Nursing Diagnosis for Diabetic Patients: A Comprehensive Guide for Nurses

Introduction

Diabetes mellitus, particularly type 2 diabetes, is a global health concern with increasing prevalence. Characterized by hyperglycemia, this chronic condition arises from defects in insulin secretion, insulin action, or both. While type 2 diabetes accounts for the vast majority of diabetes cases (around 90%), other forms include type 1 diabetes, gestational diabetes, and less common types like monogenic diabetes and drug-induced diabetes. The far-reaching complications of diabetes can affect nearly every organ system in the body, leading to significant morbidity and mortality if not effectively managed. For nurses, understanding the nuances of diabetes care, especially in identifying appropriate nursing diagnoses, is paramount to delivering optimal patient care. This article aims to provide a comprehensive overview of nursing diagnoses relevant to patients with type 2 diabetes, along with essential information on causes, risk factors, assessment, medical and nursing management, and key considerations for holistic care.

Common Nursing Diagnoses for Diabetic Patients

Nurses play a crucial role in the multidisciplinary care of patients with diabetes. Accurate nursing diagnoses are fundamental to developing individualized care plans that address the specific needs of each patient. Several nursing diagnoses may be relevant for patients with type 2 diabetes, depending on their individual health status and the presence of complications. These diagnoses can range from addressing immediate physiological needs to long-term health management and education. Here are some key nursing diagnoses to consider:

• Risk for Unstable Blood Glucose: This is a primary diagnosis for nearly all diabetic patients, reflecting the inherent challenge in maintaining glycemic control. It is particularly relevant when blood glucose levels fluctuate widely, increasing the risk of both hyperglycemia and hypoglycemia.
• Deficient Knowledge: Diabetes management is heavily reliant on patient self-management. A lack of knowledge about the disease process, treatment regimen, self-monitoring techniques, and lifestyle modifications can significantly hinder effective diabetes control and lead to complications.
• Imbalanced Nutrition: More Than Body Requirements/Less Than Body Requirements: Diet plays a cornerstone role in diabetes management. Patients may struggle with nutritional imbalances due to factors such as overeating, poor food choices, or inadequate understanding of dietary guidelines for diabetes. Conversely, some patients may experience unintentional weight loss or difficulty maintaining adequate nutrition due to the disease or related complications.
• Sedentary Lifestyle: Physical inactivity is a major risk factor for type 2 diabetes and exacerbates insulin resistance. A sedentary lifestyle contributes to poor glycemic control and increases the risk of cardiovascular complications.
• Ineffective Health Management: This diagnosis encompasses a broader scope of challenges patients may face in managing their diabetes, including medication adherence, blood glucose monitoring, lifestyle modifications, and follow-up care.
• Risk for Infection: Hyperglycemia impairs immune function, making diabetic patients more susceptible to infections. This risk is further elevated in the presence of open wounds or impaired circulation.
• Impaired Skin Integrity/Impaired Tissue Integrity: Diabetic patients are at increased risk for skin and tissue breakdown due to factors such as neuropathy, impaired circulation, and hyperglycemia. Minor injuries can quickly escalate into serious infections and non-healing ulcers, particularly in the feet.
• Risk for Peripheral Neurovascular Dysfunction: Diabetes-related neuropathy and peripheral artery disease can compromise nerve and blood vessel function in the extremities, leading to pain, numbness, loss of sensation, and impaired circulation.
• Risk for Injury: Neuropathy, vision changes (such as diabetic retinopathy), and episodes of hypoglycemia or hyperglycemia can increase the risk of falls and other injuries.
• Fluid Volume Deficit/Excess: Extreme hyperglycemia, such as in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), can lead to significant fluid imbalances. Conversely, patients with heart failure or kidney disease, common comorbidities in diabetes, may be at risk for fluid volume excess.
• Risk for Impaired Vision: Diabetic retinopathy is a leading cause of blindness. Poorly controlled diabetes increases the risk of developing and progressing retinopathy.
• Ineffective Coping: Living with a chronic condition like diabetes can be emotionally and mentally challenging. Patients may experience stress, anxiety, or depression related to their diagnosis and the demands of self-management.
• Social Isolation: The lifestyle adjustments required for diabetes management, along with potential complications, can lead to social isolation for some individuals.

