LESSON PLAN

On
“Nursing Care of patients with
Diabetes Mellitus”
SUBMITTED TO, SUBMITTED BY,
Mrs. Roseline Rhenius, Ms. Joice Das,
Professor & HOD, M.Sc. Nursing-II year
Medical-Surgical Nursing-II, Medical-Surgical Nursing,
College of Nursing, College of Nursing,
CMC, Vellore. CMC, Vellore
COURSE : Medical-Surgical Nursing speciality-II

PROGRAMME : M.Sc. Nursing II year

LEVEL OF STUDENTS : B.Sc. Nursing II year

UNIT : Endocrine Disorders

TOPIC : Nursing care of patients with diabetes mellitus

METHOD OF TEACHING : Lecture cum discussion

AUDIO-VISUAL AIDS : Power-point presentation, Chart paper, Handout

NUMBER OF STUDENTS : 50

VENUE : College of Nursing

DURATION : 60 minutes

FACULTY GUIDE : Mrs. Roseline Rhenius, Professor and HOD, Medical-Surgical Nursing-II,
CON, CMC, Vellore.

STUDENT : Ms. Joice Das, M.Sc. (N) 2nd year, Medical-Surgical Nursing, CON, CMC,
Vellore.

DATE OF PRESENTATION:
GENERAL OBJECTIVE

At the end of the class, students will be able to gain understanding on the various aspects of nursing care of patients
with diabetes mellitus and apply knowledge while taking care of patients with diabetes mellitus.

SPECIFIC OBJECTIVES

AT THE END OF THE CLASS, STUDENTS ARE ABLE TO-

 List down the signs and symptoms of diabetes mellitus- History collection & Physical examination
 Identify the relevant nursing nursing diagnosis and prepare nursing interventions.
Time Specific Content Teaching- AV aids Evaluation
Objective learning activity
5 mins INTRODUCTION Lecture cum Power-point
discussion presentation
Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin secretion, insulin
action, or both. The chronic hyperglycemia of diabetes is associated
with long-term damage, dysfunction, and failure of various organs,
especially the eyes, kidneys, nerves, heart, and blood vessels.

Several pathogenic processes are involved in the development of

diabetes. These range from autoimmune destruction of the β-cells of
the pancreas with consequent insulin deficiency to abnormalities that
result in resistance to insulin action. The basis of the abnormalities in
carbohydrate, fat, and protein metabolism in diabetes is deficient
action of insulin on target tissues. Deficient insulin action results from
inadequate insulin secretion and/or diminished tissue responses to
insulin at one or more points in the complex pathways of hormone
action. Impairment of insulin secretion and defects in insulin action
frequently coexist in the same patient, and it is often unclear which
abnormality, if either alone, is the primary cause of the
hyperglycemia.

Symptoms of marked hyperglycemia include polyuria, polydipsia,

weight loss, sometimes with polyphagia, and blurred vision.
Impairment of growth and susceptibility to certain infections may also
accompany chronic hyperglycemia. Acute, life-threatening
consequences of uncontrolled diabetes are hyperglycemia with
ketoacidosis or the non-ketotic hyperosmolar syndrome.

Long-term complications of diabetes include retinopathy with

potential loss of vision; nephropathy leading to renal failure;
peripheral neuropathy with risk of foot ulcers, amputations, and
Charcot joints; and autonomic neuropathy causing gastrointestinal,
genitourinary, and cardiovascular symptoms and sexual dysfunction.
Patients with diabetes have an increased incidence of atherosclerotic
cardiovascular, peripheral arterial and cerebrovascular disease.
 Hypertension and abnormalities of lipoprotein metabolism are often
found in people with diabetes.
15 List down the SIGNS & SYMPTOMS Lecture cum PPT
mins signs and discussion
symptoms of TYPE-I DIABETES MELLITUS
diabetes
mellitus- History History
collection &  The most common symptoms of type 1 diabetes mellitus
Physical (DM) are polyuria, polydipsia, and polyphagia, along with
examination lassitude, nausea, and blurred vision, all of which result from
the hyperglycemia itself.

 Polyuria is caused by osmotic diuresis secondary to

hyperglycemia. Severe nocturnal enuresis secondary to
polyuria can be an indication of onset of diabetes in young
children. Thirst is a response to the hyperosmolar state and
dehydration.

