A diabetic foot ulcer stands as a significant and prevalent complication among individuals grappling with uncontrolled diabetes mellitus. These ulcers can emerge in anyone with diabetes, frequently stemming from a combination of factors including suboptimal glycemic control, peripheral vascular disease, underlying neuropathy, and inadequate foot care practices.
Pathophysiology
The genesis of a diabetic foot ulcer often begins with a seemingly innocuous callus, a direct consequence of neuropathy. This nerve damage leads to a diminished sense of pain and pressure in the feet. The resulting loss of protective sensation means that repetitive stress and minor injuries may go unnoticed, leading to ongoing trauma, subtle skin breakdown, and ultimately, ulcer development. Compounding this issue, many patients with diabetes mellitus suffer from compromised circulation due to atherosclerosis and vascular damage. This impaired blood flow significantly hinders the body’s natural wound healing processes and can tragically progress to tissue necrosis and gangrene, severely complicating the management of these ulcers.
It’s estimated that a staggering 60% of individuals with diabetes will develop neuropathy, dramatically elevating their risk of foot ulcers. These ulcers most commonly manifest on the plantar surface of the foot, particularly in high-pressure areas like the heel and the tips of hammer toes. Therefore, diligent foot examinations by podiatrists and healthcare providers are paramount for diabetic patients. These examinations should meticulously evaluate for the presence of calluses and areas of diminished sensation, enabling early detection and intervention.
Several diagnostic tests play a crucial role in both diagnosing and managing diabetic foot ulcers. These include fasting blood sugar tests, complete metabolic panels, erythrocyte sedimentation rate (ESR), glycated hemoglobin (HbA1c) levels, and C-reactive protein (CRP) assessments. Additionally, imaging techniques such as X-rays and bone scans may be employed to rule out underlying fractures or osteomyelitis. An arterial Doppler ultrasound with ankle-brachial index (ABI) is often performed to assess for peripheral vascular disease, a key contributing factor to poor wound healing in diabetic foot ulcers.
Nursing Process
Effective management of diabetic foot ulcers necessitates a collaborative, interdisciplinary approach. This team typically includes podiatrists, endocrinologists, primary care providers, certified diabetes educators, nurses, and wound care specialists. Among these, nursing care plays a pivotal role in patient management and education. Patient education is not merely beneficial but absolutely essential for the prevention of diabetic foot ulcers and for mitigating delays in seeking care. Such delays can significantly exacerbate the condition and contribute to severe complications such as osteomyelitis and the potential for lower extremity amputations.
Nursing Care Plans
Once a nurse has accurately identified the pertinent nursing diagnoses for a patient with a diabetic foot ulcer, the development and implementation of structured nursing care plans become crucial. These care plans serve as dynamic roadmaps, guiding the prioritization of assessments and nursing interventions. They are designed to address both short-term and long-term goals of care, ensuring comprehensive and patient-centered management. The subsequent sections will delve into specific nursing care plan examples tailored for diabetic foot ulcers, focusing on common and critical nursing diagnoses.
Impaired Physical Mobility
Patients with diabetic foot ulcers frequently experience limitations in their physical mobility. This impairment can arise directly from the presence of the wound itself or as a consequence of amputation, should it become necessary.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Discomfort associated with the foot ulcer
- Pain, which may be significant and debilitating
- The need for pressure offloading to promote healing
- Peripheral neuropathy, contributing to balance and coordination issues
- The presence of an open wound, limiting weight-bearing
- Reluctance to move due to fear of injury or pain exacerbation
- Amputation of a lower extremity
As evidenced by:
- Observable limitations in range of motion in the affected extremity
- Verbal expressions of discomfort or pain upon movement
- The use of prosthetic devices post-amputation
- Reliance on assistive devices such as crutches or wheelchairs
- Documented inability to bear weight on the affected foot
Expected Outcomes:
- The patient will demonstrate consistent engagement in interventions designed to promote and progressively increase mobility.
- The patient will effectively and safely utilize assistive devices as needed and perform activities of daily living as independently as possible within their physical limitations.
Assessment:
1. Thoroughly assess the patient’s current extent of immobility.
Rationale: A clear understanding of the patient’s functional mobility status and level of dependence is fundamental. This assessment provides the necessary baseline for planning targeted nursing interventions and for appropriately allocating resources to meet the patient’s specific needs.
