Download Diabetes Management: Diagnosis, Treatment, and Patient Education and more Study notes Nursing in PDF only on Docsity!
20 Diabetes Mellitus Nursing Diagnosis & Care Plans
MED - SURG STUDY GUIDE
Utilize this comprehensive nursing care plan and management guide to provide effective care for patients experiencing diabetes mellitus. Gain valuable insights on nursing assessment, interventions, goals, and nursing diagnosis specifically tailored for patients with diabetes mellitus in this guide. What is Diabetes Mellitus? Diabetes mellitus (DM) is a chronic disease characterized by insufficient insulin production in the pancreas or when the body cannot efficiently use the insulin it produces. This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is characterized by disturbances in carbohydrate, protein, and fat metabolism. Sustained hyperglycemia has been shown to affect almost all tissues in the body. It is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels. Classifications of diabetes mellitus include
- Type 1 diabetes is characterized by destruction of the pancreatic beta cells leading to absolute insulin deficiency including latent autoimmune diabetes of adulthood.
- Types 2 diabetes is characterized by progressive loss of pancreatic beta cells and involves insulin resistance and impaired insulin secretion.
- Specific types of diabetes due to other causes such as monogenic diabetes syndromes (neonatal diabetes and maturity-onset diabetes of the young), diseases affecting the exocrine pancreas (cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (as a result of glucocorticoid use, treatment of HIV/AIDS, or organ transplantation).
- Gestational diabetes mellitus (GDM) refers to the onset of diabetes diagnosed during the second or third trimester of pregnancy, which was not clearly present as overt diabetes prior to conception. The criteria for the screening and diagnosis of prediabetes and diabetes are as follows: Screening Test Prediabetes Diabetes A1C 5.7-6.4% 6.5% or greater FPG 100 - 125 mg/dL 126 mg/dL or greater 2 - hour plasma glucose 75-g OGTT 140 - 199 mg/dL 200 mg/dL or greater Random plasma glucose – 200 mg/dL or greater Nursing Care Plans and Management Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose levels and decrease complications using insulin replacement, a balanced diet, and exercise. The nurse should stress the importance of complying with the prescribed treatment program through comprehensive diabetes education. Tailor your teaching to the patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control on long - term health. Nursing Problem Priorities The following are the nursing priorities for patients with diabetes:
- Glycemic control. Managing and maintaining blood glucose levels through medication, diet, and lifestyle modifications.
- Education and self-management. Providing patient education on diabetes management, including medication administration, monitoring blood glucose levels, meal planning, exercise, and recognizing signs of hyperglycemia or hypoglycemia.
- Preventing potential complications. Addressing risk factors for cardiovascular diseases, nephropathy, retinopathy, and neuropathies common among patients with diabetes.
- Weight management. Promoting a healthy weight through appropriate nutrition and physical activity, considering individual needs and comorbidities
patient’s needs. Here are examples of nursing diagnoses that may be useful for common concerns associated with diabetes:
- Imbalanced Nutrition: Less Than Body Requirements related to inadequate (or excessive) dietary intake and increased metabolic demands as evidenced by weight loss, decreased muscle mass, and reports of fatigue.
- Unstable Blood Glucose Levels related to inconsistent meal patterns, physical inactivityy, and insufficient knowledge of diabetes management.
- Knowledge Deficit related to new diagnosis of diabetes mellitus as evidenced by patient’s questions about disease management and insulin administration.
- Risk for Infection as evidenced by hyperglycemia and delayed wound healing.
- Ineffective Health Maintenance related to lack of understanding of diabetes management as evidenced by irregular blood glucose monitoring and missed medication doses.
- Fatigue related to decreased energy production as evidenced by patient reports of tiredness and inability to perform usual activities.
- Risk for Impaired Skin Integrity as evidenced by decreased sensation in feet and poor circulation.
- Activity Intolerance related to muscle weakness as evidenced by shortness of breath during exertion and patient reports of fatigue.
