Utilize this comprehensive nursing care plan and management guide to provide effective care for patients experiencing diabetes mellitus. Gain valuable insights on nursing assessment, interventions, goals, and nursing diagnosis specifically tailored for diabetes mellitus in this guide.
Table of Contents
- What is Diabetes Mellitus?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Providing Patient Education on Diabetes Management
- 2. Achieving Glycemic Control and Blood Glucose Monitoring
- Self-Monitoring of Blood Glucose (SMBG)
- Continuous Glucose Monitoring System
- Monitoring Glycated Hemoglobin (A1C)
- Monitoring Ketones
- For patients who are under nothing per orem (NPO)
- For patients under enteral tube feedings
- For patients receiving parenteral nutrition
- Glucose control during periods of stress
- 3. Insulin Therapy and Normalizing Insulin Activity
- 4. Preventing Complications of Insulin Therapy
- 5. Administering Oral Antidiabetic Agents
- 6. Promoting Nutritional Balance and Weight Management
- 7. Encouraging Regular Exercise and Physical Activity
- 8. Preventing Hyperglycemia
- 9. Preventing Hypoglycemia
- 10. Preventing Diabetic Ketoacidosis (DKA)
- 11. Preventing Hyperosmolar Hyperglycemic State (HHS)
- 12. Minimizing Risk for Cardiovascular Diseases
- 13. Minimizing Risk for Diabetic Retinopathy
- 14. Minimizing Risk for Chronic Kidney Disease
- 15. Minimizing Risk of Infection
- 16. Preventing Diabetic Neuropathies
- 17. Diabetes Foot Care
- 18. Providing Emotional Support Through Effective Coping
- 19. Promoting Self-Care and Hygiene
- 20. Glycemic Control During Surgery
- Recommended Resources
- See also
- References and Sources
What is Diabetes Mellitus?
Diabetes mellitus (DM) is a chronic disease characterized by insufficient insulin production in the pancreas or when the body cannot efficiently use the insulin it produces. This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is characterized by disturbances in carbohydrate, protein, and fat metabolism. Sustained hyperglycemia has been shown to affect almost all tissues in the body. It is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.
Classifications of diabetes mellitus include
- Type 1 diabetes is characterized by destruction of the pancreatic beta cells leading to absolute insulin deficiency including latent autoimmune diabetes of adulthood.
- Types 2 diabetes is characterized by progressive loss of pancreatic beta cells and involves insulin resistance and impaired insulin secretion.
- Specific types of diabetes due to other causes such as monogenic diabetes syndromes (neonatal diabetes and maturity-onset diabetes of the young), diseases affecting the exocrine pancreas (cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (as a result of glucocorticoid use, treatment of HIV/AIDS, or organ transplantation).
- Gestational diabetes mellitus (GDM) refers to the onset of diabetes diagnosed during the second or third trimester of pregnancy, which was not clearly present as overt diabetes prior to conception.
The criteria for the screening and diagnosis of prediabetes and diabetes are as follows:
|A1C||5.7-6.4%||6.5% or greater|
|FPG||100-125 mg/dL||126 mg/dL or greater|
|2-hour plasma glucose 75-g OGTT||140-199 mg/dL||200 mg/dL or greater|
|Random plasma glucose||–||200 mg/dL or greater|
Nursing Care Plans and Management
Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose levels and decrease complications using insulin replacement, a balanced diet, and exercise. The nurse should stress the importance of complying with the prescribed treatment program through comprehensive diabetes education. Tailor your teaching to the patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control on long-term health.
Nursing Problem Priorities
The following are the nursing priorities for patients with diabetes:
- Glycemic control. Managing and maintaining blood glucose levels through medication, diet, and lifestyle modifications.
- Education and self-management. Providing patient education on diabetes management, including medication administration, monitoring blood glucose levels, meal planning, exercise, and recognizing signs of hyperglycemia or hypoglycemia.
- Preventing potential complications. Addressing risk factors for cardiovascular diseases, nephropathy, retinopathy, and neuropathies common among patients with diabetes.
- Weight management. Promoting a healthy weight through appropriate nutrition and physical activity, considering individual needs and comorbidities
- Foot care. Ensuring proper foot hygiene, regular inspection, and addressing any signs of neuropathy or foot ulcers to prevent diabetic foot complications.
Diabetes symptoms depend on hyperglycemia levels, including polyuria, polydipsia, and polyphagia. Other symptoms include fatigue, vision changes, numbness, dry skin, slow wound healing, and infections. Diagnosis involves measuring blood glucose levels. Ongoing specialized assessment and evaluation for complications are essential for diabetes management.
Assess for the following subjective and objective data:
- Polyuria. Increased urination due to excess loss of fluid caused by osmotic diuresis.
- Polydipsia. Increased thirst as a result of fluid loss and dehydration.
- Polyphagia. Increased appetite resulting from the catabolic state caused by insulin deficiency and breakdown of proteins and fats.
- Fatigue and weakness. Feeling tired and lacking energy.
- Sudden vision changes. Rapid alterations in visual acuity.
- Tingling or numbness in hands or feet. Sensations of pins and needles or loss of sensation in extremities.
- Dry skin. Skin lacking moisture and becoming rough or flaky.
- Slow-healing skin lesions or wounds. Delayed wound healing and impaired skin regeneration.
- Recurrent infections. Frequent and persistent infections due to compromised immune function.
- Sudden weight loss (Type 1 diabetes). Unexplained and rapid weight loss.
- Nausea, vomiting, or abdominal pain (Type 1 diabetes with DKA). Symptoms associated with diabetic ketoacidosis, such as gastrointestinal distress.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with diabetes mellitus based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The patient will consistently maintain blood glucose readings of less than 180 mg/dL, fasting blood glucose levels of less than 140 mg/dL, and a hemoglobin A1C level below 7%. Additionally, the patient will demonstrate understanding of key factors that can impact glucose stability.
- The patient will accurately demonstrate knowledge of insulin injection techniques, recognize symptoms and appropriate treatment of hypoglycemia, and exhibit understanding of dietary requirements for managing their condition.
- The patient will actively acknowledge feelings of helplessness, identify healthy coping strategies to deal with these emotions, and actively participate in planning their own care while independently assuming responsibility for self-care activities.
- The patient will effectively demonstrate knowledge of diabetes self-care measures, including proper procedures, and verbalize a comprehensive understanding of the diabetes disease process and potential complications, while providing clear explanations for the rationale behind their actions.
- The patient will consume appropriate amounts of calories and nutrients as per their individual needs, exhibit their usual energy level, and demonstrate weight stabilization or gradual progress towards their usual/desired range, with laboratory values within the normal range.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with diabetes may include:
1. Providing Patient Education on Diabetes Management
To ensure successful diabetes care, a systematic approach is needed, including high-quality diabetes self-management education and support (DSMES). Four critical times to assess the need for DSMES include diagnosis, annual evaluations or when treatment targets are not met, when complicating factors arise, and during life and care transitions. DSMES should be person-centered and can be provided in group or individual settings, involving the entire diabetes care team. Providing complete information and proper education to patients with diabetes can dramatically increase adherence to the treatment regimen.
Assessing readiness to learn
Assess the patient’s and family’s readiness to learn about diabetes management.
Assessing the readiness to learn allows the nurse to tailor the education approach and pace according to the patient’s and family’s emotional readiness and capacity to absorb information effectively.
Assess the patient’s knowledge and understanding of basic diabetes skills, including pathophysiology, treatment modalities, and recognition, treatment, and prevention of acute complications.
Assessing the patient’s baseline knowledge helps determine their educational needs and enables the development of an individualized diabetes education plan.
Assess the patient’s social situation for factors that may affect diabetes treatment and education plan including factors such as low literacy level, limited financial resources, lack of health insurance, presence or absence of family support, and cultural beliefs.
Contributing factors may include the patient’s literacy level, financial resources, lack of health insurance, patient’s daily schedule, presence or absence of family support, learning disabilities, or neurologic deficits or conditions. Assessing the patient’s social situation helps identify potential barriers to diabetes treatment and education. Understanding these factors allows the nurse to develop an individualized care plan that addresses the patient’s unique needs and circumstances.
Provide emotional support and reassurance to patients and their families as they go through the grieving process associated with the diagnosis of diabetes.
Patients and families may experience a range of emotions, including shock, denial, anger, depression, negotiation, and acceptance. Offering emotional support and reassurance helps them cope with these emotions and establish a foundation for effective diabetes education.
Assess the skills and self-care behaviors of patients who’ve had diabetes for many years.
Many patients with diabetes make errors in self-care, and reassessment is a must to determine their competency in self-care and other preventive measures to prevent complications. Assessment must include direct observation of skills (through return demonstration) and not just based on the patient’s self-report.
Assess the patient’s coping strategies and provide guidance on healthy coping mechanisms.
Understanding the patient’s coping strategies allows the nurse to address any maladaptive coping behaviors and provide guidance on healthy coping mechanisms, which can contribute to improved diabetes management and emotional well-being.
Ask the patient and family about their major concerns or fears related to diabetes.
Identifying the patient’s and family’s concerns and fears helps the nurse address any misconceptions or misinformation, alleviating anxiety and providing accurate information to facilitate effective diabetes management.
Initiating diabetes education
Provide simple, direct information to dispel misconceptions and address any misinformation.
Clear and concise information helps to correct any misconceptions the patient and family may have about diabetes, its treatment, and self-management, promoting understanding and adherence to the prescribed regimen.
Educate patients on the basic pathophysiology of diabetes, including the definition of diabetes, normal blood glucose ranges, and target blood glucose levels.
Understanding the pathophysiology of diabetes empowers patients to recognize the importance of maintaining blood glucose control and adhere to treatment regimens.
Provide education on various treatment modalities, including insulin administration and oral antidiabetic medications, as well as meal planning and monitoring blood glucose and urine ketones.
Empowering patients with knowledge of treatment modalities and self-monitoring techniques promotes active participation in diabetes management and helps them make informed decisions about their care.
Educate patients on recognizing, treating, and preventing acute complications such as hypoglycemia and hyperglycemia.
Prompt recognition and appropriate management of acute complications are crucial for maintaining stable blood glucose levels and preventing complications that could lead to hospitalization or emergency care.
Emphasize the importance of lifelong diabetes education, both formal and informal, to continuously enhance knowledge and skills.
Reinforcing that diabetes education is an ongoing process helps patients understand the need for continued learning and self-improvement in managing their diabetes effectively.
Develop a comprehensive education plan for in-depth and continuing education based on the patient’s needs and interests, including topics such as carbohydrate counting, insulin adjustment, and preventive measures for long-term complications.
Providing in-depth education tailored to the patient’s specific needs helps them develop advanced diabetes management skills and preventive measures to reduce the risk of long-term complications.
Prioritize education on preventive measures, especially foot care and eye care, to promote early detection and treatment, thereby reducing the occurrence of amputations and blindness.
Emphasizing preventive measures related to foot and eye care is crucial for patients with diabetes to minimize the risk of complications that could significantly impact their quality of life.
Initiate basic skill education as early as possible for hospitalized patients, allowing them to practice skills under supervision before discharge.
Hospitalized patients often have limited time for education due to shorter lengths of stay. Early initiation of basic skill education enables patients to acquire essential diabetes management skills and receive supervised practice to enhance their confidence and competence before transitioning to home care.
Plan for follow-up in the home setting to reinforce the skills learned during the hospital stay.
Reinforcing skills in the home environment helps patients apply what they have learned in a familiar context, enhancing their ability to manage diabetes effectively in their everyday lives.
Adapt the diabetes treatment and education plan to accommodate the patient’s cultural beliefs and practices.
Cultural beliefs and practices can significantly impact a patient’s adherence to a diabetes regimen. Adapting the plan to align with the patient’s cultural context promotes cultural competence, patient-centered care, and improved treatment outcomes.
Collaborate with a multidisciplinary team, including diabetes educators and specialists, to provide comprehensive and advanced education based on the patient’s interest and ability.
Involving a multidisciplinary team ensures that the patient receives specialized and individualized education, addressing their unique needs and enabling them to achieve optimal diabetes management and self-care.
Considerations for pediatric clients
Assess the parent’s and child’s understanding of disease and ability to perform procedures and care, for educational level and learning capacity, and for developmental level.
Provides information essential to develop a learning program; children ages 8 to 10 may be able to take responsibility for some of the care.
Provide a quiet, comfortable environment; allow time for teaching small amounts at a time and for reinforcement, demonstrations, and return demonstration; start educating one day following diagnosis and limit sessions to 30 to 60 minutes.
Prevents distractions and facilitates learning.
Include as many family members in teaching sessions as possible.
Promotes understanding and support of family and feeling of security for the child.
Teach about the cause of disease, disease process, and pathology; use pamphlets and other aids appropriate for the age of the child and the level of comprehension of parents.
Provides basic information that may be used as a rationale for treatments and care and allows for different teaching strategies.
Instruct parents and child in insulin administration including drawing up insulin into the syringe, rotating the vial instead of shaking, drawing clear insulin first if mixing 2 types in the same syringe, injecting SC, storing insulin, rotating sites, adjusting dosages, reusing a syringe, and needle, and disposing of them.
Promotes proper technique of insulin administration to avoid complications.
Instruct in the use of a syringe-loaded injector.
Provides an alternative method of insulin administration if the child is afraid of skin puncture.
Teach parents and child on how to operate a portable insulin pump to regulate insulin delivery.
Provides continuous subcutaneous insulin infusion.
Instruct parents and child to monitor blood glucose levels 4 times a day (before meals and before bed), with a lancet and blood-testing meter or a reagent strip compared to a color chart; collection and testing of urine with Ketostix or Clinitest.
Monitors blood and urine for the presence of glucose and ketone.
Teach parents and children about dietary planning with the importance of proper meal times and adequate caloric intake according to age as ordered. Teach that food intake depends on activity, and describe methods to judge amounts of foods; provide a list of acceptable food items from “fast food” restaurants.
Provides information about an important aspect of the total care of a child with diabetes.
Teach parents and children about the role of exercise and changes needed in food and insulin intake with increased or decreased activity.
Provides information about common activity patterns and effects on dietary intake and insulin needs.
