Nursing 201 ursing 201 LPN Transition to RN PN Transition to RN Nursing 201 ursing 201 LPN Transition to RN PN Transition to RN Assessment and Manage ment of P atients Assessment and Man agement of Patients With With Diabetes Mellitus Diabetes Mellitus
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Pancreas doesPancreas does notnot produce any insulinproduce any insulin Insulin- dependent diabetes mellitus (IDDM)- insulinInsulin- dependent diabetes mellitus (IDDM)- insulin
must be administered to control complicationsmust be administered to control complications Onset age usually < 30 years; usually thin atOnset age usually < 30 years; usually thin at
diagnosis; with recent weight lossdiagnosis; with recent weight loss Etiology- genetic, immunologic, or environmentalEtiology- genetic, immunologic, or environmental
Body does not produceBody does not produce enoughenough insulin or the cellsinsulin or the cellsignoreignore the insulinthe insulin
Non-insulin dependent diabetes (NIDDM)-Non-insulin dependent diabetes (NIDDM)- notnotdependent upon insulin for survival,dependent upon insulin for survival, but may havebut may haveinsulin orderedinsulin ordered
Onset age > 30 years; usually obese at diagnosisOnset age > 30 years; usually obese at diagnosis Etiologies usually includes obesity, heredity, orEtiologies usually includes obesity, heredity, or
environmentalenvironmental Blood glucose usually controlled by diet and exerciseBlood glucose usually controlled by diet and exercise Ketosis rareKetosis rare, except in stress or infection, except in stress or infection Acute complication: Acute complication: Hyperglycemic hyperosmolarHyperglycemic hyperosmolar
Criteria for the Diagnosis ofriteria for the Diagnosis of
Diabetes Mellitusiabetes MellitusCriteria for the Diagnosis ofriteria for the Diagnosis of
Diabetes Mellitusiabetes Mellitus
Symptoms of diabetes + casual plasma glucoseSymptoms of diabetes + casual plasma glucose
level > or = 200 mg/dllevel > or = 200 mg/dl
Fasting plasma glucose > or = 126 mg/dlFasting plasma glucose > or = 126 mg/dl
2-hour postload glucose > or = 200 mg/dl2-hour postload glucose > or = 200 mg/dlduring an oral glucose tolerance testduring an oral glucose tolerance test
– Improve overall health through optimal nutritionImprove overall health through optimal nutrition
Individualize the nutritional interventionIndividualize the nutritional intervention
Be realistic & flexible in developing a nutritional planBe realistic & flexible in developing a nutritional plan Be consistent in timing of meals & Be consistent in timing of meals & proportions of proportions of
Typical diet consists of : CHO, Fat, Protein, & Typical diet consists of : CHO, Fat, Protein, &
Dietary FibersDietary Fibers
Exchange Lists for Meal PlanningExchange Lists for Meal Planning – Each 6 lists contains foods similar amounts of protein, fat, CHO, & Each 6 lists contains foods similar amounts of protein, fat, CHO, &
caloriescalories
starch/bread, meat, vegetable, fruit, milk, & fatstarch/bread, meat, vegetable, fruit, milk, & fat – A food on the list can be traded or exchanged for any other food A food on the list can be traded or exchanged for any other food
on that liston that list
– However, foods from one list or exchange cannot be substituted forHowever, foods from one list or exchange cannot be substituted for
foods from another list or exchangefoods from another list or exchange
Use appropriate footwearUse appropriate footwear Monitor feet closely before & after exercise for injuryMonitor feet closely before & after exercise for injury
Ensure proper hydration before & during exerciseEnsure proper hydration before & during exercise
Avoid exercising in extremely hot or cold conditions Avoid exercising in extremely hot or cold conditions
Instructions to minimize risk: Instructions to minimize risk: avoid injecting Insulin into body areas involved inavoid injecting Insulin into body areas involved in
