Diabetes Mellitus Nursing Care Plans

Diabetes mellitus (DM) is a chronic diseases characterized by insufficient production of insulin in the pancreas or when the body cannot effectively 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 and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.

Types

Diabetes mellitus occurs in four forms classified by etiology: type 1, type 2, gestational diabetes mellitus, and other specific types. Here’s a breakdown of the types:

  • Type 1 diabetes is characterized by the lack of insulin production. It is formerly known as insulin-dependent or childhood-onset diabetes. Type 1 is further subdivided into immune-mediated diabetes and idiopathic diabetes. Children and adolescents with type 1 immune-mediated diabetes rapidly develop ketoacidosis, but most adults with this type experience only modest fasting hyperglycemia unless they develop and infection as another stressor. Patients with type 1 idiopathic diabetes are prone to ketoacidosis.
  • Type 2 diabetes is caused by the body’s ineffective use of insulin. It is previously called non-insulin dependent or adult-onset diabetes. Most patients with type 2 diabetes are obese.
  • Other specific types category includes people who have diabetes as a result of a genetic defect, endocrinopathies or exposure to certain drugs or chemicals.
  • Gestational diabetes mellitus (GDM) occurs during pregnancy. Glucose tolerance levels usually return to normal after delivery.

Statistics

Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5) stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.

Nursing Care Plans

This post contains 13+ diabetes mellitus Nursing Care Plans (NCP)

Nursing Priorities

  1. Restore fluid/electrolyte and acid-base balance.
  2. Correct/reverse metabolic abnormalities.
  3. Identify/assist with management of underlying cause/disease process.
  4. Prevent complications.
  5. Provide information about disease process/prognosis, self-care, and treatment needs.

Discharge Goals

  1. Homeostasis achieved.
  2. Causative/precipitating factors corrected/controlled.
  3. Complications prevented/minimized.
  4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.
  5. Plan in place to meet needs after discharge.

Diagnostic Studies

  • Serum glucose: Increased 200–1000 mg/dL or more.
  • Serum acetone (ketones): Strongly positive.
  • Fatty acids: Lipids, triglycerides, and cholesterol level elevated.
  • Serum osmolality: Elevated but usually less than 330 mOsm/L.
  • Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.
  • Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.
  • Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.
  • Electrolytes:
  • Sodium: May be normal, elevated, or decreased.
  • Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.
  • Phosphorus: Frequently decreased.
  • Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO3 (metabolic acidosis) with compensatory respiratory alkalosis.
  • CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.
  • BUN: May be normal or elevated (dehydration/decreased renal perfusion).
  • Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.
  • Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.
  • Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.
  • Cultures and sensitivities: Possible UTI, respiratory or wound infections.

1. Risk for Infection


Nursing Diagnosis

  • Risk for Infection

Risk factors may include

  • High glucose levels, decreased leukocyte function, alterations in circulation
  • Preexisting respiratory infection, or UTI

Possibly evidenced by

  • [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]

Desired Outcomes

  • Identify interventions to prevent/reduce risk of infection.
  • Demonstrate techniques, lifestyle changes to prevent development of infection.
Nursing Interventions Rationale
Observe for the signs of infection and inflammation: fever, flushed appearance, wound drainage, purulent sputum, cloudy urine. Patients with DM may be admitted with infection, which could have precipitated the ketoacidotic state. They may also develop nosocomial infection.
Teach and promote good hand hygiene. Reduces risk of cross-contamination.
Maintain asepsis during IV insertion, administration of medications, and providing wound or site care. Rotate IV sites as indicated. Increased glucose in the blood creates an excellent medium for bacteria to thrive.
Provide catheter or perineal care. Teach female patients to clean from front to back after elimination. Minimizes risk of UTI. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract and/or vaginal yeast infections.
Provide meticulous skin care: gently massage bony areas, keep skin dry. Keep linens dry and wrinkle-free. Peripheral circulation may be ineffective or impaired, placing the patient at increased risk for skin breakdown and infection.
Auscultate breath sounds. Rhonchi may indicate accumulation of secretions possibly related to pneumonia or bronchitis. Crackles may results from pulmonary congestion or edema from rapid fluid replacement or heart failure.
Place in semi-Fowler’s position. Facilitates lung expansion; reduces risk of aspiration.
Reposition and encourage coughing or deep breathing if patient is alert and cooperative. Otherwise, suction airway using sterile technique as needed. Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection.
Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in proper handling of secretions. To minimizes spread of infection.
Encourage and assist with oral hygiene. Reduces risk of oral/gum disease.
Encourage adequate dietary and fluid intake (approximately 3000 mL/day if not contraindicated by cardiac or renal dysfunction), including 8 oz of cranberry juice per day as appropriate. Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity, reducing bacteria growth and flushing organisms out of system. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall, reducing the risk of recurrent UTI.
Administer antibiotics as appropriate. Early treatment may help prevent sepsis.