Teach parents and children about skin problems associated with diabetes, the need for regular dental examinations, foot care, protection of and proper care of nails, prevention of infections and exposure to infections, eye examinations, and immunizations.
Provides information about common complications as a result of chronic effects of the disease.
Instruct parents and child to keep a record of insulin administration, glucose monitoring, responses to diet and exercise, noncompliance in medical regimen, and effects.
Provides a method to improve self-care and demonstrates the need to notify the physician for treatment evaluation and possible modification.
Instruct the child to wear or carry identification and information about the disease, treatment, and physician name.
Provides information in case of an emergency.
Considerations for older adults
Regularly evaluate self-care skills, such as insulin administration, blood glucose monitoring, foot care, and diet planning, especially in patients with deteriorating vision and memory.
Ongoing evaluation of self-care skills is crucial for older adults with diabetes, particularly those experiencing sensory or cognitive decline. Regular assessments allow for timely interventions, adaptations, and additional support as needed.
Tailor the choice of blood glucose meter to the patient’s visual and cognitive status and dexterity.
Selecting an appropriate blood glucose meter that aligns with the patient’s visual, cognitive, and physical abilities ensures accurate monitoring and supports their ability to manage diabetes effectively at home. Individualizing the choice of meter promotes patient engagement and adherence to self-care practices.
Provide written instructions with handouts for patients to take home, facilitating diabetes management in the home setting.
Written instructions serve as a reference for patients and their families, supporting diabetes management outside the hospital. Providing handouts with clear instructions promotes adherence to the treatment plan and empowers patients to take an active role in their self-care.
Involve family members in assisting with diabetes basic skills when appropriate.
Engaging family members in diabetes care can provide support and assistance to older adults, especially in tasks that may be challenging due to physical or cognitive limitations. Involving family members helps ensure continuity of care and promotes patient well-being.
2. Achieving Glycemic Control and Blood Glucose Monitoring
The goal of diabetes management is to normalize insulin activity and blood glucose levels to prevent or reduce the development of complications that are neuropathic and vascular in nature. Glucose control and management can dramatically reduce the development and progression of complications.
Self-Monitoring of Blood Glucose (SMBG)
Self-monitoring of blood glucose (SMBG) empowers individuals with diabetes to personalize their treatment and achieve optimal blood glucose control.
Educate the patient on proper self-monitoring of blood glucose (SMBG) techniques.
SMBG is essential for diabetes management as it helps individuals monitor their blood glucose levels and make necessary adjustments to their treatment regimen. Providing education on proper SMBG techniques ensures accurate and reliable readings, reducing the risk of errors that may lead to inappropriate treatment decisions.
Assess the patient’s visual acuity, fine motor coordination, and cognitive abilities to determine the appropriate SMBG method.
The success of SMBG relies on the patient’s ability to perform the required tasks. Assessing visual acuity, fine motor coordination, and cognitive abilities helps determine the most suitable SMBG method for the patient, ensuring they can effectively use the blood glucose monitor and obtain accurate results.
Encourage regular calibration of blood glucose readings to plasma values and check the validity of readings with control solutions.
Calibration of blood glucose readings to plasma values is crucial to ensure accurate interpretation and appropriate management decisions. Encouraging patients to check the validity of readings with control solutions helps identify any discrepancies and ensures the meter and strips are functioning correctly, maintaining the accuracy of SMBG results.
Evaluate the patient’s SMBG techniques regularly, including a comparison with laboratory-measured blood glucose levels.
Regular evaluation of the patient’s SMBG techniques helps identify any errors or inconsistencies in blood glucose readings. Comparing SMBG results with laboratory-measured blood glucose levels provides an opportunity to validate the accuracy of the patient’s monitoring practices and make necessary adjustments or provide additional education if needed.
Provide guidance on proper meter cleaning and maintenance.
Proper meter cleaning and maintenance are crucial for the longevity and accuracy of blood glucose monitors. Providing guidance on cleaning techniques and regular maintenance helps prevent errors caused by damaged or improperly maintained meters, ensuring reliable SMBG results.
Assist the patient in understanding insurance coverage for meters and strips.
Meters and test strips can be costly, and understanding insurance coverage options helps patients access the necessary supplies for SMBG. Assisting patients in navigating insurance coverage ensures they have continuous access to reliable blood glucose monitoring tools without financial barriers.
Provide guidance on the frequency of SMBG based on the patient’s insulin therapy and individual needs.
The frequency of SMBG varies depending on the patient’s insulin therapy regimen, medication changes, activity levels, and suspected hypo- or hyperglycemia. Providing guidance on the appropriate frequency of SMBG ensures that patients monitor their blood glucose levels consistently, detect patterns, and make necessary adjustments to their treatment plan.
Teach patients how to keep a record or logbook (or use an app) of blood glucose levels and interpret patterns.
Keeping a record or logbook of blood glucose levels helps patients detect patterns and trends, enabling them to identify factors that may impact their blood glucose control. Teaching patients how to interpret patterns in their blood glucose readings enhances their understanding of how diet, medication, physical activity, and other factors influence their diabetes management.
Encourage positive reinforcement and address potential barriers to SMBG.
Positive reinforcement is crucial in promoting patient adherence to SMBG. Patients are more likely to continue monitoring their blood glucose levels if they feel supported and understand the benefits of doing so. Addressing potential barriers such as cost concerns and providing strategies to overcome them can help patients maintain consistent SMBG practices.
Continuous Glucose Monitoring System
Educate the patient on the use of a continuous glucose monitoring system (CGMS). CGMS is a valuable tool for monitoring blood glucose levels continuously. Educating patients about the purpose, function, and proper use of CGMS empowers them to actively participate in their diabetes management and make informed decisions based on the collected data.
Assist the patient in inserting and connecting the CGMS sensor and device.
Proper insertion and connection of the CGMS sensor and device are essential for accurate and reliable data collection. Assisting the patient in this process ensures that the CGMS functions effectively and provides accurate readings for analysis.
Collaborate with the healthcare team to download and analyze the CGMS data.
The data obtained from the CGMS device needs to be downloaded and analyzed to assess blood glucose patterns and trends. Collaborating with the healthcare team in this process ensures that the information is properly evaluated, allowing for adjustments in the patient’s diabetes treatment plan if needed.
Emphasize the role of CGMS in providing comprehensive 24-hour blood glucose monitoring.
Unlike traditional blood glucose monitoring methods, CGMS offers continuous monitoring over a 24-hour period. Communicating the benefits of CGMS, such as detecting blood glucose fluctuations throughout the day and night, helps patients understand the value of this technology in optimizing their diabetes management.
Highlight the suitability of CGMS for patients with type 1 diabetes.
CGMS is particularly beneficial for patients with type 1 diabetes who rely on external insulin administration. By emphasizing the usefulness of CGMS in monitoring blood glucose levels and assessing treatment adequacy, patients with type 1 diabetes can make informed decisions regarding insulin adjustments and overall diabetes control.
Monitoring Glycated Hemoglobin (A1C)
Glycated hemoglobin (HbA1C or A1C) is a measure of glucose control over the past three months.
Educate the patient on the significance of glycated hemoglobin (HbA1C) testing and its interpretation.
Understanding the concept and interpretation of HbA1C testing empowers the patient to comprehend their long-term glucose control. By educating the patient about the significance of A1C testing, they can understand that it provides a measure of their glucose control over the past three months. This information helps in evaluating the effectiveness of their diabetes management plan and making necessary adjustments to achieve target glycemic control. Regular A1C testing promotes self-awareness and empowers the patient to actively participate in their diabetes care.
Assist the patient in implementing strategies to achieve and maintain target HbA1C levels.
Collaborating with the patient to develop and implement strategies for glucose control promotes better glycemic management and aids in achieving target HbA1C levels. The typical range for HbA1C values is 4% to 6%, signifying near-normal blood glucose concentrations, while the target range for individuals with diabetes is set at less than 7%.
Ketones are produced as by-products of fat breakdown and accumulate in the blood and urine. Urine ketone testing is recommended for patients with type 1 diabetes with glycosuria or persistently elevated blood glucose levels (over 240 mg/dL or 13.2 mmol/L for two consecutive tests), during illness, in pregnancy with pre existing diabetes, and in gestational diabetes.
Teach the patient how to correctly use urine dipsticks (Ketostix, Chemstrip uK, or others) for monitoring ketones and glucose levels in the urine.
Accurate usage of these dipsticks is crucial for detecting ketonuria and persistently elevated glucose levels, which are indicative of deteriorating diabetes control.
Advise the patient to perform urine ketone testing whenever they have glycosuria or their blood glucose levels remain above 240 mg/dL or 13.2 mmol/L for two testing periods in a row.
Regular monitoring of urine ketones during these conditions can help detect insulin deficiency early, enabling timely intervention.
Educate the patient about the implications of ketones in the urine, emphasizing the link between ketone presence and deficient insulin levels.
Understanding the significance of ketonuria can motivate the patient to adhere to regular monitoring, contributing to better management of their diabetes.
Instruct the patient to increase the frequency of urine ketone testing during periods of illness or pregnancy.
These situations can impact the body’s insulin requirements and hence diabetes control, making it crucial to closely monitor for changes.
For patients who are under nothing per orem (NPO)
Ensure appropriate adjustments in insulin dosage and regimen for patients who are NPO.
When patients are NPO for diagnostic or surgical procedures, modifications in insulin dosage and regimen are necessary to prevent hypo- or hyperglycemia. This may involve eliminating rapid-acting insulin, giving a decreased amount of intermediate-acting insulin, or using alternative insulin regimens such as basal insulin administration or frequent dosing of rapid-acting insulin.
Administer basal insulin, as indicated, to patients with type 1 diabetes who are NPO.
In type 1 diabetes, the elimination of insulin doses can lead to the development of diabetic ketoacidosis (DKA). Providing basal insulin to patients with type 1 diabetes who are NPO helps maintain glycemic control and prevents the onset of DKA.
Perform regular glucose testing and insulin administration in patients who are NPO for extended periods.
Patients who are NPO for an extended period require regular monitoring of blood glucose levels to adjust insulin therapy accordingly. Insulin regimens may include NPH insulin every 12 hours, frequent doses of rapid-acting insulin, or an IV insulin drip. Dextrose infusions are administered to provide calories and limit ketosis.
Educate patients on the appropriate selection of clear liquid foods to maintain glycemic control.
Clear liquid diets often include simple carbohydrate foods, such as juice and gelatin desserts, which can cause rapid spikes in blood glucose levels if consumed alone. Providing education on appropriate food choices helps patients make informed decisions to manage their blood glucose levels effectively.
For patients under enteral tube feedings
Administer insulin doses at regular intervals aligned with the tube feeding schedule.
Tube feeding formulas high in simple carbohydrates can lead to increased glucose levels in patients with diabetes. Insulin doses should be given regularly, such as NPH every 12 hours or regular insulin every 4 to 6 hours, to manage glycemic control effectively during continuous tube feedings.
Coordinate with the healthcare team regarding any plans to temporarily discontinue tube feedings.
Inadvertent or purposeful discontinuation of tube feedings can result in hypoglycemia in patients receiving insulin. Discussing and planning ahead with the medical team allows for adjustments in insulin dosage or the administration of IV dextrose to prevent hypoglycemia during the temporary discontinuation of tube feedings.
Monitor for and respond promptly to unexpected problems with the tube feeding.
Unforeseen issues with the tube feeding, such as tube dislodgement, clogging, or discontinuation due to gastric contents, can impact glycemic control. Promptly notifying the primary provider, increasing the frequency of blood glucose level assessments, and administering IV dextrose when indicated help prevent and manage hypoglycemia during these situations.
For patients receiving parenteral nutrition
Administer IV insulin added to the parenteral nutrition container for patients receiving continuous parenteral nutrition.
Continuous parenteral nutrition can contribute to changes in blood glucose levels. Administering IV insulin as part of the parenteral nutrition helps regulate glycemic control and prevent hyperglycemia.
Coordinate subcutaneous insulin administration with the infusion schedule of limited-duration parenteral nutrition.
When parenteral nutrition is infused over a limited number of hours, subcutaneous insulin should be administered to align peak times of insulin action with the times of parenteral nutrition infusion. This synchronization helps maintain stable blood glucose levels during the infusion period.
Monitor blood glucose levels regularly in patients receiving parenteral nutrition.
Regular monitoring of blood glucose levels is essential to assess glycemic control and guide insulin administration. Monitoring allows for timely adjustments in insulin dosage and prevents hypo- or hyperglycemia in patients receiving parenteral nutrition.
Glucose control during periods of stress
Monitor blood glucose levels closely during periods of physiologic stress, such as infections or surgery.
Physiologic stress can contribute to hyperglycemia in patients with diabetes. Close monitoring of blood glucose levels helps identify any fluctuations and allows for timely intervention to prevent complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).
Assess the patient’s emotional well-being and provide emotional support during hospitalization.
Emotional stress related to hospitalization can negatively impact diabetic control. Providing emotional support helps alleviate stress and promote psychological well-being, which can indirectly contribute to better diabetic control.
Educate the patient about the relationship between stress and glucose levels, emphasizing the importance of maintaining the diabetes treatment plan during times of stress.
Patients with diabetes need to understand that emotional stress can affect their glucose levels. By educating them about this relationship, they can be empowered to adhere to their treatment plan even during stressful periods, reducing the risk of glucose fluctuations and complications.
Teach stress management techniques and coping strategies to the patient.
Learning strategies for minimizing and coping with stress is crucial for patients with diabetes. By providing education on stress management techniques, such as deep breathing exercises, mindfulness, or engaging in hobbies, nurses empower patients to effectively manage their stress levels and maintain better diabetic control.
Encourage the patient to engage in healthy coping mechanisms as part of diabetes self-management.
Healthy coping strategies are essential for managing diabetes effectively. Encouraging patients to engage in activities such as regular exercise, social support, relaxation techniques, and seeking professional help if needed promotes overall well-being and glycemic control.
Provide diabetes education that includes information on stress management and coping strategies.
Diabetes education should encompass not only the management of glucose levels but also the skills to cope with stress. By including stress management and coping strategies in diabetes education, patients are equipped with the tools to navigate stressful situations while maintaining diabetic control.
