Diabetes Mellitus Nursing Care Plan & Management

Notes

Description
  • Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia).
  • Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is characterized by a lack of insulin production.
  • Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) is caused by the body’s ineffective use of insulin. It often results from excess body weight and physical inactivity.
  • Gestational diabetes is hyperglycaemia that is first recognized during pregnancy.
Causes

The cause of diabetes depends on the type.

Type 1 diabetes
  • Is partly inherited, and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these triggers has been traced to particular HLA genotypes (i.e., the genetic “self” identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 DM seems to require an environmental trigger. The onset of type 1 diabetes is unrelated to lifestyle.diabetes-type1
Type 2 diabetes
  • is due primarily to lifestyle factors and genetics.
The following is a comprehensive list of other causes of diabetes:
  • Genetic defects of β-cell function
    • Maturity onset diabetes of the young
    • Mitochondrial DNA mutations
  • Genetic defects in insulin processing or insulin action
    • Defects in proinsulin conversion
    • Insulin gene mutations
    • Insulin receptor mutations
  • Exocrine pancreatic defectsdiabetes-type2
    • Chronic pancreatitis
    • Pancreatectomy
    • Pancreatic neoplasia
    • Cystic fibrosis
    • Hemochromatosis
    • Fibrocalculous pancreatopathy
  • Endocrinopathies
    • Growth hormone excess (acromegaly)
    • Cushing syndrome
    • Hyperthyroidism
    • Pheochromocytoma
    • Glucagonoma
  • Infections
    • Cytomegalovirus infection
    • Coxsackievirus B
  • Drugs
    • Glucocorticoids
    • Thyroid hormone
    • β-adrenergic agonists
    • Statins
TYPE I VERSUS TYPE 2 DIABETES
 PE I (IDDM) TYPE 2 (NIDDM)
 Age of onset  Usually younger than 40  Usually older than 40
 Body weight  Thin  Usually overweight
 Symptoms  Sudden onset  Insidious onset
 Insulin produced None  Too little, or not effective
 Insulin requirements  Exogenous insulin required  May require insulin
Pathophysiology
DM Type I
patho dm type 1
DM Type II
patho dm type 2 Signs and symptoms
  • The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent urination),polydipsia (increased thirst) and polyphagia (increased hunger).Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much more slowly and may be subtle or absent in type 2 diabetes.Main_symptoms_of_diabetes
  • Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.
Diabetic emergencies
  • People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone, a rapid, deep breathing known as Kussmaul breathing, nausea, vomiting and abdominal pain, and altered states of consciousness.
  • A rare but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration.
WARNING SIGNS OF DIABETES
 SIGNS AND SYMPTOMSS LABORATORY FINDINGS
  • Sudden onset
  • Polyurea
  • Polydipsia
  • Polyphagia
  • 20 pound weight loss
  • Irritability
  • Weakness and fatigue
  • Nausea, vomiting
  •  Insidious onset
  • Fatigue
  • Blurred vision
  • Tingling or numbness in hands and feet
  • Itching
  • Any symptoms of IDDM or hard to heal wounds
  • Frequent bladder infections

Signs, Symptoms, and Treatment of Hypoglycemia and Hyperglycemia
HYPOGLYCEMIA

Cause: Usually secondary to excess insulin, exercise, or not enough food

Signs and Symptoms

  • Nervousness
  • Irritability
  • Diaphoresis (heavy sweating)
  • Hunger
  • Weakness
  • Tachycardia
  • Fatigue
  • Hypotension
  • Palpitations
  • Tachypnea
  • Tremors or shaking Pallor
  • Blurred or double vision
  • Incoherent speech
  • Headache Numbness of tongue and lips
  • Confusion Coma
  • Seizures

Treatment

Provide rapidly absorbed source of glucose:

  • Fruit juice or cola
  • Graham crackers
  • Sugar cubes, sugar packets
  • Hard candy

As symptoms improve:

  • Provide a meal or source of complex protein or carbohydrates
HYPERGLYCEMIA

Cause: Usually secondary to insufficient insulin, illness, or excess food

Signs and Symptoms 

  • Confusion
  • Nausea
  • Irritability
  • Vomiting
  • Fatigue
  • Anorexia
  • Weakness
  • Abdominal cramping
  • Numbness
  • Thirst
  • Tachycardia
  • Lethargy
  • Hypotension
  • Küssmall breathing
  • Decreased level of consciousness
  • Increased temperature
  • Coma
  • Flushed or dry skin
  • Fruity breath
  • Poor skin turgor
  • Dry mucous membranes

Treatment (Requires Hospitalization)

  • Restore fluid balance
  • Replace electrolytes
  • Lower blood glucose with regular insulin
  • Monitor: Level of consciousness, vital signs, intake and output, and electrolytes
  • Provide emotional support
Diagnostic Procedure

Several blood tests are used to measure blood glucose levels, the primary test for diagnosing diabetes. Additional tests can determine the type of diabetes and its severity.

  • Random blood glucose test — for a random blood glucose test, blood can be drawn at any time throughout the day, regardless of when the person last ate. A random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose suggests a diagnosis of diabetes.
  • Fasting blood glucose test — fasting blood glucose testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to confirm that it remains abnormally high .
  • Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent . The test is done by taking a small sample of blood from a vein or fingertip.
  • Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glucose test.

