Pathophysiology And Nursing Management Of Client Health
CLC – Evidence-Based Practice Project: Intervention Presentation on Diabetes
- My Group
p r i m a r y c a r e d i a b e t e s 1 3 ( 2 0 1 9 ) 142–149
Contents lists available at ScienceDirect
Primary Care Diabetes
Save your time - order a paper!
Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlines
Order Paper Nowj o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / p c d
Original research
Design and implementation of an Omaha System-based integrated nursing management model for patients with newly-diagnosed diabetes
Lili Wei, Jingyuan Wang, Zhenyun Li, Yan Zhang, Yufang Gao ∗
The Affiliated Hospital of Qingdao University, Medical College of Qingdao University, Qingdao University, 16# Jiangsu Road, Qingdao, Shandong, 266003, China
a r t i c l e i n f o
Article history:
Received 28 September 2018
Accepted 7 November 2018
Available online 27 November 2018
Keywords:
Omaha System
Type 2 diabetes mellitus
Integrated nursing management
model
Continuing nursing
a b s t r a c t
Aims: The aim of the present paper was to establish and implement an integrated nursing
management model for patients with newly-diagnosed type 2 diabetes mellitus (T2DM)
based on the Omaha System and to explore its impact on blood glucose levels, quality of
life, and diabetes knowledge in these patients.
Methods: A non-randomized concurrent controlled trial was designed and the study was
conducted in a hospital on the east coast of China between September 2013 and November
2015. We screened for patients with newly-diagnosed T2DM in 12 clinics of 3 comprehensive
hospitals. A total of 367 patients with newly-diagnosed T2DM were assigned into two groups.
In the intervention group, patients received routine outpatient care plus integrated nursing
management; in the control group, only routine outpatient care was given. Changes in blood
glucose levels, quality of life, and diabetes knowledge in both groups before the intervention
and 6 months after the intervention were observed and compared.
Results: At the 6 months, blood glucose levels, quality of life, and diabetes knowledge in the
intervention group were significantly superior to those in the control group (all P < 0.01).
Conclusions: The integrated nursing management model was able to improve patients’ glu-
cose levels, quality of life, and diabetes knowledge.
ry Ca
According to an epidemiological survey released by the
© 2018 Prima
1. Background
Currently, there is no cure for type 2 diabetes mellitus (T2DM). Lifestyle modification is the primary way to control this chronic disease. Thus, nursing plays a particularly important
Abbreviations: T2DM, type 2 diabetes mellitus; DSN, diabetes spec diabetes specificity quality of life; HbA1c, hemoglobin A1c.
∗ Corresponding author. E-mail addresses: 13573828157@163.com (L. Wei), 214357624@qq.co
(Y. Zhang), gaoyufang1230@163.com (Y. Gao). https://doi.org/10.1016/j.pcd.2018.11.001 1751-9918/© 2018 Primary Care Diabetes Europe. Published by Elsevier
re Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
role in maintaining and promoting the health of patients with T2DM [1].
ialist nurses; ADKnowl, the Audit of Diabetes Knowledge; DSQL,
m (J. Wang), lizhenyun1130@163.com (Z. Li), zhyan0802@163.com
Chinese Diabetes Society in 2007–2008, the number of adult diabetic patients had reached 92.4 million in China [2]. Cur- rently, the prevalence of T2DM among adults in China is 11.6%,
Ltd. All rights reserved.
https://doi.org/10.1016/j.pcd.2018.11.001http://www.sciencedirect.com/science/journal/17519918http://www.elsevier.com/locate/pcdhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.pcd.2018.11.001&domain=pdfhttps://doi.org/10.1016/j.pcd.2018.11.001e s 1
r t c R i c o a t t
T d A l A o m s d i d t r c g m g
o a o u f a s m i t i d i t h e d b o s e
l A fi s w e d o I
p r i m a r y c a r e d i a b e t
epresenting up to 113.9 million Chinese adult patients [3]; his number is progressively increasing. There is at present no ure for T2DM, and thus patients require lifelong treatment. esearch [4] has shown that the quality of life of T2DM patients
s lower than that of healthy individuals. The chronic compli- ations of T2DM impose severe threats to both life and quality f life and also place heavy economic burdens on patients nd their families. According to the World Health Organiza- ion, diabetes and its related cardiovascular diseases cost up o 55.77 billion yuan in China between 2005 and 2015.
