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Application to the Nursing Process of Patients with Diabetes Mellitus: Chronic

Complications

y In type 1 diabetes, chronic complications usually appear about 10 years after the initial diagnosis.y The prevalence of microvascular complications (retinopathy, nephropathy) and neuropathy is higher in

type 1 diabetes.y Because of its insidious onset, chronic complications can appear at any point in type 2 diabetes.y Macrovascular complications- in particular cardiovascular disease, occurring in type 1 and type 2

diabetes- are the leading cause of morbidity and mortality among persons with diabetes.

Nursing Assessment

y Obtain a history of current problems, family history, and general health history.o Has the patient experienced polyuria, polydipsia, polyphagia, and any other symptoms?o Number of years since diagnosis of diabeteso Family members diagnosed with diabetes, their subsequent treatment, and complications

y erform a review of systems and physical examination to assess for signs and symptoms of diabetes,general health of patient, and presence of complications.

o General: recent weight loss or gain, increased fatigue, tiredness, anxietyo Skin: skin lesions, infections, dehydration, evidence of poor wound healingo Eyes: changes in vision- floaters, halos, blurred vision, dry or burning eyes, cataracts, glaucomao Mouth: gingivitis, periodontal diseaseo Cardiovascular: orthostatic hypotension, cold extremities, weakpedal pulses, leg claudicationo GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or thirsto Genitourinary (GU): increased urination, nocturia, impotence, vaginal dischargeo Neurologic: numbness and tingling of the extremities, decreased pain and temperature

perception, changes in gait and balance

Nursing Diagnoses

y Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expendituresy Fear related to insulin injectiony Risk for Injury (hypoglycemia) related to effects of insulin, inability to eaty Activity Intolerance related to poor glucose controly Deficient Knowledge related to use of oral hypoglycemic agentsy Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremitiesy

IneffectiveC

oping related to chronic disease and complex self-care regimen

STANDARDS OF CARE GUIDELINES

Caring for Patients with Diabetes MellitusWhen caring for patients with diabetes mellitus:

y Assess level ofknowledge of disease and ability to care for selfy Assess adherence to diet therapy, monitoring procedures, medication treatment, and exercise regimeny Assess for signs of hyperglycemia: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred visiony Assess for signs of hypoglycemia: sweating, tremor, nervousness, tachycardia, light-headedness,

confusiony Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular

disease and any injury to the feet or lower extremities

y Assess for trends in blood glucose and other laboratory resultsy Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercisey Make sure patient has adequate knowledge of diet, exercise, and medication treatmenty Immediately report to health care provider any signs of skin or soft tissue infection (redness, swelling,

warmth, tenderness, drainage)y Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement

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y Get help immediately for patient presenting with signs of eitherketoacidosis (nausea and vomiting,Kussmaul respirations, fruity breath odor, hypotension, and altered level of consciousness) or

hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting, hypothermia, muscleweakness, seizures, stupor, coma).

Nursing Interventions

Improving Nutrition

y Assess current timing and content of meals.y Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Reducing

intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one foodgroup and eliminate another are generally not recommended.

y Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patient's actual bodyweight) weight loss over several months is usually achievable and effective in reducing blood sugar and

other metabolic parameters.y Assist patient to identify problems that may have an impact on dietary adherence and possible solutions

to these problems. Emphasize that lifestyle changes should be maintainable for life.y Explain the importance of exercise in maintaining/reducing body weight.

o Caloric expenditure for energy in exerciseo Carryover of enhanced metabolic rate and efficient food utilization

y Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them.y Strategize with patient to address the potential social pitfalls of weight reduction.

Teaching About Insulin

y Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulininjection, conveying a sense of empathy, and identifying supportive coping techniques.

y Demonstrate and explain thoroughly the procedure for insulin self-injection.y Help patient to master technique by taking a step-by-step approach.

o Allow patient time to handle insulin and syringe to become familiar with the equipment.o Teach self-injection first to alleviate fear of pain from injection.o Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure.

y Review dosage and time of injections in relation to meals, activity, and bedtime based on patient'sindividualized insulin regimen.

Preventing Injury Secondary to Hypoglycemia

y Closely monitor blood glucose levels to detect hypoglycemia.y Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid

hypoglycemia.

y Assess patient for the signs and symptoms of hypoglycemia.o Adrenergic (early symptoms)-sweating, tremor, pallor, tachycardia, palpitations, nervousness

from the release of adrenalin when blood glucose falls rapidlyo Neurologic (later symptoms)- light-headedness, headache, confusion, irritability, slurred speech,

lackof coordination, staggering gait from depression of central nervous system as glucose level

progressively fallsy Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates.

o Half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four sugar cubes, five to six piecesof hard candy may be taken orally.

o Nutrition bar specially designed for diabetics- supplies glucose from sucrose, starch, and proteinsources with some fat to delay gastric emptying and prolong effect; may prevent relapse. Usedafter hypoglycemia treated with fact-acting carbohydrate.

o Glucagon 1 mg (subcutaneously or I.M.) is given if the patient cannot ingest a sugar treatment.Family member or staff must administer injection.

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o I.V. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to respond toglucagon within 15 minutes.

y Encourage patient to carry a portable treatment for hypoglycemia at all times.y Assess patient for cognitive or physical impairments that may interfere with ability to accurately

administer insulin.y Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent

hypoglycemia.y Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a

hypoglycemic emergency.