It’s crucial to remember that this is not an exhaustive list, and the specific nursing diagnoses will vary based on a comprehensive assessment of the individual patient.

Causes and Pathophysiology of Type 2 Diabetes

Type 2 diabetes is characterized by insulin resistance and progressive decline in insulin secretion from pancreatic beta cells. Unlike type 1 diabetes, which is an autoimmune disease resulting in absolute insulin deficiency, type 2 diabetes involves a more complex interplay of genetic and environmental factors.

Insulin Resistance: In type 2 diabetes, cells in muscles, liver, and fat become resistant to the effects of insulin. This means that even when insulin is present, glucose cannot efficiently enter these cells for energy production, leading to hyperglycemia. The pancreas initially compensates by producing more insulin to overcome this resistance (hyperinsulinemia).

Beta-Cell Dysfunction: Over time, the pancreas may not be able to sustain the increased insulin production required to maintain normal blood glucose levels. Beta-cell dysfunction ensues, leading to a relative insulin deficiency. This decline in insulin secretion further contributes to hyperglycemia.

Risk Factors for Type 2 Diabetes:

Several modifiable and non-modifiable risk factors increase the likelihood of developing type 2 diabetes:

• Age: The risk increases with age, particularly after 45 years.
• Family History: Having a first-degree relative (parent, sibling, or child) with type 2 diabetes significantly increases risk.
• Ethnicity: Certain ethnic groups, including Native Americans, African Americans, Hispanic/Latinos, Asian Americans, and Pacific Islanders, have a higher prevalence of type 2 diabetes.
• Overweight and Obesity: Excess body weight, especially abdominal obesity, is a major risk factor for insulin resistance and type 2 diabetes.
• Sedentary Lifestyle: Lack of physical activity contributes to insulin resistance and weight gain.
• History of Gestational Diabetes: Women who have had gestational diabetes during pregnancy have an increased risk of developing type 2 diabetes later in life.
• Prediabetes: Individuals with prediabetes (impaired glucose tolerance or impaired fasting glucose) are at high risk of progressing to type 2 diabetes.
• Hypertension and Hyperlipidemia: High blood pressure and abnormal lipid levels (high triglycerides, low HDL cholesterol) are often associated with insulin resistance and increase diabetes risk.
• Polycystic Ovary Syndrome (PCOS): PCOS is linked to insulin resistance and an increased risk of type 2 diabetes in women.
• History of Cardiovascular Disease: Individuals with a history of heart disease or stroke are at higher risk for developing diabetes.

Assessment of Diabetic Patients

A comprehensive assessment is crucial for identifying appropriate nursing diagnoses and developing an effective care plan. Assessment should include:

• History:
  • Medical History: Gather information about family history of diabetes, personal history of gestational diabetes, cardiovascular disease, hypertension, hyperlipidemia, PCOS, and any other relevant medical conditions.
  • Medication History: Document all current medications, including over-the-counter drugs and herbal supplements, as some medications (like corticosteroids) can induce hyperglycemia.
  • Lifestyle History: Assess dietary habits, physical activity levels, smoking status, and alcohol consumption.
  • Psychosocial History: Evaluate coping mechanisms, stress levels, social support, and any potential barriers to self-management (e.g., financial constraints, language barriers, limited access to healthy foods).
  • Diabetes History (if previously diagnosed): Duration of diabetes, previous glycemic control, history of complications, current treatment regimen (medications, insulin, diet, exercise), self-monitoring practices, and prior diabetes education.
• Physical Examination:
  • Vital Signs: Measure blood pressure, heart rate, respiratory rate, and temperature.
  • Height and Weight: Calculate Body Mass Index (BMI) to assess weight status.
  • Skin Assessment: Inspect skin for wounds, infections, pressure ulcers, and acanthosis nigricans (darkening of skin folds, a sign of insulin resistance). Pay particular attention to the feet for signs of neuropathy, poor circulation, and foot deformities.
  • Neurological Assessment: Perform sensory testing (e.g., monofilament test) to assess for peripheral neuropathy. Evaluate reflexes and motor function.
  • Eye Examination: Assess visual acuity and note any complaints of blurred vision or other visual disturbances. (A dilated fundoscopic exam by an ophthalmologist is necessary for detecting diabetic retinopathy).
  • Cardiovascular Assessment: Auscultate heart and lung sounds. Assess peripheral pulses and capillary refill.
• Laboratory Data:
  • Fasting Plasma Glucose (FPG): A level of ≥126 mg/dL on two separate occasions is diagnostic of diabetes.
  • Hemoglobin A1c (HbA1c): Reflects average blood glucose levels over the past 2-3 months. An HbA1c of ≥6.5% is diagnostic of diabetes. A level between 5.7% and 6.4% indicates prediabetes.
  • Oral Glucose Tolerance Test (OGTT): A 2-hour plasma glucose level of ≥200 mg/dL during an OGTT is diagnostic of diabetes.
  • Random Plasma Glucose: A random glucose level of ≥200 mg/dL in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) can also diagnose diabetes.
  • Lipid Panel: Assess cholesterol and triglyceride levels.
  • Renal Function Tests: Evaluate kidney function with serum creatinine and urine albumin-to-creatinine ratio.

