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This is a chronic condition that occurs when the pancreas produces insufficient, or the body is not able to utilize the insulin it produces efficiently. This results in elevated blood glucose levels (Hyperglycemia) and impacts fats, proteins, and carbohydrates metabolisms. Prolonged Hyperglycemia harms almost all body tissues resulting in complications of various organs like kidneys, eyes, blood vessels, and nerves.
- Diabetes Type 1 is distinguished by the damage of beta cells.
- Diabetes Type 2 is distinguished by insufficient secretion of Insulin.
- Diabetes mellitus is related to other conditions and occurs when other factors like hormonal imbalance, medication use, or pancreatic illness cause a specific type of Diabetes.
- Prediabetes is a newly classified stage of Diabetes that signifies the metabolic state between Diabetes and normal glucose homeostasis.
- Gestational diabetes mellitus refers to the experience of any degree of glucose tolerance during pregnancy.
Diabetes nursing care plans aim to promote appropriate interventions to achieve and maintain optimal blood glucose levels while minimizing complications through exercise, a balanced diet, and insulin replacement. The nurse must emphasize the significance of adhering to the recommended treatment regimen via practical patient education. The teaching should be tailored toward the patient’s abilities, development stage, and needs. Emphasis on the long-term health impact of blood glucose control.
- Risk for Unstable Blood Glucose Level
- Risk for Impaired Skin Integrity
- Risk for Fluid Volume Deficit
- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Infection
- Risk for Disturbed Sensory Perception
- Risk for Ineffective Management of Therapeutic Regimen
- Risk for Injury
1. Risk for Unstable Blood Glucose Level
The objective of managing Diabetes is to optimize the activities of insulin and glucose levels in the blood to minimize or prevent vascular or neuropathic complications. Controlling glucose levels can potentially minimize the progression and development of complications. There are different types of sugars, but our bodies primarily utilize glucose. When we take other sugars like lactose from milk or fructose from fruits, they are converted to glucose by our body and used for energy. Besides, starch which comprises sugar linked together is broken down into glucose. Glucose is transported from the intestines or liver through the bloodstream to body cells, where absorption takes place with the help of Insulin.
Various clinical conditions cause Hyperglycemia which is elevated sugar levels in the bloodstream. The common condition related to increased sugar levels is diabetes mellitus. Besides, particular medications cause Hyperglycemia as a side effect.
On the other hand, low blood sugar levels or Hypoglycemia occurs due to excessive Insulin use in diabetes mellitus patients. In some cases, it occurs in people with insufficient adrenal, eating disorders like excessive alcohol intake, anorexia nervosa, starvation, or prolonged fasting. In addition, low blood sugar levels after meals may be due to gastric bypass surgery or taking excess refined carbohydrates resulting in high insulin production.
- Risk for Unstable Blood Glucose Level: Demonstrated by insufficient blood glucose tracking and ineffectiveness in implementing diabetes management.
- Non-compliance with managing Diabetes.
- Inadequate monitoring of blood sugar levels.
- Inadequate understanding of diabetes management.
- Elevated levels of stress and a sedentary lifestyle.
- Too much or too little Insulin.
- Reluctant to acknowledge the diagnosis.
- Challenges with handling medication.
- Levels of development.
- Signs do not indicate a risk diagnosis. Measures are aimed at prevention.
- The patient will uphold and attain glucose levels in the acceptable range (specify)
- The patient blood sugar level is expected to be below 180 mg/dl, hemoglobin AIC levels below 7%, and fasting blood sugar levels below 140 mg/dl.
- The patient is expected to recognize essential factors leading to fluctuating glucose levels.
|Evaluate for symptoms of Hyperglycemia
|Hyperglycemia occurs as a result of inadequate Insulin to regulate glucose. Excessive glucose causes an osmotic pressure leading to hunger, urination, and thirst. Patients may also experience blurred vision and fatigue.
|Evaluate glucose levels prior to eating and bedtime.
|Random glucose level results should range from 140 to 180 mg/dl. The pre-meal level of a patient who is not in intensive care should be 140 mg/dl.
|Monitor the HbA1c-glycosylated hemoglobin levels of the patient.
|This involves measuring blood glucose in the last 2 to 3 months with a desired outcome of 6.5% to 7%.
|To aid in evaluating the adequacy of their nutritional intake.
|Assess tremors, anxiety, and slurring of speech. Use 50% dextrose to treat Hypoglycemia
|These are hypoglycemia symptoms and are treated with D50
|Evaluate the patient feet for temperature, sensation, color, and pulse.
|This helps to monitor neuropathy and peripheral perfusion
|Examine for bowel sounds and note any complaint about bloating, vomiting or nausea, and abdominal pain.