Today even in developed countries, about two-thirds of 2DM patients do not have access to effective management. In eveloping countries, diabetes control is far from satisfactory. ccording to surveys conducted in outpatient departments in
arge and middle-sized cities in 2003 and 2004, hemoglobin 1c (HbA1c) was only satisfactorily controlled in a quarter f patients with T2DM (<6.5%) [5]. Among aspects of self- anagement and education of T2DM, continuous medical
upport and patients’ self-management knowledge and skill evelopment are equally important [6]. In the integrated nurs-
ng management model, the work of endocrinologists and iabetes specialist nurses (DSN) does not end with the comple- ion of face-to-face interviews in the outpatient departments; ather, the medical staff will provide continuous health- are/nursing support from hospital to home, with an ultimate oal to establish good communication between patients and edical staff and enable patients to effectively control blood
lucose in a relatively independent manner. According to the International Council of Nurses, the role
f nursing in healthcare systems will not attract sufficient ttention and its value and significance will not be well rec- gnized and rewarded without standardized language [7]. The se of standardized language in health services is the basis
or the description, communication, and management of data nd is a useful way of ensuring data validation [8]. Currently, elf-designed record forms are often used (if any record is ade at all) during the outpatient visits and telephone vis-
ts, and descriptive record forms are also often used. Due to he lack of standardized nursing language and a standard- zed classification system, the information in these nursing ocuments cannot be encoded and thus cannot be entered
nto an information system. Patients’ nursing information, herefore, cannot be integrated into the outpatient electronic ealth records, which limits the acquisition, application, and xchange of nursing information. The lack of relevant data to emonstrate the efficacy of nursing practices and the contri- ution of nursing to patient outcomes may result in the value f nursing being undervalued by society as a whole and thus eriously hamper the sustainable development of nursing sci- nce.
The Omaha System is one of the 12 standardized nursing anguages that have been recognized by the American Nurses ssociation. It consists of three components: a problem classi- cation scheme, an intervention scheme, and a problem rating cale for outcomes [9]. This standardized classification system as initially applied in community nursing practices; how-
ver, now, in line with the idea of a continuum of care after ischarge, it also covers other settings including hospitals, utpatient departments, communities, and patients’ homes. n the field of nursing care, the Omaha System is particu-
3 ( 2 0 1 9 ) 142–149 143
larly useful in guiding clinical nursing practices, regulating nursing records, and promoting information management. Huang et al. [10] applied the Omaha System in 6 studies on community-based nursing and follow-up nursing and showed its apparent effectiveness. With Weed’s problems [11] as the guiding methods for problem-solving, and by integrating the nursing processes in evaluation records, the Omaha System provides a standardized nursing language classification sys- tem. The development of a visit evaluation form for patients with T2DM based on the Omaha problem classification system may narrow the existing data gap by effectively and rapidly revealing problems related with T2DM patient nursing and increasing nursing quality and efficiency, thus forming a sys- tematic and sustainable nursing intervention model.
Effective control of blood glucose is the essential goal of T2DM management, and can markedly decrease its chronic complications. Health education initiated immediately after the confirmation of T2DM may result in more satisfactory clin- ical outcomes [12]. Currently, in China most centers initiate nursing interventions mainly for patients with severe con- ditions that require hospitalization; in contrast, the role of nursing interventions for newly-diagnosed T2DM patients has not been well recognized. In fact, the interval from outpatient diagnosis to hospitalization due to severe disease conditions is the golden time for early intervention. Then the purpose of this study was to explore the impact of the integrated nursing management model for patients with newly-diagnosed T2DM on blood sugar levels, quality of life, and diabetes knowledge.