The standard OGTT includes a fasting blood glucose test. The person then drinks a 75 gram liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two hours later, a second blood glucose level is measured.

Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose level drawn one hour later. For women who have an abnormally elevated blood glucose level, a second OGTT is performed on another day after drinking a 100 gram glucose solution. The blood glucose level is measured before, and at one, two, and three hours after drinking the solution.

Medical Management

There is no known cure for DM. Management of the disease focuses on control of the serum glucose level to prevent or delay the development of complications. Individuals with type 1 DM require subcutaneous insulin administration. Insulin may be rapid, intermediate, or slow acting.

Patients with mild DM or those with type 2 DM or GDM may be able to control the disease by diet management alone. A diabetic diet attempts to distribute nutrition and calories throughout the 24-hour period. Daily calories consist of approximately 50% carbohydrates and 30% fat, with the remaining calories consisting of protein. The total calories allowed for an individual within the 24-hour period are based on age, weight, activity level, and medications.

In addition to strict dietary adherence to control blood glucose, obese patients with type 2 DM also need weight reduction. The dietitian selects an appropriate calorie allotment depending on the patient’s age, body size, and activity level. A useful adjunct to the management of DM is exercise. Physical activity increases the cellular sensitivity to insulin, improves tolerance to glucose, and encourages weight loss. Exercise also increases the patient’s sense of well-being concerning his or her health.

Pharmacological Highlights

When diet, exercise and maintaining a healthy weight aren’t enough, you may need the help of medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes and some people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to produce. Unfortunately, insulin can’t be taken in pill form because enzymes in your stomach break it down so that it becomes ineffective. For that reason, many people inject themselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump, which provides a continuous supply of insulin, eliminating the need for daily shots.

The most widely used form of insulin is synthetic human insulin, which is chemically identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn’t perfect. One of its chief failings is that it doesn’t mimic the way natural insulin is secreted. But newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus).

A number of drug options exist for treating type 2 diabetes, including:

  • Sulfonylurea drugs. These medications stimulate your pancreas to produce and release more insulin. For them to be effective, your pancreas must produce some insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most common side effect of sulfonylureas is low blood sugar, especially during the first four months of therapy. You’re at much greater risk of low blood sugar if you have impaired liver or kidney function.
  • Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and the results fade rapidly.
  • Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the United States. It works by inhibiting the production and release of glucose from your liver, which means you need less insulin to transport blood sugar into your cells. One advantage of metformin is that is tends to cause less weight gain than do other diabetes medications. Possible side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These effects usually decrease over time and are less likely to occur if you take the medication with food. A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in your body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication with alcohol or have impaired kidney function.
  • Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver damage.
  • Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, it’s important to have your liver checked every two months during the first year of therapy. Contact your doctor immediately if you experience any of the signs and symptoms of liver damage, such as nausea and vomiting, abdominal pain, loss of appetite, dark urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will need to investigate all possible causes.
  • Drug combinations. By combining drugs from different classes, you may be able to control your blood sugar in several different ways. Each class of oral medication can be combined with drugs from any other class. Most doctors prescribe two drugs in combination, although sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which contains both glyburide and metformin, combine different oral drugs in a single tablet.
Nursing Intervention
  • Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance.
  • Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin.
  • Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach.
  • Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.
  • Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia.
  • Explain the importance of exercise in maintaining or reducing weight.
  • Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia.
  • Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes.
  • Maintain skin integrity by protecting feet from breakdown.
  • Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.
DOCUMENTATION GUIDELINES
  • Results of urine and blood tests for glucose
  • Physical findings: Visual problems, skin problems or lesions, changes in sensation or circulation to the extremities
  • Patient teaching, return demonstrations, patient’s understanding of teaching
  • Response to insulin
DISCHARGE AND HOME HEALTHCARE GUIDELINES
MEDICATIONS. Patients need to understand the purpose, dosage, route, and possible side effects of all prescribed medications. If the patient is to self-administer insulin, have the patient demonstrate the appropriate preparation and administration techniques.
PREVENTION. The patient and family require instruction in the following areas to minimize or prevent complications of DM.
  • Diet. Explain how to calculate the American Diabetic Association exchange list to develop a satisfactory diet within the prescribed calories. Emphasize the importance of adjusting diet during illness, growth periods, stress, and pregnancy. Encourage patients to avoid alcohol and refined sugars and to distribute nutrients to maintain a balanced blood sugar throughout the 24-hour period.
  • Insulin. Patients need to understand the type of insulin prescribed. Instructions should include onset, peak, and duration of action. Stress proper timing of meals and planning snacks for the time when insulin is at its peak, and recommend an evening snack for those on long-acting insulins. Reinforce that patients cannot miss a dosage and there may be a need for increasing dosages during times of stress or illness. Teaching regarding the proper preparation of insulin, how to administer, and the importance of rotating sites is necessary.
  • Urine and Blood Testing. Teach patients the appropriate technique for testing blood and urine and how to interpret the results. Patients need to know when to notify the physician and increase testing during times of illness.
  • Skin Care. Stress the importance of close attention to even minor skin injuries. Emphasize foot care, including the importance of properly fitting shoes with clean, nonconstricting socks; daily washing and thorough drying of the feet; and inspection of the toes, with special attention paid to the areas between the toes. Encourage the patient to contact a podiatrist as needed. Because of sensory loss in the lower extremities, teach the patient to test the bath water to prevent skin trauma from water that is too hot and to avoid using heating pads.
  • Circulation. Because of the atherosclerotic changes that occur with DM, encourage patients to stop smoking. In addition, teach patients to avoid crossing their legs when sitting and to begin a regular exercise program.