2. Critically assess the underlying cause(s) of the impaired mobility.
Rationale: The etiology of impaired mobility can be multifaceted, encompassing physical, psychological, and motivational factors. For instance, some patients with diabetic foot ulcers may exhibit reluctance to move not solely due to physical limitations, but also due to pain, an overwhelming fear of falling or exacerbating their condition, or even underlying psychological conditions such as depression which can significantly impact motivation and physical activity levels. A comprehensive assessment should address these potential contributing factors.
Interventions:
1. Actively encourage the patient to engage in range of motion (ROM) exercises.
Rationale: Regular ROM exercises are crucial for maintaining joint flexibility and preventing muscle stiffness, which can further impede mobility. Furthermore, these exercises play a vital role in improving local blood circulation to the affected area, thereby supporting the healing process of the diabetic foot ulcer.
2. Proactively assist the patient in the appropriate and safe utilization of assistive devices.
Rationale: Pressure offloading is a cornerstone in the effective management and promotion of healing in diabetic foot ulcers. Assistive devices, such as wheelchairs, crutches, walkers, and trapeze bars, can be invaluable in facilitating pressure redistribution and enabling safe repositioning. Additionally, the strategic use of pillows and wedges for extremity elevation can further aid in reducing pressure and edema, thereby supporting optimal healing conditions.
3. Actively encourage the patient and their family members to participate collaboratively in the patient’s care.
Rationale: Patient motivation and the active involvement of family members can be powerful catalysts in encouraging movement and adherence to repositioning schedules. Family support can provide not only physical assistance but also crucial emotional encouragement, fostering a positive environment conducive to rehabilitation and improved mobility.
4. Facilitate a timely consultation with a prosthetist if amputation is anticipated or has occurred.
Rationale: In situations where amputation becomes necessary, either as a planned procedure or an unforeseen outcome, prompt consultation with a prosthetist is essential. A prosthetist is a specialized healthcare professional uniquely trained to work with individuals with limb loss. They are experts in fitting patients with appropriate prosthetic devices and providing comprehensive instruction on the proper wear, use, and maintenance of the prosthesis to maximize mobility and functional independence post-amputation.
Impaired Skin Integrity
A diabetic foot ulcer, by definition, is an overt breach in skin integrity. It typically presents as an open sore, often described as resembling a round crater, frequently bordered by thick, hardened calluses. The depth of these ulcers can vary significantly, in some cases extending deep enough to expose underlying tendons, muscles, or even bone, underscoring the severity of this condition.
Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
- Suboptimal glycemic control, a primary contributor to impaired wound healing
- Complications arising directly from diabetes mellitus itself
- Peripheral neuropathy, leading to reduced sensation and increased risk of injury
- The ongoing inflammatory process within the ulcerated tissue
- Poor circulation, hindering nutrient and oxygen delivery to the wound site
- Inadequate primary defenses of the skin, increasing vulnerability to breakdown
- Deficient knowledge regarding protective skin integrity measures and preventative foot care practices
As evidenced by:
- Observable abscess formation within or around the ulcer
- Reports of pain or tenderness at the ulcer site
- Active bleeding or signs of hemorrhage from the wound
- The presence of an open wound, visually confirmed
- Disruption of the epidermal and dermal layers of the skin
- Noticeable dryness of the skin surrounding the ulcer
- Altered skin turgor, indicating potential dehydration or compromised skin elasticity
Expected Outcomes:
- The patient will proactively demonstrate consistent engagement in skin care interventions, specifically tailored to promote the healing of diabetic foot ulcers.
- The patient will achieve timely and progressive wound healing, progressing towards complete closure without experiencing preventable complications.
Assessment:
1. Conduct a comprehensive and detailed assessment of the patient’s wound.
Rationale: A thorough wound assessment is paramount for effective care planning. Key characteristics to evaluate include the wound’s color (indicating tissue viability and perfusion), odor (potentially signaling infection), visibility of underlying structures like bones or tendons (severity assessment), and the presence of necrotic tissue (impeding healing). Furthermore, the color of the skin and surrounding tissues provides crucial insights into tissue vitality and the adequacy of oxygenation.