|Hyperglycemia can interfere with gastrointestinal motility in the duodenum, the jejunum, and the stomach, and treatment options.
|Observe urine albumin to serum creatinine levels for renal failure symptoms.
|Renal failure is shown by creatinine levels higher than 1.5 mg/dl.
|Assess the physical activity routine of the patient.
|Exercises are essential in reducing blood glucose levels and minimizing cardiovascular complications risk.
|Observe for Hypoglycemia.
|Individuals with type 2 diabetes utilizing Insulin are at the potential for getting Hypoglycemia. Hypoglycemia symptoms result from elevated adrenergic activities and minimized glucose circulation in the brain.
|Assess the client’s understanding of the prescribed nutrition
|Nonadherence with prescribed nutritional guidelines may lead to Hyperglycemia; thus, an individualized diet is recommended.
|Evaluates the ability of the patient to self-monitor blood glucose levels.
|The self-monitoring techniques should match the skill of the client.
|Before exercise, determine the blood glucose levels of the patient.
|Patients with urine ketones and blood glucose levels exceeding 250 mg/dl are advised to avoid engaging in physical activities.
|Discuss the health beliefs of the patient related to physical exercise. Examine the proposed exercise regimen with the patient.
|Encourage exercise simultaneously with intensity daily and increase the intensity gradually for new exercise programs.
|Provide prandial and basal Insulin as prescribed.
|Adherence to the treatment plan enhances blood flow to the tissues. Maintaining optimum blood glucose levels helps slow down microvascular disease growth.
|Be aware of morning hyperglycemia symptoms.
|This condition is distinguished by increased blood glucose levels in the morning because of inadequate Insulin.
|Educate the patient on how to monitor blood glucose at home.
|This may involve checking blood glucose levels before eating and bedtime and adjusting insulin doses based on the readings.
|Report systolic blood pressure levels greater than 160mm Hg and provide recommended antihypertensive medication.
|High blood pressure is related to Diabetes, and controlling it prevents complications like stroke, nephropathy, retinopathy, and coronary artery disease.
|Advise the patient to wear shoes always and avoid heating pads
|Due to peripheral neuropathy, the patient may experience decreased sensation in the extremities.
|Advise the patient to take oral hypoglycemia drugs as prescribed.
|Some of the medications include:
Meglitinides: stimulates the production of insulin.
Sulfonylureas are used primarily in diabetic type 2 as an insulin stimulant.
Alpha-glucosidase inhibitors: It is a rapid stimulant for insulin.
Biguanides: Reduces the level of glucose secreted by the liver.
|Advice the client to take Insulin as prescribed
|Some of the insulin includes:
Rapid-acting insulin analogs; insulin aspart; lispro Insulin (Humalog): The onset of this insulin is 15 minutes. Humalog stays in the body for about 2 to 3 hours while aspart is about 3 to hours.
Short-acting Insulin (regular Insulin); regular Humulin R. Its impacts are felt after 30 minutes. Its duration is about 4 to 8 hours
|Educate the patient on appropriate methods of insulin injection.
|Injection of insulin in particular body parts increases consistency. Absorption of Insulin is better in the abdomen, arms, thighs, and buttocks.
|Teach the patient the significance of proper rotating injection sites when injecting Insulin.
|Rotating injection sites helps prevent fatty mass growth, affecting Insulin absorption.
|Teach the patient on appropriate methods of storing Insulin.
|Insulin should be kept in a refrigerator, unfreeze, avoid direct sunlight, and avoid temperature extremes. Vials should be held at 15 to 30 degrees for 1 month to reduce irritation. Open vials should be disposed of after that time, while closed vials can last until expiry. The patient should be instructed to keep spare vials of prescribed Insulin.
|Instruct the patient to store vials in use at room temperature.
|Storing vials at room temperature minimizes irritation.
|Emphasis on the significance of attaining blood glucose levels.
|Keeping blood glucose levels at an optimum range significantly minimizes progress and the development of complications.
|Review and monitor techniques used by the patient in self-monitoring blood glucose.
|Assess if there might be errors in SMBG because of incorrect methods such as inappropriate cleaning and maintenance, too small blood drop, damage to reagent strips, and wrong application of blood. Using incorrect ways may provide the patient with false blood glucose values.
2. Risk for Impaired Skin Integrity
This can occur when diabetic people experience neuropathies that reduce or remove sensation, exposing them to damage
- Risk for impaired skin integrity
Risk factors include:
- Diabetic Neuropathies.
- Minimal sensation and circulation due to arterial obstruction, peripheral neuropathy, and diabetic neuropathy.