  References:
  • http://en.wikipedia.org/wiki/Diabetes_mellitus
  • http://www.who.int/topics/diabetes_mellitus/en/
  • http://www.nurseslearning.com/courses/nrp/NRP1605/course/section2/index.htm
  • http://nursingcrib.com/case-study/diabetes-mellitus-case-study/
  • http://en.wikipedia.org/wiki/File:Main_symptoms_of_diabetes.png
  • Disease and Disorder a Nursing Therapeutic Manual 2007
  • http://jalanhealthcare.com/images/diabetes-type1.jpg
  • http://jalanhealthcare.com/images/diabetes-type2.jpg

Exam

Welcome to your MSN Exam for Diabetes Mellitus! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 60 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider the timeframe HbA1c measures to provide insight into long-term glucose control.

1 / 60

1. Nurse Sharmaine is reviewing lab results with Mr. Patel, a client with type 1 diabetes mellitus, who has a significantly elevated glycosylated hemoglobin (HbA1c) level. While discussing the findings, what should she explain to the client to ensure he understands the test’s purpose?

💡 Hint

Consider the usual dosing schedule for Lantus insulin and whether it aligns with standard practice.

2 / 60

2. During morning rounds, Nurse AJ accompanies the physician while reviewing the care plan for a client with diabetes mellitus. Which of the physician’s orders should Nurse AJ confirm for accuracy before proceeding?

💡 Hint

Think about the autoimmune nature of Type 1 diabetes and the markers associated with its diagnosis.

3 / 60

3. Nurse Daniel is providing education to a newly diagnosed patient with Type 1 diabetes. He discusses the clinical characteristics commonly seen with this condition. Which of the following is specifically associated with Type 1 diabetes?

💡 Hint

Consider the action of glyburide and the potential risk if the medication was absorbed before vomiting occurred.

4 / 60

4. Nurse Jenny is caring for a patient with diabetes mellitus who reports nausea and vomiting one hour after taking their glyburide (DiaBeta). What nursing intervention should Nurse Jenny prioritize?

💡 Hint

Focus on the mechanism of action and proper administration of metformin, while disregarding functions that are unrelated to this medication.

5 / 60

5. Nurse Alex is educating Ms. Rivera, a newly diagnosed type 2 diabetic patient prescribed metformin (Glucophage). As part of the teaching, Nurse Alex ensures Ms. Rivera understands how the medication works and how to take it properly. What should Nurse Alex include in the patient education? (Select all that apply.)

💡 Hint

Think about the timing of oral antidiabetic medications to maximize their effectiveness in lowering post-meal blood sugar.

6 / 60

6. Nurse Karen is teaching Mr. Davis, a patient with type 2 diabetes mellitus, about his new prescription for glipizide (Glucotrol). What is the most appropriate medication instruction for Nurse Karen to provide?

💡 Hint

Focus on complications caused by long-term blood vessel and nerve damage associated with diabetes.

7 / 60

7. Nurse Sandra is reviewing the potential complications of diabetes with her patient. Which of the following should she include in her discussion? (Select all that apply.)

💡 Hint

Safe and accurate insulin administration depends on using the correct equipment designed for insulin doses.

8 / 60

8. Nurse Carla has completed a teaching session with a client who has diabetes mellitus about proper insulin administration. She evaluates the client’s understanding based on which statement the client makes?

💡 Hint

This phenomenon occurs when a drop in blood sugar overnight triggers a rebound hyperglycemia due to counterregulatory hormones.

9 / 60

9. Nurse Jenna is assessing a diabetic patient who reports alternating episodes of nocturnal hypoglycemia followed by hyperglycemia in the morning. What condition might the patient be experiencing?

💡 Hint

Focus on the long-term effects of diabetes on the eyes, nerves, and cardiovascular system.

10 / 60

10. Nurse Linda is reviewing the chronic complications of diabetes mellitus with a patient during a follow-up appointment. Which of the following sets of complications is most commonly associated with diabetes?

💡 Hint

Focus on complications related to severe metabolic derangements or infections linked to DKA.

11 / 60

11. Nurse Mia is reviewing complications associated with diabetic ketoacidosis (DKA) while caring for a patient in the ICU. Which of the following conditions should Nurse Mia recognize as unrelated to DKA?

💡 Hint

Think about the primary role of insulin in regulating blood glucose levels.

12 / 60

12. Nurse Tara is reviewing the physiological effects of insulin with a group of nursing students. She asks them to identify which of the following actions is a result of insulin release in the body.

💡 Hint

Consider glucagon's primary role in maintaining blood glucose levels during fasting states.

13 / 60

13. Nurse Elena is explaining the role of glucagon to her students during an endocrine lecture. She asks them to determine whether the following statement is accurate: "Glucagon increases blood glucose levels by stimulating the liver to break down glycogen."

💡 Hint

Consider the main treatment requirement for managing type 1 diabetes due to the destruction of insulin-producing cells.

14 / 60

14. Nurse Mia is educating a group of nursing students on the characteristics of type 1 diabetes mellitus. She asks the students to identify which statement about type 1 diabetes is incorrect.

💡 Hint

Think about interventions that address emotional well-being and provide specialized support for sensitive issues like sexual health.