2. Accurately assess the extent and depth of skin impairment.
Rationale: Pressure ulcers, a common type of diabetic foot ulcer, are clinically classified based on the depth of tissue involvement. Classification systems categorize ulcers as partial thickness, or stages 1 through 4, or as unstageable when the base of the ulcer is obscured. Additionally, meticulous inspection of the skin surrounding the ulcer is necessary to identify signs of maceration (skin softening due to excessive moisture) and erythema (redness), both of which can indicate complications or impede healing.
3. Measure and document the ulcer’s size on a weekly basis, diligently comparing these measurements with established baseline data.
Rationale: Regularly measuring the length, depth, and width of the ulcer and comparing these parameters to baseline measurements is crucial for objectively tracking the ulcer’s progression. This serial assessment allows healthcare providers to determine the effectiveness of the current treatment regimen and to make timely adjustments as needed to optimize wound healing outcomes.
Interventions:
1. Consistently remind and educate the patient about the critical importance of daily foot inspections.
Rationale: Patients with peripheral neuropathy or peripheral vascular disease may have diminished or absent sensation in their feet. Consequently, they may be unaware of minor cuts, abrasions, or areas of skin breakdown. Daily self-inspection of the feet and lower legs for any new open areas is therefore essential for early detection and intervention. Patients can be instructed to use a mirror to visualize the soles of their feet or to enlist the assistance of a family member for thorough assessment if self-inspection is challenging.
2. Strongly advise the patient to consistently avoid walking barefoot, both indoors and outdoors.
Rationale: Walking barefoot significantly increases the risk of foot trauma and injury, particularly for individuals with diabetes and neuropathy. Patients should be educated to wear protective footwear at all times, even when indoors. Wearing slippers indoors provides a crucial layer of protection against minor injuries that could initiate or exacerbate foot ulcers.
3. Provide or assist with debridement of the diabetic foot ulcer as clinically indicated.
Rationale: The presence of necrotic tissue (dead tissue) or nonviable tissue within a wound bed significantly impedes the healing process. Debridement, the removal of this nonviable tissue, is often a necessary step to create a clean wound bed that is conducive to granulation tissue formation and subsequent healing.
4. Perform meticulous wound care according to the physician’s specific orders.
Rationale: Wound care protocols for diabetic foot ulcers are highly individualized and must be implemented strictly according to physician’s orders. The specific type and thickness of the wound will dictate the most appropriate wound dressings and topical agents. Common wound care modalities may include hydrocolloid dressings, absorptive dressings, alginate dressings, hydrogels, silver nitrate treatments, and negative pressure wound therapy (wound vacs), each chosen based on the unique characteristics of the ulcer.
5. Actively encourage and educate the patient on comprehensive skin care practices.
Rationale: Maintaining optimal skin health is paramount in preventing further skin breakdown and promoting overall foot health. Patients should be instructed on the importance of keeping their skin adequately moisturized to prevent dryness and cracking, maintaining meticulous hygiene to prevent infection, and ensuring the skin remains clean and dry, particularly between the toes, to minimize the risk of fungal infections and maceration.
Ineffective Tissue Perfusion
Chronically elevated blood glucose levels, a hallmark of diabetes mellitus, inflict damage on the endothelial lining of blood vessels. This endothelial damage, in turn, leads to impaired oxygenation and reduced perfusion of tissues in the feet at the critical capillary level. This compromised blood supply significantly hinders the delivery of oxygen and essential nutrients necessary for tissue health and wound healing in the lower extremities.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related Factors:
- Persistently elevated blood glucose levels (hyperglycemia)
- Impaired oxygen transport due to vascular damage
- Interruption in arterial or venous blood flow to the lower extremities
- Nerve damage (neuropathy) affecting vascular regulation
- Insufficient knowledge regarding diabetes mellitus, its complications, and effective self-management strategies
As evidenced by:
- Observable foot ulceration, a direct consequence of tissue ischemia
- Weak or even absent peripheral pulses in the lower extremities upon palpation
- Cool and clammy skin temperature in the feet and lower legs
- Prolonged capillary refill time in the toes (greater than 3 seconds)
- Reports of numbness, burning sensations, or tingling (paresthesia) in the feet
- Delayed wound healing, indicative of poor tissue oxygenation
- Altered sensation in the lower extremities, often due to neuropathy
Expected Outcomes:
- The patient will consistently maintain optimal peripheral tissue perfusion, as objectively evidenced by the following clinical indicators:
- Presence of strong, easily palpable peripheral pulses (dorsalis pedis and posterior tibial)
- Warm and dry extremities to the touch
- Capillary refill time within the normal range (less than 3 seconds)
- Observable and documented progression of wound healing
- The patient will remain free from preventable complications directly related to ineffective tissue perfusion, such as infection, gangrene, or the need for amputation.