- Risk for Disturbed Sensory Perception as evidenced by reports of blurred vision and difficulty reading. Nursing Goals Goals and expected outcomes may include:
- The patient will consistently maintain blood glucose readings of less than 180 mg/dL, fasting blood glucose levels of less than 140 mg/dL, and a hemoglobin A1C level below 7%. Additionally, the patient will demonstrate understanding of key factors that can impact glucose stability.
- The patient will accurately demonstrate knowledge of insulin injection techniques, recognize symptoms and appropriate treatment of hypoglycemia, and exhibit understanding of dietary requirements for managing their condition.
- The patient will actively acknowledge feelings of helplessness, identify healthy coping strategies to deal with these emotions, and actively participate in planning their own care while independently assuming responsibility for self-care activities.
- The patient will effectively demonstrate knowledge of diabetes self-care measures, including proper procedures, and verbalize a comprehensive understanding of the diabetes disease process and potential complications, while providing clear explanations for the rationale behind their actions.
- The patient will consume appropriate amounts of calories and nutrients as per their individual needs, exhibit their usual energy level, and demonstrate weight stabilization or gradual progress towards their usual/desired range, with laboratory values within the normal range. Nursing Interventions and Actions Therapeutic interventions and nursing actions for patients with diabetes may include: 1. Providing Patient Education on Diabetes Management To ensure successful diabetes care, a systematic approach is needed, including high-quality diabetes self-management education and support (DSMES). Four critical times to assess the need for DSMES include diagnosis, annual evaluations or when treatment targets are not met, when complicating factors arise, and during life and care transitions. DSMES should be person- centered and can be provided in group or individual settings, involving the entire diabetes care team. Providing complete information and proper education to patients with diabetes can dramatically increase adherence to the treatment regimen. Nursing Diagnosis
- Knowledge Deficit related to diabetes management as evidenced by lack of understanding of the disease process, treatment modalities, and self-care behaviors.
- Readiness for Enhanced Health Management as evidenced by expressed interest in learning about diabetes care, active participation in educational sessions, and asking questions about the disease process and self-care behaviors. Expected Outcomes
- The patient will demonstrate improved understanding of diabetes management as evidenced by correctly explaining the disease process and the importance of blood glucose control. Assessing readiness to learn
misconceptions or misinformation, alleviating anxiety and providing accurate information to facilitate effective diabetes management. Initiating diabetes education Provide simple, direct information to dispel misconceptions and address any misinformation. Clear and concise information helps to correct any misconceptions the patient and family may have about diabetes, its treatment, and self-management, promoting understanding and adherence to the prescribed regimen. Educate patients on the basic pathophysiology of diabetes, including the definition of diabetes, normal blood glucose ranges, and target blood glucose levels. Understanding the pathophysiology of diabetes empowers patients to recognize the importance of maintaining blood glucose control and adhere to treatment regimens. Provide education on various treatment modalities, including insulin administration and oral antidiabetic medications, as well as meal planning and monitoring blood glucose and urine ketones. Empowering patients with knowledge of treatment modalities and self-monitoring techniques promotes active participation in diabetes management and helps them make informed decisions about their care. Educate patients on recognizing, treating, and preventing acute complications such as hypoglycemia and hyperglycemia. Prompt recognition and appropriate management of acute complications are crucial for maintaining stable blood glucose levels and preventing complications that could lead to hospitalization or emergency care. Emphasize the importance of lifelong diabetes education, both formal and informal, to continuously enhance knowledge and skills. Reinforcing that diabetes education is an ongoing process helps patients understand the need for continued learning and self-improvement in managing their diabetes effectively. Develop a comprehensive education plan for in-depth and continuing education based on the patient’s needs and interests, including topics such as carbohydrate counting, insulin adjustment, and preventive measures for long-term complications. Providing in-depth education tailored to the patient’s specific needs helps them develop advanced diabetes management skills and preventive measures to reduce the risk of long - term complications. Prioritize education on preventive measures, especially foot care and eye care, to promote early detection and treatment, thereby reducing the occurrence of amputations and