 Fatigue and weakness may be caused by muscle wasting from

the catabolic state of insulin deficiency, hypovolemia, and
hypokalemia. Muscle cramps are caused by electrolyte
imbalance. Blurred vision results from the effect of the
hyperosmolar state on the lens and vitreous humor. Glucose
and its metabolites cause osmotic swelling of the lens,
altering its normal focal length.

 Symptoms at the time of the first clinical presentation can

usually be traced back several days to several weeks.
However, beta-cell destruction may have started months, or
even years, before the onset of clinical symptoms.

 The onset of symptomatic disease may be sudden. It is not

unusual for patients with type 1 DM to present with diabetic
ketoacidosis (DKA), which may occur de novo or secondary to
the stress of illness or surgery. An explosive onset of
symptoms in a young lean patient with ketoacidosis always
has been considered diagnostic of type 1 DM.
  Over time, patients with new-onset type 1 DM will lose
weight, despite normal or increased appetite, because of
depletion of water and a catabolic state with reduced
glycogen, proteins, and triglycerides. Weight loss may not
occur if treatment is initiated promptly after the onset of the
disease.

Gastrointestinal (GI) symptoms of type 1 DM are as follows:

 Nausea, abdominal discomfort or pain, and change in bowel

movements may accompany acute DKA.

 Acute fatty liver may lead to distention of the hepatic capsule,

causing right upper quadrant pain.

 Persistent abdominal pain may indicate another serious

abdominal cause of DKA (eg, pancreatitis).

Chronic GI symptoms in the later stage of DM are caused by visceral

autonomic neuropathy

Neuropathy affects up to 50% of patients with type 1 DM, but

symptomatic neuropathy is typically a late development, developing
after many years of chronic prolonged hyperglycemia. Peripheral
neuropathy presents as numbness and tingling in both hands and
feet, in a glove-and-stocking pattern; it is bilateral, symmetric, and
ascending.

History in patients with established diabetes

 It is important to inquire about the type and duration of the
patient’s diabetes and about the care the patient is receiving
for diabetes.

 Determination of the type of diabetes is based on history,

therapy, and clinical judgment. The chronic complications of
 diabetes are related to the length of time the patient has had
the disease.

 Ask about the type of insulin being used, delivery system

(pump vs injections), dose, and frequency. Also ask about oral
antidiabetic agents, if any. Of course, a full review of all
medications and over-the-counter supplements being taken
is crucial in the assessment of patients with type 1 DM.

Patients using a pump or a multiple-injection regimen have a basal

insulin (taken through the pump or with the injection of a long-acting
insulin analogue) and a premeal rapid-acting insulin, the dose of
which may be determined as a function of the carbohydrate count
plus the correction (to adjust for how high the premeal glucose level
is).

In these patients, ask about the following:

 Basal rates (eg, units per hour by pump, generally 0.4-1.5

U/h, potentially varying on the basis of time of day); the total
daily dose as basal insulin is a helpful value to know

 Carbohydrate ratio (ie, units of insulin per grams of

carbohydrate, generally 1 unit of rapid-acting insulin per 10-
15 g carbohydrate)

 Correction dose (ie, how far the blood glucose level is

expected to decrease per unit of rapid-acting insulin, often 1
U of insulin per 50-mg/dL decrease, though individuals with
insulin resistance may need 1 U per 25-mg/dL decrease)

 Some patients may be taking premeal pramlintide (an amylin

analogue)

A focused diabetes history should also include the following

questions:
  Is the patient’s diabetes generally well controlled, with near-
normal blood glucose levels? (Patients with poorly controlled
blood glucose levels heal more slowly and are at increased
risk for infection and other complications)

 Does the patient have severe hypoglycemic reactions? (If the

patient has episodes of severe hypoglycemia and therefore is
at risk for losing consciousness, this possibility must be
addressed, especially if the patient drives)

 Does the patient have diabetic nephropathy that might alter

the use of medications or intravenous (IV) radiographic
contrast material?

 Does the patient have macrovascular disease, such as

coronary artery disease (CAD), which should be considered in
the emergency department (ED)?

 Does the patient self-monitor his or her blood glucose levels?

(Note the frequency and range of values at each time of day;
an increasing number of patients monitor with continuous
sensors)

 When was the patient’s hemoglobin A1c (HbA1c) value (an

indicator of long-term glucose control) last measured? What
was it?