exerciseexercise monitor BS before & after activitymonitor BS before & after activity
consistent in timing of Insulin injections & activityconsistent in timing of Insulin injections & activity
take pre-exercise snack if BS <100 to 120 mg/dl & if take pre-exercise snack if BS <100 to 120 mg/dl & if
> 90 minutes passed since last meal> 90 minutes passed since last meal
carry fast-acting CHO while exercisingcarry fast-acting CHO while exercising
Onset- 30 minutes to 1 hourOnset- 30 minutes to 1 hour Peak- 2 to 3 hoursPeak- 2 to 3 hours Duration- 4 to 6 hoursDuration- 4 to 6 hours Action - covers meals eaten within 30-60 minutes Action - covers meals eaten within 30-60 minutes Clear in appearanceClear in appearance Usually administered 20 to 30 minutes before a meal,Usually administered 20 to 30 minutes before a meal,
either alone or in combination with a longer-acting Insulineither alone or in combination with a longer-acting Insulin
Intermediate-Acting Insulinntermediate-Acting Insulin NPH Insulin (neutral protamine Hagedorn) or Lente InsulinNPH Insulin (neutral protamine Hagedorn) or Lente Insulin
Onset- 3 to 4 hoursOnset- 3 to 4 hours
Peak- 4 to 12 hoursPeak- 4 to 12 hours Duration- 16 to 20 hoursDuration- 16 to 20 hours Action - covers Insulin needs for about 1/2 the day or overnight Action - covers Insulin needs for about 1/2 the day or overnight White and cloudy in appearanceWhite and cloudy in appearance If NPH or Lente Insulin is taken alone-If NPH or Lente Insulin is taken alone- notnot critical that it becritical that it be
taken a half-hour before the mealtaken a half-hour before the meal Important for the patient to have eaten some food around theImportant for the patient to have eaten some food around the
time of onset and peak of these Insulinstime of onset and peak of these Insulins
Long-acting Insulins and Fixed Combinationsong-acting Insulins and Fixed Combinations
1.1. Ultralente InsulinUltralente Insulin Onset- 6 to 8 hoursOnset- 6 to 8 hours
Peak- 12 to 16 hoursPeak- 12 to 16 hours Duration- 20 to 30 hoursDuration- 20 to 30 hours Action- provides a low level of Insulin support for 24 hours Action- provides a low level of Insulin support for 24 hours
2.2. Fixed combinationsFixed combinations Human 50/50 (50% NPH Insulin and 50% Regular Insulin)Human 50/50 (50% NPH Insulin and 50% Regular Insulin) Humulin 70/30 (70% NPH Insulin and 30% Regular Insulin)Humulin 70/30 (70% NPH Insulin and 30% Regular Insulin) Novolin 70/30Novolin 70/30
Onset- 10 to 15 minutesOnset- 10 to 15 minutes Peak- 1 to 2 hours after injectionPeak- 1 to 2 hours after injection Duration- 3 hoursDuration- 3 hours Action - covers meals eaten at same time Action - covers meals eaten at same time
Patient should be instructed not to wait the usual 30 minutesPatient should be instructed not to wait the usual 30 minutesafter injection to eatafter injection to eat Due to short duration of action of Humalog & Novolog -Due to short duration of action of Humalog & Novolog -
patients with Type I diabetes also require a long-acting Insulinpatients with Type I diabetes also require a long-acting Insulinto maintain glucose controlto maintain glucose control
The Newest InsulinThe Newest Insulin ---Lantus---Lantus
Human Insulin analogHuman Insulin analog Basal InsulinBasal Insulin No pronounced peak No pronounced peak Duration of action- up toDuration of action- up to 2424 hourshours
Clear solutionClear solution NeverNever mix with any Insulin (separate syringe)mix with any Insulin (separate syringe) Administered SQ once a day at bedtime Administered SQ once a day at bedtime Can be used as part of regimen of combinationCan be used as part of regimen of combination
Client receiving Regular Insulin at 0730?Client receiving Regular Insulin at 0730? – The nurse should observe the client most closely for symptomsThe nurse should observe the client most closely for symptoms
associated with an insulin reaction at : (time frame???)associated with an insulin reaction at : (time frame???)
