Partial report, quanti-qualitative of action-research developed in the ward test/ ambulatory of a University Hospital, extensive to home; integrating students, teachers and nursing team. Objective: to establish standards to integrate hospital/community, seeking the man in the home circle, oppose the recovery/rehabilitation and the integration to work/society, considering the problems in the home/work and put into practice the proposition of the SUDS with extension to the hospital/community actions. Home visits raising the home conditions, family and/or community, consolidating their participation in the process. During the hospital stay nursing care was oriented to conduct the participation and realization of the care by the client and relatives happening the same in the ambulatory probation.
Self care; Diabetes Mellitus; Nursing care