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Slide 1 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Textbook For Nursing.

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Presentation on theme: "Slide 1 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Textbook For Nursing."— Presentation transcript:

1 Slide 1 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Textbook For Nursing Assistants Chapter 30 - The Endocrine System

2 Slide 2 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Structure of The Endocrine System

3 Slide 3 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Endocrine glands produce hormones and release them directly into the bloodstream Exocrine glands produce substances that are released into a hollow organ or onto a surface Examples of exocrine glands include: The salivary glands in the mouth, which produce saliva The sweat glands in the skin, which produce sweat. Exocrine glands are not part of the endocrine system Endocrine and Exocrine Glands

4 Slide 4 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Endocrine glands include: Pituitary gland Pineal gland Thyroid gland Parathyroid glands Thymus gland Adrenal glands Pancreas Sex glands (gonads) Endocrine Glands

5 Slide 5 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Endocrine Glands

6 Slide 6 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Endocrine glands are found throughout the body The pituitary gland Is about the size of a cherry Lies underneath the brain Is connected by a stalk, called the infundibulum, to the hypothalamus The pineal gland Is located underneath the brain The thyroid gland Is located in the neck Is butterfly-shaped, with two oval lobes located on either side of the larynx; connected by a narrow band of tissue called the isthmus Location of Endocrine Glands

7 Slide 7 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The parathyroid glands Are four tiny glands that are embedded in the back of the thyroid gland The thymus gland Is located in the upper part of the chest above the heart The adrenal glands Are located on top of the kidneys The pancreas Is located in the abdomen The sex glands (gonads) Are the ovaries in women and the testes in men Location of Endocrine Glands

8 Slide 8 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Functions of The Endocrine Glands

9 Slide 9 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The endocrine system controls many of the body’s processes, such as: Growth and development Reproduction Metabolism Endocrine System

10 Slide 10 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Endocrine glands produce hormones, chemicals that act on cells to produce a response The hormones are released into the bloodstream The hormone travels in the blood until it reaches its target cell Once there, it attaches to a special receptor in the cell wall Attaching a hormone to a receptor causes a specific reaction in the cell How an Endocrine System

11 Slide 11 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The secretion of many hormones is initiated by a negative-feedback system Some change in the internal environment causes the gland to begin producing its hormone The gland continues to produce the hormone until the amount of hormone (or some other related substance) reaches a certain level in the body At that point, the gland stops producing the hormone The negative-feedback system works very much like a central heating unit in a house Negative Feedback System of the Endocrine System

12 Slide 12 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Pituitary Gland

13 Slide 13 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Antidiuretic hormone (ADH) secreted by the posterior lobe; acts on the kidneys ADH limits the amount of water lost from the body in the form of urine ADH causes the kidneys to save body fluid by decreasing the amount of urine produced The lack of ADH causes the kidneys to produce more urine, eliminating excess fluid from the body Pituitary Gland: Posterior Lobe

14 Slide 14 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Oxytocin is a hormone that: Causes labor to begin Lets down milk in the breasts of a nursing mother Pituitary Gland: Posterior Lobe

15 Slide 15 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Growth hormone is what causes our bodies to get bigger and taller as we move from infancy into adulthood Growth hormone is usually released in greater amounts during short periods of time, resulting in a child’s “growth spurts” The anterior lobe continues to release growth hormone long after the growing phase of development is finished because cells continue to need to be replaced throughout a person’s lifetime Pituitary Gland: Anterior Lobe

16 Slide 16 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Thyroid-stimulating hormone (TSH) stimulates the thyroid gland Produces thyroid hormones Affects the rate of metabolism in the body’s tissues Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands Produces hormones Helps the body to cope with stress Pituitary Gland: Anterior Lobe

17 Slide 17 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prolactin stimulates the milk glands of the breasts to produce milk when a baby is born Gonadotropins regulate the functioning of the sex glands (gonads) in both males and females Two types of gonadotropins:  Follicle-stimulating hormone (FSH)  Luteinizing hormone (LH) Pituitary Gland: Anterior Lobe

18 Slide 18 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The thyroid gland produces the following two hormones: Thyroxine Calcitonin These hormones help to regulate the body’s metabolism rate Thyroid Gland