 In assessing glycemic exposure of a patient with established

type 1 DM, review of self-monitored blood glucose levels is
necessary. Ideally, this done by uploading time- and date-
stamped levels from the patient’s meter to assure full
understanding of the frequency of testing and the actual
levels.

Questions regarding hypoglycemia and hyperglycemia

  Hypoglycemia and hyperglycemia should be considered. Ask
the following questions as needed:

 Has the patient experienced recent polyuria, polydipsia,

nocturia, or weight loss?

 Has the patient had episodes of unexplained hypoglycemia? If

so, when, how often, and how does the patient treat these
episodes?

 Does the patient have hypoglycemia unawareness (ie, does

the patient lack the adrenergic warning signs of
hypoglycemia)? (Hypoglycemia unawareness indicates an
increased risk of subsequent episodes of hypoglycemia)

TYPE- II DIABETES MELLITUS

History

 The diagnosis of diabetes mellitus is readily entertained when

a patient presents with classic symptoms (ie, polyuria,
polydipsia, polyphagia, weight loss). Other symptoms that
may suggest hyperglycemia include blurred vision, lower
extremity paresthesias, or yeast infections, particularly
balanitis in men. However, many patients with type 2
diabetes are asymptomatic, and their disease remains
undiagnosed for many years.

Patients with established diabetes

 In patients with known type 2 diabetes, inquire about the

duration of the patient's diabetes and about the care the
patient is currently receiving for the disease. The duration of
diabetes is significant because the chronic complications of
diabetes are related to the length of time the patient has had
the disease.
A focused diabetes history should also include the following
questions:

 Is the patient's diabetes generally well controlled (with near-

normal blood glucose levels) - Patients with poorly controlled
blood glucose levels heal more slowly and are at increased
risk for infection and other complications.

 Does the patient have severe hypoglycemic reactions - If the

patient has episodes of severe hypoglycemia and therefore is
at risk of losing consciousness, this possibility must be
addressed, especially if the patient drives or has significant
underlying neuropathy or cardiovascular disease.

 Does the patient have diabetic nephropathy that might alter

the use of medications or intravenous (IV) radiographic
contrast material?

 Does the patient have macrovascular disease, such as

coronary artery disease (CAD) that should be considered as a
source of acute symptoms?

 Does the patient self-monitor his or her blood glucose levels -

If so, note the frequency and range of values at each time of
day?

 When was the patient's hemoglobin A1c (HbA1c; an indicator

of long-term glucose control) last measured, and what was it?

 What is the patient’s immunization history - Eg, influenza,

pneumococcal, hepatitis B, tetanus, herpes zoster?

As circumstances dictate, additional questions may be

warranted, as follows:

 Does the patient give a history of recent polyuria, polydipsia,

 nocturia, or weight loss - These are symptoms of
hyperglycemia.

 Has the patient had episodes of unexplained hypoglycemia -

If so, when, how often, and how does the patient treat these
episodes

 Does the patient have hypoglycemia unawareness (ie, does

the patient lack the adrenergic warning signs of
hypoglycemia) - Hypoglycemia unawareness indicates an
increased risk of subsequent episodes of hypoglycemia

 Regarding retinopathy, when was the patient's last dilated

eye examination, and what were the results

 Regarding nephropathy, does the patient have known kidney

disease; what were the dates and results of the last
measurements of urine protein and serum creatinine levels

 Does the patient have hypertension (defined as a blood

pressure of >130/80); what medications are taken

 Does the patient have CAD

 Regarding peripheral vascular disease, does the patient have

claudication or a history of vascular bypass

 Has the patient had a stroke or transient ischemic attack

 What are the patient's most recent lipid levels; is the patient
taking lipid-lowering medication

 Does the patient have a history of neuropathy or are

symptoms of peripheral neuropathy or autonomic
neuropathy present (including impotence if the patient is
male)
  Does the patient have a history of foot ulcers or amputations;
are any foot ulcers present

 Are frequent infections a problem; at what site.

Physical Examination

 Early in the course of diabetes mellitus, the physical

examination findings are likely to be unrevealing. Ultimately,
however, end-organ damage may be observed. Potential
findings are listed in the image below.