Medical Management of Type 2 Diabetes

The primary goals of medical management in type 2 diabetes are to achieve and maintain glycemic control, manage cardiovascular risk factors, and prevent or delay the onset and progression of complications. Management strategies are individualized and typically involve a combination of:

• Lifestyle Modifications:
  • Medical Nutrition Therapy (MNT): A cornerstone of diabetes management. MNT involves individualized dietary plans developed by a registered dietitian, focusing on balanced meals, portion control, carbohydrate management, and healthy food choices.
  • Regular Physical Activity: Aim for at least 150 minutes of moderate-intensity aerobic exercise per week, along with muscle-strengthening activities. Exercise improves insulin sensitivity and glycemic control.
  • Weight Management: Weight loss of even 5-10% of body weight can significantly improve glycemic control and reduce cardiovascular risk factors in overweight or obese individuals with type 2 diabetes.
  • Smoking Cessation: Smoking increases cardiovascular risk and worsens diabetes outcomes.
• Pharmacological Therapy: When lifestyle modifications alone are insufficient to achieve glycemic targets, medications are necessary.
  • Metformin: Usually the first-line medication for type 2 diabetes. It improves insulin sensitivity and reduces hepatic glucose production.
  • Other Oral Antidiabetic Agents: Various classes of oral medications are available, including sulfonylureas, thiazolidinediones (TZDs), dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) (injectable but not insulin). The choice of medication depends on individual patient factors, comorbidities, and treatment goals.
  • Insulin Therapy: Insulin may be needed in type 2 diabetes, especially as beta-cell function declines over time or in situations of acute hyperglycemia. Insulin preparations vary in onset, peak, and duration of action (rapid-acting, short-acting, intermediate-acting, long-acting, and premixed).

Nursing Management of Type 2 Diabetes

Nursing management encompasses a wide range of responsibilities, focusing on patient education, monitoring, and interventions to optimize health outcomes. Key aspects of nursing management include:

• Blood Glucose Monitoring:
  • Inpatient Monitoring: Regular blood glucose monitoring is essential in hospitalized patients to detect and manage hypo- and hyperglycemia. Frequency of monitoring depends on the patient’s clinical status, treatment regimen, and hospital protocols.
  • Patient Education on Self-Monitoring of Blood Glucose (SMBG): Teach patients how to accurately perform SMBG, interpret results, and use the information to adjust their medication, diet, or activity as directed by their healthcare provider.
• Medication Management:
  • Administering Medications: Administer oral antidiabetic agents and insulin as prescribed. Ensure correct dosage, route, and timing.
  • Patient Education on Medications: Provide comprehensive education about prescribed medications, including name, purpose, dosage, administration technique (especially for insulin injections), potential side effects, and actions to take if side effects occur. Emphasize medication adherence.
• Hypoglycemia and Hyperglycemia Management:
  • Recognize and Treat Hypoglycemia: Educate patients and families about the signs and symptoms of hypoglycemia (e.g., sweating, tremors, dizziness, confusion). Teach them how to treat hypoglycemia with fast-acting carbohydrates (e.g., glucose tablets, juice) and when to seek emergency help. In hospital settings, follow established protocols for hypoglycemia management, which may include oral glucose for conscious patients or intravenous dextrose or glucagon for unconscious patients.
  • Recognize and Respond to Hyperglycemia: Educate patients about the signs and symptoms of hyperglycemia (e.g., increased thirst, frequent urination, fatigue, blurred vision). Advise them on strategies to manage hyperglycemia, such as adjusting diet or medication as directed by their healthcare provider. In cases of severe hyperglycemia, such as DKA or HHS, implement emergency protocols, including intravenous fluids, insulin, and electrolyte replacement, as ordered.
• Patient Education and Health Promotion:
  • Diabetes Education: Provide comprehensive diabetes education covering all aspects of self-management, including disease process, blood glucose monitoring, medication management, diet, exercise, foot care, sick day management, and prevention of complications. Refer patients to certified diabetes educators (CDEs) for in-depth education.
  • Dietary Education: Collaborate with registered dietitians to provide individualized dietary counseling. Educate patients about carbohydrate counting, portion control, healthy food choices, and meal planning.
  • Exercise Education: Encourage regular physical activity and provide guidance on safe and effective exercise routines.
  • Foot Care Education: Emphasize the importance of daily foot inspections, proper foot hygiene, appropriate footwear, and prompt reporting of any foot problems.
  • Sick Day Management: Educate patients on how to manage their diabetes during illness, including adjusting medication and insulin doses, monitoring blood glucose more frequently, and staying hydrated.
  • Risk Factor Modification: Educate patients about modifiable risk factors for diabetes complications, such as smoking, hypertension, and hyperlipidemia, and encourage lifestyle changes to reduce these risks.
  • Vaccination: Recommend annual influenza vaccination and pneumococcal vaccination, as diabetic patients are at increased risk for complications from these infections.
• Complication Prevention and Management:
  • Assess for Complications: Regularly assess patients for signs and symptoms of diabetes complications, such as neuropathy, retinopathy, nephropathy, cardiovascular disease, and foot problems.
  • Implement Preventive Measures: Reinforce healthy lifestyle behaviors and medication adherence to prevent or delay the progression of complications.
  • Provide Support and Referrals: Refer patients to specialists (e.g., ophthalmologists, podiatrists, nephrologists, cardiologists) as needed for management of diabetes complications. Connect patients with support groups and resources for coping with chronic illness.
• Psychosocial Support:
  • Assess Coping Mechanisms: Evaluate patients’ emotional and psychological well-being and identify any signs of depression, anxiety, or stress related to their diabetes.
  • Provide Emotional Support: Offer empathy, encouragement, and support to patients and families.
  • Refer to Mental Health Professionals: Refer patients to mental health professionals if needed for counseling or therapy.
• Coordination of Care:
  • Interdisciplinary Collaboration: Collaborate effectively with other healthcare team members, including physicians, dietitians, pharmacists, diabetes educators, and specialists, to ensure comprehensive and coordinated care.
  • Discharge Planning: Develop a comprehensive discharge plan that includes medication reconciliation, follow-up appointments, referrals to community resources, and reinforcement of patient education.

When to Seek Help

Prompt medical attention is crucial in certain situations to prevent serious complications. Patients and nurses should be vigilant for the following:

• Severe Hypoglycemia: If a patient experiences severe hypoglycemia (blood glucose <70 mg/dL) with symptoms such as loss of consciousness, seizures, or inability to self-treat, immediate medical help is needed. Glucagon administration (if available and appropriate) or emergency medical services (EMS) should be activated.
• Diabetic Ketoacidosis (DKA): Symptoms of DKA include hyperglycemia, nausea, vomiting, abdominal pain, rapid breathing, fruity-smelling breath, and altered mental status. DKA is a medical emergency requiring immediate hospitalization.
• Hyperosmolar Hyperglycemic State (HHS): HHS is characterized by extreme hyperglycemia (often >600 mg/dL), dehydration, confusion, and potentially coma. HHS is also a medical emergency requiring immediate hospitalization.
• Signs of Infection: Fever, chills, redness, swelling, pain, purulent drainage from wounds, or persistent cough or shortness of breath should be promptly evaluated by a healthcare provider.
• Foot Problems: Any new foot sores, ulcers, blisters, redness, swelling, pain, or drainage should be evaluated by a healthcare professional, preferably a podiatrist, as early intervention is crucial to prevent serious infections and amputations.
• Chest Pain or Symptoms of Heart Attack/Stroke: Diabetic patients are at high risk for cardiovascular disease. Chest pain, shortness of breath, dizziness, weakness on one side of the body, slurred speech, or sudden vision changes require immediate medical attention.
• Persistent Nausea, Vomiting, or Abdominal Pain: These symptoms could indicate DKA, HHS, or other serious medical conditions and warrant prompt evaluation.