The desired results of treatment include:
- To keep the patient skin on feet and legs intact when hospitalized
- Ensure that the patient demonstrates proper foot care.
Nursing Assessment and Rationales
|Conduct a comprehensive initial and ongoing evaluation of the following.
|a) issues with lower extremities, like fissures, lesions, cellulitis, redness, dryness, blisters, or gangrene.
b) the musculoskeletal condition of the ankle, foot, bone abnormalities, and range of joint motion.
c) evaluation of the nervous system, including temperature, pain, and touch sensation.
d) assessment of vascular extremities, lesions, capillary refill, and skin temperature.
e) the hydration status.
Peripheral neuropathy is believed to increase the risk of lower extremity gangrene in diabetic people due to changes in pain, temperature, and pressure perception. Conditions like dryness, skin lesions, and hydration can lead to infections and delay healing.
|Evaluate skin integrity, deep tendon reflexes, knee, and proprioception to identify neuropathy.
|These are neuropathy signs assessments. The skin on pressure points in the lower extremities is at risk of developing ulcers.
|Assess feet for trauma or erythema daily
|These are the symptoms necessitating skin prevention from infections.
Nursing Interventions and Rationales
|Use elbow protectors, space boots, pressure-relief mattresses, and foot cradle
|To minimize pressure on sensitive points.
|Encourage the patient to clean their feet regularly with warm water and mild soap, and check the temperature before inserting the feet.
|To prevent burns and dermal injury due to reduced sensation.
|Regularly change your stockings or socks. Encourage the use of white cotton socks.
|To prevent infection from moisture. White fabrics make it easier to visualize exudates or blood.
|Moisturize feet gently
|It helps to prevent skin cracking
|Soften toenails with water and cut them straight across.
|It helps to reduce ingrown toenails that may cause infection.
|Instruct the patient always to wear shoes.
|To prevent the risk of trauma and ulceration, and infection.
|Wash feet daily with mild soap and lukewarm water.
|Good foot hygiene reduces the chance of infection.
|Instruct the patient to avoid hot baths.
|Patients with peripheral neuropathy should avoid hot baths to prevent burn injuries due to low-temperature sensation.
|Discuss the need for smoking cessation if possible.
|Smoking could lead to vasoconstriction, compromising the blood supply in the feet.
|Promptly clean and treat blisters and cuts with antiseptic.
|Immediate treatment of wounds minimizes the risk of infection. Thus, if the scars on the patient appear infected, encourage them to notify healthcare providers.
3. Risk for Fluid Volume Deficit
Hyperglycemia is associated with excessive thirst and urination as the body tries to eliminate excess water, electrolytes, and glucose, leading to fluid volume shortage.
- Risk for fluid volume deficit
- Osmotic diuresis
- Extreme gastric secretions via vomiting and diarrhea.
- Limited intake: confusion, nausea.
- The patient is expected to show they are sufficiently hydrated by presenting stable vital signs, healthy skin elasticity, a detectable peripheral, proper amount of urine output, and electrolyte levels dropping to the optimum range.
Nursing Assessment and Rationale
|Evaluate the client’s medical history regarding the intensity or duration of signs like excessive urination and vomiting.
|This assessment aids in estimating the amount of fluid depletion. The duration of these signs may vary from a few hours to many days. Besides, the infection may lead to fever and hypermetabolic states, leading to insensible fluid loss.
|Observe essential symptoms.
|Orthostatic blood pressure changes: low blood volume or Hypovolemia can cause a fast heart rate and low blood pressure. Reduced systolic blood pressure for more than 10 mmHg when changing position, either from lying to sitting or standing, can aid in assessing the severity of Hypovolemia. It is important to note that cardiac neuropathy may impact reflexes that elevate heartbeats.
Monitor breathing patterns such as acetone breath and Kussmaul’s respiration: helps to signify respiratory alkalosis due to ketoacidosis. Acetone breath results from acetoacetic acid breakdown and is expected to reduce with the correction of ketosis.
Assess respiratory quality and rate, utilization of accessory muscles, apnea periods, and cyanosis appearance: these signs indicate respiratory fatigue and compensation of lost acidosis.
Observe temperature, moisture, skin color, and turgor: these are signs of dehydration, especially when accompanied by chills, fever, and diaphoresis.
|Evaluate capillary refill, peripheral pulse, and mucous membranes.
|It helps in assessing the hydration level and circulating volume requirement.
|Observe output and intake, and note urine-particular gravity.
|It provides a continuous approximate volume replacement requirements, the effectiveness of therapy, and kidney function
|Weigh the patient daily.
|Provides the effective evaluation of current fluid volume and fluid replacement requirement.