2. Materials and methods
In September 2013 we established and applied the Omaha System-based integrated nursing management model, which included the standardized management of diabetes clin- ics, management of patients with T2DM, and post-discharge self-management. A diabetes education team was also established. The members of the team comprised diabetes specialists, head nurses, DSNs, and researchers. The inte- grated nursing management model for the T2DM patients included the following three phases: Phase 1, from the first diagnosis of the disease to the transfer of the patient from the outpatient office to DSNs; Phase 2, from T2DM education to telephone visits; and Phase 3, outpatient follow-up visits after telephone visits.
2.1. Participants
A non-randomized concurrent controlled trial was conducted in a university affiliated hospital in Qingdao, China, from September 2013 to November 2015. We screened for partici- pants in 12 clinics of 3 comprehensive hospitals with ethical approval and written informed consent.
2.1.1. Inclusion criteria
Included in the study were patients who were confirmed with a newly confirmed diagnosis of T2DM [13], between 18 and 70 years old, able to read and provide informed written con- sent, and able to attend regular visits.
https://doi.org/10.1016/j.pcd.2018.11.001144 p r i m a r y c a r e d i a b e t e s 1 3 ( 2 0 1 9 ) 142–149
Fig. 1 – Schematic of the Omaha System-based integrated nursing management model for patients with newly-diagnosed diabetes.
2.1.2. Exclusion criteria Patients who had severe complications of diabetes or had par- ticipated in another interventional study were excluded.
2.2. Interventions
Patients in the control group received physical examinations and medications in the outpatient department and mean- while received general instructions from DSNs. Patients in the intervention group were managed using the Omaha System-
based integrated nursing management model (Fig. 1).
Five diabetes specialists were responsible for conducting physical examinations, adjusting treatment protocols, and providing professional instructions. All were associate chief
physicians or chief physicians with at least 5-year experiences in diabetes management.
Six DSNs who were recognized by the Chinese Nursing Association and had obtained a DSN certificate were respon- sible for disease assessment, health education, follow-up, and data collection. They had intermediate (or above) professional titles and had served in this position for 5 or more years.
First, DSNs established a health record for each patient enrolled. The recorded information included name, gender, age, education, occupation, and other demographic data as
well as disease-related data including previous disease his- tory, current disease status, time of disease confirmation, oral medications, insulin, glycated hemoglobin, fasting blood glu- cose levels, and postprandial glucose levels. Patients were
https://doi.org/10.1016/j.pcd.2018.11.001p r i m a r y c a r e d i a b e t e s 1 3 ( 2 0 1 9 ) 142–149 145
m of
i l f a f
f s B p t b C
t w t v b P w a w b b t
p a
l f e
Fig. 2 – Flow diagra
nstructed to complete the diabetes knowledge and quality of ife scales; records were then transferred to the physicians for urther clinical decision-making. Health records were man- ged by an assigned staff member and updated during each ollow-up visit.
DSNs then carried out a comprehensive evaluation on the our domains using the self-designed Omaha Question Clas- ification System-based T2DM Patient Visit Evaluation Form. ased on the nursing problems encountered by individual atients, customized interventions were provided according o the Chinese Guidelines on the Management of Type 2 Dia- etes Mellitus (2013 edition) [2] and the Chinese Guidelines on linical Application of Blood Glucose Monitoring [14].
DSNs distributed standardized learning manuals and rou- inely updated the video tutorials. Follow-up telephone visits ere then arranged for the first, third, and fifth months after
he first outpatient education. During the follow up phone call isits, patients were instructed to accurately monitor their lood sugar by utilizing the standardized learning manual. atients were reminded to watch the video tutorials, which ere updated regularly and accessible via the Internet, and an ppointment was made for their next outpatient visit. Patients ere asked to measure their blood glucose levels one day efore the outpatient visit so that the results could be used y the physician during the visit. After each telephone visit, he nurse completed the Follow-up Record.