15 / 60

15. Nurse Liam is caring for a postoperative male patient with diabetes mellitus who expresses concerns about impotence and its potential impact on his marriage. When planning care, what would be the most appropriate intervention?

💡 Hint

Consider the electrolyte most closely regulated by insulin's effect on cellular uptake, particularly relevant in diabetes and DKA.

16 / 60

16. Nurse Angela is explaining the effects of insulin on electrolytes to a nursing student. Which electrolyte does insulin drive from the plasma into the cells?

💡 Hint

Proper insulin storage is important to maintain potency, especially for unopened vials not in use.

17 / 60

17. Nurse Mia visits a client with diabetes mellitus at home and observes that the client's extra insulin vials are not stored in the refrigerator. What is Nurse Mia's best action at this time?

💡 Hint

Think about which condition increases the susceptibility of the heart to bacterial infections, especially after invasive procedures.

18 / 60

18. Nurse Lauren is preparing discharge education for Ms. Harper, a client with a history of rheumatic fever and mitral valve replacement surgery, who is now scheduled for a tooth extraction. Which aspect of her history places her at the highest risk for developing infective endocarditis?

💡 Hint

Effective diabetes management in older adults includes a combination of holistic care and preventative strategies.

19 / 60

19. Nurse Clara is working with an older adult patient struggling with poor glycemic control. She focuses on the primary objectives of therapy for this population. What should Nurse Clara emphasize as the principal goals of care?

💡 Hint

Remember which type of diabetes involves insulin resistance and can be managed with oral medications.

20 / 60

20. Mr. Thompson, a patient with type 1 diabetes mellitus, asks Nurse Jack if he can take oral antidiabetic medications instead of insulin. How should Nurse Jack explain the circumstances under which these medications are effective?

💡 Hint

Think about the link between diabetes, poor wound healing, and the importance of early detection to prevent complications.

21 / 60

21. Mr. Rodriguez, recently diagnosed with diabetes, asks Nurse Kelly why it’s important to inspect his feet daily. What is Nurse Kelly's best response?

💡 Hint

In situations involving changes to a patient’s usual medication routine, it’s crucial to involve the prescribing provider for guidance.

22 / 60

22. Nurse Ella is caring for Mr. Jones, a patient with diabetes mellitus who is taking oral medications and is scheduled for a diagnostic test requiring him to remain NPO. How should Nurse Ella best manage the administration of his oral diabetes medications in this situation?

💡 Hint

Think about common skin or mucosal symptoms linked to hyperglycemia, particularly in older adults.

23 / 60

23. Nurse Mia is assessing an older woman with diabetes mellitus who visits the clinic with concerns about her condition. Which symptom is the patient most likely to report?

💡 Hint

Consider the role of medications that affect the cardiovascular system and how they might influence the body’s response to glucose and glucagon.

24 / 60

24. Nurse Sophia administers glucagon to her diabetic client experiencing severe hypoglycemia. Afterward, she carefully monitors the client for any potential adverse drug interactions. Which type of medication is known to interact negatively with glucagon?

💡 Hint

Diabetes typically affects metabolism in ways that increase fat breakdown rather than decreasing it.

25 / 60

25. Nurse Tara is educating a patient on the effects of diabetes and its potential complications. Which of the following is not a known effect of diabetes?

💡 Hint

Think about the fastest and most effective way to stabilize blood glucose levels in a critical situation like DKA.

26 / 60

26. Nurse Carla is initiating insulin therapy for a patient with diabetic ketoacidosis (DKA) to treat hyperglycemia. Which method of insulin administration should be used initially?

💡 Hint

Focus on the role of the pancreas in insulin production and how type 1 diabetes affects this process.

27 / 60

27. A patient newly diagnosed with type 1 diabetes mellitus asks Nurse Sarah what this diagnosis means. What is the best response by the nurse? Select all that apply:

💡 Hint

Consider the leading cause of morbidity and mortality in patients with diabetes.

28 / 60

28. Nurse Laura is discussing long-term complications of diabetes with her patient during a follow-up visit. She explains the most common and serious complication associated with diabetes. What is it?

💡 Hint

Consider which professional specializes in helping clients adapt daily tasks to physical limitations.

29 / 60

29. Nurse Emma is visiting Mrs. Howard, a client with diabetes and arthritis, who is struggling to draw up her insulin due to joint pain and limited dexterity. To provide the best support, Nurse Emma should recommend a referral to:

💡 Hint

Think about what should be done when the sterile field is compromised to maintain sterility.

30 / 60

30. Nurse Carol is providing wound care for Mr. Lawson, a client with type 1 diabetes mellitus who has a foot ulcer. She needs to adhere strictly to principles of surgical asepsis during the procedure. Which of the following actions demonstrates proper surgical aseptic technique?

💡 Hint

Think about the condition directly related to chronic elevated blood glucose levels leading to HHNS.

31 / 60

31. Nurse Clara is assessing a patient admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS). What is the most common underlying cause of this condition?

💡 Hint

Think about how decreased oral intake combined with diabetes can affect blood sugar levels, especially when the body is under stress.

32 / 60

32. Nurse Rachel is caring for Mrs. Lawson, a post-operative patient with a history of diabetes mellitus, on her second day after cholecystectomy. Mrs. Lawson, unable to eat solid food and experiencing nausea, suddenly appears confused and shaky. What is the most likely cause of these symptoms?