3. Insulin Therapy and Normalizing Insulin Activity
Effective insulin management is vital for optimal diabetes control. Individuals with type 1 diabetes rely on lifelong insulin administration, while those with type 2 diabetes may require insulin if other treatments fail. Regular blood glucose monitoring and appropriate insulin dosage adjustments are necessary for maintaining stable levels. By managing insulin effectively, individuals can reduce the risk of complications and improve their overall quality of life.
Educating patients on insulin therapy
Assess the patient’s readiness and ability to participate in insulin therapy.
Insulin regimens can vary in complexity, and it is crucial to determine the patient’s willingness and capability to engage in self-management activities. Assessing their readiness helps in selecting an appropriate insulin regimen that matches their lifestyle and preferences.
Assess the patient’s cognitive and physical abilities to manage a complex insulin regimen.
Insulin therapy may involve multiple injections, blood glucose monitoring, and record-keeping. Evaluating the patient’s cognitive and physical abilities helps determine if they can effectively manage the tasks associated with a complex insulin regimen or if a simplified regimen is more appropriate.
Assess the patient’s understanding of insulin administration techniques.
It is essential to ensure that the patient knows how to properly administer insulin injections. The nurse should assess the patient’s technique, provide guidance if necessary, and address any concerns or misconceptions related to insulin administration.
Administer insulin injections as prescribed.
In type 1 diabetes, exogenous insulin is necessary for life due to the inability of the body to produce insulin. In type 2 diabetes, insulin may be required on a long-term basis if other treatment options are ineffective or when insulin deficiency occurs.
Insulin plays a crucial role in regulating blood glucose levels, preventing complications associated with high or low sugar levels. The different types of insulin are as follows:
Rapid-acting insulin analogs [lispro insulin (Humalog), insulin aspart]
Has a clear appearance. Have an onset of action within 15 minutes of administration. The duration of action is 2 to 3 hours for Humalog and 3 to 5 hours for aspart. Patient must eat immediately after injection to prevent hypoglycemia.
Short-acting insulin (regular insulin) [regular (Humulin R)]
Short-acting insulins have a clear appearance, has an onset of action within 30 minutes of administration, duration of action is 4-8 hours. Regular insulin is the only insulin approved for IV use.
Intermediate-acting insulin (NPH insulin) [neutral protamine Hagedorn (NPH), insulin zinc suspension (Lente)]
They appear cloudy and have either protamine or zinc added to delay their action. Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours. This type of insulin should be inspected for flocculation, a frosted-whitish coating inside the bottle. If frosted, it should not be used.
Long-acting insulin [Ultralente, insulin glargine (Lantus)]
Have a clear appearance and do not need to be injected with a meal. Long-acting insulins have an onset of one hour after administration, and have no peak action because insulin is released into the bloodstream at a relatively constant rate. Duration of action is 36 hours for Ultralente is 36 hours and glargine is at least 24 hours. They cannot be mixed with other insulin because they are in a suspension with a pH of 4, doing so will cause precipitation.
Intermediate and rapid [70% NPH/30% regular]
Premixed concentration has an onset of action similar to that of a rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin.
Educate the patient about different insulin regimens and their advantages/disadvantages.
Providing information about various insulin regimens empowers the patient to make an informed decision. By understanding the potential benefits and costs of each regimen, the patient can actively participate in the selection process.
Teach the patient about meal planning and its impact on insulin requirements.
Proper meal planning plays a significant role in managing blood glucose levels. The nurse should educate the patient on the relationship between food intake and insulin doses. For instance, rapid-acting or short-acting insulins are intended to cover the increase in glucose levels after meals, while intermediate-acting insulins help regulate subsequent meals.
Provide education on self-monitoring of blood glucose (SMBG) and carbohydrate counting.
SMBG helps patients monitor their blood glucose levels and make necessary adjustments to insulin doses. Teaching carbohydrate counting enables patients to match insulin doses to their food intake, providing flexibility in timing and content of meals.
Instruct patients on practical information such as where to purchase and store insulin, syringes, and glucose monitoring supplies, as well as when and how to contact their primary healthcare provider.
Practical information ensures patients have the necessary tools and resources for self-management and know when to seek professional assistance.
Instructing the patient on proper timing of insulin administration.
Different insulin preparations have varying onset, peak, and duration of action. It is crucial to educate the patient about the timing of insulin injections to ensure optimal glucose control. For example, rapid-acting insulins should be administered shortly before meals, while basal insulins should be taken consistently to maintain glucose levels irrespective of meals.
Monitor and assess the patient’s response to insulin therapy.
Regular monitoring of the patient’s blood glucose levels, along with ongoing assessment of their glycemic control and any adverse effects, allows for timely adjustments in the insulin regimen. Monitoring also helps evaluate the patient’s adherence to the prescribed therapy.
Monitor for signs and symptoms of hypo- and hyperglycemia.
Diabetes management aims to maintain blood glucose levels within a target range. Hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) are potential complications. Regular monitoring and early detection of these conditions allow for prompt interventions to prevent further complications.
Provide support and education on preventing and managing hypoglycemia.
Intensive insulin regimens pose a higher risk of hypoglycemia. Educating the patient about the signs, symptoms, and management of hypoglycemia helps prevent and address this potential complication.
Educate patients on the importance of preparing insulin injections consistently and avoiding errors in dosing or using the wrong type of insulin.
Consistent preparation of insulin injections minimizes the risk of dosing errors and ensures proper insulin administration. Accurate preparation is crucial for achieving glycemic control and preventing adverse effects.
Explain the recommended order for drawing up mixed insulins, with regular insulin being drawn up first.
Drawing up regular insulin before other types of insulin helps ensure accurate dosing and maintains consistency in technique. Following a specific order reduces the risk of incorrect insulin doses and promotes safe administration.
Emphasize the importance of not injecting cloudy insulin into a vial of clear insulin to prevent contamination and alteration of insulin action.
Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial, affecting its therapeutic properties and potentially leading to inconsistent glycemic control. Patient adherence to proper injection techniques helps maintain insulin integrity and efficacy.
Educate patients on alternative options if they have difficulty mixing insulins, such as using premixed insulins, prefilled syringes, or taking separate injections.
Providing information about alternative options supports patients in finding a suitable method for insulin administration that aligns with their individual needs and capabilities. These options ensure accurate dosing and simplify the injection process for patients who may have difficulties with mixing insulin.
Insulin storage and syringe safety
Educate patients to refrigerate all unused insulin vials, including spare vials or pens, to maintain their effectiveness.
Refrigeration helps preserve the potency of insulin and prevents degradation that can occur due to temperature fluctuations, ensuring the insulin remains effective for use.
Advise patients to avoid exposing insulin to extreme temperatures, such as freezing, direct sunlight, or hot car interiors.
Extreme temperatures can compromise the efficacy of insulin, leading to potential fluctuations in blood glucose control. It is important to protect insulin from temperature extremes to maintain its therapeutic value.
Instruct patients to keep the insulin vial in use at room temperature to reduce the risk of local irritation at the injection site.
Cold insulin can cause discomfort and local irritation upon injection, which can be minimized by allowing the insulin vial to reach room temperature. This promotes patient comfort and improves adherence to insulin therapy.
Educate patients about the storage duration of insulin vials, advising that if a vial will be used within 1 month, it can be kept at room temperature.
Insulin can be safely stored at room temperature for up to one month without compromising its effectiveness. This knowledge empowers patients to manage their insulin storage appropriately and ensures they have access to insulin that is ready for use.
Instruct patients to gently mix cloudy insulins by inverting the vial or rolling it between their hands before drawing the solution into a syringe or pen.
Cloudy insulins contain particles that need to be evenly distributed throughout the solution. Mixing the insulin ensures a consistent dose and promotes accurate administration.
Emphasize the importance of checking the expiration date on all types of insulin before use.
Expired insulin may have reduced efficacy or potency, which can lead to suboptimal blood glucose control. Checking the expiration date helps ensure patients use insulin that is safe and effective.
Teach patients to inspect bottles of intermediate-acting insulin for flocculation, which appears as a frosted, whitish coating inside the bottle.
Flocculation is an indication that the insulin has been exposed to extreme temperatures and may have lost its effectiveness. Discarding insulin with flocculation helps prevent administering compromised insulin and maintains proper glycemic control.
Ensure that the appropriate syringe size is selected to match the insulin concentration being used and on the different sizes of insulin syringes available (1mL, 0.5mL and 0.3mL) and their corresponding unit increments.
Selecting the correct syringe size is crucial to accurately measure and draw up the prescribed insulin dose. Using syringes with the appropriate capacity ensures accurate insulin administration and helps prevent dosing errors. Providing information about syringe sizes and their markings helps patients understand the available options and choose the most suitable syringe for their insulin needs. Awareness of unit increments promotes accurate measurement and dosing.
Instruct patients on the importance of using a new, disposable needle for each insulin injection.
Using a new needle for each injection helps maintain needle sharpness, reduce discomfort, minimize the risk of infection, and ensure accurate insulin delivery. It is essential for patient safety and proper injection technique.
Advise patients to keep the needle capped when not in use to maintain cleanliness and sterility.
Keeping the needle capped when not in use helps prevent contamination, maintain needle sterility, and reduce the risk of infection. It ensures a safe and hygienic insulin administration process.
Emphasize the importance of not sharing insulin syringes with others to prevent cross-contamination and the spread of infections.
Sharing syringes can transmit bloodborne infections, including viral diseases such as HIV and hepatitis. Educating patients about the risks associated with sharing syringes promotes safe injection practices and protects against potential health hazards.
Instruct patients on proper syringe disposal techniques, such as clipping off the needle or using a device that safely contains and disposes of the needle.
Proper syringe disposal helps prevent accidental needlestick injuries, protects others from potential harm, and ensures the safe management of medical waste. Teaching patients appropriate disposal methods promotes community safety and adherence to waste management regulations.
Provide guidance on local regulations and resources for disposing of used syringes, including contacting the refuse company or waste authority for guidance.
Proper disposal of used syringes is essential to prevent environmental contamination and comply with local waste management regulations. Informing patients about available resources helps them navigate safe disposal practices effectively.
Educate patients on safe syringe transport during travel, advising them to pack used syringes in a secure container to prevent accidental needlesticks.
Traveling with used syringes requires careful handling to avoid injuries and maintain personal and public safety. Providing instructions on proper syringe transport reduces the risk of accidental needlesticks during travel.
Insulin pumps (continuous subcutaneous insulin infusion)
Assess the patient’s suitability for insulin pump therapy.
Insulin pump therapy is suitable for patients who desire continuous subcutaneous insulin infusion and are willing to actively participate in self-management. Assessing the patient’s readiness, psychological stability, commitment to frequent blood glucose monitoring, and ability to work closely with a healthcare team helps determine if insulin pump therapy is appropriate.
Provide extensive education on insulin pump use and self-management of blood glucose and insulin doses.
Insulin pump therapy requires thorough education to ensure proper understanding and safe use of the device. Educating the patient about insulin pump operation, insertion site care, troubleshooting techniques, blood glucose monitoring, and calculating insulin doses based on carbohydrate counting promotes effective self-management.
Teach the patient about potential risks and complications associated with insulin pump therapy.
Patients need to be aware of potential risks and complications, such as occlusions in the infusion set or tubing, interruptions in insulin flow, and the increased risk of ketoacidosis. Educating patients about recognizing signs of occlusions, administering manual injections when needed, and seeking prompt medical attention for any concerns helps minimize risks and promote patient safety.
Instruct the patient on proper care, maintenance, and replacement of the insulin pump.
Proper care and maintenance of the insulin pump, including regular changing of infusion sets, is essential for optimal function and prevention of complications. Teaching the patient about proper hygiene, safe storage, battery replacement, and when to seek technical support helps ensure uninterrupted insulin delivery and device performance.
Monitor the patient’s response to insulin pump therapy.
Regular monitoring of blood glucose levels, along with ongoing assessment of the patient’s glycemic control and insulin requirements, helps evaluate the effectiveness of insulin pump therapy. This monitoring allows for adjustments in insulin dosages and troubleshooting of any issues to maintain optimal glucose control.
Provide support and addressing concerns related to wearing the pump.
Some patients may find wearing the insulin pump for 24 hours a day inconvenient or may have concerns about its visibility. Offering support, addressing concerns, and discussing options for temporary disconnection (e.g., for showering, exercise, swimming, or sexual activity) help promote patient comfort and adherence to therapy.
Assess the patient’s suitability for insulin pen use.
Insulin pens are suitable for patients who need to inject one type of insulin at a time or can use premixed insulins. Assessing the patient’s insulin regimen and individual needs helps determine if an insulin pen is a suitable option for them.
Instruct the patient on proper insulin pen technique and safety measures.
Proper technique in using insulin pens ensures accurate dosage delivery and minimizes the risk of complications. Education on how to load the insulin cartridge, dial the appropriate dose, attach the disposable needle, and perform the injection helps the patient use the device effectively and safely.
Teach the patient about storage and maintenance of insulin pens.
Insulin pens should be stored properly to maintain the integrity of the insulin and the device. Educating the patient on storage conditions, such as avoiding extreme temperatures, and the need for regular cleaning and replacement of needles promotes optimal performance of the insulin pen.
Monitor the patient’s response to insulin pen therapy.
Regular monitoring of blood glucose levels and ongoing assessment of the patient’s glycemic control and insulin requirements help evaluate the effectiveness of insulin pen therapy. This monitoring allows for adjustments in insulin dosages as needed to maintain optimal glucose control.
Insulin jet injectors
Assess the patient’s suitability for jet injector use.
Jet injectors are an alternative to needle injections for delivering insulin. Assessing the patient’s insulin regimen, preferences, and individual needs helps determine if a jet injector is a suitable option for them.
Provide thorough training and supervision for the patient when initiating jet injector use.
Proper training is crucial when using jet injectors to ensure accurate and safe insulin delivery. Providing comprehensive education on how to operate the device, maintain hygiene, and troubleshoot any issues helps the patient use the jet injector effectively and minimizes the risk of complications.
Educate the patient about the differences in insulin absorption rates, peak activity, and insulin levels with a jet injector.
Jet injectors may result in differences in insulin absorption rates compared to traditional needle injections. Educating the patient about these variations helps them understand the potential differences in insulin action and adjust their self-management strategies accordingly.