During the outpatient follow-up visits, a DSN updated atients’ health records, completed the evaluation scales gain, and recorded the patients’ biochemical indicators.
Finally, to help diabetic patients to establish healthy ifestyles, DSNs organized diabetes clubs, meeting quarterly, or newly or previously diagnosed T2DM patients to share their xperiences.
patient inclusion.
T2DM patients were the implementers of the integrated nursing management model after discharge. Under the guid- ance of DSNs, patients in the intervention group carried out self-management by using the standardized learning manual and video tutorials, so as to ensure that they could reliably deal with problems encountered in their daily lives. The stan- dardized learning manual was divided into four parts: Part one, sample menus of 3 meals a day for a T2DM patient and the food exchange list; Part two, daily monitoring records, including time points for blood glucose measurements, mea- sured blood glucose values, incidences of hypoglycemia, types and amount of diets, and types and amounts of medications; Part three, exercise and insulin injection-related consider- ations; and part four, patient’s diary, in which to record daily experiences and feelings so as to encourage better self- management of the disease. The manual was designed to enable patients to manage their daily lives in a more reliable way.
2.3. Measurements
2.3.1. The Audit of Diabetes Knowledge (ADKnowl) (abbreviated version) The Audit of Diabetes Knowledge (ADKnowl) [15], developed by Speight and Bradley and translated by Zhejiang Univer- sity, includes 8 item-sets relating to treatment, sick days, hypoglycemia, effects of physical activity, reducing complica- tion risks, smoking/alcohol effects, foot care, and diet/food. According to clinical experiences and real-life conditions in
China, the scale was modified after repeated consultations and finally, an abbreviated version of the ADKnowl scale (including 73 items) was developed. The reliability of the scale was investigated, with Cronbach’s alpha (a measure of inter-
https://doi.org/10.1016/j.pcd.2018.11.001146 p r i m a r y c a r e d i a b e t e s 1 3 ( 2 0 1 9 ) 142–149
Table 1 – General data in two groups.
Item Intervention group (n = 179) Control group (n = 179) �2value P value
n Percentage n Percentage
Age 30–40 19 10.61% 17 9.50% 1.995 0.573 40–50 66 36.87% 59 32.96% 50–60 63 35.20% 76 42.46% 60–70 31 17.32% 27 15.08%
Gender Men 107 59.78% 121 67.60% 2.367 0.124 Women 72 40.22% 58 32.40%
Marital status Unmarried 0 0.00% 0 0.00% 1.996 0.158 Married 175 97.77% 170 94.97% Widowed 4 2.23% 9 5.03%
Education background Primary school and below 36 20.11% 27 15.08% 2.282 0.516 Middle school 63 35.20% 71 39.66% Senior high school or technical secondary school 49 27.37% 54 30.17% College or higher 31 17.32% 27 15.08%
Employment Employed 121 67.60% 134 74.86% 2.304 0.129 Unemployed or retired 58 32.40% 45 25.14%
Table 2 – Nursing-related problems identified during visits among T2DM patients in the intervention group (n = 179).