Outcome Identification and Monitoring

Expected outcomes for patients with type 2 diabetes are individualized and focus on:

• Glycemic Control: Achieving and maintaining target blood glucose levels (HbA1c, fasting glucose, postprandial glucose) as recommended by their healthcare provider.
• Prevention or Delay of Complications: Adopting lifestyle modifications and adhering to treatment regimens to minimize the risk of developing or progressing diabetes complications.
• Improved Quality of Life: Managing diabetes effectively to minimize symptoms, maintain physical function, and promote overall well-being.
• Self-Management Empowerment: Gaining knowledge, skills, and confidence to effectively manage their diabetes on a daily basis.

Monitoring:

• Regular HbA1c Testing: Typically every 3-6 months to assess long-term glycemic control.
• Self-Monitoring of Blood Glucose (SMBG): Frequency and timing of SMBG are individualized based on treatment regimen and patient needs.
• Annual Comprehensive Diabetes Exam: Includes assessment of glycemic control, blood pressure, lipid profile, renal function, foot exam, eye exam (dilated fundoscopic exam), and screening for complications.
• Ongoing Assessment of Nursing Diagnoses: Regularly reassess nursing diagnoses and adjust the care plan as needed based on the patient’s changing health status and needs.

Coordination of Care and Interdisciplinary Team

Effective diabetes care requires a collaborative, interdisciplinary approach. The healthcare team may include:

• Primary Care Physician (PCP) or Endocrinologist: Provides overall medical management of diabetes.
• Registered Dietitian (RD): Provides medical nutrition therapy and dietary education.
• Certified Diabetes Educator (CDE): Provides comprehensive diabetes education and self-management training.
• Pharmacist: Provides medication management and counseling.
• Nurse: Provides patient education, monitoring, and care coordination.
• Podiatrist: Specializes in foot care and management of diabetic foot problems.
• Ophthalmologist: Performs dilated eye exams to screen for and manage diabetic retinopathy.
• Nephrologist: Manages diabetic kidney disease.
• Cardiologist: Manages cardiovascular complications of diabetes.
• Mental Health Professional: Provides counseling and support for emotional and psychological aspects of diabetes.
• Social Worker or Case Manager: Assists with psychosocial and financial issues and access to resources.
• Physical Therapist and Occupational Therapist: Assist with rehabilitation needs related to diabetes complications (e.g., stroke, amputation).

Health Teaching and Health Promotion

Patient education is a cornerstone of diabetes management. Nurses play a vital role in equipping patients with the knowledge and skills they need to effectively self-manage their condition and prevent complications. Key areas for health teaching and health promotion include:

• Diabetes Education: Provide comprehensive education on the disease process, risk factors, treatment goals, self-management strategies, and complication prevention.
• Lifestyle Modification Education:
  • Nutrition Education: Teach principles of healthy eating, carbohydrate counting, portion control, and meal planning. Emphasize the importance of limiting sugary drinks, processed foods, and unhealthy fats.
  • Physical Activity Education: Encourage regular exercise and provide guidance on safe and effective exercise routines.
  • Weight Management Education: Provide support and resources for weight loss if needed.
  • Smoking Cessation Counseling: Offer counseling and resources to help patients quit smoking.
• Medication Education: Provide detailed information about prescribed medications, including administration techniques, potential side effects, and importance of adherence.
• Blood Glucose Monitoring Education: Teach patients how to accurately perform SMBG, interpret results, and use the information to make informed self-management decisions.
• Hypoglycemia and Hyperglycemia Education: Educate patients on recognizing, treating, and preventing hypo- and hyperglycemia.
• Foot Care Education: Emphasize daily foot inspections, proper foot hygiene, and appropriate footwear.
• Sick Day Management Education: Provide guidelines for managing diabetes during illness.
• Importance of Regular Follow-up Care: Stress the need for regular check-ups with their healthcare team, including HbA1c testing, comprehensive diabetes exams, and specialist appointments.
• Resources and Support: Connect patients with diabetes support groups, online resources, and community programs.

