetes Mellitus, Complications of diabetes, Metabolic alterations of diabetes, Oral glucose tolerance test, WHO criteria of OGTT interpretation, Classification of diabetes mellitus, Gestational diabetes, Pre-diabetes, Insulin, Biosynthesis of insulin, Insulin actions, Hypoglycemia, Impaired fasting glucose, Insulin structure
A comprehensive presentation on Diabetes Mellitus for undergraduate students from medical /dental/biotechnology /pharmacology education.It describes causes, classification, symptoms ,diagnostic biochemical tests,biochemical changes in metabolism,Management, drugs used for DM .Google images relevant to text are presentation.
What is diabetes mellitus, Epidemiology of diabetes, Diabetes diagnosis, Features of diabetes, WHO classification of Diabetes Mellitus, Complications of diabetes, Metabolic alterations of diabetes, Oral glucose tolerance test, WHO criteria of OGTT interpretation, Classification of diabetes mellitus, Gestational diabetes, Pre-diabetes, Insulin, Biosynthesis of insulin, Insulin actions, Hypoglycemia, Impaired fasting glucose, Insulin structure
Educational Grand Rounds: Diabetes and Lifestyle ModificationS'eclairer
Dr. Zahida Chaudhary presents a slide deck on Diabetes along with James Ellermeyer as they discuss what our society is doing to contribute to the problem and what we can do to change it in our own lives on a case by case basis.
Definition of diabetes - introduction - classification of diabetes - etiology of diabetes type 1 and type 2- risk factors for diabetes - diagnosis of diabetes - clinical manifestations of diabetes type 1 and type 2- investigations for diabetes - treatment of diabetes - non-pharmacological treatment and pharmacological treatment - pharmacotherapy of type 1 and type 2 - acute complications of diabetes and treatment
The term ‘diabetes’ means excessive urination and the word ‘mellitus’ means honey.
Diabetes mellitus is a lifelong condition caused by a lack, or insufficiency of insulin. Insulin is a hormone – a substance of vital importance that is made by your pancreas. Insulin acts like a key to open the doors into your cells, letting sugar (glucose) in. In diabetes, the pancreas makes too little insulin to enable all the sugar in your blood to get into your muscle and other cells to produce energy. If sugar can’t get into the cells to be used, it builds up in the bloodstream. Therefore, diabetes is characterized by high blood sugar (glucose) levels.
The Diabetic coma is one the most dangerous and again emergent case experienced during dental care delivery. Actually it mistreated and aggravated-diabetic cases resulting coma, that is categorized into Hypoglycemic coma, Diabetic ketoacidosis and Hyperosmolar coma.
Educational Grand Rounds: Diabetes and Lifestyle ModificationS'eclairer
Dr. Zahida Chaudhary presents a slide deck on Diabetes along with James Ellermeyer as they discuss what our society is doing to contribute to the problem and what we can do to change it in our own lives on a case by case basis.
Definition of diabetes - introduction - classification of diabetes - etiology of diabetes type 1 and type 2- risk factors for diabetes - diagnosis of diabetes - clinical manifestations of diabetes type 1 and type 2- investigations for diabetes - treatment of diabetes - non-pharmacological treatment and pharmacological treatment - pharmacotherapy of type 1 and type 2 - acute complications of diabetes and treatment
The term ‘diabetes’ means excessive urination and the word ‘mellitus’ means honey.
Diabetes mellitus is a lifelong condition caused by a lack, or insufficiency of insulin. Insulin is a hormone – a substance of vital importance that is made by your pancreas. Insulin acts like a key to open the doors into your cells, letting sugar (glucose) in. In diabetes, the pancreas makes too little insulin to enable all the sugar in your blood to get into your muscle and other cells to produce energy. If sugar can’t get into the cells to be used, it builds up in the bloodstream. Therefore, diabetes is characterized by high blood sugar (glucose) levels.
The Diabetic coma is one the most dangerous and again emergent case experienced during dental care delivery. Actually it mistreated and aggravated-diabetic cases resulting coma, that is categorized into Hypoglycemic coma, Diabetic ketoacidosis and Hyperosmolar coma.
Nursing Management · Monitor blood sugar and use a sliding scale to treat high levels of glucose · Educate patient about diabetes · Examine feet .
Diagnosis involves measuring blood glucose levels. Ongoing specialized assessment and evaluation for complications are essential for diabetes management.
Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications.
Diabetes mellitus (DM) is a syndrome of chronic hyperglycaemia is due to one of two mechanisms:
Inadequate production of insulin , or
Inadequate sensitivity of cells to the action of insulin.
It affects more than 220 million people worldwide, and it is estimated that it will affect 440 million by the year 2030
"Diabetes" comes from the Greek word for "siphon", and implies that a lot of urine is made.
The second term,"mellitus" comes from the Latin word, "mel" which means "honey", and was used because the urine was sweet.
• The onset of type 1 diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. DIABETES MELLITUS
•Diabetes mellitus is a metabolic disorder
characterized by hyperglycemia and results
from defective insulin production,
secretion, or utilization.