Nursing problems Domains n Percentage
1. Nutrition Health-related behaviors domain 175 97.5 2. Blood glucose monitoring Health-related behaviors domain 170 95.0 3. Physical activity Health-related behaviors domain 170 95.0 4. Health care mentoring Health-related behaviors domain 107 60.0 5. Medication regimen Health-related behaviors domain 103 57.5 6. Circulation Physiological domain 98 55.0 7. Substance use Health-related behaviors domain 98 55.0 8. Income Environmental domain 90 50.0 9. Vision Physiological domain 67 37.5 10. Mental health Psychosocial domain 63 35.0 11. Skin Physiological domain 63 35.0 12. Oral health Physiological domain 45 25.0 13. Neuro-musculo-skeletal function Physiological domain 45 25.0 14. Role change Psychosocial domain 22 12.5 15. Sanitation Environmental domain 18 10.0 16. Residence Environmental domain 18 10.0 17. Pain Physiological domain 18 10.0 18. Urinary function Physiological domain 13 7.5
doma d beh
19. Grief Psychosocial 20. Sleep and rest patterns Health-relate
nal consistency) and content validity index found to be 0.876 and 0.8905, respectively.
Each item has three possible responses: Correct, Incorrect, and Don’t Know. Each “Correct” answer is worth 1 point, with no point given for “Incorrect” and “Don’t Know” answers. The advantages of ADKnowl include that it (a) targets the knowl- edge that may affect clinical outcomes; (b) directly displays correct and incorrect rates of knowledge; (c) includes common and severe knowledge gaps; and d) includes a set “Don’t Know”
response, which rules out an effect of guessing answers. The DSNs instructed patients to complete the scale before and 6 months after the initiation of the model.
in 13 7.5 aviors domain 9 5.0
2.3.2. Diabetes specificity quality of life scale (DSQL) The DSQL, as developed by Fang et al. [16], includes four item-sets (physiological functions, psychological and mental functions, social relations, and treatment) and 27 items. Each item is scored using a linear scoring method: from 1 to 5. Total possible scores for the four item-sets and the overall quality of life are 60, 40, 20, 15, and 135. A higher score represents more severe functional impairment and poorer quality of life. The internal consistency (or internal reliability) of this scale was
0.95, the split-half reliability was 0.91, and the cross-time sta- bility coefficient was 0.84. Thus, this scale has good structural validity and has been widely applied by Chinese authors. The
https://doi.org/10.1016/j.pcd.2018.11.001p r i m a r y c a r e d i a b e t e s 1 3 ( 2 0 1 9 ) 142–149 147
Table 3 – Comparison of fasting and postprandial blood glucose levels before and after the intervention in the two groups (mean ± SD). BG (mmol/L) Time Intervention group (n = 179) Control group (n = 179) t P
FBG Before intervention 9.964 ± 2.707 10.490 ± 2.781 −1.816 0.070 Six months after intervention 7.792 ± 0.925 9.042 ± 1.561 −9.218 0.000 t 10.157 6.915 P 0.000 0.000
2hPBG Before intervention 14.612 ± 4.685 14.692 ± 4.400 −0.167 0.868 Six months after intervention 9.980 ± 1.446 12.275 ± 2.120 −11.972 0.000 t 12.640 6.620 P 0.000 0.000
Table 4 – Comparison of the level of diabetes knowledge before and after the intervention in the two groups (mean ± SD). Time Intervention group (n = 179) Control group (n = 179) t P
Before intervention 80.715 ± 12.940 81.251 ± 12.056 −0.406 0.685 Six months after intervention 52.279 ± 11.127 68.760 ± 9.464 −15.094 0.000
Table 5 – Comparison of quality of life before and after the intervention in the two groups (mean ± SD). Time Intervention group (n = 179) Control group (n = 179) t P
At initial presentation 44.223 ± 11.098 43.430 ± 10.015 0.710 0.478
D 6
2 F l w m
2
S w u t p u
3
3
A o N t v o n o a ( c
b
Six months after intervention 63.022 ± 6.311 t −19.700 P 0.000
SNs instructed the patients to complete the scale before and months after the initiation of the model.
.3.3. Metabolic markers asting blood glucose levels, 2 h postprandial blood glucose evels, and glycosylated hemoglobin values in both groups ere recorded before and 6 months after the initiation of the odel for comparisons.
