ms diabetes mellitus

DDiiaabbeetteess mmeelllliittuuss Diabetes mellitus (DM) is a chronic disease that causes high blood glucose

levels. It results from insulin nonproduction, insufficient insulin production, or

inadequate insulin utilization. DM causes carbohydrate, protein, and fat

metabolism disturbances in two primary forms: autoimmune disease that destroys

islets of Langerhans pancreatic beta cells, which produce insulin, and metabolic

disease caused by insulin resistance, with a resulting defect in compensatory

insulin production.

Pathophysiology

Insulin allows cells to use glucose as energy or to store it as glycogen. It also

stimulates protein synthesis and free fatty acid storage in adipose tissues. A

deficiency compromises body tissues' access to essential nutrients for fuel and

storage.

Complications

■ Microvascular disease (including retinopathy, nephropathy, and neuropathy)

■ Dyslipidemia

■ Macrovascular disease (including coronary, peripheral, and cerebral artery

disease)

■ Diabetic ketoacidosis

■ Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

■ Excessive weight gain

■ Skin ulcerations

■ Chronic renal failure

AAsssseessssmmeenntt ((oonnllyy ppootteennttiiaall aabbnnoorrmmaalliittiieess lliisstteedd)) NURSING HISTORY BY FUNCTIONAL HEALTH PATTERN Health perception and management Type 1

■ Family history of diabetes

■ Age younger than 30

■ Flulike syndrome with acute symptom onset

Type 2

■ Family history of diabetes

■ Age older than 45

■ Gradual symptom onset Nutrition and metabolism Type 1

■ Increased thirst (polydipsia)

■ Increased appetite (polyphagia)

■ Weight loss

■ Ketosis

■ Nausea (occasionally)

Type 2

■ Polydipsia

■ Polyphagia

■ History of high−refined carbohydrate, high-calorie diet

■ Excess weight (possible recent weight gain) Elimination Type 1

■ Polyuria

■ Constipation

■ Diarrhea

Type 2

■ Nocturia

■ Polyuria

■ Constipation

■ Diarrhea

■ Diuretics (taken for another condition)

■ Acute or recurrent urinary tract infections (UTIs) Activity and exercise Type 1

■ Sudden weakness

■ Increased fatigue

■ Sleepiness

Type 2

■ Weakness and fatigability (gradually increasing)

■ Lack of regular exercise Cognition and perception Type 1

■ Dizziness

■ Orthostatic hypotension

■ Abdominal pain

Type 2

■ Pruritus

■ Poorly healing skin infections

■ Myopia

■ Blurred vision

■ Muscle cramping

■ Abdominal pain

■ Extremity numbness, pain, or tingling

■ Irritability Sleep and rest Type 1

■ Sleep disturbance (due to nocturia)

Type 2

■ Sleep disturbance

■ Drowsiness after meals Sexuality and reproduction Type 2

■ Loss of sex drive

■ Erectile dysfunction

■ Recurrent vaginitis or vaginal infections Roles and relationships Types 1 and 2

■ Role strain

■ Workplace disruption due to treatment responsibilities or complications Coping and stress management Types 1 and 2

■ Noncompliance due to denial

PHYSICAL EXAMINATION Integumentary ■ Poorly healing skin wounds, especially on feet

■ Skin infections

■ Warm, flushed, dry skin (in diabetic ketoacidosis [DKA]) Respiratory ■ Deep, rapid (Kussmaul's) respirations

■ Fruity breath odor (in DKA)

Cardiovascular ■ Tachycardia

■ Orthostatic hypotension

■ Hypertension

■ Cool extremities

■ Decreased pulses Gastrointestinal ■ Abdominal distention

■ Decreased bowel sounds

■ Abdominal tenderness Neurologic ■ Drowsiness

■ Confusion

■ Coma (in DKA)

■ Altered reflexes Renal and urinary ■ Vaginal discharge

■ Perineal irritation

DIAGNOSTIC STUDIES ■ Random serum glucose test reveals a level greater than or equal to 200 mg/dl.

■ Fasting serum glucose test reveals a level greater than or equal to 126 mg/dl

(confirms DM).