Improving Activity Tolerance

y Advise patient to assess blood glucose level before and after strenuous exercise.y Instruct patient to plan exercises on a regular basis each day.y Encourage patient to eat a carbohydrate snackbefore exercising to avoid hypoglycemia.y Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid

nocturnal hypoglycemia.

y Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketonesare present. Patient should contact health care provider if levels remain elevated.

y Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.

Providing Information About Oral Antidiabetic Agents

y Identify barriers to learning, such as visual or hearing impairments, low literacy, distractiveenvironment.

y Encourage active participation of the patient and family in the educational process.y Teach the action, use, and adverse effects of oral antidiabetic agents.

o Sulfonylurea compounds promote the increased secretion of insulin by the pancreas and partiallynormalize both receptor and postreceptor defects. Many drug interactions exist, so patient shouldalert all health care providers of use. Potential adverse reactions include hypoglycemia,

photosensitivity, GI upset, allergic reaction, reaction to alcohol, cholestatic jaundice, and blooddyscrasias.

o Metformin (Glucophage), a biguanide compound, appears to diminish insulin resistance. Itdecreases hepatic glucose production and intestinal reabsorption of glucose and increases insulin

reception and glucose transport in cells.Many drug interactions exist, so patient should alert allhealth care providers of its use. Metformin must be used cautiously in renal insufficiency,

conditions that may cause dehydration, and hepatic impairment. Potential adverse reactionsinclude GI disturbances, metallic taste, and lactic acidosis (rare).

o Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the digestion andabsorption of complex carbohydrates (including sucrose or table sugar) into simple sugars, such

as glucose and fructose, thereby lowering postprandial and fasting glucose levels.

o Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos]) primarilydecrease resistance to insulin in skeletal muscle and adipose tissue without increasing insulinsecretion. Secondarily, they reduce hepatic glucose production. They should be used cautiously

in liver disease and heart failure. Liver function tests should be monitored periodically.Ovulation may occur in anovulatory premenopausal women. Adverse reactions include edema,

weight gain, anemia, and elevation in serum transaminases.o Meglitinide analogues (repaglinide [Prandin]) and amino acid derivatives (nateglinide [Starlix])

stimulate pancreatic release of insulin in response to a meal. They have a more rapid onset andshorter duration than sulfonylureas. They should not be taken when a meal is skipped or missed.

They should be used cautiously in patients with renal and hepatic dysfunction, and may causehypoglycemia.

Maintaining Skin Integrity

y Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness,hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes.

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o Use a monofilament to test sensation of the feet and detect early signs of peripheral neuropathyo Test vibratory sense over interphalangeal joints of the feet using a low-frequency tuning fork.

Vibratory sense is typically lost before tactile sensation.y Maintain skin integrity by protecting feet from breakdown.

o Use heel protectors, special mattresses, foot cradles for patients on bed rest.o Avoid applying drying agents to skin (eg, alcohol).o Apply skin moisturizers to maintain suppleness and prevent cracking and fissures.

y Instruct patient in foot care guidelines.y Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and

enhance peripheral blood flow. Help patient to establish behavior modification techniques to eliminate

smoking in the hospital and to continue them at home for smoking-cessation program.

Improving Coping Strategies

y Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life, occupation.y Explore previous coping strategies and skills that have had positive effects.y Encourage patient and family participation in diabetes self-care regimen to foster confidence.y Identify available support groups to assist in lifestyle adaptation.y Assist family in providing emotional support.

PATIENT EDUCATION GUIDELINES

Diabetes Sick-Day Guidelines

y Never omit insulin dosage. Checkwith health care provider about oral medication. For instance,Glucophage should be withheld if vomiting or in danger of becoming dehydrated.

o Take at least the usual dosage of insulin.o Keep regular insulin on hand for supplemental doses as prescribed by health care provider.

y Monitor blood glucose and urine ketones q2-4h.o Whenever blood glucose is > 240 mg/dL, test urine ketones.o Record all test results.

y Drinkplenty of fluids.o 6 to 8 oz of fluid every hour is recommended.o If unable to eat, drink fluids that contain carbohydrates (eg, fruit juices, regular soda).

y Contact health care provider if illness becomes severe or unmanageable.o Fever, nausea, vomiting, and diarrhea increase riskof dehydration.o Signs and symptoms of infection redness, swelling, drainage need immediate attention.o Large amount of urine ketones or other signs and symptoms of diabetic ketoacidosis: call health

care provider immediately.

Patient Education and Health Maintenance

y Ongoing education of patient to include advanced skills and rationales for treatment, prevention, andmanagement of complications.

y Educational focus lifestyle management issues, to include sick-day management (see Patient EducationGuidelines), exercise adjustments, travel preparations, foot care guidelines, intensive insulinmanagement, and dietary considerations for dining out.

Evaluation: Expected Outcomes

y Maintains ideal body weight with body mass index less than 25y Demonstrates self-injection of insulin with minimal feary Hypoglycemia identified and treated appropriatelyy Exercises dailyy Verbalizes appropriate use and action of oral hypoglycemic agentsy No skin breakdowny Verbalizes initial strategies for coping with diabetes