.4. Statistical analysis
tatistical analysis was performed using the SPSS 17.0 soft- are package. The normally distributed data are presented sing mean ± standard deviation, and the non-normally dis- ributed data using median ± standard deviation. Changes in arameters before and after the intervention were compared sing a t-test.
. Results
.1. Participant characteristics
total of 367 participants were enrolled from 12 clinics f 3 comprehensive hospitals between September 2013 and ovember 2015. Participants were numbered according to
heir order of presentation, then assigned either into the inter- ention group (n = 183) or control group (n = 184) according to dd and even numbers. Of the 9 participants whose data were ot included in the final statistical analysis, four refused the utpatient follow-up visits, two migrated, and three refused ny further telephone visits (Fig. 2). Therefore, 358 participants
228 males and 130 females) with a mean age of 50.1 ± 9.1 years ompleted the study.
General characteristics, including age, gender, fasting lood glucose levels, quality of life, and education background,
51.268 ± 7.342 16.243 0.000 −8.445 0.000
showed no significant difference between the two groups (P > 0.05) (Tables 1, 3–5).
3.2. Nursing-related problems identified during the visits
A total of 20 nursing-related problems (environmental, n = 3; psycho-social, n = 3; physiological, n = 7; and health-related behavioral, n = 7) were identified among participants in the intervention group. In total, 1405 nursing-related problems were found in 179 patients (average: 7.85 problems per patient). Since all subjects were newly-diagnosed with T2DM, the problems most commonly seen were health-related behavioral problems. Nursing-related problems with an inci- dence >50% included nutrition, blood glucose monitoring, physical activity, healthcare mentoring, medications, circula- tion, substance abuse, and income (Table 2).
3.3. Changes in biochemical markers, diabetes knowledge, and quality of life among T2DM patients
At 6 months, fasting and postprandial blood glucose levels in the intervention group were significantly lower than those in the control group (all P < 0.01). Furthermore, quality of life and diabetes knowledge in the intervention group were sig- nificantly higher than those in the control group (all P < 0.01) (Tables 3–5).
4. Discussion
The components of the Omaha System used in our cur-
rent study included four domains (environment, psychosocial issues, physiology, and health-related behaviors) and 42 prob- lems. We selected problems related to the nursing of T2DM patients, as well as problems such as blood glucose mon-
https://doi.org/10.1016/j.pcd.2018.11.001e t e s
148 p r i m a r y c a r e d i a b
itoring. Based on the Delphi expert survey report [17], we developed the Omaha Problem Classification System-based T2DM Patient Visit Evaluation Form. This form had 32 prob- lems covering the four domains including environment (4 problems, including income and hygiene), psychosocial issues (6 problems, including mental health and role-change), physi- ology (14 problems, including respiration and circulation), and health-related behaviors (8 problems, including health care mentoring and physical activity).
As shown in Table 2, among 179 T2DM patients in the intervention group who had undergone evaluation using the Omaha problem classification system, an average of 7.85 nursing-related problems was identified in each patient. This indicates that the use of this system enabled the identifica- tion of multiple complex nursing problems in these patients. In this group, the incidence of nursing-related problems was >50% in 8 patients and >30% in 11 patients, suggesting that the system had good consistency in evaluating the patients’ nursing-related problems and was well able to reflect com- mon problems. Since the subjects enrolled in this study were newly-diagnosed patients, health-related behavioral prob- lems accounted for the highest proportion of all the problems identified. The findings of the study also showed that there were 7 problems in the health-related behaviors domain, 3 in the environmental domain and 3 in the psychosocial domain, indicating that the Omaha System not only takes into account the physiological domain but also considers the other 3 domains, reflecting the concept of holistic nursing. There- fore, the use of the Omaha problem classification system in the integrated nursing management model can describe most symptoms and signs that may occur in patients who receive follow-up visits and thus can inform further nursing interven- tions.