■ Urinalysis reveals glycosuria and, in type 1, ketonuria. (Urine microalbumin is

the earliest indication of diabetic renal disease.)

■ Glucose tolerance test reveals a level greater than or equal to 200 mg/dl in the

2-hour sample.

■ Blood insulin level is absent or minimal in type 1, and low, normal, or high in

type 2.

■ Glycosylated hemoglobin test detects elevations or wide fluctuations in blood

glucose over time; greater than 8% indicates poor glucose control in either type

1 or type 2.

■ Arterial blood gas studies can reveal metabolic acidosis, particularly common

in type 1, with compensatory respiratory alkalosis.

■ Electrolyte panel (needed to establish baseline) may be normal or reveals

hyponatremia or hyperkalemia associated with dehydration or DKA (type 1).

■ Blood urea nitrogen (BUN) levels (needed to establish baseline) may be normal

or elevated in DKA or HHNS.

■ BUN and creatinine levels (needed to establish baseline) may be normal or

elevated in the presence of renal involvement.

Nursing care plan Nursing diagnosis Nursing priorities Risk for unstable glucose level related to inadequate endogenous insulin (type 1 DM) or inadequate endogenous insulin and insulin resistance (type 2 DM)

■ Prevent or minimize complications when establishing treatment regimen to control altered glucose metabolism.

Deficient knowledge (self-care) related to newly diagnosed complex chronic disease

■ Establish a diabetes control regimen, emphasizing self-care.

Ineffective therapeutic regimen management related to lack of material resources, lack of support, or ineffective coping

■ Optimize management of personal therapeutic regimen.

Other potential nursing diagnoses: Ineffective coping related to denial ■ Risk for imbalanced fluid volume related to physiologic manifestations of disease process ■ Risk prone health behavior related to inability to modify lifestyle with change in health status

RRiisskk ffoorr uunnssttaabbllee gglluuccoossee lleevveell rreellaatteedd ttoo iinnaaddeeqquuaattee eennddooggeennoouuss iinnssuulliinn ((ttyyppee 11 DDMM)) oorr iinnaaddeeqquuaattee eennddooggeennoouuss iinnssuulliinn aanndd iinnssuulliinn rreessiissttaannccee ((ttyyppee 22 DDMM)) EXPECTED OUTCOME The patient will maintain a stable blood glucose level.

Suggested NOC Outcomes

Neurological status: Consciousness

NURSING INTERVENTIONS Intervention type Intervention Rationale Collaborative Administer insulin or oral

antidiabetic medications, as ordered.

Insulin increases cellular glucose uptake and decreases gluconeogenesis. Exogenous insulin is essential for controlling type 1 DM and may also be used in type 2 DM. Oral agents stimulate beta cells to secrete insulin, block glucose absorption in the small intestine, increase insulin sensitivity in peripheral tissue, or reduce glucose production in the liver.

Collaborative Monitor fingerstick blood glucose levels according to facility protocol, clinical status, and before giving antidiabetic medications. Follow established

Assessment of glucose levels is essential for monitoring the patient's response and adjusting treatment. Checking the glucose level and

protocol for withholding the dose based on normal values.

withholding the dose if the level is acceptable prevents medication-induced hypoglycemia. Protocols for withholding doses vary depending on the antidiabetic medication ordered and the patient's status.

Collaborative Note differences in peak action and duration of action for various antidiabetic medications. ■ Rapid-acting insulins (insulin aspart) peak between 1 and 2 hours. ■ Short-acting insulins (regular, Humulin R), peak within 2 and 4 hours. ■ Intermediate-acting insulins (NPH, lente) peak between 6 and 12 hours. ■ Long-acting insulins (Ultralente, insulin glargine) peak between 10 and 30 hours. ■ Oral antidiabetic drugs with a 24-hour duration peak on the average between 3 and 4 hours.

Awareness of these characteristics helps the nurse correlate onset and duration of signs and symptoms with peaks and troughs in serum drug levels.

Collaborative Establish and maintain an I.V. fluid infusion, as ordered. Monitor for dry mucous membranes, poor skin turgor, cracked lips, abdominal pain, elevated urine specific gravity, elevated hematocrit, and other signs or symptoms of dehydration. Keep an accurate intake and output record. Document daily weight.