Client receiving NPH Insulin at 0730?Client receiving NPH Insulin at 0730? – The nurse should observe for symptoms of insulin reaction at :The nurse should observe for symptoms of insulin reaction at :
Teaching Self Administration of Insulineaching Self Administration of Insulineaching Self Administration of Insulineaching Self Administration of Insulin
Administered into SQ tissue with special insulin syringe Administered into SQ tissue with special insulin syringe Syringes matched with Insulin concentration (i.e. U-100)Syringes matched with Insulin concentration (i.e. U-100) Most insulin syringes- 27 to 29 gauge needle- approximately 0.5Most insulin syringes- 27 to 29 gauge needle- approximately 0.5
inch longinch long Short-acting clear in appearanceShort-acting clear in appearance Long-acting cloudy and white- must be mixed gently inverted orLong-acting cloudy and white- must be mixed gently inverted or
rolled in the hands before userolled in the hands before use Draw upDraw up Regular Insulin firstRegular Insulin first if mixing insulinif mixing insulin Debate regarding storage of insulin bottle either in theDebate regarding storage of insulin bottle either in the
refrigerator or kept at room temperaturerefrigerator or kept at room temperature
Complications of Insulin Therapyomplications of Insulin Therapyomplications of Insulin Therapyomplications of Insulin Therapy
Local Allergic ReactionsLocal Allergic Reactions – redness, swelling, tenderness, & induration at injection site 1 to 2redness, swelling, tenderness, & induration at injection site 1 to 2
hours after injection administeredhours after injection administered
– usually occurs in beginning stage & disappears with continued use of usually occurs in beginning stage & disappears with continued use of InsulinInsulin
Systematic Allergic ReactionsSystematic Allergic Reactions – rare; local skin reaction gradually spreads entire bodyrare; local skin reaction gradually spreads entire body
LipodystrophyLipodystrophy – localized reaction due tolocalized reaction due to repeated use of same injection siterepeated use of same injection site
– loss of SQ fat (appears as slight dimpling)loss of SQ fat (appears as slight dimpling) – important to rotate injection site & use of Human Insulin- almostimportant to rotate injection site & use of Human Insulin- almost
eliminates this complicationeliminates this complication
– treatment- administer purer insulin & occasionally Prednisonetreatment- administer purer insulin & occasionally Prednisone
– need to monitor for hypoglycemianeed to monitor for hypoglycemia
Dawn PhenomenonDawn Phenomenon – relatively normal BS level until 0300; result from nighttime release of relatively normal BS level until 0300; result from nighttime release of
growth hormone that causes increase BS at 0500 to 0700growth hormone that causes increase BS at 0500 to 0700
– not preceded by an episode of hypoglycemianot preceded by an episode of hypoglycemia
– diagnosis: measurement of BS levels at 0300- level normal & FBS atdiagnosis: measurement of BS levels at 0300- level normal & FBS at0700 is high0700 is high
– treated by changing evening dose of insulin- giving intermediate-treated by changing evening dose of insulin- giving intermediate-acting insulin at 2200 instead of beforeacting insulin at 2200 instead of before dinner at 1800dinner at 1800
Complications of Insulin TherapyComplications of Insulin Therapy
Somogyi EffectSomogyi Effect – periods of nocturnal hypoglycemia followed by reboundperiods of nocturnal hypoglycemia followed by rebound
hyperglycemia (BS levels increase despite increasing doses of hyperglycemia (BS levels increase despite increasing doses of insulin)insulin)
– causes: excessive insulin therapy & release of stress hormonescauses: excessive insulin therapy & release of stress hormones – patient awakes with H/A, c/o restless sleep, nightmares, orpatient awakes with H/A, c/o restless sleep, nightmares, or
unexplained N & Vunexplained N & V
– insulin peaks at 0200 to 0300- blood glucose levels may beinsulin peaks at 0200 to 0300- blood glucose levels may belower- decrease in metabolismlower- decrease in metabolism
– diagnosis: BS levels at 0200, 0400, & 0700- if 1st measurementdiagnosis: BS levels at 0200, 0400, & 0700- if 1st measurement
between 50 to 60 mg/dl & 0700 measurement > 180 to 200between 50 to 60 mg/dl & 0700 measurement > 180 to 200mg/dlmg/dl