blindness. Emphasizing preventive measures related to foot and eye care is crucial for patients with diabetes to minimize the risk of complications that could significantly impact their quality of life. Initiate basic skill education as early as possible for hospitalized patients, allowing them to practice skills under supervision before discharge. Hospitalized patients often have limited time for education due to shorter lengths of stay. Early initiation of basic skill education enables patients to acquire essential diabetes management skills and receive supervised practice to enhance their confidence and competence before transitioning to home care. Plan for follow-up in the home setting to reinforce the skills learned during the hospital stay. Reinforcing skills in the home environment helps patients apply what they have learned in a familiar context, enhancing their ability to manage diabetes effectively in their everyday lives. Adapt the diabetes treatment and education plan to accommodate the patient’s cultural beliefs and practices. Cultural beliefs and practices can significantly impact a patient’s adherence to a diabetes regimen. Adapting the plan to align with the patient’s cultural context promotes cultural competence, patient-centered care, and improved treatment outcomes. Collaborate with a multidisciplinary team, including diabetes educators and specialists, to provide comprehensive and advanced education based on the patient’s interest and ability. Involving a multidisciplinary team ensures that the patient receives specialized and individualized education, addressing their unique needs and enabling them to achieve optimal diabetes management and self-care. Considerations for pediatric clients Assess the parent’s and child’s understanding of disease and ability to perform procedures and care, for educational level and learning capacity, and for developmental level. Provides information essential to develop a learning program; children ages 8 to 10 may be able to take responsibility for some of the care. Provide a quiet, comfortable environment; allow time for teaching small amounts at a time and for reinforcement, demonstrations, and return demonstration; start educating one day following diagnosis and limit sessions to 30 to 60 minutes. Prevents distractions and facilitates learning. Include as many family members in teaching sessions as possible. Promotes understanding and support of family and feeling of security for the child.
Provides a method to improve self-care and demonstrates the need to notify the physician for treatment evaluation and possible modification. Instruct the child to wear or carry identification and information about the disease, treatment, and physician name. Provides information in case of an emergency. Considerations for older adults Regularly evaluate self-care skills, such as insulin administration, blood glucose monitoring, foot care, and diet planning, especially in patients with deteriorating vision and memory. Ongoing evaluation of self-care skills is crucial for older adults with diabetes, particularly those experiencing sensory or cognitive decline. Regular assessments allow for timely interventions, adaptations, and additional support as needed. Tailor the choice of blood glucose meter to the patient’s visual and cognitive status and dexterity. Selecting an appropriate blood glucose meter that aligns with the patient’s visual, cognitive, and physical abilities ensures accurate monitoring and supports their ability to manage diabetes effectively at home. Individualizing the choice of meter promotes patient engagement and adherence to self-care practices. Provide written instructions with handouts for patients to take home, facilitating diabetes management in the home setting. Written instructions serve as a reference for patients and their families, supporting diabetes management outside the hospital. Providing handouts with clear instructions promotes adherence to the treatment plan and empowers patients to take an active role in their self-care. Involve family members in assisting with diabetes basic skills when appropriate. Engaging family members in diabetes care can provide support and assistance to older adults, especially in tasks that may be challenging due to physical or cognitive limitations. Involving family members helps ensure continuity of care and promotes patient well-being.
2. Achieving Glycemic Control and Blood Glucose Monitoring The goal of diabetes management is to normalize insulin activity and blood glucose levels to prevent or reduce the development of complications that are neuropathic and vascular in nature. Glucose control and management can dramatically reduce the development and progression of complications. Nursing Diagnosis
- Risk for Unstable Blood Glucose Levels as evidenced by [e.g., inadequate diabetes knowledge, inconsistent self-care practices, and potential barriers such as limited resources, lack of family support, or cultural beliefs] Expected Outcomes
- The patient will demonstrate stable blood glucose levels within the target range as evidenced by regular self-monitoring and adherence to the prescribed treatment plan.