Accurate intake and output documentation and daily weights are essential for assessing fluid status and for early detection of inadequate renal function. Daily weight is a gross indicator of general fluid and nutritional status.

Collaborative Observe for signs and symptoms of medication-induced hypoglycemia. Reactions are most likely to coincide with peak insulin effect or late or missed meals, depending on the type of insulin and the patient's response. If a reaction occurs, notify the physician, measure blood glucose level, and treat immediately with oral glucose, I.V. glucose, or glucagon, depending on protocol and the patient's responsiveness. Recheck blood glucose in 10 minutes. Feed the patient a small snack of carbohydrate and protein if his next meal is more than 1 hour away.

Insulin reactions can occur with relative suddenness. Oral glucose is used for mild to moderate hypoglycemia when the patient can swallow; parenteral glucagon or glucose is used when the person is unconscious or can't swallow.

Collaborative Make sure the patient is served the prescribed therapeutic diet at consistent times.

The patient with DM—especially type 1 DM—needs diet guidelines tailored to meet his specific needs. Consistent carbohydrate intake distributed throughout the day is fundamental to all types of

medical nutrition therapy for DM because it helps stabilize blood glucose levels. Insulin and oral antidiabetic drugs are prescribed to fit the normal diet schedule; a missed or delayed meal can lead to hypoglycemia.

Collaborative Observe for signs and symptoms of DKA (in type 1 DM only): ■ Early: nausea; fatigue; polyuria; dry, flushed skin; dry mucous membranes; thirst; and tachycardia. ■ Late: vomiting, poor skin turgor, lethargy, Kussmaul's respirations, acetone breath, hypotension, and abdominal pain. If the patient's condition suggests DKA, notify the physician immediately.

Rapid identification of DKA allows for prompt treatment and prevents more serious complications.

Collaborative Observe for signs and symptoms of HHNS (in type 2 DM), including lethargy or stupor, fatigue, drowsiness, confusion, coma, seizures, intense thirst, and very dry mucous membranes. If the patient's condition suggests HHNS, notify the physician immediately.

Rapid identification of HHNS allows for prompt treatment and prevents more serious complications.

[Additional individualized interventions]

Suggested NIC Interventions

Hyperglycemia management: Intravenous (IV) therapy; Laboratory data

interpretation; Neurologic monitoring

DDeeffiicciieenntt kknnoowwlleeddggee ((sseellff--ccaarree)) rreellaatteedd ttoo nneewwllyy ddiiaaggnnoosseedd ccoommpplleexx cchhrroonniicc ddiisseeaassee EXPECTED OUTCOME The patient will demonstrate proficiency in injection technique and produce

evidence of site rotation documentation (if insulin is ordered); discuss disease

management in relation to medication, diet, exercise, and stress; demonstrate

proper foot care; discuss hypoglycemia and hyperglycemia and their appropriate

treatments; initiate diet planning with dietitian and plan adequate diet for 3-day

period; and perform and interpret blood glucose tests accurately.


Knowledge: Disease process; Knowledge: Health behavior; Knowledge:

Treatment regimen

NURSING INTERVENTIONS Intervention type Intervention Rationale Independent Provide information regarding

disease process, treatment regimen, and reduction of risk factors to improve health status.

Providing information may help the patient comply with the treatment plan and adjust his lifestyle appropriately to reduce risk factors.

Independent Teach the significance of insulin or oral antidiabetic medications for disease control. Demonstrate injection techniques, and observe the patient's performance.

Patient understanding is essential for home management of DM. Observing the patient's injection technique and providing opportunities for supervised practice help ensure accuracy.

Independent Involve the patient, his family, and dietitian in planning a therapeutic diet. Reinforce nutritional guidelines. Encourage supervised weight loss if the patient is overweight. Ensure that the patient has been given written diet guidelines before discharge. Provide referral for further questions and special situations (such as "sick day" management, pregnancy, dining out, exercise, use of alcohol, or complications).

Involving the patient and his family with dietary planning helps ensure compliance at home. Written materials help minimize misunderstanding. Referral ensures an ongoing source of dietary information.