19 Slide 19 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The hormone thyroxine sets the rate of metabolism for the cells of the body If the thyroid gland releases more thyroxine, the metabolic rate of the cells increases If the thyroid gland releases less thyroxine, the metabolic rate of the cells decreases Thyroid Gland: Thyroxine

20 Slide 20 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The thyroid gland needs iodine to produce thyroxine Iodine is found in: Fish and shellfish Added to salt and other commercial products Goiter can occur when a person is deficient of iodine Thyroid Gland: Thyroxine

21 Slide 21 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Calcitonin regulates the level of calcium in the bloodstream Calcitonin transports the extra calcium to the bones Tetany (cramping of the skeletal muscles and an irregular heart beat) may result if the calcium level drops too low Too much calcium in the bloodstream causes muscles to become weak and slow to respond Thyroid Gland: Calcitonin

22 Slide 22 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The parathyroid glands produce parathyroid hormone (PTH) PTH increases the amount of calcium in the blood: Causes calcium to be released from the bones into the bloodstream Helps the kidneys to keep calcium, instead of excrete it in the urine Allows us to draw on stored calcium later in life The actions of calcitonin and PTH balance each other and help to keep the levels of calcium in the bloodstream constant Parathyroid Glands

23 Slide 23 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. If parathyroid glands are surgically removed or become damaged by disease: PTH is not produced in adequate amounts The calcium levels may drop, causing tetany Tumors of the parathyroid gland can cause an overproduction of PTH that results in: Excess calcium being removed from the bones Fragile bones Formation of kidney stones Parathyroid Glands

24 Slide 24 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The thymus gland secretes thymosin Thymosin helps infection-fighting T cells to mature An increase in the secretion of thymosin stimulates the body to produce more T cells during an infection or illness Thymus Gland

25 Slide 25 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Each adrenal gland has two separate parts: The medulla, or inner portion The cortex, or outer portion Each part secretes distinct hormones Adrenal Glands

26 Slide 26 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Adrenal Glandsand Hormones

27 Slide 27 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The medulla of the adrenal glands secretes two hormones: Epinephrine Norepinephrine Responsible for the “fight-or-flight” response of the body in emergency situations Help the heart and lungs deliver more oxygen and nutrients to the muscles, preparing the body to “stand up and fight or turn tail and run” Dry mouth Pounding heart Adrenal Glands-Medullary Hormones

28 Slide 28 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Glucocorticoids: Help to metabolize fats and proteins Help to maintain a reserve of glucose that can be used in times of stress Suppress the body’s inflammatory response Glucocorticoids are given in the form of drugs for severe inflammatory disorders such as: Asthma Rheumatoid arthritis Severe allergic reactions Hydrocortisone is a common medication that is a glucocorticoid Adrenal Glands-Cortical Hormones

29 Slide 29 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Mineralocorticoids help to regulate the level of certain minerals in the body, particularly sodium and potassium Aldosterone is the primary hormone in this group Aldosterone helps the kidneys to reabsorb sodium and secrete potassium Adrenal Glands-Cortical Hormones

30 Slide 30 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Androgens are secreted in small amounts by the adrenal cortex Androgens are converted by the body into the sex hormones Testosterone (in men) Estradiol (in women) Adrenal Glands-Cortical Hormones

31 Slide 31 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The pancreas is both an exocrine gland and an endocrine gland It functions as an exocrine gland by producing and secreting enzymes into the small intestine that help to digest food It functions as an endocrine gland by producing two hormones, insulin and glucagon Pancreas

32 Slide 32 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Special cells within the pancreas, called the islets of Langerhans, produce and secrete the hormone insulin Insulin affects all of the body’s cells Insulin allows glucose (sugar) to be transported from the bloodstream into the individual cells, where it is used for energy Insulin lowers the blood glucose level Pancreas: Action of Insulin

33 Slide 33 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Glucagon is responsible for raising the blood glucose level When the glucose levels in the bloodstream drop, when a person has not eaten for some time, the pancreas secretes glucagon Glucagon stimulates the liver to release the glucose that has been stored as glycogen into the bloodstream, to supply the cells of the body with fuel for energy Pancreas: Action of Glucagon