3. Classification of diabetes
1. Type 1 diabetes mellitus – was formerly
known as IDDM, Juvenile diabetes mellitus.
a. Little or no endogenous insulin requiring injection of insulin
to control.
b. 5 to 10 % of diabetic patients have type 1.
c . Etiology: autoimmunity, viral, ain genetic
d. Usual presentation is rapid with classic symptoms of
polydipsia, polyphagia, polyuria, and weight loss.
e. Most Commonly seen in patients under age 30
but can seen in older adults.
4. Classification of diabetes….
2. Type 2 diabetes mellitus - was formerly known as NIDDM or
adult onset diabetes mellitus.
a. Insulin resistance and insulin deficiency.
b. Approximately 90% of diabetic patients have type 2.
c. Etiology: hereditary with obesity commonly occurs
persons over age 40.
e. Usually presentation is slow and typically insidious
with symptoms of fatigue, weight gain, poor wound
healing, recurrent infection.’
5. Pathophysiology and Etiology
1. There is an absolute or relative Lack of insulin produced by the beta
cell resulting in hyperglycemia.
2. Defects at the cell level, impaired secretory response of insulin to
rises in glucose, and increased nocturnal hepatic glucose production
(gluconeogenesis) are see in type 2 diabetes.
3. Etiology of type 1 diabetes is not well understood; viral,
autoimmune, and envioromental factors.
4. Etiology of type 2 diabetes involves heredity, genetics, and obesity.
6. Clinical features
Hyperglycemia
1. Weight loss fatigue
2. Polyurea, polydipsia, polyphagia
3. Blurred vision
Others
1. Poor wound healing
2 . Recurrent infection, particularly of the skin
7. Investigation
1. Diabetics can be diagnosed in any of the following ways (and should
be confirmed on a different day by any of these)
a. FBS of greater than or equal to 126 mg/dL
b. RBS of greater than or equal to 200 mg/dL
c. OGTT greater than or equal to 200 mg/dL 2-hour
sample.
- FBS
- 75 g oral glucose
- samples after ½ hour, 1 hour, 2 hour, 3 hour
8. Management
Diet
1. Dietary control with caloric restriction of
CHO and saturated fats.
2. Meal planning is to control blood glucose and lipid
levels
10. Management…
Medication
1. Oral antidiabetic agents for patients
with type 2 diabetes.
2. Insulin therapy for patients with type I diabetes who
require replacement.
• May also be used for type 2 diabetes when unresponsive to diet,
exercise, and oral antidiabetic therapy.
15. Complications
• Acute
1. Hypoglycemia.
2. DKA
3. Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) –
type 2 DM, severe dehydration, hyperglycemia, hyperosmolarity,
and stupor.
16. Complications….
• Chronic
1. In type I diabetes, chronic complications usually appear about 10
years after the initial diagnosis.
2. Microvascular complications - retinopathy, nephropathy and
neuropathy is higher in type I diabetes.
3. Cardiovascular disease - occurring in type 1 and type 2 diabetes are
the leading cause of morbidity and mortality
17. Nursing Assessment
• Obtain history of current problem, family history, and
general health history.
• Polyuria, polydipsia, polypagia and other symptoms?
• Number of years since diagnosis of diabetes.
• Family numbers diagnosis with diabetes, treatment and
complication.
18. Nursing Assessment…..
• Perform physical examination to assess sign and
symptoms and presence of complication.
• Skin lesions, dehydration, poor wound healing.
• Eye – change in vision, cataract, glucoma.
• Mouth – gingivitis, periodontal disease.
• Cardiovascular – orthostatic hypotension, cold extremities,
weak pulse, leg claudication.
• GI – diarrhea, constipation, early satiety, increased flatulence.
• GU – Impotence, vaginal discharge.
• Neurologic – Numbness of extremities, gait change
19. Nursing Diagnoses
• Impaired Nutrition:More than Body Requirements.
• Fear related to insulin injection.
• Risk for Injury (hypoglycemia) related to effects of insulin.
• Activity Intolerance related to poor glucose control.
• Deficient Knowledge related to use of oral hypoglycemic agents.
• Risk for Impaired Skin Integrity related to decreased sensation and
circulation to lower extremities.
• Ineffective Coping related to chronic disease.
20. Nursing intervention
Improving nutrition
• Assess current timing and content of meals.
• Advise patient on the importance of an individualized meal
plan in meeting weight-loss goals. Reducing intake of
carbohydrates may benefit some patients; however, fad diets
or diet plans that stress one food group and eliminate another
are generally not recommended.
• Discuss the goals of dietary therapy for the patient. Setting a
goal of a 10% (of patient’s actual body weight) weight loss over
several months is usually achievable and effective in reducing
blood sugar and other metabolic parameters.
21. Nursing intervention
Improving nutrition…
• Assist patient to identify problems that may have an impact on dietary
adherence and possible solutions to these problems.
• Emphasize that lifestyle changes should be maintainable for life.