💡 Hint

Type 2 diabetes is primarily characterized by insulin resistance at the cellular level.

33 / 60

33. Nurse Martha is educating a client with type 2 diabetes about the condition. She evaluates the effectiveness of her teaching based on which statement made by the client?

💡 Hint

Think about how type 2 diabetes is often initially managed before insulin therapy is considered necessary.

34 / 60

34. Nurse Kevin is reviewing characteristics of type 2 diabetes mellitus with a group of nursing students. He asks them to identify which statement about type 2 diabetes is incorrect.

💡 Hint

For an unconscious hypoglycemic patient, consider an intervention that does not rely on the ability to eat or drink.

35 / 60

35. Paramedics bring in Mr. Johnson, an unconscious patient experiencing severe hypoglycemia. Upon his arrival at the emergency department, what is the nurse's priority intervention to address his condition?

💡 Hint

Insulin administration can shift electrolytes, particularly this one, into the cells, leading to hypokalemia.

36 / 60

36. Nurse Megan is caring for Liam, a 16-year-old with type 1 diabetes mellitus who is receiving insulin therapy. To monitor for potential complications related to insulin administration, which laboratory test should Nurse Megan prioritize assessing?

💡 Hint

Consider the lifestyle, physical, and biological factors that are known contributors to diabetes development. Ignore those that do not correlate with evidence-based risk factors.

37 / 60

37. Nurse Lauren is reviewing diabetes prevention strategies with Mr. Reynolds, a 52-year-old patient with a family history of diabetes. As part of her teaching, she identifies risk factors for developing diabetes mellitus. Which of the following should Nurse Lauren include as risk factors? (Select all that apply.)

💡 Hint

Recall that NPH insulin typically peaks 4 to 12 hours after administration, requiring attention to mid-afternoon glucose levels.

38 / 60

38. Nurse Carla is reviewing insulin therapy with Mr. Greene, a client prescribed NPH insulin. She asks him how he plans to manage his meals and snacks based on the medication's peak action. Which response indicates he understands when the insulin's peak effect occurs?

💡 Hint

This breathing pattern is a classic sign of metabolic acidosis, often seen in diabetic ketoacidosis.

39 / 60

39. Nurse Rachel enters a patient’s room and notices the patient breathing rapidly with a fruity odor on their breath. This type of breathing pattern is referred to as:

💡 Hint

Focus on the recommended carbohydrate amount for rapidly raising blood glucose during mild hypoglycemia.

40 / 60

40. Nurse Lily is caring for Ms. Parker, a client with type 1 diabetes mellitus, who was just treated for an acute hypoglycemic episode in the emergency department. To help prevent future episodes, Nurse Lily educates her on how to manage hypoglycemia by consuming what amount of a simple carbohydrate?

💡 Hint

Consider how stress and infection impact blood glucose levels and insulin requirements.

41 / 60

41. Nurse Linda is advising a patient with type 1 diabetes about managing their condition during an infection. What adjustment to their daily routine might they need to make?

💡 Hint

Think about how long-acting insulin works to maintain steady blood glucose levels without peaks.

42 / 60

42. Nurse Paula is reviewing Rose's medication plan and explains the benefits of Glargine (Lantus) insulin. What is one of the key advantages of this medication?

💡 Hint

Think about the classic signs and symptoms of hypoglycemia when insulin is taken without food.

43 / 60

43. Matt administers his prescribed insulin but forgets to eat afterward. What is the most likely assessment the nurse will make?

💡 Hint

This class of medications primarily targets the pancreas to help boost insulin production.

44 / 60

44. Nurse Clara is caring for a patient with type 2 diabetes mellitus who has been prescribed a sulfonylurea, such as long-acting glyburide (Micronase). She understands that the primary purpose of this medication is to:

💡 Hint

Certain ethnic groups, including this one, have a higher risk of developing diabetes mellitus due to genetic and socioeconomic factors.

45 / 60

45. During a hospital visit, student nurses are asked to identify which individual is most likely to be diagnosed with diabetes mellitus. They would give the correct answer by identifying a 44-year-old:

💡 Hint

Think about the effect of poor intake and infection on glucose levels in type 2 diabetes, particularly in older patients.

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46. Nurse Clara is admitting Mrs. Thompson, a 70-year-old woman with type 2 diabetes mellitus, who has been ill with pneumonia and eating poorly. During assessment, Nurse Clara evaluates potential complications of diabetes that may arise from her current illness. What is the most likely issue affecting Mrs. Thompson?

💡 Hint

Consider which types of insulin are approved for IV use and whether the nurse’s action aligns with established guidelines for managing hyperglycemia emergencies.

47 / 60

47. Nurse Karen is caring for Rita, a patient with critically high blood sugar levels of 563 mg/dL. Following a physician's order for IV insulin, Nurse Karen administers insulin lispro (Humalog) intravenously. Upon evaluation, which of the following statements reflect the nurse's actions? (Select all that apply.)

💡 Hint

Consider when a medication designed to control daytime blood sugar levels would be most effective when taken.

48 / 60

48. Nurse Carla is educating Mr. Harris, a patient with diabetes mellitus, about his new prescription for Glucotrol XL (glipizide). To ensure optimal blood sugar control throughout the day, when should Nurse Carla instruct Mr. Harris to take this medication?

💡 Hint

Consider the cells in the pancreas that play a role in raising blood glucose levels.