34 Slide 34 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The sex glands (or gonads) secrete hormones that: Cause the onset of puberty Regulate reproduction Sex Glands

35 Slide 35 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The Effects of Aging on the Endocrine System

36 Slide 36 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The normal processes of aging: decrease the amount of hormones produced slow the secretion by the endocrine glands Decrease in thyroid hormone levels slows the body’s metabolism In women, menopause occurs as a result of decreased hormone production by the ovaries In men, secretion of hormones by the testes decreases, affecting sexual drive and function The Effects of Aging

37 Slide 37 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Disorders of the Endocrine Glands

38 Slide 38 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Disorders of the endocrine system can be caused: when the body produces too much or too little of a certain hormone by disorders of the hypothalamus, the pituitary gland, or the specific endocrine gland responsible for the hormone as a result of poor nutrition Corrective measures may be needed to restore the body’s homeostasis and prevent the imbalances from causing health problems Disorders of the Endocrine System

39 Slide 39 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. A deficiency in the amount of growth hormone secreted during the growing years results in a condition known as pituitary dwarfism A person with pituitary dwarfism is much smaller than average, but still well proportioned If the condition is diagnosed while the person is still a child, growth hormone may be given to help stimulate growth Pituitary Dwarfism

40 Slide 40 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. An excess in the amount of growth hormone secreted during the growing years results in a condition known as pituitary gigantism A person with pituitary gigantism is much larger than average, but still well proportioned Pituitary Gigantism

41 Slide 41 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The secretion of too much growth hormone after a person has reached adulthood causing excessive growth of the bones of the hands, feet, and face Causes disproportioned appearance, especially in the face and hands Person does not grow taller Acromegaly

42 Slide 42 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Secretion of thyroid hormones is controlled by the pituitary gland Thyroid disorders can be caused by: Pituitary gland abnormalities Thyroid gland abnormalities Nutrient deficiencies, such as a lack of iodine A simple blood test can be used to detect imbalances in thyroid hormones Once detected, these imbalances can usually be treated Thyroid Disorders

43 Slide 43 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Hyperthyroidism or Graves’ disease is caused by the excessive secretion of thyroxine In a person with hyperthyroidism, the metabolic rate of the body’s cells is increased Hyperthyroidism

44 Slide 44 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Signs and symptoms of hyperthyroidism: Increased hunger accompanied by weight loss Irregular heartbeat Inability to sleep Irritability Confusion Increased perspiration, and intolerance to heat Hyperthyroidism may be treated by: Surgically removing part of the thyroid gland Destroying part of the gland with radiation Hyperthyroidism: Sign and Symptoms

45 Slide 45 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Hypothyroidism results when thyroxine secretion is too low Congenital hypothyroidism, if left untreated, can result in a condition known as cretinism Cretinism is characterized by a lack of physical growth and mental development Hypothyroidism and Cretinism

46 Slide 46 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Most cases of hypothyroidism develop later in life, as a result of a disorder of the: Hypothalamus Pituitary gland, or Thyroid gland Hypothyroidism is more common among women and the elderly Hypothyroidism is treated by administering thyroxine in the form of a pill Causes of Hypothyroidism

47 Slide 47 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Signs and symptoms of hypothyroidism: Fatigue Weakness Depression Anorexia Weight gain Constipation Intolerance to cold The administration of oral thyroxine helps to restore the body’s metabolism to a normal rate and relieve the signs and symptoms of hypothyroidism Hypothyroidism: Sign and Symptoms

48 Slide 48 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Two of the most common adrenal gland disorders are: Addison’s disease Cushing’s syndrome Result from imbalances of the adrenal cortical hormones Adrenal Gland Disorders

49 Slide 49 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. In Addison’s disease, the adrenal cortex is destroyed, resulting in low levels of the adrenal cortical hormones A person with Addison’s disease experiences: Muscle weakness and atrophy Dark discoloration of the skin Disturbances in the body’s salt and water balance Hypertension A person with Addison’s disease may need assistance with walking and range-of-motion exercises Addison’s Disease