 A diabetes-focused examination includes vital signs,

funduscopic examination, limited vascular and neurologic
examinations, and a foot assessment. Other organ systems
should be examined as indicated by the patient's clinical
situation.

Assessment of vital signs

 Baseline and continuing measurement of vital signs is an
important part of diabetes management. In addition to vital
signs, measure height, weight, and waist and hip
circumferences.

 In many cases, blood pressure measurement will disclose

hypertension, which is particularly common in patients with
diabetes. Patients with established diabetes and autonomic
neuropathy may have orthostatic hypotension. Orthostatic
vital signs may be useful in assessing volume status and in
suggesting the presence of an autonomic neuropathy.

 If the respiratory rate and pattern suggest Kussmaul

respiration, diabetic ketoacidosis (DKA) must be considered
immediately, and appropriate tests ordered. DKA is more
 typical of type 1 diabetes, but it can occur in type 2.

Funduscopic examination
 The funduscopic examination should include a careful view of
the retina. The optic disc and the macula should be visualized.

 If hemorrhages or exudates are seen, the patient should be

referred to an ophthalmologist as soon as possible. Examiners
who are not ophthalmologists tend to underestimate the
severity of retinopathy, especially if the patients' pupils are
not dilated.

 Whether patients develop diabetic retinopathy depends on

the duration of their diabetes and on the level of glycemic
control maintained.

Foot examination

 The dorsalis pedis and posterior tibialis pulses should be

palpated and their presence or absence noted. This is
particularly important in patients who have foot infections,
because poor lower-extremity blood flow can slow healing
and increase the risk of amputation.

 Documenting lower-extremity sensory neuropathy is useful in

patients who present with foot ulcers because decreased
sensation limits the patient's ability to protect the feet and
ankles. This can be assessed with the Semmes Weinstein
monofilament or by assessment of reflexes, position, and/or
vibration sensation.

 If peripheral neuropathy is found, the patient should be made

aware that foot care (including daily foot examination) is very
important for preventing foot ulcers and avoiding lower-
extremity amputation. (For more information, see Diabetic
Foot and Diabetic Foot Infections.)
 Differentiation of type 2 from type 1 diabetes

Type 2 diabetes mellitus can usually be differentiated from type 1

diabetes mellitus on the basis of history and physical examination
findings and simple laboratory tests (see Workup: Tests to
Differentiate Type 2 and Type 1 Diabetes). Patients with type 2
diabetes are generally obese, and may have acanthosis nigricans
and/or hirsutism in conjunction with thick necks and chubby cheeks.

30 Identify the NURSING MANAGEMENT

mins relevant nursing
nursing Nurses should provide accurate and up-to-date information about the
diagnosis and patient’s condition so that the healthcare team can come up with
prepare nursing appropriate interventions and management.
interventions.
NURSING ASSESSMENT

The nurse should assess the following for patients with Diabetes
Mellitus:

 Assess the patient’s history. To determine if there is presence

of diabetes, assessment of history of symptoms related to the
diagnosis of diabetes, results of blood glucose monitoring,
adherence to prescribed dietary, pharmacologic, and exercise
regimen, the patient’s lifestyle, cultural, psychosocial, and
economic factors, and effects of diabetes on functional status
should be performed.
 Assess physical condition. Assess the patient’s blood pressure
while sitting and standing to detect orthostatic changes.
 Assess the body mass index and visual acuity of the patient.
 Perform examination of foot, skin, nervous system and
mouth.

 Laboratory examinations. HgbA1C, fasting blood glucose, lipid

profile, microalbuminuria test, serum creatinine level,
urinalysis, and ECG must be requested and performed.
NURSING DIAGNOSIS

Here are 17 nursing care plans and nursing diagnoses for diabetes
mellitus (DM):

 Risk for Unstable Blood Glucose Level

 Deficient Knowledge
 Risk for Infection
 Risk for Disturbed Sensory Perception
 Powerlessness
 Risk for Ineffective Therapeutic Regimen Management
 Risk for Injury
 Imbalanced Nutrition: Less Than Body Requirements
 Risk for Deficient Fluid Volume
 Fatigue
 Risk for Impaired Skin Integrity
 Risk for risk-prone behavior—risk factors may include all-
encompassing changes in lifestyle, self-concept requiring
lifelong adherence to therapeutic regimen, and
internal/altered locus of control.
 Compromised family coping—may be related to inadequate
or incorrect information or understanding by primary
persons, other situation crises or situations the SO’s may be
facing, lifelong condition requiring behavioral changes
impacting family.
 Risk for sexual dysfunction related to peripheral neuropathy.
 Risk for ineffective coping related to diabetes management
regimen.
 Anxiety related to loss of control, fear of inability to manage
diabetes, misinformation related to diabetes, fear of diabetes
complications
 Fluid and electrolyte imbalance related to fluid shift or loss.
Risk for Unstable Blood Glucose Level
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.