Nursing Interventions and Rationale
|Ensure the patient takes a minimum of 2500 ml of fluid daily when they resume oral intake.
|It helped to uphold hydration and required circulating volume.
|Develop a comfortable environment for the client by covering them with a light sheet.
|It prevents overheating that may lead to fluid loss.
|Monitor level of consciousness and change in mentation.
|This could result from electrolyte imbalance, low or high glucose levels, acidosis, developing hypoxia, or reduced cerebral perfusion. Compromised consciousness may lead to an elevated risk of aspiration.
|Insert indwelling urinary catheter and maintain it as necessary.
|This procedure precisely measures the amount of urine produced, especially in cases where autonomic neuropathies cause the neurogenic bladder, resulting in urinary retention or overflow incontinence. After the client’s condition stabilizes, the catheter can be taken out.
4. Imbalanced Nutrition: Less Than Body Requirements
In the treatment and management of diabetes, nutrition plays an essential role. There should be a balance between dietary intake, energy utilization, dose, and timing of antidiabetic agents or insulin.
Imbalanced Nutrition: Less Than Body Requirements
It is associated to
- Hypermetabolic state: discharge of infection process and stress hormones like cortisol, epinephrine, and growth hormone.
- Reduced oral intake: nausea, anorexia, abdominal pain, gastric fullness, and altered consciousness.
- Insulin deficiency: less glucose uptake and usage by the body leads to high fat/protein metabolism.
Possibly indicated by
- Elevated urinary output
- Heightened ketones
- Reduced interest in food resulting in reduced intake.
- Weakness, poor muscle tone, fatigue, and weight loss.
- Indicates a steady weight or progress towards the desired range while upholding optimum laboratory values.
- Exhibit an average level of energy.
- Consume a prescribed quantity of calories and nutrients.
Nursing assessment and Rationale
|Weigh every day or as prescribed
|This acts as an evaluation tool for assessing nutritional intake.
|Find out what the patient eats and compare it to recent intake.
|It helps to identify deviations and gaps from a prescribed nutritional regimen and provides feedback to reinforce teaching.
|Evaluate the nutritional needs of the patient
|This helps determine the information to give the patient or caregivers.
|Discuss the eating habit of the patient and encourage them to stick with the prescribed diet.
|This helps in managing the patient’s condition via an appropriate diet.
|Review the dietary history of the patient
|Dietary history aid in identifying the eating habits and the lifestyle of the patient that can be included in the meal plan. Consider food preference, nutritional needs, cultural background, eating time, and weight management requirements.
|Involve the patient in reviewing the meal plan and focus on the prescribed calories from proteins, carbohydrates and fats.
|Fats: 20% of the calories should be obtained from fats. Diabetic people should reduce their intake of saturated fats and maintain cholesterol below 300 mg/dl per day to minimize the risk of heart disease.
Carbohydrates: 60% of the total calories should be obtained from carbohydrates. A carbohydrate-rich diet has a more significant impact on glucose levels, thus, should be included in the patient’s diet to prevent postprandial blood glucose development.
Proteins: proteins should be about 10 to 20% of the patient calorie intake. Some protein sources like legumes, whole grains, and nuts significantly help reduce cholesterol and saturated fats.
Fiber: fiber helps enhance blood glucose levels, reduce insulin needs, and lower cholesterol levels.
|Document the actual weight of the patient instead of estimating.
|Record patients eating time, pattern, and amount of food taken daily. Estimating the patient’s weight may not help them know whether they are losing or gaining weight.
|Listen to the sounds made by the patient’s bowel. Record every report about bloating, vomiting of undigested food, nausea, and abdominal pain. Follow NPO (nothing by mouth) status as prescribed.
|Electrolyte, fluid, and hyperglycemia imbalance can impact gastrointestinal function and motility. Poor intestinal motility and reduced gastric emptying time signify autonomic neuropathies requiring symptomatic treatment.