Assessment:
1. Meticulously monitor peripheral pulses, assessing both their presence and symmetry bilaterally.
Rationale: Diminished or absent peripheral pulses, particularly in the dorsalis pedis and posterior tibial arteries, are highly suggestive of arterial insufficiency, often stemming from ischemia (inadequate blood supply). This finding is a critical indicator requiring prompt and thorough investigation to determine the underlying cause and necessitates timely medical and nursing interventions to restore adequate perfusion and prevent further tissue damage.
2. Carefully assess skin color and temperature in the lower extremities.
Rationale: Cool, pale skin is a classic sign of arterial obstruction, indicating compromised blood flow. Conversely, a reddish-blue discoloration (cyanosis) may suggest damaged blood vessels or venous insufficiency. Brownish discoloration of the skin is often associated with chronic venous insufficiency and venous stasis.
3. Assess for patient reports of discomfort or reduced sensations in the lower extremities.
Rationale: Chronically elevated blood glucose levels are neurotoxic and directly damage peripheral nerves, leading to neuropathy. This nerve damage commonly manifests as reduced sensation or numbness in the feet. Patients may also describe abnormal sensations such as tingling, prickling, or burning pain in their feet, all of which are indicative of neuropathic changes impacting tissue perfusion and sensation.
4. Thoroughly assess the patient’s past medical history, paying particular attention to chronic disease history.
Rationale: Diabetes mellitus is unequivocally a major risk factor for the development of peripheral artery disease (PAD), a condition characterized by reduced blood flow to the limbs. Furthermore, other chronic conditions such as hypertension (high blood pressure) and hypercholesterolemia (high cholesterol) are also well-established risk factors for PAD and can exacerbate perfusion deficits in individuals with diabetes. A comprehensive medical history is essential to identify and address these contributing factors.
Interventions:
1. Provide comprehensive patient education regarding the importance of maintaining an optimal hemoglobin A1c (HbA1c) level.
Rationale: Educate the patient on the specific HbA1c target recommended by their healthcare provider, typically less than 7% for many individuals with diabetes. Explain that maintaining near-normal blood glucose levels, reflected in HbA1c, is crucial for minimizing long-term vascular damage and improving tissue perfusion.
2. Consider performing bedside Duplex ultrasonography if peripheral pulses are difficult to palpate or assess reliably.
Rationale: If palpation of peripheral pulses is challenging due to edema, obesity, or other factors, a portable Doppler ultrasound device can be a valuable tool. Doppler ultrasonography allows nurses to non-invasively assess for alterations in blood flow in the arteries and veins of the lower extremities and can aid in detecting venous insufficiency or arterial occlusions that may be compromising tissue perfusion.
3. Assess the patient’s ankle-brachial index (ABI) as appropriate.
Rationale: ABI measurement is a recommended screening test for PAD, particularly in patients with diabetes who are over the age of 50 or those with risk factors for PAD. An ABI result of <0.9 is generally indicative of PAD and warrants further vascular evaluation and management to improve tissue perfusion.
4. Explore the potential benefit of hyperbaric oxygen therapy for recalcitrant wounds.
Rationale: For diabetic foot ulcers that demonstrate inadequate healing despite 30 days of conventional wound care and optimized medical management, hyperbaric oxygen therapy may be considered. Hyperbaric oxygen therapy involves delivering 100% oxygen to the patient under increased atmospheric pressure. This treatment modality can significantly increase the amount of oxygen delivered to the wound tissues, potentially accelerating the rate of wound healing and reducing the risk of complications in chronic, non-healing diabetic foot ulcers.
5. Provide thorough education to the patient regarding lifestyle factors that can promote improved tissue perfusion.
Rationale: Lifestyle modifications play a crucial role in optimizing tissue perfusion, particularly in individuals with diabetes and PAD risk factors. Educate the patient on the following key measures that can decrease venous compression and stasis and reduce arterial vasoconstriction:
- Avoiding crossing legs when sitting for prolonged periods.