– treated by decreasing insulin dosages - nocturnal hypoglycemiatreated by decreasing insulin dosages - nocturnal hypoglycemiadoes not occur & bedtime snack of does not occur & bedtime snack of proteinprotein
Complications of Insulin TherapyComplications of Insulin Therapy
Alternative Methods of Insulin Deliverylternative Methods of Insulin Deliverylternative Methods of Insulin Deliverylternative Methods of Insulin Delivery
Insulin PensInsulin Pens
Jet InjectorsJet Injectors
Insulin PumpsInsulin Pumps Implantable and Inhalant Insulin DeliveryImplantable and Inhalant Insulin Delivery
1.1. SulfonylureasSulfonylureas Drugs:Drugs: Diabinese, Micronase, Glucatrol, Orinase, AmarylDiabinese, Micronase, Glucatrol, Orinase, Amaryl Action: Action: Stimulates beta cells of pancreas to secrete moreStimulates beta cells of pancreas to secrete more of of
its own insulinits own insulin Functioning pancreas necessary & Functioning pancreas necessary & cannot be used in Type Icannot be used in Type I
DMDM Peak- 3 to 4 hrs; duration- 6 to 12 hrs (varies with type)Peak- 3 to 4 hrs; duration- 6 to 12 hrs (varies with type) Hypoglycemia occurs: excessive doses, meals omitted orHypoglycemia occurs: excessive doses, meals omitted or
delayed, food intake decreased, or activity is increaseddelayed, food intake decreased, or activity is increased Some meds may increase or decrease BS levelsSome meds may increase or decrease BS levels Common side effects: GI symptoms & dermatologicalCommon side effects: GI symptoms & dermatological
reactionsreactions
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
cell production of sugarcell production of sugar – no effect on pancreatic beta cellsno effect on pancreatic beta cells
– Peak- unknown; duration- 6 to 12 hoursPeak- unknown; duration- 6 to 12 hours
– Interacts with anticoagulants, Corticosteroids, diuretics, & oralInteracts with anticoagulants, Corticosteroids, diuretics, & oral
contraceptivescontraceptives
– contraindicated in patients with renal impairments & who drink contraindicated in patients with renal impairments & who drink alcohol heavilyalcohol heavily
– should be discontinued for 2 days before any diagnostic testingshould be discontinued for 2 days before any diagnostic testing
requiring use of contrast agent- potential risk for Lactosis Acidosisrequiring use of contrast agent- potential risk for Lactosis Acidosis
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
– Action: reduces digestion of starch into sugar in the intestines; Action: reduces digestion of starch into sugar in the intestines;
less sugar is absorbed into the blood after mealsless sugar is absorbed into the blood after meals – Peak- 1hr; duration- unknownPeak- 1hr; duration- unknown
– Does not enhance insulin secretionDoes not enhance insulin secretion
– Can be used with dietary treatment or conjunction with other oralCan be used with dietary treatment or conjunction with other oralantidiabetic meds (when used in conjunction- hypoglycemia mayantidiabetic meds (when used in conjunction- hypoglycemia mayoccur)occur)
– Work on food absorption- must be taken immediately before aWork on food absorption- must be taken immediately before amealmeal
– Action: stimulates beta cells of the pancreas to secrete more of its Action: stimulates beta cells of the pancreas to secrete more of its
own insulinown insulin – Contraindicated in patients with Type I DMContraindicated in patients with Type I DM
– Fasting action & short durationFasting action & short duration
– Help manage BS changes after specific mealsHelp manage BS changes after specific meals
– Indicated for useIndicated for use in conjunction with Glucophagein conjunction with Glucophage (patients who(patients who
hypoglycemia cannot be controlled by diet, exercise, & eitherhypoglycemia cannot be controlled by diet, exercise, & eitherGlucophage or Prandin alone)Glucophage or Prandin alone)
– Principle side effect: hypoglycemiaPrinciple side effect: hypoglycemia
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
IV. Pharmacological Therapy-Oral Antidiabetic Agents: Classifications
– Knowledge deficit- medication and dietary regimen r/t self-careKnowledge deficit- medication and dietary regimen r/t self-care
skills aeb ????skills aeb ????
– Anxiety r/t fear of diabetic complications aeb ??? Anxiety r/t fear of diabetic complications aeb ??? – Altered nutrition, more than body requirements, r/t failure to follow Altered nutrition, more than body requirements, r/t failure to follow
diet and exercise plan aeb ???diet and exercise plan aeb ???