Changes in fasting and postprandial blood glucose levels after the implementation of the integrated nursing manage- ment model in the two groups are shown in Table 3. These two parameters showed a significant difference from before to after the intervention in both groups; this suggests that a single diabetes specialist visit in the control group could, to a certain extent, improve patients’ degree of compliance and help to achieve the target of blood glucose control, consistent with the findings of Wang and Zhu [18]. The differences in fasting and postprandial blood glucose levels were also sta- tistically significant between groups after the intervention; patients in the intervention group had significantly better con- trol of fasting blood glucose and postprandial blood glucose than the control group. This indicates that continuous and systematic nursing care can help patients to better control their blood glucose levels.
The changes in diabetes knowledge and quality of life in the two groups after the implementation of the integrated nursing management model are shown in Tables 4 and 5. As shown in Tables 4 and 5, after the implementation of the integrated nursing management model, diabetes knowledge and quality of life were significantly better in the intervention group than in the control group. Zhang et al. [19] found that
patients who had received blood glucose monitoring according to the guidelines had better-controlled blood glucose; how- ever, up to 62.3% of patients did not follow the guidelines. We identified a similar problem in follow-up visits. In the
1 3 ( 2 0 1 9 ) 142–149
integrated nursing management model, by referring to the Chinese Guidelines on Clinical Application of Blood Glucose Monitoring, we developed a tailored blood glucose monitoring frequency and protocol for each patient. This may have con- tributed to improved diabetes knowledge and better control of blood glucose, thus improving quality of life.
5. Conclusion
In summary, under the premise of following the origi- nal clinical protocols, the integrated nursing management model—including the standardized management of dia- betes clinics, management of patients with T2DM, and post-discharge self-management—may effectively control patients’ blood glucose levels, increase diabetes knowledge, and improve quality of life. As an extension of hospital nurs- ing, this model may be able to promote family-based diabetes education and could be a valuable healthcare model appropri- ate for use in China.
Ethics approval and consent to participate
This study was approved by the medical ethical committee of Affiliated Hospital of Qingdao University. All participants of this study signed informed consent forms prior to data collec- tion.
Consent for publication
Not applicable.
Availability of data and material
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Conflict of interest
The authors state that they have no conflict of interest.
Funding
This study was funded by the grant of Qingdao science and technology development projects (Kzd-26).
Authors’ contributions
LW designed the study protocol. ZL and YZ participated in the collect of data. JW and ZL analysed the data. LW, JW and YG wrote the manuscript. All authors read and approved the final manuscript.
https://doi.org/10.1016/j.pcd.2018.11.001e s 1
A
T n
r
p r i m a r y c a r e d i a b e t
cknowledgements
he authors would like to sincerely thank the patients with ewly-diagnosed diabetes for their participation in this study.
e f e r e n c e s
[1] X.Y. Li, R. Xu, Y. Liu, Design and implementation of an hospital-community-family nursing care mode, Chin. Nurs. Manage. 12 (2012) 18–19.
[2] Chinese Diabetes Society, Guidelines for prevention and treatment of type 2 diabetes mellitus in China (2013), Chin. J. Diabetes 6 (2014) 447–498.
[3] G. Ning, W.H. Zhao, W.Q. Wang, Study evaluates prevalence of diabetes among adults in China Chicago, JAMA 10 (2013) 161–163.
[4] D.L. Kong, Y.L. Ding, X.Y. Zuo, et al., Adaptation of the audit of diabetes-dependent quality of life questionnaire to people with diabetes in China, Diabetes Res. Clin. Prac. 94 (2011) 45–52.
[5] C.Y. Pan, The management status of diabetes in China — gaps between guide and practice, Section Endocrinol Foreign Med. Sci. 25 (2008) 174–178.
[6] H.E. Chen, Q.Q. Ge, Y.H. Zheng, M.M. Chen, The effect of peer-support scene health education on self-management among elderly patients with diabetes, Chin. Nurs. Manage. 14 (2014) 497–499.