- Engaging in regular, physician-approved exercise to improve circulation.
- Maintaining a healthy body weight to reduce strain on the circulatory system.
- Strictly abstaining from smoking, as nicotine is a potent vasoconstrictor that severely impairs blood flow.
Risk for Infection
Patients with diabetic foot ulcers are inherently at a significantly heightened risk of developing infections. Foot ulcers, by their nature, are often sites of delayed healing and are particularly vulnerable to becoming infected. When infection does occur, it can rapidly spread to the surrounding soft tissues and even to the underlying bone (osteomyelitis), potentially leading to severe consequences, including lower-limb amputation.
Nursing Diagnosis: Risk for Infection
Related Factors:
- The presence of an open wound, providing a portal of entry for pathogens
- The underlying disease process of diabetes mellitus, compromising immune function
- Delayed wound healing, prolonging the period of vulnerability to infection
- Inadequate primary defenses against infection due to impaired immune response and compromised skin integrity
As evidenced by:
A risk nursing diagnosis is not evidenced by existing signs and symptoms, as the problem has not yet manifested. Nursing interventions are proactively directed at preventing the occurrence of infection and the development of associated signs and symptoms.
Expected Outcomes:
- The patient will remain free from clinical signs and symptoms of infection throughout the course of care.
- The patient will consistently demonstrate active engagement in interventions specifically designed to promote optimal wound healing and effectively reduce the risk of infection.
Assessment:
1. Obtain a wound swab for culture and sensitivity testing if signs of infection are present or suspected.
Rationale: If clinical indicators of infection are present, such as increased drainage, purulent exudate, or worsening erythema, obtaining a wound swab for culture and sensitivity is crucial. Wound cultures help identify the specific bacterial pathogens colonizing the ulcer (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, etc.). Sensitivity testing determines which antibiotics will be most effective in eradicating the identified bacteria, guiding appropriate antibiotic therapy.
2. Conduct a comprehensive assessment of the patient’s wound, specifically looking for clinical signs of infection.
Rationale: Meticulous wound assessment is essential for detecting early signs of infection. Key wound characteristics suggestive of infection include: green or yellow purulent drainage, a distinctly foul odor emanating from the wound, increasing erythema (redness) and warmth surrounding the wound, increased pain or tenderness, and localized swelling.
3. Review relevant imaging and laboratory results to assess for deeper infection.
Rationale: If there is clinical suspicion of osteomyelitis (bone infection), Magnetic Resonance Imaging (MRI) is often the imaging modality of choice for diagnosis due to its superior sensitivity in detecting bone marrow edema and inflammation. Additionally, an elevated white blood cell count (leukocytosis) in laboratory results is a systemic indicator of infection and can support the diagnosis.
Interventions:
1. Consistently utilize aseptic technique during all wound dressing changes and wound care procedures.
Rationale: Strict adherence to aseptic technique is paramount in minimizing the risk of introducing exogenous pathogens into the diabetic foot ulcer and preventing healthcare-associated infections. Aseptic technique includes meticulous hand hygiene, the use of sterile gloves, sterile instruments, and sterile dressings to maintain a contamination-free environment during wound care.
2. Administer antibiotics as prescribed by the physician.
Rationale: Severely infected diabetic foot ulcers often require systemic antibiotic therapy to effectively eradicate the infection. In some cases, inpatient hospitalization and intravenous (IV) antibiotic administration may be necessary to ensure adequate drug levels and close monitoring of the patient’s response to treatment. Antibiotic selection should be guided by wound culture and sensitivity results whenever possible.
3. Emphasize and ensure tight glycemic control in the patient.
Rationale: Uncontrolled diabetes and persistent hyperglycemia significantly impair the body’s natural wound healing capabilities. Elevated blood glucose levels reduce oxygen delivery to tissues, compromise immune function, and create an environment conducive to bacterial growth. Therefore, meticulous blood glucose management and maintaining tight glycemic control are essential for promoting wound healing and preventing infection. Frequent glucose monitoring and adjustments to the diabetes management plan are often necessary.