- The patient will recognize early signs and symptoms of hypoglycemia and hyperglycemia and respond with appropriate interventions. Self-Monitoring of Blood Glucose (SMBG) Self-monitoring of blood glucose (SMBG) empowers individuals with diabetes to personalize their treatment and achieve optimal blood glucose control. Educate the patient on proper self-monitoring of blood glucose (SMBG) techniques. SMBG is essential for diabetes management as it helps individuals monitor their blood glucose levels and make necessary adjustments to their treatment regimen. Providing education on proper SMBG techniques ensures accurate and reliable readings, reducing the risk of errors that may lead to inappropriate treatment decisions. Assess the patient’s visual acuity, fine motor coordination, and cognitive abilities to determine the appropriate SMBG method. The success of SMBG relies on the patient’s ability to perform the required tasks. Assessing visual acuity, fine motor coordination, and cognitive abilities helps determine the most suitable SMBG method for the patient, ensuring they can effectively use the blood glucose monitor and obtain accurate results. Encourage regular calibration of blood glucose readings to plasma values and check the validity of readings with control solutions. Calibration of blood glucose readings to plasma values is crucial to ensure accurate interpretation and appropriate management decisions. Encouraging patients to check the validity of readings with control solutions helps identify any discrepancies and ensures the meter and strips are functioning correctly, maintaining the accuracy of SMBG results. Evaluate the patient’s SMBG techniques regularly, including a comparison with laboratory- measured blood glucose levels. Regular evaluation of the patient’s SMBG techniques helps identify any errors or inconsistencies in blood glucose readings. Comparing SMBG results with laboratory-measured blood glucose levels provides an opportunity to validate the accuracy of the patient ’s monitoring practices and make necessary adjustments or provide additional education if needed.
reliable data collection. Assisting the patient in this process ensures that the CGMS functions effectively and provides accurate readings for analysis. Collaborate with the healthcare team to download and analyze the CGMS data. The data obtained from the CGMS device needs to be downloaded and analyzed to assess blood glucose patterns and trends. Collaborating with the healthcare team in this process ensures that the information is properly evaluated, allowing for adjustments in the patient’s diabetes treatment plan if needed. Emphasize the role of CGMS in providing comprehensive 24-hour blood glucose monitoring. Unlike traditional blood glucose monitoring methods, CGMS offers continuous monitoring over a 24-hour period. Communicating the benefits of CGMS, such as detecting blood glucose fluctuations throughout the day and night, helps patients understand the value of this technology in optimizing their diabetes management. Highlight the suitability of CGMS for patients with type 1 diabetes. CGMS is particularly beneficial for patients with type 1 diabetes who rely on external insulin administration. By emphasizing the usefulness of CGMS in monitoring blood glucose levels and assessing treatment adequacy, patients with type 1 diabetes can make informed decisions regarding insulin adjustments and overall diabetes control. Monitoring Glycated Hemoglobin (A1C) Glycated hemoglobin (HbA1C or A1C) is a measure of glucose control over the past three months. Educate the patient on the significance of glycated hemoglobin (HbA1C) testing and its interpretation. Understanding the concept and interpretation of HbA1C testing empowers the patient to comprehend their long-term glucose control. By educating the patient about the significance of A1C testing, they can understand that it provides a measure of their glucose control over the past three months. This information helps in evaluating the effectiveness of their diabetes management plan and making necessary adjustments to achieve target glycemic control. Regular A1C testing promotes self-awareness and empowers the patient to actively participate in their diabetes care. Assist the patient in implementing strategies to achieve and maintain target HbA1C levels. Collaborating with the patient to develop and implement strategies for glucose control promotes better glycemic management and aids in achieving target HbA1C levels. The typical range for HbA1C values is 4% to 6%, signifying near-normal blood glucose concentrations, while the target range for individuals with diabetes is set at less than 7%.