Advise the patient about the possibility of bruising associated with jet injector use.
Some patients may experience bruising at the injection site when using jet injectors. Informing the patient about this potential side effect helps manage their expectations and promotes early identification of any complications or adverse reactions.
4. Preventing Complications of Insulin Therapy
Insulin administration can sometimes lead to local and systemic allergic reactions, with local reactions causing redness, swelling, tenderness, and wheals at the injection site. Systemic reactions are rare but can result in generalized urticaria or even anaphylaxis.
Preventing allergic reactions
Assess and monitor for local allergic reactions at the injection site.
Local allergic reactions, such as redness, swelling, tenderness, or wheal formation, can occur after insulin injections. Regular assessment of injection sites helps identify and monitor any allergic reactions. If reactions persist, an alternative type of insulin can be prescribed.
Educate the patient about systemic allergic reactions to insulin and the appropriate response.
Although rare, systemic allergic reactions can occur, presenting as generalized urticaria (hives) or even anaphylaxis. Patients should be aware of these potential reactions and know to seek immediate medical attention if they experience any symptoms. Desensitization with gradually increasing insulin doses may be necessary for treatment.
Educate the patient about insulin lipodystrophy and the importance of rotation of injection sites.
Lipodystrophy refers to localized reactions at injection sites, including lipoatrophy (loss of subcutaneous fat) or lipohypertrophy (fibrofatty masses). Using human insulin has greatly reduced the occurrence of lipodystrophy. Patients should be educated about the importance of rotating injection sites to prevent the development of lipohypertrophy and delayed insulin absorption.
Monitor for insulin resistance and collaborating with the healthcare team to adjust insulin doses.
Insulin resistance may occur in some patients with diabetes, requiring higher insulin doses for adequate glycemic control. Regular monitoring of blood glucose levels and close collaboration with the healthcare team allow for adjustments in insulin doses to address insulin resistance and control diabetes symptoms effectively.
Managing morning hyperglycemia
Provide education on the causes of morning hyperglycemia and strategies to address it.
Morning hyperglycemia can result from the dawn phenomenon, insulin waning, or the Somogyi effect. Educating the patient about these causes helps them understand the importance of blood glucose monitoring during the night to determine the underlying cause. Adjustments in insulin doses and timing can be made accordingly to prevent morning hyperglycemia.
Teach the patient about proper timing of insulin administration to address insulin waning.
Insulin waning refers to a progressive increase in blood glucose levels from bedtime to morning. Instructing the patient to administer the evening NPH insulin dose at bedtime rather than before dinner helps prevent insulin waning and ensures better glycemic control upon waking.
5. Administering Oral Antidiabetic Agents
Oral antidiabetic agents are prescribed for patients with type 2 diabetes who do not respond effectively to medical nutrition therapy (MNT) and exercise alone.
Assess the patient’s understanding of oral antidiabetic agents and their role in diabetes management.
It is important to evaluate the patient’s knowledge and comprehension regarding oral antidiabetic agents to ensure their active participation in medication adherence and self-management.
Assess the patient’s knowledge of the various classes of oral antidiabetic medications and their mechanisms of action.
Understanding the different classes of oral antidiabetic agents and how they work can empower the patient to actively participate in their treatment plan and recognize the importance of medication adherence.
Oral Antidiabetic Agents
Oral antidiabetic agents are used for patients with type 2 diabetes who cannot effectively manage their condition through diet and exercise alone. It’s important for patients to understand that these oral agents are supplementary to other treatment approaches and may require temporary discontinuation if hyperglycemia occurs, with insulin as a potential alternative. Oral antidiabetic agents may include:
Second-Generation Sulfonylureas [glipizide (Glucotrol), glimepiride (Amaryl), glyburide (Diabeta)]
Sulfonylureas stimulate insulin release from the beta cells in the pancreas. They improve binding insulin to receptors and may increase number of insulin receptors. They are indicated as adjunct to diet and exercise (MNT). They are more potent than first-generation sulfonylureas and can be used in combination with metformin or insulin to improve glucose control.
Biguanides [metformin (Glucophage)]
Biguanides decreased the product and increases the uptake of glucose in the liver. It is effective in lowering blood glucose and does not cause hypoglycemia as the sulfonylureas do. It has been associated with development of lactic acidosis and GI distress and long term use may cause vitamin B12 deficiency.
Alpha-Glucosidase Inhibitors [acarbose (Precose), miglitol (Glyset)]
inhibit alpha-glucosidase, an enzyme that breaks down glucose for absorption. Therefore, they delay the absorption of glucose. They have only a mild effect on glucose levels and do not enhance insulin secretion. They are associated with severe hepatic toxicity and GI distress.
Non-Sulfonylurea Insulin Secretagogues [repaglinide (Prandin), nateglinide (Starlix)]
Stimulates the pancreas to secrete insulin. It can be used alone or in combination with metformin to improve control of glucose.
Thiazolidinediones or Glitazones [pioglitazone (Actos), rosiglitazone (Avandia)]
Decreases insulin resistance by sensitizing the body to insulin and by stimulating insulin receptor sites to lower blood glucose and improve action of insulin.
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors [sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta)]
Slows the breakdown of GLP-1 to prolong the effects of increased insulin secretion, decreased glucagon secretion, and slowed GI emptying ultimately producing improved glucose control.
Glucagon-like Peptide-1 Agonist (GLP-1) [liraglutide (Victoza), dulaglutide (Trulicity)]
Enhances glucose-dependent insulin secretion and exhibit other antihyperglycemic actions following their release into the circulation from the gastrointestinal tract. They may also lead to weight loss but can have side effects such as pancreatitis, diarrhea, nausea, and vomiting. Not suitable for patients with type 1 diabetes.
Sodium-Glucose Co-Transporter 2 (SGL-2) Inhibitors [dapagliflozin (Forxiga), canagliflozin (Invokana)]
Increases urinary glucose excretion and lowers the renal threshold for glucose. It is also prescribed to reduce the risk of major cardiovascular events in patients with established cardiovascular disease and type 2 DM. This drug improves glycemic control by decreasing glucose concentration in the blood through increased urinary excretion and reduced renal absorption of glucose.
Educate the patient about the complementary nature of oral antidiabetic agents with other treatment modalities, such as medical nutrition therapy (MNT) and exercise.
Reinforcing the importance of a comprehensive approach to diabetes management encourages the patient to adhere to a balanced diet and engage in regular physical activity, which can enhance the effectiveness of oral antidiabetic agents.
Monitor the patient’s blood glucose levels regularly, especially during periods of infection, trauma, or surgery.
Hyperglycemia resulting from these conditions may require temporary discontinuation of oral antidiabetic agents and initiation of insulin therapy. Regular monitoring helps detect any fluctuations in blood glucose levels and informs appropriate medication adjustments.
Provide education on insulin therapy and its potential use in combination with oral agents, particularly for newly diagnosed patients with type 2 diabetes who have symptomatic hyperglycemia and high blood glucose and A1C levels.
Some patients may require insulin therapy as an adjunct to oral antidiabetic agents to achieve glycemic targets. Educating the patient about insulin therapy helps alleviate any fears or misconceptions they may have and promotes acceptance and adherence to the prescribed treatment regimen.
Emphasize the importance of regular follow-up visits and laboratory tests to evaluate the effectiveness of oral antidiabetic agents and make necessary adjustments.
Ongoing monitoring and assessment are crucial to assess the patient’s response to treatment and ensure optimal glycemic control. Regular follow-up visits and laboratory tests enable healthcare providers to modify the treatment plan as needed.
Encourage the patient to report any adverse effects or changes in symptoms related to oral antidiabetic agents promptly.
Early identification and management of adverse effects or changes in symptoms associated with oral antidiabetic agents are essential to prevent complications and optimize treatment outcomes. Open communication encourages patients to seek timely medical assistance when needed.
6. Promoting Nutritional Balance and Weight Management
Proper nutrition and meal planning are essential for diabetes management. Educating patients about healthy food choices, portion control, and balanced meals can help them achieve and maintain optimal blood glucose levels, lipid profiles, and blood pressure.
Conduct a comprehensive assessment of the patient’s dietary history, food preferences, lifestyle, and cultural background.
Understanding the patient’s individual food preferences, eating habits, and cultural background helps in developing a personalized meal plan. By considering these factors, nurses can ensure that the plan is realistic, acceptable, and aligned with the patient’s cultural and personal beliefs, enhancing adherence and promoting long-term success.
Calculate the patient’s energy needs and caloric requirements based on individual factors.
Determining a person’s energy needs and caloric requirements is crucial for developing an appropriate meal plan. Calculations based on age, gender, height, and weight help determine the baseline caloric intake required for weight maintenance and overall health. This individualized approach supports accurate calorie control and ensures nutritional adequacy.
Factor in the patient’s activity level to determine the actual number of calories required.
Considering the patient’s activity level helps determine the appropriate caloric intake for weight maintenance. Factoring in physical activity provides a more accurate estimation of energy needs and supports the patient in achieving their weight goals.
Subtract 500 to 1000 calories from the daily total to promote a safe and gradual weight loss.
To promote a 1- to 2-pound weight loss per week, a calorie deficit of 500 to 1000 calories is recommended. This approach supports gradual weight loss, which is associated with better long-term success and reduces the risk of adverse effects.
Simplify meal planning information and provide opportunities for practice and repetition.
Some aspects of meal planning, such as using food exchange systems, may be challenging for patients due to intellectual limitations or emotional barriers. Simplifying information and providing opportunities for practice and repetition can enhance patient understanding and proficiency in meal planning techniques. This approach helps patients develop confidence and competence in managing their dietary choices and fosters long-term adherence.
Distribute calories into carbohydrates, proteins, and fats based on the patient’s individual needs.
Balancing the distribution of macronutrients is crucial for maintaining optimal nutrition and supporting blood glucose control. Tailoring the distribution of calories into carbohydrates, proteins, and fats based on the patient’s individual needs ensures adequate nutrient intake and promotes overall health.
Educate the patient about the recommended percentages of calories from carbohydrates, proteins, and fats.
Providing education on the recommended caloric distribution helps patients understand the importance of balancing macronutrients in their diet. By educating patients about the recommended percentages of calories from carbohydrates, proteins, and fats, nurses empower patients to make informed dietary choices that support blood glucose control, lipid management, and overall health.
- Carbohydrates. It is recommended that 60% of calories should be derived from carbohydrates. Carbohydrate foods have the greatest effect on the levels of blood glucose because they are digested more quickly as compared to other food sources.All carbohydrates should be taken in moderation to avoid postprandial blood glucose levels.
- Fats. It is recommended that 20-30% of calories should be derived from fats. Dietary recommendations for fat intake for patients with diabetes includes reducing the total percentage of calories from fat sources to less than 30% and limiting the amount of saturated fats. Dietary cholesterol should be less than 300 mg/day to help reduce the development of coronary artery disease which is the leading cause of death and disability among people with diabetes.
- Protein. Protein sources should be composed 10-20% of the patient’s caloric intake. Include non animal sources of proteins such as legume, whole grains, nuts, to help reduce saturated fat and cholesterol intake.
- Fiber. Fiber should be increased in the diet as it can improve blood glucose levels, decrease the need for insulin sources, and lowers the total cholesterol and low-density lipoprotein levels.
Highlight the importance of increased fiber intake for improved blood glucose levels and other health benefits.
Increased fiber intake plays a significant role in improving blood glucose levels, lowering cholesterol, and promoting satiety. Educating patients about the benefits of fiber-rich foods, such as legumes, whole grains, fruits, and vegetables, encourages their inclusion in the meal plan and supports overall dietary and health goals.
Gradually increase fiber intake in consultation with a dietitian to prevent adverse effects.
Sudden increases in fiber intake can lead to gastrointestinal discomfort and require adjustments in dosage of insulin or antidiabetic agents to prevent hypoglycemia. Gradually increasing fiber intake in consultation with a dietitian allows for proper monitoring and adjustment of the meal plan to mitigate potential adverse effects.
Educate patients about the use of exchange lists for meal planning.
Exchange lists are a commonly used tool in nutritional management for individuals with diabetes. Educating patients about the concept of exchange lists helps them understand how foods can be organized into groups with similar characteristics, such as calorie content and macronutrient composition. This knowledge enables patients to create a well-balanced meal plan that maintains consistency in nutrient intake while providing variety in food choices. You can learn more about the Food Exchange List here.
Teach patients how to read nutrition labels and understand carbohydrate content.
Reading food labels is an essential skill for patients with diabetes when shopping for food. Understanding the carbohydrate content of foods listed on nutrition labels allows patients to make informed choices and accurately determine the amount of medication needed, particularly for those who require premeal insulin.
Explain the concept of carbohydrate counting and its flexibility in food choices.
Carbohydrate counting is a popular nutritional tool used for blood glucose management in both type 1 and type 2 diabetes. Educating patients about carbohydrate counting helps them understand that carbohydrates have the most significant impact on blood glucose levels. This approach provides flexibility in food choices while maintaining blood glucose control. By incorporating carbohydrate counting into their meal planning, patients can achieve more accurate insulin management and maintain a balanced diet.
Educate patients about healthy food choices, portion control, and serving sizes.
Encouraging patients to make healthy food choices and practice portion control is important for achieving and maintaining blood glucose control and weight management. Teaching patients to measure servings or choices, such as using standard portion sizes or the MyPlate Food Guide, helps them understand appropriate portion sizes for different food groups. This approach can promote balanced nutrition, supports portion control, and simplifies meal planning for patients who may find more complicated systems challenging.
Discuss the concept of the glycemic index and its potential impact on blood glucose levels.
The glycemic index measures how much a particular food increases blood glucose levels compared to an equivalent amount of glucose. Educating patients about the glycemic index helps them understand how different foods affect their blood glucose levels.
Encourage patients to monitor their blood glucose levels after consuming specific foods to create their own glycemic index.
Monitoring blood glucose levels after eating specific foods allows patients to assess the individual impact of those foods on their blood glucose control. This personalized approach empowers patients to make dietary adjustments based on their own glycemic response. By using this information, patients can modify their meal plans and insulin doses accordingly, leading to improved blood glucose control and individualized diabetes management.
Emphasize consistent meal timing and portion control.