• Explain the importance of exercise in maintaining/reducing body weight.
a. Caloric expenditure for energy in exercise.
b. Carryover of enhanced metabolic rate and efficient food utilization.
• Assist patient to establish goals for weekly weight loss and incentives to assist in
achieving them.
• Strategize with patient to address the potential social pitfalls of weight
reduction.
22. Nursing intervention…..
Teaching about insulin
• Assist patient to reduce fear of injection by encouraging verbalization of fears
regarding insulin injection, conveying a sense of empathy, and identifying
supportive coping techniques.
• Demonstrate and explain thoroughly the procedure for insulin self-injection
• Help patient to master technique by taking a step-by-step approach.
a. Allow patient time to handle insulin and syringe to become familiar with
the equipment.
b. Teach self-injection first to alleviate fear of pain from injection.
c. Instruct patient in filling syringe when he or she expresses confidence in
self-injection procedure.
• Review dosage and time of injections in relation to meals, activity, and bedtime based on
patient’s individualized insulin regimen.
25. Nursing intervention…..
Preventing injury secondary to hypoglycemia
• Closely monitor blood glucose levels to detect hypoglycemia.
• Instruct patient in the importance of accuracy in insulin preparation and meal
timing to avoid hypoglycemia.
• Assess patient for the signs and symptoms of hypoglycemia.
a. Adrenergic (early symptoms)—sweating, tremor, pallor, tachycardia,
palpitations, nervousness from the release of adrenalin when blood glucose
falls rapidly.
b. Neurologic (later symptoms)—light-headedness, headache, confusion,
irritability, slurred speech, lack of coordination, staggering gait from
depression of central nervous system as glucose level progressively falls.
26. Nursing intervention…..
Preventing injury secondary to hypoglycemia…
• Treat hypoglycemia promptly...
• One-half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four
sugar cubes, five to six pieces of hard candy may be taken orally.
• Encourage patient to carry a portable treatment for hypoglycemia at all
times.
• Assess patient for cognitive or physical impairments that may interfere
with ability to accurately administer insulin.
• Between-meal snacks as well as extra food taken before exercise should
be encouraged to prevent hypoglycemia.
• Encourage patients to wear an identification bracelet or card that may
assist in prompt treatment in a hypoglycemic emergency.
27. Nursing intervention…..
Improving activity tolerance
• Advise patient to assess blood glucose level before and after strenuous
exercise.
• Instruct patient to plan exercises on a regular basis each day.
• Encourage patient to eat a carbohydrate snack before exercising to avoid
hypoglycemia.
• Advise patient that prolonged strenuous exercise may require increased food at
bedtime to avoid nocturnal hypoglycemia.
• Instruct patient to avoid exercise whenever blood glucose levels exceed 250
mg/day and urine ketones are present. Patient should contact health care
provider if levels remain elevated.
• Counsel patient to inject insulin into the abdominal site on days when arms or
legs are exercised.
28. Nursing intervention…..
Providing information about oral anti diabetic agent
• Identify barriers to learning, such as visual or hearing
impairments, low literacy, distractive environment.
• Encourage active participation of the patient and family in the
educational process.
• Teach the action, use, and adverse effects of oral antidiabetic
agents
• Identify financial barriers to accessing medications and follow-
up care. Offer resources such as Partnership for Prescription
Assistance
29. Nursing intervention…..
Maintaining Skin Integrity
• Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns,
calluses, dryness, hammertoe or bunion deformation, hair distribution, pulses,
deep tendon reflexes.
• Maintain skin integrity by protecting feet from breakdown.
a. Use heel protectors, special mattresses, foot cradles for patients on bed rest.
b. Avoid applying drying agents to skin (eg, alcohol).
c. Apply skin moisturizers (preferably creams) to maintain suppleness and prevent cracking
and fissures.
30. Nursing intervention…..
Maintaining Skin Integrity…
• Instruct patient in foot care guidelines.
• Advise the patient who smokes to stop smoking, or reduce if possible, to reduce
vasoconstriction and enhance peripheral blood flow. Help patient to establish
behavior modification techniques to eliminate smoking in the hospital and to
continue them at home for smoking-cessation program.
31. Nursing intervention…..
Improving Coping Strategies
• Discuss with the patient the perceived effect of diabetes on
lifestyle, finances, family life, occupation.
• Explore previous coping strategies and skills that have had
positive effects.
• Encourage patient and family participation in diabetes selfcare
regimen to foster confidence.
• Identify available support groups to assist in lifestyle adaptation.
Refer to a certified diabetes educator.
• Assist family in providing emotional support.
32. Health education
• Regular follow up clinic…………
• Teach pt checking fingerstick glucose & urine sugar…..
• Teach pt self administration of insulin……..
• Instruct pt to maintaining good body hygiene specially foot
care.
• Instruct pt to keep all time a handy source of glucose / sugar.
• Teach and provide guideline of meal planning.
• Ongoing education of pt about treatment, prevention and
management of complication