Nursing Diagnosis: Risk for Unstable Blood Glucose Level as

evidenced by inadequate blood glucose monitoring, inability to follow
diabetes management

Risk factors
Inadequate blood glucose monitoring
Lack of adherence to diabetes management
Medication management
Deficient knowledge of diabetes management
Developmental level
Lack of acceptance of diagnosis
Stress, sedentary activity level
Insulin deficiency or excess
May be evidenced by
A risk diagnosis is not evidenced by signs and symptoms.
Interventions are directed at prevention.

Desired outcomes
Patient has a blood glucose reading of less than 180 mg/dL; fasting
blood glucose levels of less than <140 mg/dL; hemoglobin A1C level
<7%.
Patient will achieve and maintain glucose in satisfactory range
(specify).
Patient will acknowledge key factors that may contribute to unstable
glucose levels
Nursing Assessment and Rationale
1. Assess for signs of hyperglycemia.
Hyperglycemia results when there is an inadequate amount of insulin
to glucose. Excess glucose in the blood creates an osmotic effect that
increases thirst, hunger, and increased urination. The patient may
also report nonspecific symptoms of fatigue and blurred vision.

2. Assess blood glucose levels before meals and at bedtime.

Random blood glucose test results should be between 140 to 180
mg/dL. Non-intensive care patients should be maintained at pre-meal
levels <140 mg/dL.

3. Monitor the patient’s HbA1c-glycosylated hemoglobin.

This is a measure of blood glucose over the previous 2 to 3 months. A
level of 6.5% to 7% is desirable.

4. Weight daily.
To help assess the adequacy of nutritional intake.

5. Assess for anxiety, tremors, and slurring of speech. Treat

hypoglycemia with 50% dextrose.
These are signs of hypoglycemia, and D50 is the treatment for it.

6. Assess feet for temperature, pulses, color, and sensation.

To monitor peripheral perfusion and neuropathy.

7. Assess bowel sounds by auscultation and note any reports of

abdominal pain, bloating, nausea or vomiting.
Hyperglycemia disrupts gastric motility in the stomach, duodenum,
and jejunum and may affect the choice of interventions.

8. Monitor urine albumin to serum creatinine for renal failure.

Renal failure causes creatinine >1.5 mg/dL. Microalbuminuria is the
first sign of diabetic nephropathy.

9. Assess the pattern of physical activity.

Physical activity helps lower blood glucose levels. Regular exercise is a
core part of diabetes management and reduces the risk for
cardiovascular complications.

10. Monitor for signs of hypoglycemia.

A patient with type 2 diabetes who uses insulin as part of the
treatment plan is at increased risk for hypoglycemia. Manifestations
of hypoglycemia may vary among individuals but are consistent in the
same individual. The signs of hypoglycemia result from both
increased adrenergic activity and decreased glucose delivery to the
brain. Therefore, the patient may experience changes in LOC,
tachycardia, diaphoresis, dizziness, headache, fatigue, cold and
clammy skin, hunger, shakiness, and visual changes.

11. Explore patient’s health beliefs about physical exercise and review
exercise program recommendations with the patient.
Stress that the patient should exercise at the same time and the same
intensity each day. Exercise should be done preferably when the
blood glucose levels are at their optimum. For patients starting their
exercise program, emphasize the need for a slow and gradual
increase in the intensity of their exercise regimen.

12. Determine the blood glucose levels of the patient before

exercising.
The patient should not begin exercising if their blood glucose levels
are above 250 mg/dL and have ketones in their urine. Elevated blood
glucose levels during exercise increase glucagon secretion, and
ultimately, the liver produces more glucose resulting in a further
increase in blood glucose levels.