Consistency in meal timing and portion control helps regulate blood glucose levels. Patients should be educated on the importance of regular meals and the distribution of caloric intake throughout the day. Avoiding skipped meals prevents glucose fluctuations and excessive demands on the pancreas.
Support patients in implementing lifestyle changes.
Lifestyle changes, including dietary modifications and increased physical activity, are integral to diabetes management. Nurses play a vital role in providing support, motivation, and education to help patients adopt and sustain these changes.
Encourage weight loss and maintenance.
Weight management is particularly important for obese patients with diabetes. Losing weight can improve blood glucose control and reduce the need for medication. There is also substantial evidence indicating that managing obesity can significantly delay the progression from prediabetes to type 2 diabetes and provides significant benefits in the treatment of type 2 diabetes. Nurses should emphasize the significance of weight loss, provide guidance on healthy weight loss strategies, and offer ongoing support.
Address emotional issues and provide psychological support related to dietary changes.
Some patients may struggle with emotional issues, such as accepting the diagnosis of diabetes or experiencing feelings of deprivation and restriction in eating. Providing psychological support and addressing these concerns helps patients navigate the emotional aspects of meal planning. By emphasizing that meal planning is a new way of thinking about food rather than a restrictive approach, nurses can promote a positive mindset and facilitate the patient’s acceptance and adherence to the meal plan.
Provide behavioral therapy and ongoing nutrition counseling.
Consistently following a meal plan and maintaining weight loss can be challenging. Behavioral therapy, group support, and ongoing nutrition counseling can help patients incorporate new dietary habits into their lifestyles and sustain positive changes.
Collaborate with a registered dietitian.
Registered dietitians specialize in medical nutrition therapy (MNT) for diabetes management. Collaborating with them ensures that the plan aligns with the patient’s dietary requirements, weight goals, and diabetes management objectives. This collaboration optimizes the effectiveness of the meal plan and supports the patient’s understanding and implementation of dietary changes.
Reinforce the role of the nurse in communicating relevant information to the dietitian and promoting patient understanding.
Effective communication between the nurse and the dietitian facilitates a coordinated and individualized approach to meal planning. The nurse acts as a bridge between the patient and the dietitian, ensuring that important patient information is accurately shared, reinforcing the patient’s comprehension of the plan, and addressing any concerns or questions that arise during the educational process.
Educate patients about the importance of consistent eating habits and the relationship between food and insulin.
Consistency in the amount of calories and carbohydrates ingested at each meal is crucial for patients requiring insulin to control blood glucose levels. Educating patients about this relationship helps them understand the impact of food on insulin requirements and blood glucose control. It empowers patients to make informed choices about their meal timings and contents, fostering better glucose management.
Emphasize the importance of moderation in alcohol consumption. Educate patients about the potential adverse effects of alcohol specific to diabetes.
Moderation is crucial when it comes to alcohol consumption for patients with diabetes. Educating patients about the recommended limits for alcohol intake helps them understand the need to consume alcoholic beverages in controlled quantities. By promoting moderation, nurses assist patients in minimizing the potential negative impact of alcohol on their diabetes management.
Caution patients about the risk of hypoglycemia associated with alcohol consumption.
Alcohol consumption can increase the risk of hypoglycemia, particularly for patients taking insulin or insulin secretagogues. Educating patients about the potential effects of alcohol on blood glucose levels helps them understand the importance of consuming food along with alcohol to prevent hypoglycemia. By providing this information, nurses empower patients to make informed decisions about alcohol consumption and take appropriate measures to prevent hypoglycemia.
Encourage patients to incorporate food intake along with alcohol consumption.
Consuming food along with alcohol can help reduce the risk of hypoglycemia. By advising patients to have a meal or snack when consuming alcohol, nurses help ensure that patients maintain stable blood glucose levels. However, it is important to note that carbohydrates consumed with alcohol may raise blood glucose levels. Providing this guidance helps patients strike a balance and make informed choices regarding food intake when consuming alcohol.
Discuss the potential impact of alcohol on weight, hyperlipidemia, and glucose levels.
Alcohol consumption can contribute to weight gain, hyperlipidemia, and elevated glucose levels. Educating patients about the potential effects of alcohol on these aspects of their health helps them understand the importance of moderation and incorporating alcohol calories into their overall meal plan.
Sweeteners and sugar-free foods
Educate patients about lower-calorie or less-sweet drink options.
Recommending lower-calorie or less-sweet drink options, such as light beer or dry wine, helps patients make choices that align with their diabetes management goals.
Educate patients about artificial sweeteners, including their types and use and emphasize moderation in sweetener use to avoid potential adverse effects.
Encouraging patients to use sweeteners in moderation helps prevent potential negative consequences. By promoting mindful consumption, patients can avoid excessive intake and maintain a balanced diet. Explaining the distinction between nutritive (e.g., fructose, sorbitol, xylitol) and nonnutritive sweeteners helps patients understand their caloric content and impact on blood glucose levels.
Address potential side effects of certain sweeteners, such as sorbitol.
Informing patients about potential side effects, such as the laxative effect of sorbitol-containing sweeteners, enables them to make decisions regarding the use of these products. Patients can monitor their individual tolerance and adjust their intake accordingly.
Educate patients about the potential caloric content of “sugarless” or “sugar-free” foods.
It is crucial to inform patients that foods labeled as “sugarless” or “sugar-free” may still provide calories similar to sugar-containing products if they are made with nutritive sweeteners. Patients need to be aware that “sugarless” or “sugar-free” foods, despite their labeling, can still elevate blood glucose levels due to their caloric content. By clarifying that these foods should not be consumed in unlimited quantities, patients can manage their blood glucose levels more effectively and prevent potential spikes.
7. Encouraging Regular Exercise and Physical Activity
Regular exercise is essential in diabetes management as it helps lower blood glucose levels, improve insulin utilization, and reduce cardiovascular risk factors. Regular exercise is highly beneficial for individuals with diabetes. By encouraging patients to engage in regular exercise, nurses promote the importance of physical activity in managing blood glucose levels, reducing cardiovascular risk factors.
Provide guidelines for exercise frequency and duration.
Guidelines for exercise frequency and duration help patients establish a structured exercise routine. By specifying three times per week with no more than two consecutive days without exercise, patients can maintain consistency in their exercise regimen, which contributes to better blood glucose control and overall fitness. The American Diabetes Association recommends the following guidelines for physical activity:
- For children and adolescents with type 1 diabetes, type 2 diabetes, or prediabetes, it is recommended to engage in at least 60 minutes per day of moderate- to vigorous-intensity aerobic activity. They should also participate in vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week.
- Most adults with type 1 diabetes or type 2 diabetes should aim for 150 minutes or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days. For younger and physically fit individuals, shorter durations of vigorous-intensity or interval training may be sufficient (minimum 75 minutes per week). Resistance exercise should be performed 2-3 times per week on nonconsecutive days.
Educate adults with type 2 diabetes about the significance of reducing sedentary behavior and interrupting prolonged sitting every 30 minutes for blood glucose benefits.
It is recommended for all adults, especially those with type 2 diabetes, to reduce sedentary behavior and interrupt prolonged sitting every 30 minutes for blood glucose benefits. Older adults with diabetes should incorporate flexibility and balance training 2-3 times per week, with options such as yoga and tai chi. Individuals with type 1 diabetes and type 2 diabetes should evaluate their baseline physical activity and sedentary time, aiming to increase non sedentary activities above their baseline.
Discuss the benefits of exercise and weight loss for individuals with type 2 diabetes.
For individuals with type 2 diabetes who are overweight or obese, engaging in exercise alongside dietary management offers multiple benefits, including improved glucose metabolism and enhanced body fat loss. Exercise coupled with weight loss improves insulin sensitivity and may decrease the need for insulin or oral antidiabetic agents. Educating patients on the potential positive outcomes of exercise and weight loss encourages them to incorporate physical activity as part of their diabetes management plan.
Emphasize the importance of a gradual increase in exercise duration.
A slow and gradual increase in the duration of exercise sessions is recommended to prevent excessive strain or injury. Allowing the patient to gradually build endurance and fitness levels over time, the nurse can promote safe and sustainable exercise habits.
Recommend walking as a safe and accessible form of exercise.
Walking is a low-impact and easily accessible form of exercise that can be performed by most individuals with diabetes. It requires no special equipment other than proper shoes and can be incorporated into daily routines. By recommending walking, nurses provide patients with a practical and feasible exercise option that can be sustained long-term.
Encourage patients to discuss an exercise program with their primary healthcare provider and undergo a medical evaluation.
Before initiating an exercise program, it is important for patients to consult with their primary healthcare provider and undergo a medical evaluation. This evaluation helps identify any underlying health concerns, assess fitness levels, and ensure that patients are medically cleared for exercise and ensure that exercise recommendations are tailored to each individual’s specific needs.
Exercise precautions for patients with diabetes
Assess blood glucose and ketone levels before initiating exercise.
Monitoring blood glucose and ketone levels before exercise is crucial for patients with diabetes. If blood glucose levels exceed 250 mg/dL (14 mmol/L) and ketones are present in urine, exercising should be postponed until ketone test results are negative and blood glucose levels are closer to normal. Exercising with elevated blood glucose levels can further increase blood glucose levels, potentially leading to hyperglycemia and other complications.
Educate patients on pre-exercise carbohydrate snacks for insulin-treated individuals.
Patients who require insulin should be taught to consume a 15-g carbohydrate snack or a snack of complex carbohydrates with protein before engaging in moderate exercise. This pre-exercise snack helps prevent unexpected hypoglycemia by providing the necessary fuel for physical activity and counteracting the potential decrease in circulating insulin during exercise.
Provide instructions on managing post-exercise hypoglycemia for patients taking insulin.
Hypoglycemia can occur hours after exercise in patients taking insulin. To prevent post-exercise hypoglycemia, patients may need to consume a snack at the end of the exercise session and at bedtime, as well as monitor their blood glucose levels more frequently. Patients who are capable, knowledgeable, and responsible can learn to adjust their insulin doses in collaboration with a diabetes educator. Others require specific instructions on managing their blood glucose levels during and after exercise.
Educate patients on regular blood glucose monitoring during extended periods of exercise.
Patients taking insulin and engaging in extended periods of exercise should monitor their blood glucose levels before, during, and after the exercise period. This monitoring helps them adjust their carbohydrate intake to maintain blood glucose levels within the target range.
Inform exercise participants and observers about the individual’s diabetes status.
It is important for others involved in exercise activities to be aware that the person exercising has diabetes. By informing exercise participants and observers, they can provide appropriate assistance in case of severe hypoglycemia. This promotes a safe exercise environment and ensures that prompt action can be taken if a diabetes-related emergency occurs.
Provide education on exercise considerations for patients with diabetic complications.
Patients with diabetic complications, such as retinopathy, autonomic neuropathy, sensorimotor neuropathy, and cardiovascular disease, may require modifications in their exercise regimen.
Educate patient with diabetes on the importance of proper footwear and protective equipment.
Wearing appropriate footwear and protective equipment reduces the risk of injuries during exercise. This is particularly important for individuals with diabetes, as they may have reduced sensation in their lower extremities due to peripheral neuropathy. By emphasizing the use of proper footwear and protective equipment, nurses help prevent foot injuries and promote safety during exercise.
Advise patients to meticulously inspect their feet daily after exercise.
Patients with diabetes are at a higher risk of foot complications. By instructing patients to inspect their feet daily after exercise, nurses promote early detection of any foot abnormalities, such as blisters or wounds. Timely identification and appropriate management of foot issues can prevent the development of serious complications, such as foot ulcers.
Provide recommendations for avoiding exercise in extreme weather conditions and periods of poor metabolic control.
Extreme heat or cold can pose risks to individuals with diabetes during exercise. Additionally, exercising during periods of poor metabolic control may lead to unstable blood glucose levels. By advising patients to avoid exercise in extreme weather conditions and during periods of poor metabolic control, nurses promote patient safety and help maintain stable blood glucose levels.
Exercise precautions among older people
Assess the physical capacity and functional limitations of older adults with diabetes before initiating an exercise program.
Older adults may have specific physical limitations, chronic conditions, or age-related changes that need to be considered when planning an exercise program. Assessing their physical capacity and functional abilities helps determine appropriate exercises and adaptations to ensure safety and optimize the benefits of physical activity.
Develop an individualized exercise plan that includes low-impact activities, balance exercises, and flexibility training.
Older adults may have reduced joint mobility, balance issues, and age-related musculoskeletal changes that require modifications in exercise programming. Including low-impact activities (e.g., walking, swimming), balance exercises (e.g., tai chi), and flexibility training (e.g., stretching) helps improve mobility, reduce the risk of falls, and maintain joint flexibility, promoting overall functional independence and quality of life.
Emphasize the importance of gradual progression and frequent rest breaks during exercise sessions.
Older adults may need more time to adapt and recover from exercise due to decreased stamina and reduced exercise tolerance. Encouraging gradual progression, such as increasing exercise duration or intensity in small increments, and incorporating frequent rest breaks during exercise sessions helps prevent overexertion, fatigue, and injury. This approach supports older adults in safely building endurance and strength while minimizing the risk of adverse events.
Provide education on the use of assistive devices and safe exercise techniques.
Older adults may benefit from the use of assistive devices (e.g., canes, walkers) to enhance stability and mobility during exercise. Teaching proper use of assistive devices and demonstrating safe exercise techniques help minimize the risk of falls, strains, and other injuries.
Incorporate social support and group activities for motivation and enjoyment.
Older adults often thrive in supportive and socially engaging environments. Encouraging participation in group exercise classes, walking groups, or community-based programs fosters social interaction, motivation, and enjoyment. The positive social aspect of exercise can enhance adherence and long-term commitment to regular physical activity among older adults with diabetes.
8. Preventing Hyperglycemia
Hyperglycemia is a common occurrence in hospitalized patients, particularly those admitted for the illness that led to hospitalization. Several factors contribute to hyperglycemia, including changes in treatment regimen, medications such as corticosteroids, inadequate insulin therapy with IV dextrose, inappropriate insulin management, and mismatched timing of meals and insulin. Nursing interventions play a crucial role in correcting these factors to prevent hyperglycemia.
Assess the patient’s usual home routine for insulin, meals, and activities.