50 Slide 50 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Cushing’s syndrome results from: Excessive secretion of glucocorticoids Disorders of the pituitary gland that affect ACTH secretion Disorders of the adrenal gland itself Administering high doses of steroid medications, such as hydrocortisone, for a long period of time Cushing’s Syndrome

51 Slide 51 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Pockets of fat in the abdomen, on the back, and in the face Increased facial hair High blood glucose levels, since one of the effects of glucocorticoids is to decrease the use of glucose by the tissues Cushing’s Syndrome: Sign and Symptoms

52 Slide 52 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Diabetes mellitus results when the pancreas is unable to produce enough insulin Diabetes mellitus can occur in people of all ages and races People between the ages of 65 and 74 years and people of African descent are affected most often Diabetes mellitus is the most common of all endocrine gland disorders and is the seventh leading cause of death among the elderly There are two types of diabetes mellitus, type I and type II Diabetes Mellitus

53 Slide 53 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Caused by destruction of the insulin- producing cells of the pancreas Form of diabetes that most often affects children Most people who have type I diabetes are diagnosed while they are children or young adults Juvenile Diabetes (Type I)

54 Slide 54 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. A person with Type I diabetes mellitus must receive daily injections of insulin The insulin is injected into the subcutaneous layer of the skin, where it is absorbed by the bloodstream Several types of insulin are available The types of insulin differ in the speed at which they start working and how long they last in the body Some patients or residents receive only one injection of insulin each day, while others may receive two or three Insulin can also be delivered continuously by a pump device Insulin

55 Slide 55 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. People who are receiving insulin injections need to have their blood glucose levels monitored closely Too much insulin causes hypoglycemia, a dangerous drop in blood glucose Hypoglycemia robs the brain of the glucose that is essential for it to function Too little insulin results in hyperglycemia, or too much glucose in the bloodstream If a person’s blood glucose level increases too much, he can enter a state called diabetic coma If not treated, diabetic coma can lead to death Hypoglycemia and Hyperglycemia

56 Slide 56 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. People who are receiving insulin injections must eat an adequate amount of nutritious food at regular intervals Meals Snacks A person with type I diabetes must eat a diet with specific amounts of: Carbohydrates Sugars Fats Proteins to react with the amount of injected insulin Diet for a Person with Diabetes

57 Slide 57 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. If a person does not eat at the recommended time after receiving her insulin, her blood glucose level can drop too low, resulting in a condition known as insulin shock If one of your patients or residents with diabetes refuses to eat or only partially finishes his meal or snack, report this to the nurse immediately Diet of a Diabetic Person

58 Slide 58 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Type II diabetes mellitus: most common in overweight adults In people with type II diabetes mellitus: The pancreas still produces some insulin but the cells of the body are unable to respond to the insulin The body is unable to transport the glucose into the cells This results in higher blood glucose levels Symptoms of type II diabetes mellitus may occur gradually and go undetected for a long time Type II Diabetes Mellitus

59 Slide 59 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Type II diabetes is treated through: Diet Exercise Use of oral medications to increase the effectiveness of insulin People with severe type II diabetes may need to be treated with insulin injections, especially during times of illness or stress When caring for a person with type II diabetes, be sure to watch closely the amounts and types of food the person eats Type II Diabetes Mellitus

60 Slide 60 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Signs and symptoms of hyperglycemia and hypoglycemia are often very similar and should be reported to the nurse immediately. These signs include: Excessive hunger Excessive thirst Weakness, dizziness, or both Drowsiness and confusion Shaking and increased perspiration Hypoglycemia and Hyperglycemia: Symptoms

61 Slide 61 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Many organ systems can be affected by uncontrolled diabetes mellitus of either type Low insulin levels increase the release of lipids (fats) into the bloodstream The lipids then build up in the linings of the arteries, damaging the blood vessels and possibly leading to: Atherosclerosis High blood pressure Heart disease Kidney disease Blindness (diabetic retinopathy) Complications of Diabetes

62 Slide 62 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Early detection of diabetes mellitus is essential for preventing complications Once diabetes mellitus is diagnosed, measures can be taken to keep the disease under control and minimize the risk of developing complications: Weight loss (if applicable) Regular exercise Close attention to recommended diet Proper use of prescribed medications Preventing Complications of Diabetes

63 Slide 63 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. End of Presentation


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