Risk Management and Safety Considerations

Patient safety is paramount in diabetes care. Nurses must be vigilant in identifying and mitigating potential risks:

• Hypoglycemia Risk: Educate patients and families about hypoglycemia risk factors, symptoms, treatment, and prevention strategies. Ensure patients know how to use glucagon if prescribed.
• Hyperglycemia Risk: Educate patients about hyperglycemia risk factors and management strategies.
• Foot Ulcer and Amputation Risk: Emphasize foot care education and regular foot exams to prevent foot problems.
• Medication Errors: Ensure accurate medication administration and provide thorough medication education to prevent errors.
• Falls Risk: Assess for falls risk factors (neuropathy, vision impairment, hypoglycemia) and implement fall prevention strategies.
• Infection Risk: Educate patients about infection prevention measures and early recognition of infection signs.
• Driving Safety: Counsel patients about safe driving practices, especially related to hypoglycemia awareness and management.

Discharge Planning

Effective discharge planning is essential to ensure a smooth transition from hospital to home and continued diabetes management. Discharge planning should include:

• Medication Reconciliation: Review and reconcile all medications, ensuring the patient understands their medication regimen.
• Discharge Instructions: Provide clear and concise written and verbal discharge instructions, including:
  • Medication schedule and refills.
  • Blood glucose monitoring schedule.
  • Dietary guidelines and meal plan.
  • Exercise recommendations.
  • Foot care instructions.
  • Sick day management guidelines.
  • Hypoglycemia and hyperglycemia management.
  • Warning signs and symptoms to watch for.
  • Follow-up appointments with healthcare providers.
  • Referrals to community resources (e.g., diabetes education programs, support groups).
• Arrange Follow-up Appointments: Schedule follow-up appointments with the PCP or endocrinologist, diabetes educator, and other specialists as needed.
• Assess Home Support and Resources: Evaluate the patient’s home environment, social support, and access to resources to ensure they can effectively manage their diabetes at home.

Evidence-Based Practice in Diabetes Nursing

Nursing care for diabetic patients should be grounded in evidence-based practices. Numerous studies have demonstrated the effectiveness of various interventions in improving diabetes outcomes, including:

• Diabetes Self-Management Education (DSME): DSME programs have been shown to improve glycemic control, self-care behaviors, and quality of life in people with diabetes.
• Medical Nutrition Therapy (MNT): MNT is effective in improving glycemic control, lipid levels, and blood pressure.
• Regular Physical Activity: Exercise improves insulin sensitivity, glycemic control, and cardiovascular health.
• Team-Based Care: Interdisciplinary team approaches have been shown to improve diabetes outcomes.
• Technology-Assisted Diabetes Management: Continuous glucose monitoring (CGM), insulin pumps, and telehealth interventions can enhance diabetes management.

Nurses should stay updated on the latest evidence-based guidelines and incorporate them into their practice to provide the best possible care for patients with diabetes.

Pearls and Key Takeaways

• Nursing diagnoses for diabetic patients are diverse and should be individualized based on comprehensive assessment.
• Type 2 diabetes is characterized by insulin resistance and progressive beta-cell dysfunction.
• Lifestyle modifications are foundational to diabetes management, along with pharmacological therapy when needed.
• Nurses play a critical role in patient education, monitoring, and care coordination for diabetic patients.
• Hypoglycemia and hyperglycemia are acute complications requiring prompt recognition and management.
• Long-term complications of diabetes can be prevented or delayed through effective management.
• Interdisciplinary collaboration is essential for optimal diabetes care.
• Evidence-based practices should guide nursing care for diabetic patients.
• Patient education empowers individuals to effectively self-manage their diabetes and improve their health outcomes.

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Disclosures: (Keep the original disclosures)

Disclosure: Rajeev Goyal declares no relevant financial relationships with ineligible companies.

Disclosure: Mayank Singhal declares no relevant financial relationships with ineligible companies.

Disclosure: Ishwarlal Jialal declares no relevant financial relationships with ineligible companies.

Disclosure: Marinela Castano declares no relevant financial relationships with ineligible companies.