13. Assess the patient’s adeptness in self-monitoring of blood

glucose.
Methods for SMBG must match the skill level of the patient.

14. Assess the patient’s current knowledge and understanding of the

prescribed diet.
Nonadherence to dietary guidelines can result in hyperglycemia. An
individualized diet plan is recommended.

Nursing Interventions and Rationale

1. Administer basal and prandial insulin.
Adherence to the therapeutic regimen promotes tissue perfusion.
Keeping glucose in the normal range slows the progression of
microvascular disease.

2. Watch out for signs of morning hyperglycemia.

As the name suggests, Morning hyperglycemia is an elevated blood
glucose level arising in the morning due to an insufficient level of
insulin. Causes include the dawn phenomenon (normal blood glucose
levels until 3 AM, then levels begin to rise), insulin waning
(progressive increase in glucose levels from bedtime to morning), and
Somogyi effect (nocturnal hypoglycemia then rebound
hyperglycemia).

3. Teach the patient how to perform home glucose monitoring.

Blood glucose is monitored before meals and at bedtime. Glucose
values are used to adjust insulin doses.

4. Report BP of more than 160 mm Hg (systolic). Administer

hypertensive as prescribed.
Hypertension is commonly associated with diabetes. Control of BP
prevents coronary artery disease, stroke, retinopathy, and
nephropathy.

5. Instruct the patient to avoid heating pads and always to wear shoes
when walking.
Patients have decreased sensation in the extremities due to
peripheral neuropathy.

6. Instruct patient to take oral hypoglycemic medications as directed:

6.1. Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta),

glimepiride (Amaryl)
Sulfonylureas stimulate insulin secretion by the pancreas, used mostly
in type 2 diabetes to control blood glucose levels. They also enhance
cell receptor sensitivity to insulin and decrease the liver synthesis of
glucose from amino acids and stored glycogen.

6.2. Meglitinides: repaglinide (Prandin)

Stimulates insulin secretion by the pancreas.

6.3. Biguanides: metformin (Glucophage)

These drugs decrease the amount of glucose produced by the liver
and improve insulin sensitivity. They enhance muscle cell receptor
sensitivity to insulin.
6.4. Phenylalanine derivatives: nateglinide (Starlix)
Stimulates rapid insulin secretion to reduce the increases in blood
glucose that occur soon after eating.

6.5. Alpha-glucosidase inhibitors: acarbose (Precose), miglitol

(Glyset).
Inhibits the production of glucose by the liver and increases the
body’s sensitivity to insulin. Used in controlling blood glucose levels in
type 2 diabetes.

6.6. Thiazolidinediones: pioglitazone (Actos), rosiglitazone (Avandia)

Sensitizes body tissues to insulin and stimulates insulin receptor sites
to lower blood glucose and improve the action of insulin.

6.7. Incretin modifiers: sitagliptin phosphate (Januvia), vildagliptin

(Galvus)
Increases and prolongs the action of incretin which increases insulin
secretion and decreases glucagon levels.

7. Instruct patient to take insulin as directed:

7.1. 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.

7.2. 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.

7.3. 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.

7.4. 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.

7.5. 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.

8. Instruct patient on the proper injection of insulin.

The absorption of insulin is more consistent when insulin is always
injected in the same anatomical site. Absorption is fastest in the
abdomen, followed by the arms, thighs, and buttocks. It is
recommended by the American Diabetes Association to administer
insulin into the subcutaneous tissue of the abdomen using insulin
syringes.

9. Educate patient on the correct rotation of injection sites when

administering insulin.

Over time, injection of insulin in the same site will result in

lipoatrophy and lipohypertrophy with reduced insulin absorption.
Repeated use of an injection site can cause the development of fatty
masses called lipohypertrophy, which can impair the absorption of
insulin when used again.

10. Instruct the patient on the proper storage of insulin.

Insulins should be refrigerated, not be allowed to freeze, avoid
extremes of temperatures, and avoid exposure to direct sunlight. To
prevent irritation from “cold insulin,” vials may be stored at
temperatures of 15º to 30ºC (59º to 86ºF) for 1 month. Opened vials
are to be discarded after that time, while unopened vials may be
stored until their expiration date. Instruct patient to keep a spare vial
of the insulin types prescribed. Cloudy insulins should be thoroughly
mixed by rolling the vials between the hands before drawing the
solution.