Nursing interventions and Rationale
|Go through the carbohydrate counting technique with the patient.
|This involves counting carbohydrate grams in a meal and matching it to an insulin dose.
|Advise the client on the impact of alcohol on diabetic people.
|Alcohol is absorbed before other nutrients and converted to fats resulting in DKA. Excessive intake of alcohol may compromise glucose production resulting in Hypoglycemia.
|Provide fluids with electrolytes and nutrients and proceed to solid food gradually.
|The oral routine is recommended when the client is alert and bowel activity is at optimum.
|Note the patient’s food choices, including ethnic and cultural requirements.
|This should be included in the meal plan if it is possible to encourage cooperation with dietary needs after discharge.
|Include the family in meal planning to enhance understanding of the patient’s nutritional needs.
|Different nutritional planning techniques include pre-selected menus, exchange lists, glycemic indexes, and point systems.
|Look out for hypoglycemia signs like change in LOC, clammy skin and cold, hunger, anxiety, irritability, shakiness, and headache.
|When the blood glucose level is decreased, Hypoglycemia can occur. In addition, the production of insulin and carbohydrate metabolism resumes.
|Do a fingerstick glucose testing
|This technique is more precise than observing urine sugar. The sensitivity of urine glucose is inadequate to detect changes in serum levels. Furthermore, it may be impacted by urinary retention.
|Provide glucose solution: half-normal saline and dextrose.
|After the blood glucose level drops to about 400 mg/dl, a glucose solution may be incorporated. Care should be provided to prevent Hypoglycemia when carbohydrate metabolism approaches the optimum level.
|Provide meals with 20% fats, 20% proteins, and 60% carbohydrates.
|Some complex carbohydrates like peas, broccoli, carrots, dried beans, apples, and oats reduce insulin requirements and glucose levels, lower serum cholesterol levels, and improve satiation.
|Provide other prescribed medication: tetracycline; metoclopramide (Reglan).
|It is essential in treating symptoms associated with autonomic neuropathies that impact the GI tract, thus improving absorption and oral food intake.
|Encourage regular exercise.
|Encourage the patient to visit a cardiac rehabilitation nurse, physiologist and physical therapist for particular exercise guidance.
|Consult a physician or dietician for further recommendations and assessment on nutritional support.
|This could help identify significant adjustments to patient nutritional intake and promote a better understanding of particular.
5. Risk for Infection
Infections occur in individuals whose immune system is inadequate to protect them. Microorganisms, including viruses, fungi, bacteria, and others, invade prone individuals through exposures and injuries. The human immune system plays a crucial role in promoting survival in a world of harmful and deadly microbes. In this case, impairment of the system makes individuals susceptible to life-threatening infections. In addition, infections prolong healing among patients and can lead to death when left untreated.
Patients with diabetes mellitus are more susceptible to infectious diseases due to the disease conditions such as hyperglycemia and other complications that promote dysfunction of the immune system, among other conditions such as gastrointestinal dysmotility, urine antibacterial activity decline, neuropathy, etc. Specific nursing interventions associated with the infection of a patient with diabetes depend on the nature and severity of the risk. However, the nurse should educate the patient on recognizing infection signs to help reduce their risk.
- Risk for Infection
The risk factors for infection include
- Inadequate knowledge to avoid pathogens.
- Compromised immune system due to diabetes mellitus.
- Inadequate blood glucose control.
- High levels of glucose.
- Reduced WBCs function.
- Microangiopathy due to diabetes.
- Respiratory infection.
- Compromised or altered circulation.
- Urinary tract infection due to urinary tract abnormalities or recurrent vaginitis.
- The patient stays free from infections.
- The nurse will identify nursing interventions to reduce or prevent infection risk.
- The patient will restore immunity (defense system).
- The patient will demonstrate approaches to recognize infections and prevent their development.
Nursing Assessment and Rationales
Assessing a patient suffering from diabetes mellitus is crucial since it helps identify factors that could lead to infections. The nursing assessment guideline below provides a framework for nurses to identify objective and subjective data for their care plan.
|Assess the patient for signs and symptoms of mucous membranes and skin infections.
|Localized redness, swelling, tenderness, pain, and loss of function in the affected area could indicate infection.
|Monitor and report signs and symptoms of infection.
|There are varied signs and symptoms of infection, each varying based on the involved body area. The signs and symptoms could include:
|Auscultate the patient’s breath sounds.
|Rhonchi (large bubbling/gurgling sounds could indicate bronchitis or pneumonia-related lung secretions. In addition, crackles could indicate edema, pulmonary congestion from heart failure, or rapid fluid replacement.
|Monitor leucocytes (WBC) count.
|Increased white blood cells level may indicate the presence of an infection, with the increasing count demonstrating the body’s effort to fight pathogens.
On the other hand, a significantly low WBC count could indicate an increased risk of infection.
|Assess and monitor medications that could lead to immunosuppression.
|Some medications, such as corticosteroids, could suppress the body’s immunity.
|Assess the patient’s immunization history and status.
|People who are not immunized could be at greater risk of infections.