Monitoring Ketones Ketones are produced as by-products of fat breakdown and accumulate in the blood and urine. Urine ketone testing is recommended for patients with type 1 diabetes with glycosuria or persistently elevated blood glucose levels (over 240 mg/dL or 13.2 mmol/L for two consecutive tests), during illness, in pregnancy with pre existing diabetes, and in gestational diabetes. Teach the patient how to correctly use urine dipsticks (Ketostix, Chemstrip uK, or others) for monitoring ketones and glucose levels in the urine. Accurate usage of these dipsticks is crucial for detecting ketonuria and persistently elevated glucose levels, which are indicative of deteriorating diabetes control. Advise the patient to perform urine ketone testing whenever they have glycosuria or their blood glucose levels remain above 240 mg/dL or 13.2 mmol/L for two testing periods in a row. Regular monitoring of urine ketones during these conditions can help detect insulin deficiency early, enabling timely intervention. Educate the patient about the implications of ketones in the urine, emphasizing the link between ketone presence and deficient insulin levels. Understanding the significance of ketonuria can motivate the patient to adhere to regular monitoring, contributing to better management of their diabetes. Instruct the patient to increase the frequency of urine ketone testing during periods of illness or pregnancy. These situations can impact the body’s insulin requirements and hence diabetes control, making it crucial to closely monitor for changes. For patients who are under nothing per orem (NPO) Ensure appropriate adjustments in insulin dosage and regimen for patients who are NPO. When patients are NPO for diagnostic or surgical procedures, modifications in insulin dosage and regimen are necessary to prevent hypo- or hyperglycemia. This may involve eliminating rapid-acting insulin, giving a decreased amount of intermediate-acting insulin, or using alternative insulin regimens such as basal insulin administration or frequent dosing of rapid- acting insulin. Administer basal insulin, as indicated, to patients with type 1 diabetes who are NPO. In type 1 diabetes, the elimination of insulin doses can lead to the development of diabetic ketoacidosis (DKA). Providing basal insulin to patients with type 1 diabetes who are NPO helps maintain glycemic control and prevents the onset of DKA.
Administering IV insulin as part of the parenteral nutrition helps regulate glycemic control and prevent hyperglycemia. Coordinate subcutaneous insulin administration with the infusion schedule of limited - duration parenteral nutrition. When parenteral nutrition is infused over a limited number of hours, subcutaneous insulin should be administered to align peak times of insulin action with the times of parenteral nutrition infusion. This synchronization helps maintain stable blood glucose levels during the infusion period. Monitor blood glucose levels regularly in patients receiving parenteral nutrition. Regular monitoring of blood glucose levels is essential to assess glycemic control and guide insulin administration. Monitoring allows for timely adjustments in insulin dosage and prevents hypo- or hyperglycemia in patients receiving parenteral nutrition. Glucose control during periods of stress Monitor blood glucose levels closely during periods of physiologic stress, such as infections or surgery. Physiologic stress can contribute to hyperglycemia in patients with diabetes. Close monitoring of blood glucose levels helps identify any fluctuations and allows for timely intervention to prevent complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Assess the patient’s emotional well-being and provide emotional support during hospitalization. Emotional stress related to hospitalization can negatively impact diabetic control. Providing emotional support helps alleviate stress and promote psychological well-being, which can indirectly contribute to better diabetic control. Educate the patient about the relationship between stress and glucose levels, emphasizing the importance of maintaining the diabetes treatment plan during times of stress. Patients with diabetes need to understand that emotional stress can affect their glucose levels. By educating them about this relationship, they can be empowered to adhere to their treatment plan even during stressful periods, reducing the risk of glucose fluctuations and complications. Teach stress management techniques and coping strategies to the patient. Learning strategies for minimizing and coping with stress is crucial for patients with diabetes. By providing education on stress management techniques, such as deep breathing exercises, mindfulness, or engaging in hobbies, nurses empower patients to effectively manage their stress levels and maintain better diabetic control.
Encourage the patient to engage in healthy coping mechanisms as part of diabetes self- management. Healthy coping strategies are essential for managing diabetes effectively. Encouraging patients to engage in activities such as regular exercise, social support, relaxation techniques, and seeking professional help if needed promotes overall well-being and glycemic control. Provide diabetes education that includes information on stress management and coping strategies. Diabetes education should encompass not only the management of glucose levels but also the skills to cope with stress. By including stress management and coping strategies in diabetes education, patients are equipped with the tools to navigate stressful situations while maintaining diabetic control.