49 / 60

49. Nurse Elena is teaching a group of nursing students about pancreatic hormones. During her lesson, she asks, "Which type of cells in the pancreas are responsible for secreting glucagon?"

💡 Hint

Consider what happens to proteins, like insulin, when they pass through the digestive system.

50 / 60

50. Nurse Sophia is educating a client with type 1 diabetes who is curious about why insulin cannot be taken in pill form instead of by injection. What is the best response Nurse Sophia should give to address the client’s question?

💡 Hint

Think about the body’s compensatory mechanisms for metabolic acidosis and how ketones affect breath odor.

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51. Nurse Jessica is caring for a patient in diabetic ketoacidosis (DKA) caused by an infection. As the condition progresses, which symptoms should Nurse Jessica expect to observe?

💡 Hint

Hypoglycemia symptoms are caused by low blood glucose and activation of the sympathetic nervous system. Consider which option does not align with these effects.

52 / 60

52. Nurse Sophia is assessing Mr. Daniels, a client with diabetes, for signs of hypoglycemia. She asks her students to identify which of the following is not typically a symptom of a hypoglycemic condition.

💡 Hint

Think about how physical activity and lower food intake affect blood glucose and the body's insulin demands.

53 / 60

53. Nurse Joy is educating Mr. Rivera, a newly diagnosed type 1 diabetes patient, and his family about how diet and physical activity influence insulin needs. Which guideline should Nurse Joy emphasize to help them manage his condition effectively?

💡 Hint

Consider the substances that appear in urine when blood glucose is elevated and fat metabolism is increased.

54 / 60

54. Nurse Clara is reviewing diagnostic indicators of diabetes with her students. She asks what a urine test might reveal in an undiagnosed diabetic client.

💡 Hint

Think about the localized changes in subcutaneous tissue that can occur with repeated injections at the same site.

55 / 60

55. Nurse Elena is teaching a patient with diabetes about the importance of rotating insulin injection sites. What complication does site rotation primarily prevent?

💡 Hint

Consider the factor most strongly linked to insulin resistance and diabetes risk.

56 / 60

56. During a community health class on diabetes prevention, Nurse Taylor discusses risk factors for developing diabetes mellitus. She observes several participants and considers their health habits. Which individual in the group would Nurse Taylor assess as having the highest risk of developing diabetes?

💡 Hint

Consider the organ responsible for insulin production and how its dysfunction might lead to the patient’s symptoms.

57 / 60

57. Nurse Joanna is caring for a 50-year-old widower admitted with diabetes mellitus, reporting rapid weight loss, high blood glucose, and polyphagia. Based on these symptoms, Nurse Joanna should anticipate which possible secondary medical diagnosis?

💡 Hint

Think about the quickest and safest intervention to stabilize blood sugar for a conscious patient experiencing hypoglycemia.

58 / 60

58. Nurse Leah is assisting Mrs. Turner, a patient with type 1 diabetes mellitus, who suddenly begins showing signs of confusion, dizziness, and unusual behavior. Mrs. Turner is still alert and responsive. What should Nurse Leah do first to address the situation?

💡 Hint

Alcohol can interfere with glucose regulation by affecting the liver's ability to release stored glucose.

59 / 60

59. Nurse Jamie is educating a patient with type 1 diabetes who receives insulin and mentions enjoying a glass of wine with dinner. What should Nurse Jamie include in her teaching plan to address the potential effects of alcohol consumption?

💡 Hint

Focus on the specific pancreatic cells that lower blood glucose levels by releasing insulin.

60 / 60

60. Nurse Jamie is reviewing the physiology of the pancreas with her patient newly diagnosed with diabetes. She asks, "Which type of pancreatic cells are responsible for secreting insulin?"

Nursing Care Plan

Nursing Diagnosis
  • Risk for Infection
Risk factors may include
  • High glucose levels, decreased leukocyte function, alterations in circulation
  • Preexisting respiratory infection, or UTI

Possibly evidenced by

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

Nursing Diagnosis
  • Risk for Disturbed Sensory Perception

Risk factors may include

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

Possibly evidenced by

  • [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]
Desired Outcomes
  • Maintain usual level of mentation.
  • Recognize and compensate for existing sensory impairments.
Nursing Interventions
  • Monitor vital signs and mental status.
    • Rationale: To provide baseline from which to compare abnormal findings.
  • Call the patient by name, reorient as needed to place, person, and time. Give short explanations, speak slowly and enunciate clearly.
    • Rationale: Decreases confusion and helps maintain contact with reality.
  • Schedule and cluster nursing time and interventions.
    • Rationale: To provide uninterrupted rest periods and promote restful sleep, minimize fatigue and improve cognition.
  • Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able.
    • Rationale: Helps keep patient in touch with reality and maintain orientation to the environment.
  • Protect patient from injury by avoiding or limiting the use of restraints as necessary when LOC is impaired. Place bed in low position and pad bed rails if patient is prone to seizures.
    • Rationale: Disoriented patients are prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration, and falls.
  • Evaluate visual acuity as indicated.
    • Rationale: Retinal edema or detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care.
  • Observe and investigate reports of hyperesthesia, pain, or sensory loss in the feet or legs. Investigate and look for ulcers, reddened areas, pressure points, loss of pedal pulses.
    • Rationale: Peripheral neuropathies may result in severe discomfort, lack of or distortion of tactile sensation, potentiating risk of dermal injury and impaired balance.
  • Provide bed cradle. Keep hands and feet warm, avoiding exposure to cool drafts and/or hot water or use of heating pad.
    • Rationale: Reduces discomfort and potential for dermal injury.
  • Assist patient with ambulation or position changes.
    • Rationale: Promotes patient safety, especially when sense of balance is affected.
  • Monitor laboratory values: blood glucose, serum osmolality, Hb/Hct, BUN/Cr.
    • Rationale: Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication).
  • Carry out prescribed regimen for correcting DKA as indicated.
    • Rationale: Alteration in thought processes or potential for seizure activity is usually alleviated once hyperosmolar state is corrected.