Understanding the patient’s normal routine helps approximate their home schedule in the hospital setting, promoting consistency in insulin administration, meals, and activities.
Monitor blood glucose levels regularly.
Blood glucose monitoring is a vital sign and provides essential information for assessing glycemic control. It helps identify hyperglycemia and informs the need for additional insulin doses.
Obtain orders for extra doses of insulin when blood glucose levels are elevated.
Blood glucose monitoring results inform nurses of the need for additional doses of insulin. Administering additional doses of insulin at appropriate times helps manage hyperglycemia and promote glycemic control.
Do not withhold insulin when blood glucose levels are within the normal range.
Withholding insulin when blood glucose levels are normal can lead to hyperglycemia. It is important to administer insulin consistently to maintain glycemic control.
Test blood glucose levels before meals and administer insulin at that time.
Administering insulin before meals, based on premeal blood glucose levels, helps prevent postprandial hyperglycemia and promotes a physiologic response to glucose intake.
Administer short-acting insulin to avoid postprandial hyperglycemia.
Short-acting insulin is necessary to control blood glucose levels after meals, even in patients with normal pre-meal glucose levels. Administering it at the appropriate time ensures effective glycemic control.
Be cautious with the use of corticosteroids (e.g., prednisone) and monitor blood glucose levels closely.
Corticosteroids can induce hyperglycemia, so close monitoring of blood glucose levels is essential. Adjustments to insulin therapy may be necessary to maintain glycemic control.
Use normal saline (NS) as the preferred solution for IV antibiotics, if possible, to minimize dextrose infusion.
Excessive infusion of dextrose through IV fluids can contribute to hyperglycemia. Using NS as the diluent for IV antibiotics helps avoid this potential cause of elevated blood glucose levels.
Avoid overly aggressive treatment of hypoglycemia.
Aggressive treatment of hypoglycemia can lead to rebound hyperglycemia. Managing hypoglycemia with appropriate measures prevents subsequent hyperglycemia.
9. Preventing Hypoglycemia
Hypoglycemia in hospitalized patients is often attributed to excessive insulin administration or delays in eating.
Follow the established hospital protocol for treating hypoglycemia.
Adhering to the hospital’s standardized protocol ensures consistent and appropriate management of hypoglycemia, promoting patient safety and glycemic control.
Assess the pattern of glucose values and avoid repeated doses of insulin leading to hypoglycemia.
Evaluating the patient’s glucose values over time helps identify patterns and avoid giving insulin doses that consistently result in hypoglycemia. Adjustments in insulin therapy may be necessary to prevent recurrent hypoglycemia.
Administer repeat treatments for hypoglycemia if the initial treatment does not sufficiently increase glucose levels, following the specified time interval (e.g., 15 minutes).
Repeat treatments allow for further correction of hypoglycemia if the initial intervention was insufficient. Following the specified time interval ensures appropriate timing and monitoring of the patient’s response.
Limit successive doses of subcutaneous regular insulin to no more than every 3 to 4 hours.
Administering multiple doses of regular insulin in quick succession increases the risk of hypoglycemia. Adhering to appropriate dosing intervals helps maintain glycemic stability.
Exercise caution when administering supplemental doses of regular insulin in patients receiving intermediate insulin before breakfast and dinner.
Careful consideration is needed when providing additional regular insulin doses in patients who are already receiving intermediate-acting insulin. Timing and dosage adjustments should be made to prevent overlapping peaks and subsequent hypoglycemia.
Arrange for snacks to be given if meals are delayed due to procedures, physical therapy, or other activities.
Delayed food intake can contribute to hypoglycemia. Providing snacks as needed helps maintain glucose levels and prevent hypoglycemic reactions in patients whose meals are delayed.
Monitor the patient for signs and symptoms of hypoglycemia, such as sweating, tremor, tachycardia, confusion, and changes in behavior.
Regular monitoring allows the nurse to detect early signs of hypoglycemia and intervene promptly to prevent complications.
Administer fast-acting sources of carbohydrate, such as fruit juice or glucose gel, as ordered, to raise the patient’s blood glucose levels.
Immediate administration of carbohydrates helps restore blood glucose levels and alleviate hypoglycemic symptoms.
Prepare and administer glucagon, as prescribed, in emergency situations when the patient is unconscious or unable to swallow.
Glucagon stimulates the liver to release stored glucose, rapidly increasing blood glucose levels. Administration of glucagon can be life-saving in severe hypoglycemia.
Provide emotional support and reassurance to the patient during episodes of hypoglycemia, addressing any fears or concerns they may have.
Emotional support helps alleviate anxiety and encourages the patient to actively participate in their diabetes management.
Educate the patient and their family or caregivers on recognizing and managing hypoglycemic episodes, including the use of fast-acting carbohydrates and glucagon.
Patient and caregiver education promotes awareness and empowers them to respond effectively to hypoglycemia, ensuring timely treatment.
Educate the patient on the signs and symptoms of hypoglycemia and the importance of early recognition and prompt treatment.
Early recognition of hypoglycemia allows for timely intervention and prevents the condition from worsening. Prompt treatment helps restore blood glucose levels to a safe range, preventing complications and promoting patient well-being.
Instruct the patient on the appropriate management of hypoglycemia with fast-acting sources of carbohydrate, such as fruit juice or glucose tablets.
Fast-acting carbohydrates quickly raise blood glucose levels, providing immediate relief from hypoglycemic symptoms. Patients need to be aware of the recommended sources of carbohydrates and the appropriate quantities to consume for effective management.
Teach patients and their families or caregivers about the use of glucagon in emergency situations when the patient is unconscious or unable to swallow.
Glucagon is a life-saving hormone that stimulates the liver to release stored glucose, raising blood glucose levels rapidly. It is crucial for family members and caregivers to understand how to administer glucagon in emergency situations to ensure timely treatment.
Emphasize the importance of regular blood glucose monitoring, especially before driving or engaging in potentially dangerous activities.
Regular blood glucose monitoring helps patients with diabetes assess their glycemic status and anticipate changes in insulin requirements. It enables them to take appropriate actions to prevent hypoglycemia and maintain safe blood glucose levels.
Provide education on lifestyle factors that can contribute to hypoglycemia, such as meal timing, physical activity, and medication adherence.
Proper meal planning, adherence to medication schedules, and awareness of the impact of physical activity help patients prevent hypoglycemia. Education empowers patients to make informed decisions and take proactive steps to manage their condition effectively.
Encourage patients to carry a source of simple sugar (e.g., glucose tablets) with them at all times to address hypoglycemic episodes when away from home.
Carrying a source of fast-acting carbohydrates ensures that patients can quickly treat hypoglycemia, even in situations where other food options may not be readily available. It promotes patient autonomy and preparedness for managing hypoglycemic episodes.
10. Preventing Diabetic Ketoacidosis (DKA)
Monitor the patient for signs and symptoms of DKA, including hyperglycemia, dehydration, electrolyte imbalances, and acidosis.
Regular monitoring allows for early detection of DKA and prompt intervention to prevent complications.
Administer intravenous fluids, such as normal saline (NS) or half-strength NS, as indicated and at the prescribed rate, to rehydrate the patient and restore tissue perfusion.
Rehydration is crucial in managing DKA to maintain fluid balance, improve tissue perfusion, and facilitate the excretion of excess glucose and ketones.
Monitor the patient’s vital signs, including blood pressure, heart rate, and orthostatic changes, to assess fluid status and adjust fluid replacement accordingly.
Monitoring vital signs helps identify signs of dehydration or fluid overload and guides appropriate fluid management.
Monitor electrolyte levels, particularly potassium, and replace electrolytes as indicated to maintain balance and prevent dysrhythmias.
DKA can cause electrolyte imbalances, including hyperkalemia or hypokalemia, which require careful monitoring and timely replacement to prevent complications. Cautious administration of potassium supplements helps prevent rapid potassium fluctuations and the risk of hyperkalemia. It ensures a gradual and controlled increase in serum potassium levels.
Administer insulin therapy as prescribed, usually through continuous intravenous infusion, to reverse acidosis and promote glucose utilization.
Insulin administration inhibits fat breakdown, stops ketone production, and helps correct acidosis in DKA. Continuous infusion ensures a steady supply of insulin until subcutaneous insulin therapy can be resumed.
Educate the patient and their family/caregivers about sick day rules for managing diabetes during illness, emphasizing the importance of never eliminating insulin doses when experiencing nausea or vomiting.
Proper management during illness helps prevent DKA episodes and promotes early intervention to maintain glycemic control.
For more information, please visit: 4 Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Care Plans
11. Preventing Hyperosmolar Hyperglycemic State (HHS)
Monitor the patient for signs and symptoms of HHS, including hypotension, profound dehydration, tachycardia, and neurologic changes.
Regular monitoring allows for early detection of HHS and prompt intervention to prevent complications.
Administer intravenous fluids, such as 0.9% or 0.45% normal saline (NS), as indicated and at prescribed rate, to rehydrate the patient and restore volume.
Rehydration is essential in managing HHS to improve tissue perfusion, correct dehydration, and restore fluid balance.
Monitor the patient’s vital signs, fluid intake and output, and electrolyte levels to assess fluid status and guide appropriate fluid replacement and electrolyte correction.
Monitoring vital signs, fluid balance, and electrolyte levels helps identify dehydration, electrolyte imbalances, and prevents complications such as fluid overload or cardiac dysrhythmias. Close monitoring of fluid balance and urine output is crucial due to the high risk of kidney failure resulting from severe dehydration. As HHS commonly affects older patients, the nurse should take into account the physiological changes associated with aging. It is important for the nurse to carefully assess cardiovascular, pulmonary, and kidney function throughout the acute and recovery phases of HHS to ensure appropriate management and prevent complications.
Administer potassium supplements as indicated and monitor potassium levels closely to maintain electrolyte balance and prevent cardiac dysrhythmias.
Potassium replacement is necessary to correct electrolyte imbalances and prevent complications related to hypokalemia or hyperkalemia.
Administer insulin therapy as prescribed to treat hyperglycemia and promote glucose utilization.
Although insulin plays a lesser role in HHS compared to DKA, it is still administered to manage hyperglycemia. Continuous low-rate insulin infusion is usually given to achieve glycemic control.
Monitor neurologic status closely, including mental status changes and focal neurologic deficits, to assess the response to treatment and identify any complications related to cerebral dehydration.
Monitoring neurological status helps determine the effectiveness of treatment and allows for early intervention if neurologic complications arise.
Provide patient education on self-management strategies, including medication adherence, lifestyle modifications, and regular self-monitoring of blood glucose levels.
Patient education empowers the individual to manage their condition effectively, prevent recurrence of HHS, and maintain optimal glycemic control.
12. Minimizing Risk for Cardiovascular Diseases
ASCVD (atherosclerotic cardiovascular disease) is a significant cause of morbidity and mortality in individuals with diabetes. It primarily affects the medium to large blood vessels, leading to thickening, sclerosis, and plaque formation, which eventually obstruct blood flow. The three main types of macrovascular complications seen frequently in diabetes are coronary artery disease, cerebrovascular disease, and peripheral arterial disease.
Assess cardiovascular risk factors. Perform a comprehensive assessment of the patient’s risk factors, including obesity/overweight, hypertension, dyslipidemia, smoking history, family history of premature coronary disease, chronic kidney disease (CKD), and presence of albuminuria.
Individuals with diabetes have a higher risk of myocardial infarction (MI), which is more common and carries an increased likelihood of complications and recurrent events compared to those without diabetes. Coronary artery disease is a leading cause of death in diabetes, and MIs may be “silent” or lack typical symptoms due to autonomic neuropathy. Identifying and assessing these risk factors helps in developing an individualized care plan and determining the appropriate management strategies.
Educate the patient on the importance of risk factor control. Provide education on the significance of managing risk factors such as obesity, hypertension, dyslipidemia, and smoking cessation.
Patient education empowers individuals to take an active role in managing their risk factors, promoting better control and reducing the likelihood of macrovascular complications.
Monitor blood pressure regularly. Measure blood pressure at each routine clinical visit and encourage patients to monitor their blood pressure at home.
Hypertension control is essential in individuals with diabetes, and regular blood pressure monitoring, both at clinical visits and at home, is recommended. Regular blood pressure monitoring helps in identifying and managing hypertension, a significant risk factor for ASCVD, and allows for timely intervention and treatment adjustments. Treatment targets should be individualized based on cardiovascular risk factors and patient preferences. Lifestyle interventions, such as weight loss, adopting a Dietary Approaches to Stop Hypertension (DASH) eating pattern, reducing sodium intake, and increasing physical activity, are recommended. Pharmacologic interventions, including antihypertensive drug therapy, are initiated when blood pressure is persistently elevated, and combination therapy may be necessary to achieve targets.
Encourage lifestyle modifications. Promote adherence to lifestyle interventions, including medical nutrition therapy (MNT), weight loss when indicated, adoption of a Dietary Approaches to Stop Hypertension (DASH) eating pattern, reduction of sodium intake, moderation of alcohol consumption, and increased physical activity.
Lifestyle modifications play a crucial role in managing obesity, hypertension, and hyperlipidemia, reducing the risk of ASCVD and macrovascular complications.
Administer medications as prescribed. Ensure the patient receives prescribed medications for managing hypertension, hyperlipidemia, and diabetes.
Lipid management plays a crucial role in preventing ASCVD in diabetes. Lifestyle modifications, such as weight loss, adopting a Mediterranean or DASH eating pattern, reducing saturated and trans fats, and increasing physical activity, are recommended. Lipid profiles should be obtained regularly, and statin therapy is recommended for primary and secondary prevention based on age, ASCVD risk factors, and baseline LDL cholesterol levels. Additional lipid-lowering agents, such as ezetimibe or icosapent ethyl, may be considered in certain cases. Pharmacologic interventions are necessary to achieve optimal control of blood pressure, lipid levels, and glucose management, reducing the risk of macrovascular complications. Antiplatelet therapy with aspirin is recommended for secondary prevention in individuals with diabetes and a history of ASCVD. Dual antiplatelet therapy may be considered after an acute coronary syndrome. Screening for coronary artery disease is not recommended in asymptomatic individuals if ASCVD risk factors are adequately treated. However, investigations for CAD are indicated in the presence of atypical cardiac symptoms, signs of associated vascular disease, or ECG abnormalities.