11. Instruct patient that insulin vial that is in use should be kept at
room temperature.
Keeping insulin at room temperature helps reduce local irritation at
the injection site.

12. Stress the importance of achieving blood glucose control.

Control of blood glucose levels within the nondiabetic range can
significantly reduce the development and progression of
complications.

13. Explain the importance of weight loss to obese patients with

diabetes.
Weight loss is an important factor in the treatment of diabetes.
Weight loss of around 5-10% of the total body weight can reduce or
eliminate the need for medications and significantly improve blood
glucose levels.

14. Explain the importance of having consistent meal content or

timing.
The recommendation is three meals of equal size, evenly spaced meal
times (5-6 hours apart), with one or two snacks. Pacing food intake
throughout the day places more manageable demands on the
pancreas.

15. Refer the patient to support groups, diet, and nutrition education,
and counseling.
To help the patient incorporate weight management and learn new
dietary habits.

16. Educate the patient on maintaining consistency in food and the

approximate time intervals between meals.
A consistent amount of food and time interval between meals helps
prevent hypoglycemic reactions and maintain overall blood glucose
control.

17. Educate the patient about the health benefits and importance of
exercise in the management of diabetes.
Exercise plays a role in lowering blood glucose and reducing
cardiovascular risk factors for patients with diabetes. Exercise lowers
blood glucose levels by increasing the uptake of glucose and
improving the utilization of insulin.

18. Review exercise precautions for patients taking insulin.

Hypoglycemia may occur hours after exercise, stressing the patient’s
need to eat a snack at the end of the exercise session.

19. Provide instructions to patients using self-monitoring blood

glucose (SMBG).
Frequent SMBG is another important factor in diabetes management.
When patients know their SMBG results, they can adjust their
treatment regimen and obtain optimal blood glucose control.
Additionally, SMBG helps motivate patients to continue their
treatment. It can also help in monitoring the effectiveness of exercise,
diet, and oral antidiabetic agents.

20. Observe and review the patient’s technique in self-monitoring

blood glucose (SMBG).
Determines if there are errors in SMBG due to incorrect technique
(e.g., blood drop too small, improper cleaning and maintenance,
improper application of blood, damage to reagent strips). The patient
may obtain erroneous blood glucose values when using incorrect
techniques in SMBG. Additionally, the patient should compare their
device’s result with lab-measured blood glucose levels to determine
the validity of the device’s reading.
21. For patients using insulin pumps, educate the patient on the
importance of maintaining its patency.
The needle or tubing in an insulin pump may become occluded (from
battery drainage or depletion of insulin), which may increase the
patient’s risk for DKA.

Deficient Knowledge
The focus of diabetes education should be patient empowerment to
address changes in health behavior and self-care. Providing complete
information and proper education to patients with diabetes can
dramatically increase adherence to the treatment regimen.

May be related to
Unfamiliarity with insulin injection
Dietary modifications
Exercise for normoglycemia
Unfamiliarity with information
Interpretation
May be evidenced by
Requests of information
Statements of concern
Inadequate follow-through of instructions
Development of preventable complications
Desired outcomes
Before discharge, patient will demonstrate knowledge of insulin
injection, symptoms, and treatment of hypoglycemia and diet.

Nursing Assessment and Rationales

1. Assess the patient’s and family’s readiness to learn before initiating

an education plan.
Patients who are recently diagnosed with diabetes often go through
various stages of the grieving process. Provide reassurance to the
patient and family that these feelings are normal.

2. Assess the patient’s fears and major concerns about diabetes.

Encourage the patient to discuss feelings and fears related to
complications of diabetes. Providing simple and direct information
can help clear out any misconceptions about diabetes that may
contribute to their anxiety.

3. Assess the patient’s social situation for factors that may affect
diabetes treatment and education plan.
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.

4. 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.

5. Verify that the patient understands and demonstrates the

technique and timing of home monitoring of glucose.
Monitoring provides data on the degree of glucose control and
identifies the need for changes in insulin dosage.

Nursing Interventions and Rationales

1. Explain that long-acting insulin (Lantus) only need to be injected

once or twice daily.
Long-acting insulin does not have a peak of action. Insulin glargine is
effective for over 24 hours.