Nursing Interventions and Rationale
Nursing interventions for the risk of infection in patients with diabetes mellitus are key to preventing and reducing infection risks. The goal is to prevent the infection or the development and spread of the underlying infection.
|Promote good hand hygiene.
|The nurse should perform hand hygiene by washing hands before having any form of contact with the patient. Instances for performing hand hygiene include:
|Teach the patient and impart hand hygiene duties to the patient and their significant other (SO).
|Educating is an effective way to eliminate or reduce the transmission of pathogens. Promoting good hand hygiene is one of the most essential and effective approaches to preventing disease transmission. Using running water and proper friction can help get rid of pathogens on the hands, reducing exposure risk.
|Ensure asepsis is maintained during medication administration, IV insertions, and during wound care.
|Elevated blood glucose creates excellent conditions for immunosuppression, allowing pathogens to thrive. Maintaining asepsis can help prevent infection.
|Provide the patient perineal care or a catheter as necessary. Educate female patients to use the front-to-back cleaning method after elimination.
|Patients with diabetes mellitus have a higher risk of urinary tract infections. In addition, diabetes mellitus predispose female patients to vaginitis. In this case, poor perineal hygiene could increase vaginitis risk, which could spread through the urinary tract leading to infection.
|Provide appropriate skincare to the patient by ensuring the skin is dry, keeping linens dry, and massaging bony areas.
|Poor peripheral circulation and skin impairment can increase the patient’s risk of skin breakdown (loss of skin integrity), exposing the patient to infections.
|Keep the patient in a semi-Fowler’s position.
|This is crucial to reduce the risk of aspiration and promote lung expansion.
|Encourage regular change of position, coughing, and deep breathing techniques.
|This will help ventilate the lungs and reduce bronchia tree and lung secretion statis that may lead to respiratory tract infection.
|Provide trash bags and tissues in locations convenient to throw patient secretions and teach about secretion handling.
|This will help prevent infections and minimize spread.
|Encourage patients and help with maintaining oral hygiene. Encourage the use of soft-bristle toothbrushes.
|Maintaining oral hygiene is key to reducing gum disease. Recommending the use of a soft-bristled toothbrush can help prevent compromise of the mucous membrane integrity, preventing pathogen entry.
|Recommend and encourage increased fluid intake if not contraindicated.
|Increasing fluid intake increases urinary flow by diluting urine, hence preventing urine stasis. This is crucial in reducing the risk of the urinary tract or bladder infection.
|Administer antibiotics to the patient as indicated.
|Early intervention after infection could help prevent the spread and complications such as sepsis in patients with diabetes.
|Recommend flu and pneumonia vaccination as indicated.
|Vaccination for influenza virus and streptococcus pneumonia is important for patients with diabetes since these pathogens are associated with respiratory infections, which result in hospitalization.
6. Risk for Disturbed Sensory Perception
This refers to a change in the perception of the pattern or amount of incoming stimuli resulting in a distorted, diminished, impaired, or exaggerated response to the stimuli. Patients with diabetes mellitus taking insulin and other hypoglycemic agents can develop hypoglycemia. In addition, excessive physical activity or inadequate food/carbohydrates could worsen the complication. The changes in blood glucose levels could impair the functioning of the central nervous system altering the level of patient consciousness.
- Risk for Disturbed Sensory Perception.
The risk factor include
- Sensory perception impairment.
- Excessive stimulation.
- Alteration of endogenous chemicals due to medication or electrolyte imbalance.
- The patient will maintain an optimum mentation level.
- The patient will identify external factors that contribute to altered perception.
- The patient will modify or compensate for existing impairments.
Nursing Assessment and Rationale
The nursing assessment for diabetes patients with a risk for disturbed sensory perception includes the following:
|Assess and monitor blood glucose levels and report abnormal values.
|In patients with diabetes, changes in CNS mainly occur due to altered blood glucose levels, especially hypoglycemia.
|Monitor vital signs and the patient’s mental status.
|This will provide the data to compare against the baseline values to establish abnormal findings.
|Assess the patient’s adherence to medication.
|Non-adherence to diabetes medication, including overdose, can lead to hypoglycemia.
|Assess and evaluate visual acuity as required.
|Various factors such as cataracts, retinal edema, hemorrhage, and extraocular muscles temporary paralysis could impair vision requiring corrective therapy and supportive care.
|Monitor, signs or reports of hyperesthesia, loss of sensation on feet and pain. Check for reddened areas, ulcers, and loss of pulse on the legs/feet.
|Peripheral neuropathy could lead to increase discomfort impairing tactile sensation and increasing the risk of injury and balance impairment.
|Monitor lab values, including Hb, Hct, Serum osmolality, BUN/Cr, and blood glucose.
|Imbalances in these values could impair the patient’s mentation.