3. Insulin Therapy and Normalizing Insulin Activity Effective insulin management is vital for optimal diabetes control. Individuals with type 1 diabetes rely on lifelong insulin administration, while those with type 2 diabetes may require insulin if other treatments fail. Regular blood glucose monitoring and appropriate insulin dosage adjustments are necessary for maintaining stable levels. By managing insulin effectively, individuals can reduce the risk of complications and improve their overall quality of life. Nursing Diagnosis - Deficient Knowledge related to insulin therapy and self-management as evidenced by lack of understanding of insulin administration techniques, timing, and potential complications. Expected Outcomes - The patient will demonstrate proper insulin administration techniques, including appropriate timing and site rotation, as evidenced by return demonstration. - The patient will verbalize understanding of the different types of insulin, their onset, peak, and duration of action, and how they relate to meal planning and blood glucose control. - The patient will demonstrate safe practices for insulin storage, preparation, and syringe disposal, reducing the risk of contamination, infection, and dosing errors. Educating patients on insulin therapy Assess the patient’s readiness and ability to participate in insulin therapy. Insulin regimens can vary in complexity, and it is crucial to determine the patient’s willingness
Type of Insulin Examples Appearance Onset of Action Duration of Action Notes Intermediate- acting insulin
NPH
(Neutral Protamine Hagedorn), Lente Cloudy 1 hour 18 - 26 hours Inspect for flocculation; do not use if frosted. Long-acting insulin Ultralente, insulin glargine (Lantus) Clear 1 hour 36 hours (Ultralente), ≥24 hours (Lantus) No peak action, cannot be mixed with other insulin due to pH causing precipitation. Intermediate and rapid combination insulin
NPH/30%
regular Cloudy Similar to rapid- acting Similar to intermediate- acting Premixed for combined rapid onset and longer duration. Educate the patient about different insulin regimens and their advantages/disadvantages. Providing information about various insulin regimens empowers the patient to make an informed decision. By understanding the potential benefits and costs of each regimen, the patient can actively participate in the selection process. Teach the patient about meal planning and its impact on insulin requirements. Proper meal planning plays a significant role in managing blood glucose levels. The nurse should educate the patient on the relationship between food intake and insulin doses. For instance, rapid-acting or short-acting insulins are intended to cover the increase in glucose levels after meals, while intermediate-acting insulins help regulate subsequent meals. Provide education on self-monitoring of blood glucose (SMBG) and carbohydrate counting. SMBG helps patients monitor their blood glucose levels and make necessary adjustments to
insulin doses. Teaching carbohydrate counting enables patients to match insulin doses to their food intake, providing flexibility in timing and content of meals. Instruct patients on practical information such as where to purchase and store insulin, syringes, and glucose monitoring supplies, as well as when and how to contact their primary healthcare provider. Practical information ensures patients have the necessary tools and resources for self- management and know when to seek professional assistance. Instructing the patient on proper timing of insulin administration. Different insulin preparations have varying onset, peak, and duration of action. It is crucial to educate the patient about the timing of insulin injections to ensure optimal glucose control. For example, rapid-acting insulins should be administered shortly before meals, while basal insulins should be taken consistently to maintain glucose levels irrespective of meals. Monitor and assess the patient’s response to insulin therapy. Regular monitoring of the patient’s blood glucose levels, along with ongoing assessment of their glycemic control and any adverse effects, allows for timely adjustments in the insulin regimen. Monitoring also helps evaluate the patient’s adherence to the prescribed therapy. Monitor for signs and symptoms of hypo- and hyperglycemia. Diabetes management aims to maintain blood glucose levels within a target range. Hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) are potential complications. Regular monitoring and early detection of these conditions allow for prompt interventions to prevent further complications. Provide support and education on preventing and managing hypoglycemia. Intensive insulin regimens pose a higher risk of hypoglycemia. Educating the patient about the signs, symptoms, and management of hypoglycemia helps prevent and address this potential complication. Educate patients on the importance of preparing insulin injections consistently and avoiding errors in dosing or using the wrong type of insulin. Consistent preparation of insulin injections minimizes the risk of dosing errors and ensures proper insulin administration. Accurate preparation is crucial for achieving glycemic control and preventing adverse effects. Explain the recommended order for drawing up mixed insulins, with regular insulin being drawn up first. Drawing up regular insulin before other types of insulin helps ensure accurate dosing and maintains consistency in technique. Following a specific order reduces the risk of incorrect insulin doses and promotes safe administration.