2. Risk for Disturbed Sensory Perception


Nursing Diagnosis

  • Risk for Disturbed Sensory Perception

Risk factors may include

  • Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance

Possibly evidenced by

  • [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]

Desired Outcomes

  • Maintain usual level of mentation.
  • Recognize and compensate for existing sensory impairments.
Nursing Interventions Rationale
Monitor vital signs and mental status. To provide baseline from which to compare abnormal findings.
Call the patient by name, reorient as needed to place, person, and time. Give short explanations, speak slowly and enunciate clearly. Decreases confusion and helps maintain contact with reality.
Schedule and cluster nursing time and interventions. To provide uninterrupted rest periods and promote restful sleep, minimize fatigue and improve cognition.
Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. Helps keep patient in touch with reality and maintain orientation to the environment.
Protect patient from injury by avoiding or limiting the use of restraints as necessary when LOC is impaired. Place bed in low position and pad bed rails if patient is prone to seizures. Disoriented patients are prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration, and falls.
Evaluate visual acuity as indicated. Retinal edema or detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care.
Observe and investigate reports of hyperesthesia, pain, or sensory loss in the feet or legs. Investigate and look for ulcers, reddened areas, pressure points, loss of pedal pulses. Peripheral neuropathies may result in severe discomfort, lack of or distortion of tactile sensation, potentiating risk of dermal injury and impaired balance.
Provide bed cradle. Keep hands and feet warm, avoiding exposure to cool drafts and/or hot water or use of heating pad. Reduces discomfort and potential for dermal injury.
Assist patient with ambulation or position changes. Promotes patient safety, especially when sense of balance is affected.
Monitor laboratory values: blood glucose, serum osmolality, Hb/Hct, BUN/Cr. Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication).
Carry out prescribed regimen for correcting DKA as indicated. Alteration in thought processes or potential for seizure activity is usually alleviated once hyperosmolar state is corrected.

3. Powerlessness


Nursing Diagnosis

  • Powerlessness

May be related to

  • Long-term/progressive illness that is not curable
  • Dependence on others

Possibly evidenced by

  • Reluctance to express true feelings; expressions of having no control/influence over situation
  • Apathy, withdrawal, anger
  • Does not monitor progress, nonparticipation in care/decision making
  • Depression over physical deterioration/complications despite patient cooperation with regimen

Desired Outcomes

  • Acknowledge feelings of helplessness.
  • Identify healthy ways to deal with feelings.
  • Assist in planning own care and independently take responsibility for self-care activities.
Nursing Interventions Rationale
Encourage patient and/or SO to express feelings about hospitalization and disease in general. Identifies concerns and facilitates problem solving.
Acknowledge normality of feelings. Recognition that reactions are normal can help patient problem-solve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health.
Assess how patient has handled problems in the past. Identify locus of control. Knowledge of individual’s style helps determine needs for treatment goals. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors.
Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful to patient. Enhances sense of being involved and gives SO a chance to problem-solve solutions to help patient prevent recurrence.
Ascertain expectations and/or goals of patient and SO. Unrealistic expectations or pressure from others or self may result in feelings of frustration and loss of control. These can impair coping abilities.
Determine whether a change in relationship with SO has occurred. Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns affecting self-concept may add further stress.
Encourage patient to make decisions related to care: ambulation, schedule for activities, and so forth. Communicates to patient that some control can be exercised over care.
Support participation in self-care and give positive feedback for efforts. Promotes feeling of control over situation.

4. Imbalanced Nutrition: Less Than Body Requirements


Nursing Diagnosis

  • Imbalanced Nutrition: Less Than Body Requirements

May be related to

  • Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)
  • Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
  • Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process

Possibly evidenced by

  • Increased urinary output, dilute urine
  • Reported inadequate food intake, lack of interest in food
  • Recent weight loss; weakness, fatigue, poor muscle tone
  • Diarrhea
  • Increased ketones (end product of fat metabolism)

Desired Outcomes

  • Ingest appropriate amounts of calories/nutrients.
  • Display usual energy level.
  • Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
Nursing Interventions Rationale
Weigh daily or as ordered. Weighing serves as an assessment tool to determine the adequacy of nutritional intake.
Ascertain patient’s dietary program and usual pattern then compare with recent intake. Identifies deficits and deviations from therapeutic needs.
Auscultate bowel sounds. Note reports of abdominal pain, bloating, nausea, vomiting of undigested food. Maintain NPO status as indicated. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility and/or function (due to distention or ileus) affecting choice of interventions. Note: Chronic difficulties with decreased gastric emptying time and poor intestinal motility may suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment.
Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. Oral route is preferred when patient is alert and bowel function is restored.
Identify food preferences, including ethnic and cultural needs. If patient’s food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge.
Include SO in meal planning as indicated. To promote sense of involvement and provide information to the SO to understand the nutritional needs of the patient. Note: Various methods available or dietary planning include exchange list, point system, glycemic index, or pre selected menus.
Observe for signs of hypoglycemia: changes in LOC, cold and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. Hypoglycemia can occur once blood glucose level is reduced and carbohydrate metabolism resumes and insulin is being given. If the patient is comatose, hypoglycemia may occur without notable change in LOC. This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished.
Perform fingerstick glucose testing. Beside analysis of serum glucose is more accurate than monitoring urine sugar. Urine glucose is not sensitive enough to detect fluctuations in serum levels and can be affected by patient’s individual renal threshold or the presence of urinary retention. Note: Normal levels for fingerstick glucose testing may vary depending on how much the patient ate during his last meal. In general: 80–120 mg/dL (4.4–6.6 mmol/L) before meals or when waking up; 100–140 mg/dL (5.5–7.7 mmol/L) at bedtime.
Administer regular insulin by intermittent or continuous IV method: IV bolus followed by a continuous drip via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr. Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia.
Administer glucose solutions: dextrose and half-normal saline. Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia.
Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals and snacks. Complex carbohydrates (apples, broccoli, peas, dried beads, carrots, peas, oats) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics and individual patient response. Note: A snack at bedtime of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response.
Administer other medications as indicated: metoclopramide (Reglan); tetracycline. May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients.

NO COMMENTS

LEAVE A REPLY