[7] M.J. Kerr, C. Flaten, M.L. Honey, R. Gargantua-Aguila Sdel, et al., Feasibility of using the Omaha System for
community-level observations, Public Health Nurs. 33 (2016) 256–263.
[8] S. Tastan, G.C. Linch, G.M. Keenan, et al., Evidence for the existing American Nurses Association-recognized
3 ( 2 0 1 9 ) 142–149 149
standardized nursing terminologies: a systematic review, Int. J. Nurs. Stud. 51 (2014) 1160–1170.
[9] M. Topaz, N. Golfenshtein, K.H. Bowles, The Omaha System: a systematic review of the recent literature, J. Am. Med. Inform. Assoc. 21 (2014) 163–170.
[10] J.Y. Huang, S.L. Wang, J.Y. Zhou, Use of Omaha System in community nursing and transitional care, Chin. J. Nurs. 45 (2010) 320–323.
[11] L.L. Weed, Medical records that guide and teach, N. Engl. J. Med. 278 (1968) 593.
[12] S.H. Ko, K.H. Song, S.R. Kim, et al., Long-term effects of a structured intensive diabetes education programmer(SIDEP)in patients with type 2 diabetes mellitus-a 4-year follow-up study, Diabetes Med. 24 (2007) 55–62.
[13] J. Li, N.W. Tong, ADA: medical diagnosis and treatment criteria of diabetes — 2013, Chin. J. Front. Med. Sci. 5 (2013) 61–66.
[14] Chinese Diabetes Society, Guidelines on the clinical application of blood glucose monitoring, Chin. J. Diabetes 3 (2011) (2011) 13–21.
[15] J. Speight, C. Bradley, The ADKnowl: identifying knowledge deficits in diabetes care, Diabetic Med. 18 (2001) 626–633.
[16] J.Q. Fang, Q. Yu, C.H. Fang, Quality of Life Measurement Method and Application, Peking University Medical Press, BeiJing, 2000, pp. 79–92.
[17] W.Y. Sui, L.L. Wei, N.L. Yang, et al., Omaha System-based nursing problem analysis of outpatients with type 2 diabetes mellitus in early stage, J. Nurs. (China) 21 (2014) 10–14.
[18] L.F. Wang, G.H. Zhu, The research status and development tendency of diabetic nurse-led clinic, Chin. J. Mod. Nurs. 19 (2013) 3439–3442.
[19] Z.D. Zhang, C.L. Meng, X.B. Wu, The current situation of self-monitoring of blood glucose status among patients with type 2 diabetes mellitus, Chin. Nurs. Manage. 14 (2014) 545–547.
https://doi.org/10.1016/j.pcd.2018.11.001http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0005http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0010http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0015http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0020http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0025http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0030http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0035http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0040http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0045http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0050http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0055http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0060http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0065http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0070http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0075http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0080http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0085http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090http://refhub.elsevier.com/S1751-9918(18)30325-5/sbref0090 - Group Forum
This is a Collaborative Learning Community (CLC) assignment.
As a group, identify a research or evidence-based article published within the last 5 years that focuses comprehensively on a specific intervention or new treatment tool for the management of diabetes in adults or children. The article must be relevant to nursing practice.
Create a 10-15 slide PowerPoint presentation on the study’s findings and how they can be used by nurses as an intervention. Include speaker notes for each slide and additional slides for the title page and references.
Include the following:
- Describe the intervention or treatment tool and the specific patient population used in the study.
- Summarize the main idea of the research findings for a specific patient population. The research presented must include clinical findings that are current, thorough, and relevant to diabetes and nursing practice.
- Provide a descriptive and reflective discussion of how the new tool or intervention can be integrated into nursing practice. Provide evidence to support your discussion.
- Explain why psychological, cultural, and spiritual aspects are important to consider for a patient who has been diagnosed with diabetes. Describe how support can be offered in these respective areas as part of a plan of care for the patient. Provide examples.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.