– Fluid volume deficit r/t loss of fluids aeb diarrhea, vomiting, andFluid volume deficit r/t loss of fluids aeb diarrhea, vomiting, and
osmotic diuresis from hyperglycemiaosmotic diuresis from hyperglycemia
– Impaired skin integrity r/t decreased tissue perfusion or infectionImpaired skin integrity r/t decreased tissue perfusion or infectionaeb ???aeb ???
– Potential for injury or trauma r/t inability to feel pain secondary toPotential for injury or trauma r/t inability to feel pain secondary toperipheral nerve degenerationperipheral nerve degeneration
Nursing Care for Patients with Diabetes Mellitus
ADPIE - Nursing DiagnosesNursing Care for Patients with Diabetes Mellitus
Client OutcomesClient Outcomes (before addition of time and measurement(before addition of time and measurementconditions)conditions)
Client will show increasing knowledge base toClient will show increasing knowledge base to
demonstrate self-caredemonstrate self-care by describing ___ by date.by describing ___ by date. Client will verbalize an understanding of common DMClient will verbalize an understanding of common DM
complications and their management bycomplications and their management by listing ____ bylisting ____ bydatedate
Client will follow prescribed diet planClient will follow prescribed diet plan Client will maintain adequate intake of fluids andClient will maintain adequate intake of fluids and
electrolyteselectrolytes Client will maintain skin integrity and avoid injuriesClient will maintain skin integrity and avoid injuries
Nursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus ADPDPIE –– V. InterventionsV. Interventions
Nursing Care for Patients with Diabetes Mellitusursing Care for Patients with Diabetes Mellitus ADPDPIE –– V. InterventionsV. Interventions
1.1. Encourage to follow practices that promote health & preventEncourage to follow practices that promote health & prevent
injury adhering to prescribed diet, getting sufficient exercise,injury adhering to prescribed diet, getting sufficient exercise,
taking care of feet, inspecting skin daily, checking temperaturetaking care of feet, inspecting skin daily, checking temperature
of bath water before use, and applying heating devices carefullyof bath water before use, and applying heating devices carefully
2.2. Teach to use an appropriate method of self-monitoring of bloodTeach to use an appropriate method of self-monitoring of blood
glucoseglucose
3.3. Teach about types of insulin prescribed for DM self-injectableTeach about types of insulin prescribed for DM self-injectable
InsulinInsulin
4.4. Teach how to treat complications of diabetes causes, symptoms,Teach how to treat complications of diabetes causes, symptoms,& prevention of hypoglycemia, hyperglycemia, diabetic& prevention of hypoglycemia, hyperglycemia, diabetic
Acute Complications of Diabetes:cute Complications of Diabetes:Hypoglycemiaypoglycemia
Acute Complications of Diabetes:cute Complications of Diabetes:Hypoglycemiaypoglycemia
– BS level falls < 60 to 70 mg/dlBS level falls < 60 to 70 mg/dl – may occur with either types of diabetesmay occur with either types of diabetes – most common causes:most common causes:
too much insulin or oral antidiabetic agenttoo much insulin or oral antidiabetic agent too little food intake (delayed or missed meal)too little food intake (delayed or missed meal)
too much exercise at wrong time of daytoo much exercise at wrong time of day ingestion of alcohol, esp. when not eatingingestion of alcohol, esp. when not eating – onset is rapid - 1 to 3 hrs & if prolonged, coma may resultonset is rapid - 1 to 3 hrs & if prolonged, coma may result – Symptoms: cold & clammy, pallor, perspiration, shaking or tremors, hunger, headache,Symptoms: cold & clammy, pallor, perspiration, shaking or tremors, hunger, headache,
10 to 15 grams of a fast-acting CHO orally10 to 15 grams of a fast-acting CHO orally
– 3 to 4 commercially prepared glucose tablets, 4 to 6 oz of fruit juice or regular3 to 4 commercially prepared glucose tablets, 4 to 6 oz of fruit juice or regularsoda, 6 to 10 Life Savers or either hard candies, or 2 to 3 tsp.. of sugar orsoda, 6 to 10 Life Savers or either hard candies, or 2 to 3 tsp.. of sugar orhoneyhoney