Nursing Diagnosis
  • Powerlessness

May be related to

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

Possibly evidenced by

  • Reluctance to express true feelings; expressions of having no control/influence over situation
  • Apathy, withdrawal, anger
  • Does not monitor progress, nonparticipation in care/decision making
  • Depression over physical deterioration/complications despite patient cooperation with regimen
Desired Outcomes
  • Acknowledge feelings of helplessness.
  • Identify healthy ways to deal with feelings.
  • Assist in planning own care and independently take responsibility for self-care activities.
Nursing Interventions
  • Encourage patient and/or SO to express feelings about hospitalization and disease in general.
    • Rationale: Identifies concerns and facilitates problem solving.
  • Acknowledge normality of feelings.
    • Rationale: Recognition that reactions are normal can help patient problem-solve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health.
  • Assess how patient has handled problems in the past. Identify locus of control.
    • Rationale: Knowledge of individual’s style helps determine needs for treatment goals. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors.
  • Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful to patient
    • Rationale: Enhances sense of being involved and gives SO a chance to problem-solve solutions to help patient prevent recurrence.
  • Ascertain expectations and/or goals of patient and SO.
    • Rationale: 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.
    • Rationale: Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns affecting self-concept may add further stress.
  • Encourage patient to make decisions related to care: ambulation, schedule for activities, and so forth.
    • Rationale: Communicates to patient that some control can be exercised over care.
  • Support participation in self-care and give positive feedback for efforts.
    • Rationale: Promotes feeling of control over situation.

Nursing Diagnosis
  • Imbalanced Nutrition: Less Than Body Requirements

May be related to

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

Possibly evidenced by

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

Nursing Diagnosis
  • Deficient Fluid Volume

May be related to

  • Osmotic diuresis (from hyperglycemia)
  • Excessive gastric losses: diarrhea, vomiting
  • Restricted intake: nausea, confusion

Possibly evidenced by

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

Possibly evidenced by

  • Increased urinary output, dilute urine
  • Weakness; thirst; sudden weight loss
  • Dry skin/mucous membranes, poor skin turgor
  • Hypotension, tachycardia, delayed capillary refill
Desired Outcomes
  • Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.
Nursing Interventions
  • Assess patient’s history related to duration or intensity of symptoms such as vomiting, excessive urination.
    • Rationale: Assists in estimation of total volume depletion. Symptoms may have been present for varying amounts of time (hours to days). Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses.

Monitor vital signs: 

  • Note orthostatic BP changes.
    • Rationale: Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when patient’s systolic BP drops more than 10 mmHg from a recumbent to a sitting then a standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate.
  • Respiratory pattern: Kussmaul’s respirations, acetone breath.
    • Rationale: Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Acetone breath is due to breakdown of acetoacetic acid and should diminish as ketosis is corrected. Correction of hyperglycemia and acidosis will cause the respiratory rate and pattern to approach normal.
  • Respiratory rate and quality, use of accessory muscles, periods of apnea, and appearance of cyanosis.
    • Rationale: In contrast, increased work of breathing, shallow, rapid respirations, and presence of cyanosis may indicate respiratory fatigue and/or that patient is losing ability to compensate for acidosis.
  • Temperature, skin color, moisture, and turgor.
    • Rationale: Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin and decreased skin turgor may reflect dehydration.
  • Assess peripheral pulses, capillary refill, and mucous membranes.
    • Rationale: Indicators of level of hydration, adequacy of circulating volume.
  • Monitor I&O and note urine specific gravity.
    • Rationale: Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
  • Weigh daily.
    • Rationale: Provides the best assessment of current fluid status and adequacy of fluid replacement.
  • Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed.
    • Rationale: Maintains hydration and circulating volume.
  • Promote comfortable environment. Cover patient with light sheets.
    • Rationale: Avoids overheating, which could promote further fluid loss.
  • Investigate changes in mentation and LOC.
    • Rationale: Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose patient to aspiration.
  • Insert and maintain indwelling urinary catheter.
    • Rationale: Provides for accurate ongoing measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder (urinary retention/overflow incontinence). May be removed when patient is stable to reduce risk of infection.

Nursing Diagnosis
  • Fatigue

May be related to

  • Decreased metabolic energy production
  • Altered body chemistry: insufficient insulin
  • Increased energy demands: hypermetabolic state/infection

Possibly evidenced by

  • Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone
  • Impaired ability to concentrate, listlessness, disinterest in surroundings
Desired Outcomes
  • Verbalize increase in energy level.
  • Display improved ability to participate in desired activities.
Nursing Interventions
  • Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue.
    • Rationale: Education may provide motivation to increase activity level even though patient may feel too weak initially.
  • Alternate activity with periods of rest and uninterrupted sleep.
    • Rationale: To prevent excessive fatigue.
  • Monitor pulse, respiratory rate, and BP before and after activity.
    • Rationale: Indicates physiological levels of tolerance.
  • Discuss ways of conserving energy while bathing, transferring, and so on.
    • Rationale: Patient will be able to accomplish more with a decreased expenditure of energy.
  • Increase patient participation in ADLs as tolerated.
    • Rationale: Increases confidence level, self-esteem and tolerance level.