4. Provide timely referral to a wound care specialist or specialized wound care center as clinically indicated.
Rationale: Diabetic foot ulcers that are complicated, infected, non-healing, or demonstrate slow progress often necessitate specialized wound care management. Referral to a wound care specialist or a dedicated wound care center ensures that the patient receives ongoing assessment, advanced wound care modalities, and comprehensive management from an interdisciplinary wound care team experienced in treating complex wounds.
Risk For Unstable Blood Glucose Level
Patients experiencing hyperglycemia (elevated blood glucose) or exhibiting labile (fluctuating) glucose levels are at an increased risk for developing diabetic foot ulcers and experiencing impaired wound healing should ulcers occur. Maintaining stable blood glucose within the target range is critical for preventing complications and promoting optimal health in individuals with diabetes.
Nursing Diagnosis: Risk For Unstable Blood Glucose Level
Related Factors:
- Insufficient adherence to the prescribed diabetes management plan, including medication, diet, and exercise
- Inadequate or inconsistent blood glucose monitoring practices
- Exposure to excessive physical or emotional stress, which can impact glucose levels
- Significant weight gain or unintended weight loss, affecting insulin sensitivity and glucose metabolism
- Improper dietary choices and inconsistent meal patterns
As evidenced by:
A risk nursing diagnosis is not evidenced by existing signs and symptoms, as the problem is a potential risk and has not yet occurred. The primary goal of nursing interventions is proactive prevention of unstable blood glucose levels.
Expected Outcomes:
- The patient will consistently maintain a preprandial (before meal) blood glucose level within the target range specified by their healthcare provider.
- The patient will demonstrate a hemoglobin A1c (HbA1c) level of less than 7%, or another individualized target set by their physician.
- The patient will effectively verbalize a clear understanding of their individualized glucose monitoring regimen and the correct administration of their prescribed antidiabetic medications.
Assessment:
1. Closely monitor for any signs and symptoms indicative of hypoglycemia (low blood glucose).
Rationale: Hypoglycemia is a potentially dangerous complication of diabetes treatment. Prompt recognition and treatment are essential. Signs and symptoms of hypoglycemia may include: shakiness, dizziness, diaphoresis (sweating), intense hunger, confusion, irritability, and in severe cases, loss of consciousness.
2. Closely monitor for any signs and symptoms indicative of hyperglycemia (high blood glucose).
Rationale: Hyperglycemia, if prolonged or severe, can lead to serious complications, including diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Common signs and symptoms of hyperglycemia include: polyuria (frequent urination), polydipsia (excessive thirst), blurred vision, unexplained fatigue, and headache.
Interventions:
1. Thoroughly review the patient’s glucose logs, whether recorded in a device or in written form.
Rationale: Reviewing glucose logs provides valuable insights into glucose trends and patterns over time. Identification of unstable glucose levels or persistent, uncontrolled hyperglycemia necessitates a re-evaluation and potential modifications to the patient’s current diabetes treatment plan to achieve better glycemic control.
2. Request return verbalization from the patient regarding their diabetes treatment plan.
Rationale: Assess the patient’s true understanding of their diabetes management by asking them to verbally explain key aspects of their treatment plan. This includes: their individualized glucose goals, the correct timing and method for administering insulin or other antidiabetic medications, identification of foods that significantly impact glucose levels, and specific steps to take when experiencing hypoglycemia or hyperglycemia. This “teach-back” method confirms patient comprehension and identifies areas needing further education.
3. Explore the potential benefits of utilizing continuous glucose monitoring (CGM) devices for suitable patients.
Rationale: For patients who experience challenges with traditional fingerstick glucose monitoring or who have highly labile glucose levels, CGM devices can be extremely beneficial. CGM systems continuously track glucose levels in real-time, providing patients and healthcare providers with detailed glucose trend data. This information empowers patients to better understand glucose patterns, identify factors influencing glucose variability, and improve overall diabetes self-management.
4. Engage in open discussion with the patient to identify and address potential barriers to proper glucose control.
Rationale: Effective diabetes management requires addressing individual barriers that may impede optimal glucose control. Educate the patient about common barriers to normoglycemia, such as elevated stress levels, inconsistent exercise patterns, dietary indiscretions, medication adherence issues, and other lifestyle factors. Encourage the patient to reflect on their specific challenges and circumstances so that the nurse and the interdisciplinary healthcare team can collaboratively develop tailored interventions and strategies to overcome these barriers and improve glucose management.
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