Nursing Interventions and Rationale
The nursing intervention of diabetes patients with a risk for disturbed sensory perception includes the following:
|Refer or call out the patient by name. Reorient the patient to place, time, and person as needed. Speak slowly and provide short explanations.
|This will reduce confusion and help the patient regain and maintain contact with reality.
|Maintain blood glucose within the normal range.
|This will prevent hypoglycemia and associated CNS changes.
|Cluster and schedule nursing and intervention time.
|To give the patient uninterrupted rest periods reducing fatigue and improving cognition.
|Maintain consistency in patient routine. Encourage the patient’s participation in activities of daily living.
|Helps maintain orientation to the environment allowing the patient to keep in touch with reality.
|Limit restraints in patients with impaired levels of consciousness to protect the patient from injury. Ensure the bed position is lowered and pad the bed rail to avoid falls.
|Disoriented patients may get injured, especially at night, due to loss of balance and falls.
|Offer bed cradle, avoid exposure of hands and feet to hot water or heating pad.
|This will reduce discomfort and dermal injury.
|Assist the patient with position changes and ambulation.
|This will promote patient safety when their sense of balance is impaired.
Powerlessness refer to a situation where one feels like they lack control over their own situation. Patients diagnosed with diabetes may feel like they lack control over the disease due to the chronic effects of the disease and the complexity of self-care needed to effectively manage the condition. Nurses play a crucial role of acknowledging the negative feelings patients expresss allowing the to identify patient strengths and empower them to solve problems.
It is related to
- Increased dependence on others.
- Incurable long term and progressive illness.
- Anger, apathy and withdrawal (social isolation).
- Reports of lacking influence or control over the disease/situation.
- Depression over progressive illness, deterioration and increased complications despite adherence with the treatment regimen.
- Failure to participate in treatment decision making.
Desired Goals and Outcomes
- The feelings of helplessness will be acknowledged.
- The patient will contribute to their care planning.
- Identify appropriate ways to deal with helplessness feelings.
- The patient will gain independence in carrying out self-care activities.
Nursing Assessment and Rationales
The nursing assessment for powerlessness in patients with diabetes include the following:
|Assess the patient’s feeling of hopelessness, depression and apathy.
|These are the moods that indicate powerlessness.
|Establish diabetes’ role in the powerlessness.
|Establish disease factors that contribute to the sense of powerlessness.
|Establish the patient’s need for diabetes control.
|This will help the patient establish self-governance perspectives that are relevant to them.
|Assess the patient’s ability to handle problems in the past including the locus of control.
|This will help establish the patient’s needs and treatment goals.
|Assess the patient’s need for information about the disease.
|Information request could help distinguish knowledge deficit from powerlessness.
Nursing Interventions and Rationales
The nursing intervention for powerlessness in patients with diabetes include the following:
|Acknowledge the feelings and their normality.
|Recognizing the normality of the feelings and reactions can help address the problems.
|Allow the patient’s significant other (SO) to express the patient’s concerns.
|This give’s the SO an opportunity to find solutions for the patient to enhance a sense of engagement.
|Encourage the patient to express his/her feelings about the disease and hospitalization.
|This will help identify concerns to help find solutions to the problems.
|Identify and ascertain goals and expectations of the patient and caregiver or significant other.
|Unrealistic expectations and pressure from self or others could lead to frustration and continued loss of control impairing the patient’s ability to cope.
|Engage and encourage the patient to contribute to decision making regarding their care.
|This give the patient an opportunity to exercise control over care.
|Support the patient’s participation in self-care and ADL.
|Provide positive feedback to the patient for efforts made to promote a sense of control.
8. Risk for Ineffective Management of Therapeutic Regimen
The nurse is responsible for investigating the patients’ ineffective management of treatment, especially following reports of increased blood glucose levels or preventable complications.
- Risk for Ineffective Therapeutic Regimen Management.
Risk factors may include
- Lack of adequate diabetes management knowledge.
- New on set of diabetes complications.
- Increased complexity of the treatment regimen.
- The patient will have an understanding of of diabetes disease.
- The patient will demonstrate their knowledge of self-care approaches to diabetes.
- The patient will perform all the necessary measures for diabetes management.
Nursing Assessment and Rationale
Nursing assessment for the risk for ineffective management of diabetes therapeutics regimen include the following:
|Assess the patient’s initial efforts to manage diabetes care.
|This can be a crucial starting point to help understand the difficulties and complexities in disease management. For instance, the patient could verbalize being overwhelming in the attempt to effectively manage diet, exercise, medications and other diabetes management measures.
|Evaluate the patient’s self-management skills.
|This can help establish the education needs.
|Assess and identify various factors that could affect success with the care regimen.
|Factors that could limit adherence to the treatment/care regiment include:
· Limited vision. This could limit the patient’s ability to effectively and accurately prepare and administer insulin.