Nursing diagnosis
  • Deficient Fluid Volume related to intracellular dehydration secondary to diabetes mellitus

Possibly evidenced by

  • Elevated temperature
  • Increased urine output
  • Sweating
  • Thirst
  • Exhaustion
  • Weight loss
  • Dry skin and/or mucous membrane
Desired outcomes
  • Patient will verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications.
  • Patient will improve or maintain fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane, and stable vital signs.
Nursing Interventions
  • Establish rapport
    • Rationale: Friendly and trusting relationship with patient and to be able to understand each other’s concern.
  • Take and record vital signs.
    • Rationale: To obtain baseline data.
  • Monitor the temperature.
    • Rationale: To monitor changes in temperature.
  • Assess skin turgor and mucous membranes for signs of dehydration.
    • Rationale: Dry mucous membranes are signs of dehydration.
  • Monitor intake and output
    • Rationale: To assess for signs of dehydration.
  • Encourage patient to increase fluid intake as tolerated.
    • Rationale: To replace fluid loss and prevent dehydration.
  • Administer IVF as ordered.
    • Rationale: To replace lost electrolytes and fluids.

Nursing Diagnosis
  • Imbalanced Nutrition: less than body requirement r/t insulin deficiency

Possibly evidenced by

  • Poor muscle tone
  • Generalized weakness
  • Increased thirst
  • Increased urination
  • Polyphagia
  • Loss of weight
Desired outcomes
  • Patient will verbalize understanding of causative factors when known and necessary interventions are identified for diabetic client.
  • Patient will demonstrate improvement of weight and nutrition towards goal.
Nursing Interventions
  • Ascertain understanding of individual nutritional needs.
    • Rationale: To determine what information to be provided to client or SO.
  • Discuss eating habits and encourage diabetic diet (balanced diet) as prescribed by the doctor.
    • Rationale: To achieve health needs of the patient with the proper food diet for his condition.
  • Document actual weight, do not estimate. Note total daily intake including patterns and time of eating.
    • Rationale: Patients may be unaware of their actual weight or weight loss due to estimation of weight.
  • Consult dietician and/or physician for further assessment and recommendation regarding food preferences and nutritional support.
    • Rationale: To reveal changes that should be made in the client’s dietary intake. For greater understanding and further assessment of specific foods.

Nursing Diagnosis
  • Risk for Infection

Risk factors

  • Chronic hyperglycemia
  • Neurogenic bladder
  • Peripheral vascular disease

Possibly evidenced by

  • [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]
Desired outcomes
  • Patient will be free of infections as evidenced by normothermia, negative cultures, and WBC within normal levels.
Nursing Interventions
  • Assess temperature every four (4) hours. Notify physician if fever occurs.
    • Rationale: Fever is a sign of an infection Infection is the most common cause of diabetic ketoacidosis (DKA).
  • Monitor for signs of infection (e.g., fever, rhonchi, dyspnea, and/or cough).
    • Rationale: These are indicators of pneumonia which is common among patients with DM.
  • Assess for dysuria, tachycardia, diaphoresis, nausea, vomiting, and abdominal pain.
    • Rationale: These are indicators of UTI. Neurogenic bladder predisposes to UTI.
  • Assess for erythema, swelling, and purulent drainage at IV sites.
    • Rationale: These are signs of IV catheter infections.

Nursing Diagnosis
  • Risk for Impaired Skin Integrity

Risk factors

  • Decreased circulation and sensation caused by peripheral neuropathy and arterial obstruction.

Possibly evidenced by

  • [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]
Desired outcomes
  • Patient’s skin on legs and feet remains intact while the patient is hospitalized.
  • Patient will demonstrate proper foot care.
Nursing Interventions
  • Assess integrity of the skin. Assess knee and deep tendon reflexes and proprioception.
    • Rationale: These are assessments for neuropathy. Skin on lower extremity pressure points is at great risk for ulceration.
  • Use foot cradle on the bed. Use space boots on ulcerated heels, elbow protectors, and pressure-relief mattresses.
    • Rationale: To prevent pressure on pressure-sensitive points.
  • Wash feet daily with mild soap and warm water. Check water temperature before immersing feet in the water.
    • Rationale: Decreased sensation increases the risk for burns.
  • Inspect feet daily for erythema or trauma.
    • Rationale: These are signs that the skin needs preventive care.
  • Change socks or stockings daily. Encourage the patient to wear white cotton socks.
    • Rationale: To prevent infection from moisture. White fabric enables easy visualization of blood or exudates.
  • Use gentle moisturizers on the feet.
    • Rationale: Moisturizers soften and lubricate dry skin, preventing skin cracking.
  • Cut toenails straight across after softening toenails with a bath.
    • Rationale: This action prevents ingrown toenails, which could cause infection.
  • The patient should not walk barefoot.
    • Rationale: This is a high risk for trauma and may result in ulceration and infection.