Monitor blood glucose levels. Regularly assess and monitor blood glucose levels in patients with symptoms suggestive of acute diabetic complications or stroke.
Elevated blood glucose levels can worsen the outcome of a stroke and may mimic symptoms of acute diabetic complications, making it crucial to assess and treat abnormal glucose levels promptly. Cerebrovascular disease is also more prevalent in individuals with diabetes, increasing the risk of transient ischemic attacks and strokes. Prompt assessment of blood glucose levels is crucial in differentiating stroke symptoms from acute diabetic complications. Diabetes-related atherosclerosis affects the large blood vessels in the lower extremities, leading to occlusive peripheral arterial disease and an increased risk of gangrene and amputation. Diabetic foot disease is also influenced by neuropathy and impaired wound healing.
Promote adherence to statin therapy. Educate patients about the importance of adhering to statin therapy for lipid management, especially for individuals with ASCVD or high cardiovascular risk.
Statin therapy has proven benefits in reducing LDL cholesterol and preventing cardiovascular events in individuals with diabetes and ASCVD.
13. Minimizing Risk for Diabetic Retinopathy
Nursing management plays a vital role in implementing individual care plans and educating patients. Patient education emphasizes the importance of regular eye examinations, glycemic and blood pressure control, and self-care for eye health
Conduct frequent visual examinations using appropriate tools and techniques to monitor changes in visual acuity and identify potential signs of retinopathy progression.
Regular visual assessments by nurses help in detecting early signs of retinal changes and allow for timely intervention and referral to ophthalmology specialists. Screening recommendations include initial and subsequent dilated eye examinations by ophthalmologists or optometrists, with increased frequency if retinopathy is present or progressing.
Provide comprehensive education to patients regarding the significance of regular eye examinations, adherence to prescribed medications, and self-care practices to maintain optimal eye health.
Education empowers patients with knowledge and promotes proactive engagement in eye care, facilitating early intervention and better management of diabetic retinopathy. Retinal photography programs can be alternative screening strategies. Treatment recommendations emphasize prompt referral for management of macular edema and any level of nonproliferative or proliferative retinopathy.
Emphasize to patients the role of consistent blood glucose management through medication adherence, lifestyle modifications, and regular monitoring.
Maintaining normal or near-normal blood glucose levels through intensive insulin therapy and patient education significantly reduces the risk and progression of retinopathy in both type 1 and type 2 diabetes. Nurses play a crucial role in reinforcing the importance of glycemic control, as it directly impacts the progression of retinopathy and reduces the risk of vision loss.
Assist patients in making transportation arrangements to ensure they can attend regular ophthalmology appointments and follow-up visits for retinopathy management.
Many patients with visual impairments may face challenges in accessing transportation. By helping them secure transportation options, nurses promote continuity of care and timely interventions.
Provide detailed instructions on the correct administration techniques, dosage schedules, and potential side effects of prescribed eye medications used for retinopathy management.
Proper medication administration is crucial for the effectiveness of treatment. Nurse education empowers patients to self-administer eye medications correctly, promoting treatment adherence and better outcomes.
Regularly assess and monitor for complications associated with retinopathy, such as macular edema or vitreous hemorrhage, and promptly communicate any changes to the healthcare team for appropriate intervention.
Early detection and management of complications can prevent further visual impairment and improve the chances of preserving vision in patients with diabetic retinopathy.
Teach patients self-care techniques for maintaining eye health, including proper eye hygiene, protection from UV light, and recognition of warning signs requiring immediate medical attention.
Empowering patients with self-management skills enhances their ability to actively participate in the prevention and early detection of complications related to diabetic retinopathy.
14. Minimizing Risk for Chronic Kidney Disease
Nephropathy is a common complication of diabetes, characterized by kidney disease resulting from microvascular changes. Consistently elevated blood glucose levels stress the kidney’s filtration system, causing blood protein leakage and increased pressure in the kidney’s blood vessels, leading to nephropathy.
Monitor blood glucose levels regularly.
Regular monitoring of blood glucose levels helps assess glycemic control and identify any fluctuations that may contribute to kidney dysfunction. It allows for timely adjustments in medication dosages or treatment plans. Intensive blood glucose control has been shown to reduce early signs of nephropathy in type 1 diabetes, while managing blood glucose levels effectively in type 2 diabetes can lower the incidence of overt nephropathy.
Assess urinary albumin levels annually and check for the presence of microalbumin in the urine.
Urinary albumin is an early indicator of kidney damage. Detecting microalbuminuria allows for early intervention and treatment to prevent the progression of nephropathy. Patients with type 1 diabetes (duration ≥5 years) and all people with type 2 diabetes should have annual assessment of urinary albumin (e.g., spot UACR) and eGFR. People with established diabetic kidney disease (DKD) should have monitoring of urinary albumin and eGFR 1-4 times per year depending on the stage of the disease.
Monitor serum creatinine and BUN levels. Conduct regular assessments of serum creatinine and blood urea nitrogen (BUN) levels.
Serum creatinine and BUN levels help evaluate kidney function. Monitoring these levels annually aids in detecting any decline in kidney function and guides treatment decisions.
Administer angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), as indicated, to manage hypertension in patients with diabetes and kidney disease.
Hypertension is a common complication in patients with diabetes and can contribute to kidney damage. ACE inhibitors and ARBs help control blood pressure and reduce proteinuria, thus protecting the kidneys. ACE inhibitors or ARBs are not recommended for the primary prevention of CKD in people with diabetes who have normal blood pressure, normal urinary albumin, and normal eGFR.
Encourage a low-sodium and low-protein diet. Educate the patient about the importance of following a diet low in sodium and protein.
A low-sodium diet helps manage hypertension, while a low-protein diet reduces the workload on the kidneys. These dietary modifications can slow the progression of kidney disease and minimize complications.
Monitor for signs of worsening kidney function. Assess the patient regularly for signs and symptoms of declining kidney function, such as increased proteinuria, decreased urine output, fluid retention, and changes in electrolyte levels.
Early identification of worsening kidney function enables timely interventions and prevents further damage. Close monitoring helps in adjusting treatment plans and preventing complications.
15. Minimizing Risk of Infection
Infectious diseases are more frequent and more serious in patients with diabetes mellitus due to the hyperglycemic environment that favors immune dysfunction (e.g., damage to the neutrophil function, depression of the antioxidant system, and humoral immunity), micro-and macro-angiopathies, neuropathy, decrease in the antibacterial activity of urine, gastrointestinal and urinary dysmotility, and the greater number of medical interventions in these patients.
Monitor for the signs of infection and inflammation: fever, flushed appearance, wound drainage, purulent sputum, cloudy urine.
Early diagnosis and treatment of infections can control their severity and decreases complications. Patients with diabetes may be admitted with infection, which could have precipitated the ketoacidosis state. They may also develop a nosocomial infection.
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 immune dysfunction and for pathogens to thrive.
Provide catheter or perineal care. Teach female patients to clean from front to back after elimination.
Urinary tract infections are more prevalent in individuals with diabetes. Diabetes is a predisposing factor for vaginitis. Poor perineal hygiene increases the risk of vaginitis and can spread through the urinary tract causing infection.
Provide meticulous skincare by gently massaging bony areas, keeping skin dry. Keep linens dry and wrinkle-free.
An impairment or ineffective peripheral circulation can place the patient at risk for increased skin breakdown and the development of infection.
Recommend obtaining vaccines, as indicated.
Streptococcus pneumonia and influenza virus are the most frequent respiratory infections associated with persons with diabetes. They are six times more likely to need hospitalizations during influenza epidemics than non-diabetic patients. Anti-pneumococcal and influenza vaccines are recommended.
16. Preventing Diabetic Neuropathies
Diabetic neuropathy encompasses various nerve disorders affecting peripheral, autonomic, and spinal nerves. Elevated blood glucose levels over time contribute to the development of neuropathy, and controlling blood glucose levels can reduce its incidence. The underlying causes involve vascular and metabolic factors, including capillary basement membrane thickening, capillary closure, demyelination of nerves, and disruptions in nerve conduction.
Peripheral neuropathy primarily impacts the distal areas of the nerves, particularly those in the lower extremities. It tends to affect both sides of the body equally and can potentially extend in a proximal direction.
Assess and document the patient’s sensory and motor function, including paresthesias, burning sensations, and numbness in the lower extremities, to establish a baseline and monitor the progression of peripheral neuropathy.
Diabetic neuropathy can be asymptomatic in some patients, but it may manifest as paresthesias, burning sensations, and numbness in the feet. This can lead to decreased proprioception, light touch sensation, and an unsteady gait. Reduced pain and temperature sensations increase the risk of unnoticed foot injuries and infections. Charcot joints, foot deformities, can also occur. Physical examination reveals decreased reflexes and vibratory sensation, providing important indicators of neuropathic changes. Other potential causes should be ruled out in patients with neuropathy symptoms. Regular assessment helps in identifying changes in the patient’s condition, guiding appropriate interventions, and evaluating the effectiveness of management strategies.
Educate the patient about the importance of maintaining optimal blood glucose control through intensive insulin therapy, emphasizing the correlation between glycemic control and the delay in the onset and progression of neuropathy.
Proper blood glucose control helps in minimizing nerve damage and reducing the severity of symptoms associated with diabetic neuropathy.
Provide education on foot care and hygiene, including daily foot inspections, proper cleaning, moisturizing, and protection of the feet to prevent injuries, infections, and foot deformities.
Teaching patients about foot care promotes early detection of foot problems, reduces the risk of complications, and improves overall foot health in individuals with neuropathy.
Administer prescribed analgesic agents, such as non opioid medications, as part of a comprehensive pain management plan to alleviate neuropathic pain in the lower extremities.
Initial pharmacologic treatments for neuropathic pain in diabetes include gabapentinoids, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and sodium channel blockers. Analgesic medications help in reducing pain and discomfort, enhancing the patient’s quality of life, and facilitating engagement in daily activities.
Management strategies for autonomic neuropathy aim to alleviate symptoms and modify risk factors
Perform a comprehensive assessment of the patient’s sensory and motor functions, focusing on the lower extremities. Assess for paresthesias, burning sensations, and numbness. Perform regular neurologic assessments including deep tendon reflexes, vibratory sensation, and evaluation of proprioception to monitor for changes in neuropathy status.
Early detection and monitoring of neuropathic symptoms allow for timely intervention and prevention of complications. Autonomic neuropathies involve dysfunctions in various organ systems, including the cardiac, gastrointestinal, renal, and sexual systems. Symptoms can range from cardiovascular abnormalities like tachycardia and orthostatic hypotension to gastrointestinal issues such as delayed gastric emptying and diabetic constipation or diarrhea. Autonomic neuropathy can also lead to urinary retention and neurogenic bladder, increasing the risk of urinary tract infections. Additionally, it can cause hypoglycemic unawareness, reduced sweating in the extremities (sudomotor neuropathy), and sexual dysfunction.
Assess deep tendon reflexes.
Monitoring deep tendon reflexes helps in evaluating the patient’s neurological status and identifying any changes or abnormalities that may be indicative of neuropathy or other neurological complications.
Provide education and support to patients experiencing sexual dysfunction related to autonomic neuropathy, including erectile dysfunction in men and changes in sexual function in women.
Sexual dysfunction is a common complication of diabetes and can have a significant impact on the patient’s self-esteem and relationships. Offering information, counseling, and appropriate referrals can help address concerns and promote sexual health.
Provide education on the management of blood glucose levels through adherence to prescribed insulin therapy and self-monitoring of blood glucose.
Glycemic control helps delay the progression of neuropathy and minimize associated symptoms.
Provide guidance on the management of diabetic diarrhea, which may involve the use of bulk-forming laxatives or antidiarrheal agents based on individual patient needs.
Delayed gastric emptying can be addressed with a low-fat diet, frequent small meals, blood glucose monitoring, and agents that increase gastric motility. Diabetic diarrhea may require bulk-forming laxatives or antidiarrheal agents, while constipation can be managed with a high-fiber diet, hydration, and possible medication use
Assist the patient in accessing appropriate resources for physical therapy and occupational therapy to improve balance, gait, and proprioception. Rehabilitation programs can enhance mobility and reduce the risk of falls.
Educate the patient about the importance of daily foot inspections and self-care practices to prevent injuries and infections. Emphasize the need to keep the feet clean, dry, and moisturized.
Proper foot care reduces the risk of foot ulcers and infections. Peripheral neuropathy increases the risk of foot injuries and infections due to decreased pain and temperature sensations. Regular foot inspections help identify any abnormalities or wounds that require prompt attention.
Teach the patient about the use of protective footwear and encourage them to wear appropriate shoes that provide cushioning and support. Proper footwear reduces the risk of foot trauma and pressure ulcers.
Monitor the patient’s skin integrity, especially in areas prone to pressure and trauma, such as the feet. Implement preventive measures such as turning and repositioning to prevent pressure ulcers.
Neuropathy-related decreased sensation increases the risk of skin breakdown.
17. Diabetes Foot Care
Between 50% and 75% of lower extremity amputations occur in individuals with diabetes, with over 50% of these amputations being preventable through proper foot care. Regular foot assessment, adherence to preventive measures, and patient education are essential components of managing and minimizing the risks associated with diabetic foot problems.
Educate patients about proper foot care measures and emphasize the importance of daily practice. Provide information on foot assessment, self-care techniques, and risk factor management.
By educating patients about foot care, nurses empower them to take proactive measures to prevent foot problems and infections. Individuals with evidence of sensory loss, prior ulceration, or amputation should have their feet inspected at every visit to monitor for any changes or potential problems. Teach appropriate methods for foot examination, such as palpation or visual inspection using an unbreakable mirror.
Perform regular foot assessments during healthcare visits or at least once per year for patients at high risk.
This evaluation should include skin inspection, assessment of foot deformities, neurological assessment using monofilament testing and other sensory assessments, and vascular assessment including checking pulses in the legs and feet. Regular foot assessments help identify early signs of neuropathy and detect any changes or abnormalities that require further attention and intervention.
Encourage patients to maintain proper foot hygiene, including bathing, drying, and lubricating the feet.