Recheck BS 15 minutes later- retreat if BS <70 to 75 mg/dlRecheck BS 15 minutes later- retreat if BS <70 to 75 mg/dl Symptoms resolved- snack containing protein & starch unless eat a regular mealSymptoms resolved- snack containing protein & starch unless eat a regular meal Unconscious & cannot swallow- injection of Glucagon 1mg administered either SQ orUnconscious & cannot swallow- injection of Glucagon 1mg administered either SQ or
IM;IM;
Hospital setting- treated with 25 to 50 ml of 50% Dextrose in water (D50)-Hospital setting- treated with 25 to 50 ml of 50% Dextrose in water (D50)-administered IV- immediate effectsadministered IV- immediate effects
– Very high BS level- due to inadequate insulin effect Very high BS level- due to inadequate insulin effect
– Predisposing factors:Predisposing factors:
newly diagnosed DM,newly diagnosed DM,
insufficient education about DM & insufficient education about DM & conditions that increase counterregulatory hormonesconditions that increase counterregulatory hormones
status changesstatus changes InterventionsInterventions
– HyperglycemiaHyperglycemia
Monitor BS levels, VS, airway patency & LOC along withMonitor BS levels, VS, airway patency & LOC along with
UO & mental status every hourUO & mental status every hour
– HydrationHydration IV fluid- 0.9% NS at high rate, usually 0.5 to 1 liter perIV fluid- 0.9% NS at high rate, usually 0.5 to 1 liter per
hour for 2 to 3 hourshour for 2 to 3 hours (IV rate ???)(IV rate ???) Monitor VS, lung assessment, I & O, andMonitor VS, lung assessment, I & O, and signs for fluidsigns for fluid
overload!overload!
When BS reaches 300 or <- IV fluid may be changed to D5WWhen BS reaches 300 or <- IV fluid may be changed to D5W
Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA) Cont’d.
Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA) Cont’d.
Electrolyte LossElectrolyte Loss – Monitor K+Monitor K+ level b/c insulin pushes K into cells; caution but timelylevel b/c insulin pushes K into cells; caution but timely
K+ replacement to avoid dysrhythmiasK+ replacement to avoid dysrhythmias
– Frequent EKG readings and lab measurements of K+ esp. during 1stFrequent EKG readings and lab measurements of K+ esp. during 1st8 hours of treatment8 hours of treatment
Acidosis Acidosis – Insulin infused IVInsulin infused IV at a slow, continuous rateat a slow, continuous rate
– Hourly BS monitoringHourly BS monitoring
– Dextrose added to IV fluidsDextrose added to IV fluids (NS)- BS level reach 250 to 300 mg/dl(NS)- BS level reach 250 to 300 mg/dl – IV Insulin continued 12 to 24 hrs- until serum bicarbonate levelIV Insulin continued 12 to 24 hrs- until serum bicarbonate level
improves & client can eatimproves & client can eat
Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA) Cont’d.
Acute Complications of Diabetes:Diabetic Ketoacidosis (DKA) Cont’d.
cobwebs in visual field or sudden visual changes-cobwebs in visual field or sudden visual changes-spotty or hazy vision or complete loss of visionspotty or hazy vision or complete loss of vision
DiagnosisDiagnosis
– direct visualization with ophthalmoscope ordirect visualization with ophthalmoscope orfluorescent anigographyfluorescent anigography ManagementManagement
– maintenance of BS levelmaintenance of BS level – advanced cases- Argon Laser Photocoagulationadvanced cases- Argon Laser Photocoagulation
3.3. Diabetic NeuropathiesDiabetic Neuropathies – affects all types of nerves including peripheral, autonomic, & affects all types of nerves including peripheral, autonomic, &
spinal nervesspinal nerves – Two common types:Two common types:
sensations (esp. at night); progression- the feetsensations (esp. at night); progression- the feet
become numb; decrease awareness of posture & become numb; decrease awareness of posture & movement of body & decrease sensation lead tomovement of body & decrease sensation lead tounsteady gaitunsteady gait
– ManagementManagement intensive insulin therapy & control of BS; painintensive insulin therapy & control of BS; pain
management with analgesics, antidepressants or TENSmanagement with analgesics, antidepressants or TENS
4.4. Diabetic NephropathyDiabetic Nephropathy – Renal disease 2nd to diabetic microvascular changes in the kidney;Renal disease 2nd to diabetic microvascular changes in the kidney;
3rd most common listed diagnosis of pts treated for ESRD3rd most common listed diagnosis of pts treated for ESRD