· Limited mobility. Loss of mobility and fine motor control could affect the skills needed for effective insulin administration and blood glucose monitoring.
· Reduced joint mobility. Joint problems or pre-existing disability could affect the patient’s ability to evaluate their feet.
|Assess the health care financial resources for the patient.
|A high cost of diabetes medication and blood glucose monitoring devices could hinder effective diabetes management for patients with limited finances.
Nursing Intervention and Rationale
The nursing intervention for the risk of ineffective therapeutic management include the following:
|Teach and instruct the patient clearly about the treatment regimen.
|Providing adequate and clear information about diabetes management can help patients easily follow treatment.
|Provide feedback and positive reinforcement as necessary
|Motivating the patient to continue with the treatment regimen can help reduce or avoid the risk of ineffective diabetes management. Use positive reinforcement instead of fear/scares to modify the patient’s lifestyle.
|Educate the patient about diabetes symptoms, causes, treatment and preventive measures for hyperglycemia and hypoglycemia.
|Elevated blood glucose or significant drop of blood glucose levels in a diagnosed patient could indicate the need to re-evaluate diabetes management.
|Inform the patient about available resources for people with diabetes.
|This will help address the financial barriers to medication and other diabetes management resources.
9. Risk for Injury
Diabetes complications including impaired mobility, neurological and sensory deficits could increase the risk of injury among patients. For instance, neuropathy affects patient’s muscle control, sensation and gait increasing injury risks. In addition, retinopathy and cataracts are associated with visual impairment increasing the risk of injury in diabetes patients. Other diabetes-related factors that could increase the risk of injury include hyperglycemia, which alters eye lenses causing blurred vision. In addition, significant change in blood glucose levels such as hypoglycemia could affect the patient’s consciousness level leading to seizures which increase the risk of injury.
- Risk for Injury
Risk factors could include
- Cataracts and retinopathy
- Blurred vision
- Peripheral sensory neuropathy
- Impaired immune system
- Hypoglycemia and hyperglycemia
- Autonomic neuropathy
- Vascular insufficiency
Desired Goals and Outcomes
- The patient will be free from injuries
- The patient will verbalize approaches to reduce or prevent injuries
Nursing Assessment and Rationale
The nursing assessment for risk of injury in diabetes patients include the following:
|Assess factors that could contribute to injury risk.
|This provides the baseline data for developing a personalized/individualized care.
|Assess the foot appearance.
|Lesions on the foot and associated infections increase the risk of hospitalization for patients with diabetes. Inspecting the foot condition at every clinic visit is crucial since loss of sensation could make it difficult for the patient to realize foot injuries. Poor vision could also make it difficult to inspect the feet.
|Assess the nails to establish their status.
|Impaired immunity in diabetic patients lead to increased infection risks. In this case, fungal infections in nails could lead to bacterial infections.
|Assess skin integrity
|Autonomic neuropathy is associated with reduced sweating leading to skin dryness and fissuring, which make the patient prone to infection.
|Assess the patient for corns or callus formation.
|Callus formation could be caused by pressure over bony areas leading to skin breakdown.
|Assess for signs or evidence of infection.
|Infections could lead to amputation. Since pain and tenderness symptoms may lack due to neuropathy, looking for signs of infection such as drainage, redness and swelling can help.
|Assess the patient for edema.
|Edema is a risk factor for ulceration.
Nursing Intervention and Rationale
The nursing interventions for risk of injury in patients with diabetes include the following:
|Instruct the patient about foot hygiene. This include washing feet in walm soapy water, avoiding soaking the feet, avoiding the area between toes, proper and gentle drying of feet and the use of applying moisturizing lotion.
|Using lotion helps moisturize feet due to dryness following autonomic neuropathy.
|Instruct the patient to inspect their feet for cuts and scratches. Instruct the patient to use visual and touch inspection methods.
|Examining all feet surfaces is crucial to establish alterations including the area between toes.
|Instruct the patient to always inspect their shoes to avoid sharp objects.
|This will reduce the risk of foot injury.
|Educate the patient and instruct on the need to always avoid staying barefoot.
|One of the most effective way to prevent feet injuries is to keep them always covered.
|Educate the patient on the need to always keep nails trimmed, straight and filed to match toe contours.
|This helps avoid toe injury when self-care is not provided.
|Test the patient regulary for urine ketone as indicated
|Initiating urine ketone testing is important especially for patients with persistent hyperglycemia and glycosuria.