Proper foot hygiene helps prevent infections and skin breakdown. To minimize risk of diabetic foot, preventive measures may include the following:
- Daily foot inspection for cuts, blisters, red spots, and swelling.
- Proper foot hygiene, including washing with warm water, thorough drying (especially between the toes), and applying lotion without accumulating moisture between the toes.
- Using closed-toed, well-fitting shoes, and considering orthotics or custom-made shoes for those with specific needs.
- Trimming toenails straight across, avoiding sharp corners.
- Reducing risk factors such as smoking and elevated blood lipids that contribute to peripheral vascular disease.
- Avoiding high-risk behaviors, such as walking barefoot, using heating pads, wearing open-toed shoes, soaking feet, or shaving calluses.
- Seeking professional help from podiatrists for pressure areas, calluses, and toenail care.
- Avoiding home remedies and self-medication for foot problems.
- Maintaining optimal blood glucose control to improve resistance to infections and prevent diabetic neuropathy.
Instruct patients to wear closed-toed shoes that fit well and provide adequate protection for the feet.
Proper footwear reduces the risk of foot injuries and pressure-related problems.
Teach patients how to properly trim their toenails straight across and file sharp corners to follow the contour of the toe.
Correct toenail care reduces the risk of ingrown toenails and subsequent infections. Additionally, referring patients visual impairments or thickened toenails to a podiatrist for nail trimming.
Screen for peripheral artery disease (PAD) by assessing lower-extremity pulses, capillary refill time, skin color changes with dependency and elevation, and venous filling time.
Refer individuals with symptoms like leg fatigue, claudication, and rest pain relieved with dependency, or decreased/absent pedal pulses for ankle-brachial index measurement and further vascular assessment if necessary.
Discuss the importance of reducing risk factors associated with peripheral vascular disease, such as smoking and elevated blood lipids.
Managing risk factors improves peripheral circulation and enhances wound healing.
Advise patients to avoid home remedies, over-the-counter agents, and self-medication for foot problems. Encourage them to consult their healthcare provider or a podiatrist for appropriate treatment.
Seeking professional guidance ensures proper management and reduces the risk of exacerbating foot conditions.
Emphasize the significance of blood glucose control in preventing decreased resistance to infections and diabetic neuropathy.
Maintaining optimal blood glucose levels promotes overall health and supports wound healing.
18. Providing Emotional Support Through Effective Coping
Patients newly diagnosed with diabetes may feel like they have no control over their situation. Enduring the chronic effects of diabetes and living through complex self-care required by diabetes can negatively impact its management. Nurses can assist by acknowledging negative feelings expressed by the patient, identifying strengths, and empowering patients by correcting misinformation and suggesting problem-solving behaviors.
Assess how the patient has handled problems in the past. Identify locus of control.
Knowledge of an individual’s style helps determine the needs for treatment goals. A patient whose locus of control is internal usually looks at ways to gain control over their own treatment program. The 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.
Acknowledge the normality of feelings.
Recognition that reactions are normal can help patients problem-solve and seek help as needed. Diabetes management and control is a full-time job that serves as a constant reminder of disease and threat to a patient’s health.
Provide an opportunity for significant other (SO) to express concerns and discuss ways in which they can be helpful to the patient.
Enhances sense of being involved and gives SO a chance to problem-solve solutions to help the patient prevent a recurrence.
Encourage patient and SO to express feelings about hospitalization and disease in general.
Identifies concerns and facilitates problem-solving.
Ascertain expectations and goals of the 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 diabetes management often shift the focus of a relationship. The development of psychological concerns affecting self-concept may add further stress.
Support participation in self-care and give positive feedback for efforts.
Promotes a feeling of control over the situation.
Assess family coping mechanisms and its effectiveness, family dynamics and expectations related to long-term care, developmental level of family, the response of siblings, knowledge, and use of support systems and resources, presence of guilt and anxiety, overprotection, and overeating behaviors.
Recognizes coping methods that work and the need to develop new coping skills and behaviors, family attitudes; a child with special long-term needs may tighten or strain family relationships, and that over-protection may be deleterious to the child’s growth and development.
Allow family members and child to express difficult areas, and anxiety and explore solutions responsibly.
It lessens anxiety and improves understanding; provides the family with an opportunity to recognize problems and generate problem-solving methods.
Assist the family to establish short- and long-term goals for the child and to involve the child in the activities of the family; include the participation of all family members in care routines.
Promotes engagement in and control over situations and keeps the role of family members and parents.
Encourage family members to verbalize feelings, to tell how they handle the chronic needs of the family member, and to define coping patterns that support or inhibit adjustment to the problems.
Encourages expression of feelings to identify the need for information and support and to dismiss guilt and anxiety.
Provide support to social workers, counselors, clergy, or others as needed.
Provides assistance to the family dealing with the long-term care of a child with chronic illness.
Teach the family about long-term care and treatments.
Improves family’s understanding of treatment regimen and responsibilities of family.
Teach the family that overprotective behavior may inhibit growth and development so they should treat the child as normally as possible.
Facilitates an understanding of the significance of making the child a part of the family and illustrates the unfavorable effects of being overprotective.
Explain the importance of attending follow-up appointments for physical examinations and laboratory tests.
Promotes positive outcomes when the family collaborates with the physician and health team to monitor disease.
19. Promoting Self-Care and Hygiene
Hospitalization offers an opportunity to assess and reinforce patients’ self-care skills and provide necessary education. Nurses should observe patients performing insulin administration, blood glucose monitoring, and foot care rather than relying solely on questioning
Assist the patient with daily dental care.
Patients with diabetes are at an increased risk for periodontal disease. Assisting the patient with daily dental care helps maintain oral hygiene and reduces the risk of complications related to periodontal disease.
Perform careful assessments of the oral cavity and the skin.
Regular assessments of the oral cavity and skin are crucial in detecting any abnormalities, such as dryness, cracks, breakdown, redness, and pressure points. Early detection allows for timely intervention and prevention of complications.
Assist the patient in maintaining clean and dry skin, especially in areas of skin contact (e.g., groin, axilla, under the breasts).
Patients with diabetes are prone to chafing and fungal infections in areas where two skin surfaces come in contact. Keeping the skin clean and dry reduces the risk of skin breakdown and infections.
Emphasize prevention of skin breakdown at pressure points, especially the heels.
Patients with diabetes may experience sensory neuropathy, leading to a loss of sensation of pain and pressure. This makes the heels particularly vulnerable to breakdown. Preventive measures help protect the skin and minimize the risk of pressure ulcers.
Clean, dry, and lubricate the patient’s feet, excluding the area between the toes. Inspect the feet frequently.
Proper foot care is essential for patients with diabetes to prevent complications such as foot ulcers. Cleaning, drying, and lubricating the feet maintain skin integrity, while frequent inspections help identify any changes or signs of infection or injury.
Elevate the lower legs on a pillow when the patient is in the supine position, with the heels positioned over the edge of the pillow.
Elevating the lower legs on a pillow relieves pressure on the heels and reduces the risk of pressure ulcers in patients who spend extended periods in the supine position.
Position the patient’s feet to avoid pressure on the heels when seated in a chair.
Proper positioning of the feet helps prevent pressure on the heels, reducing the risk of skin breakdown and pressure ulcers in patients who are seated for extended periods.
Provide preventive care for the unaffected foot and special care for the affected foot if the patient has an ulcer.
Patients with foot ulcers require specialized care to promote healing and prevent infection. Providing preventive care for the unaffected foot helps maintain overall foot health and minimize the risk of complications.
Instruct female patients with diabetes about measures to avoid vaginal infections, particularly when blood glucose levels are elevated.
Elevated blood glucose levels can increase the risk of vaginal infections in female patients with diabetes. Providing instructions on preventive measures helps promote vaginal health and reduces the risk of infections.
Emphasize the importance of daily personal hygiene during the patient’s hospitalization.
Reinforcing the importance of daily personal hygiene helps patients understand the significance of maintaining good hygiene practices and encourages them to continue practicing self-care even after leaving the hospital.
Self-care and hygiene considerations for older adults
Assess barriers to learning and self-care for older adults with diabetes during their hospital stay.
Identifying barriers such as decreased vision, hearing loss, memory deficits, decreased mobility, and other limitations helps in planning appropriate diabetes treatment and educational interventions tailored to the individual’s needs and abilities.
Present brief and simplified instructions with ample opportunity for practice of diabetes self-care skills.
Older adults may experience cognitive deficits or decreased physical abilities, making it important to provide instructions that are easy to understand and practice. Simplifying instructions and allowing sufficient practice time enhances learning and promotes skill acquisition.
Utilize special devices such as a magnifier for insulin syringes, insulin pens, or mirrors for foot inspections to assist older adults with diabetes.
Older adults may benefit from the use of assistive devices that compensate for sensory or physical limitations. Providing specialized devices helps enhance their ability to perform diabetes self-care tasks effectively.
20. Glycemic Control During Surgery
During periods of physiological stress, such as surgery, blood glucose levels tend to increase due to elevated stress hormones. Various approaches are available for managing glucose control during the perioperative period, with frequent blood glucose monitoring being crucial.
Perform frequent blood glucose monitoring.
During periods of physiologic stress, such as surgery, diabetic patients are at risk of experiencing hyperglycemia or hypoglycemia. If hyperglycemia is not controlled during surgery, osmotic diuresis may occur, resulting in excessive loss of fluids and electrolytes. Patients with type 1 diabetes are particularly at risk of developing ketoacidosis during periods of stress. Regular monitoring allows for timely detection of hyperglycemia or hypoglycemia, enabling nurses and healthcare providers to adjust insulin doses or interventions accordingly.
Administer IV insulin and dextrose as prescribed.
IV insulin can effectively regulate blood glucose levels during surgery, while dextrose provides a source of glucose to prevent hypoglycemia and counterbalance the effects of insulin.
Ensure preoperative fasting guidelines are followed to prevent hypoglycemia or hyperglycemia.
Hypoglycemia is a significant concern in diabetic patients undergoing surgery, especially during the preoperative period if surgery is delayed after the patient has received a morning injection of intermediate-acting insulin. Following preoperative fasting guidelines helps prevent complications associated with uncontrolled glucose levels, such as hyperglycemia or hypoglycemia.
Monitor vital signs regularly, including blood pressure, heart rate, and oxygen saturation.
Vital sign monitoring helps assess the patient’s physiological response to stress, surgical interventions, and glucose management, enabling early detection of complications.
Assess the patient’s level of consciousness and cognitive function.
Altered levels of consciousness or cognitive function may indicate hypo- or hyperglycemia, requiring immediate intervention to stabilize blood glucose levels.
Protect the patient from injury by avoiding or limiting restraints as necessary when LOC is impaired. Place bed in low position and pad bed rails if the 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.
Monitor for signs of wound infection and skin breakdown during the postoperative period.
Diabetic patients are at an increased risk of wound infections and skin breakdown due to impaired healing and reduced sensation. Regular monitoring allows for early detection and prompt treatment.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to endocrine system and metabolism disorders:
- Acid-Base Balance
- Addison’s Disease | 3 Care Plans
- Cushing’s Disease | 6 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Diabetes Mellitus Type 2 | 20 Care Plans UPDATED!
- Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) | 4 Care Plans
- Eating Disorders: Anorexia & Bulimia Nervosa | 7 Care Plans
- Fluid and Electrolyte Imbalances
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperthyroidism | 7 Care Plans
- Hypothyroidism | 3 Care Plans
- Obesity | 5 Care Plans
- Thyroidectomy | 5 Care Plans
References and Sources
References and recommended sources to further your reading about this care plan guide for Diabetes Mellitus:
- Recommended resource: American Diabetes Association. (2021). Standards of medical care in diabetes—2021 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 39(1), 14.
- American Diabetes Association. (2004). Physical activity/exercise and diabetes. Diabetes care, 27(suppl 1), s58-s62.
- Björnsson, E. S., Urbanavicius, V., Eliasson, B., Attvall, S., Smith, U., & Abrahamsson, H. (1994). Effects of hyperglycemia on interdigestive gastrointestinal motility in humans. Scandinavian journal of gastroenterology, 29(12), 1096-1104.
- Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier.
- Brunner, L. S., & Suddarth, D. S. (2004). Medical surgical nursing. Philadelphia: Lippincott Williams & Wilkins.
- Casqueiro, J., Casqueiro, J., & Alves, C. (2012). Infections in patients with diabetes mellitus: A review of pathogenesis. Indian journal of endocrinology and metabolism, 16 Suppl 1(Suppl1), S27–S36.
- Chambers, B. K., & Camire, M. E. (2003). Can cranberry supplementation benefit adults with type 2 diabetes?. Diabetes Care, 26(9), 2695-2696.
- Cryer, P. E. (2008). The barrier of hypoglycemia in diabetes. Diabetes, 57(12), 3169-3176.
- Cryer, P. E., Davis, S. N., & Shamoon, H. (2003). Hypoglycemia in diabetes. Diabetes care, 26(6), 1902-1912.
- Desouza, C. V., Bolli, G. B., & Fonseca, V. (2010). Hypoglycemia, diabetes, and cardiovascular events. Diabetes care, 33(6), 1389-1394.
- Diabetes Control and Complications Trial Research Group. (1997). Hypoglycemia in the diabetes control and complications trial. Diabetes, 46(2), 271-286.
- Fritschi, C., & Quinn, L. (2010). Fatigue in patients with diabetes: a review. Journal of psychosomatic research, 69(1), 33-41.
- Guay, D. R. (2009). Cranberry and urinary tract infections. Drugs, 69(7), 775-807.
- Ishizuka, T., Ogawa, S., Mori, T., Nako, K., Nakamichi, T., Oka, Y., & Ito, S. (2009). Characteristics of the antibodies of two patients who developed daytime hyperglycemia and morning hypoglycemia because of insulin antibodies. Diabetes research and clinical practice, 84(2), e21-e23.
- Rosenberg, C. S. (1990). Wound healing in the patient with diabetes mellitus. The Nursing clinics of North America, 25(1), 247-261.
- Umpierrez, G., & Freire, A. X. (2002). Abdominal pain in patients with hyperglycemic crises. Journal of critical care, 17(1), 63-67.
- White, P. (1974). Diabetes mellitus in pregnancy. Clinics in perinatology, 1(2), 331-348.