Independent Teach blood glucose testing methods for home use. Observe patient demonstrations for accuracy of testing, interpretation of results, calibration, and documentation. Provide target glucose ranges. Encourage the patient to keep a daily record of glucose monitoring.

Successful home management of DM requires that the patient perform self-monitoring to ensure that the prescribed regimen of medication, diet, and exercise remains appropriate to needs.

Independent Emphasize the importance of regular activity and exercise and of maintaining the same level of activity from day to day. Teach the patient to check his blood glucose level before exercise and consume a carbohydrate snack if blood glucose is lower than 100 mg/dl.

Exercise stimulates carbohydrate metabolism, lowers blood pressure, aids in weight control, and may help avert or minimize circulatory complications by increasing levels of high-density lipoproteins. Exercise induces blood glucose fluctuations, and increases or decreases in activity may require dietary or medication changes. Checking his blood glucose level before exercising and eating a carbohydrate snack, if indicated, minimizes the patient's hypoglycemia risk.

Independent Tell the patient to be aware of increased susceptibility to infections; discuss ways to avoid exposure. Review signs of infection, such as redness,

Awareness of signs of infection may help ensure prompt treatment.

swelling, exudate, and fever. Emphasize the importance of prompt, appropriate treatment of even minor injuries to avoid serious complications.

Independent Discuss ways to prevent the vascular complications of DM, such as proper leg and foot care. Emphasize the need to use protective footwear. Teach the patient about potential eye complications, symptoms of UTI, and renal impairment. Help the patient understand the significance of careful disease control.

DM is characterized by degenerative vascular changes that predispose the patient to infections, ulcerations, and gangrene, particularly of the legs and feet. Proper foot care and protective footwear reduce the risk of complications from altered peripheral perfusion. Careful disease control can help minimize the complications caused by DM.



Teaching: Disease process; Teaching: Foot care; Teaching: Individual; Teaching:

Prescribed activity/exercise; Teaching: Prescribed diet; Teaching: Prescribed

medication; Teaching: Procedure/treatment

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EXPECTED OUTCOME The patient will verbalize an understanding of the need for lifestyle changes, ask

appropriate questions, verbalize feelings about diagnosis, participate actively in

disease control planning, have resource deficits resolved or appropriate referrals

completed, and have a home visit or outpatient follow-up appointment scheduled.


Compliance behavior; Knowledge: Diet; Knowledge: Treatment regimen;

Participation in health care decisions; Treatment behavior: Illness or injury

NURSING INTERVENTIONS Intervention type Intervention Rationale Independent Assess the patient's resources,

including financial status, physical abilities, and family support system.

Financial status, physical disabilities, and lack of support can interfere with successful home treatment.

Independent Involve the patient's family in all teaching and planning.

Family members may help reinforce teaching and encourage compliance.

Independent Arrange appropriate follow-up home health visits.

Home visits allow assessment of environmental factors that may contribute to noncompliance.

Independent Refer the patient and his family to community resources and mutual support groups.

Community or mutual support groups can offer ongoing education and support.

Independent Encourage verbalization of feelings, and support healthy coping behaviors.

Expression of feelings is a necessary prelude to acceptance of the disease and active, responsible management. Supporting healthy coping behaviors helps maintain the patient's independence and sense of self-control—both essential for compliance.



Behavior modification; Decision-making support; Health system guidance;

Mutual goal-setting; Patient contracting; Self-modification assistance; Self-

responsibility facilitation

TTeeaacchhiinngg cchheecckklliisstt ■ Disease and its implications

■ Medication regimen (purpose, dosage, administration schedule, and adverse

effects)

■ Signs and symptoms requiring urgent medical treatment

■ Blood glucose testing procedure and results

■ Dietary changes

■ Signs and symptoms, prevention, and treatment of hypoglycemia and

hyperglycemia

■ Exercise regimen

■ Foot care

■ Signs and symptoms of complications, the need to report them, and appropriate

treatment

■ Community resources and support

■ Ways to obtain emergency medical treatment

■ Follow-up care

ms diabetes mellitus

Health & Medicine