2. Explain that regular prandial insulins (Humulin) should be injected

30 mins before meals. Rapid-acting insulins (Novolog, Humalog) may
be injected before or after eating.
Dosage may be adjusted based on the amount of food ingested
because rapid-acting insulins can be given after a meal.
3. Explain that insulin dosages may need to be adjusted.
Insulin dosage should be reduced when fasting for surgery, when not
eating, or when hypoglycemia occurs. Illness or infection may
increase insulin requirements.

4. Teach the patient to rotate insulin injection sites.

Systematic rotation of injection sites is recommended to prevent
lipodystrophy.

5. Explain the importance of inserting the needle perpendicular to the

skin.
A 90-degree angle is the best insertion angle because this ensures
deep subcutaneous administration of insulin. An injection that is too
deep or too shallow may affect the rate of absorption of the insulin.

6. Use various tools to complement teaching and maintain flexibility

about the teaching method.
In using various teaching materials, make sure that they match the
patient’s learning needs, language, and reading level. Tip: Use the
free resources from the American Diabetes Association (ADA) to
complement or outline your diabetes teaching plan.

7. Teach the patient to follow a low in simple sugars, low in fat, and
high in fiber and whole grains.
A diet low in fat and high in fiber helps to control cholesterol and
triglycerides. Three daily meals and an evening snack are
recommended. Refined and simple sugars should be reduced, and
complex carbohydrates, such as cereals, rice should be increased.

8. Teach the patient and/or SO to recognize the signs of

hypoglycemia.
Signs include shakiness, sweating, nervousness, weakness, hunger,
changes in LOC. Hypoglycemia occurs when the blood glucose levels
drop to less than 60 mg/dL. Explain that hypoglycemia occurs when
too much insulin, too little food, too much oral hypoglycemic agents,
or excessive physical activity.
9. Teach the patient to treat hypoglycemia with crackers, a snack, or
glucagon injection.
Hypoglycemia should be treated with a carbohydrate snack (15g from
a fast-acting source). Examples include fruit juice, soda, hard candies,
teaspoons of sugar, or commercially prepared glucose tablets. If the
patient is unconscious, glucagon should be given IM or SQ by a
caregiver.

10. Teach the patient the proper disposal of syringes and needles.
Insulin syringes, lancets, pens, and needles should be disposed of
according to local regulations. Used sharps should be placed in a
puncture-resistant container.

11. Provide written information about diabetes management for the

patient to refer to.
Reinforces learning and conveys the maximum amount of
information.

Risk for 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.

Risk factors may include

Inadequate glycemic control
Diabetic microangiopathy
High glucose levels
Decreased or impaired leukocyte function
Alterations in circulation
Preexisting respiratory infection
UTI
Recurrent vaginitis
Anatomical and functional abnormalities of the urinary tract
Desired Outcomes
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques, lifestyle changes to prevent development of
infection.

Nursing Assessment and Rationales

1. 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.

2. Auscultate breath sounds.

Rhonchi may indicate accumulation of secretions possibly related to
pneumonia or bronchitis. Crackles may result from pulmonary
congestion or edema from rapid fluid replacement, or heart failure.

Nursing Interventions and Rationales

1. Teach and promote good hand hygiene.
Hand hygiene is the single most effective way to prevent the
transmission of diseases. Include the patient’s SO in teaching.

2. 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.

3. 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.
4. 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.

5. Place in semi-Fowler’s position.

Facilitates lung expansion; reduces the risk of aspiration.

6. Encourage coughing or deep breathing if the patient is alert and

cooperative. Frequent repositioning is also recommended.
Helps in the ventilation of all lung areas and mobilizing secretions –
stasis of secretions can increase the risk of infection.

7. Provide tissues and trash bags in a convenient location for sputum

and other secretions. Instruct patient in the proper handling of
secretions.
To help minimize the spread of infection.

8. Encourage and assist with oral hygiene.

Reduces risk of oral/gum disease.

9. Encourage an increase in fluid intake unless contraindicated.

Encourage intake of cranberry juice per day as appropriate.
Increase fluid intake to approximately 3,000 mL per day to increase
urinary flow and prevent stasis of urine, increasing susceptibility to
infection (i.e., urinary tract infection). Regular intake of cranberry
juice can help inhibit the adhesion of pathogens to the bladder wall
and impair colonization.

10. Administer antibiotics as indicated.

Early treatment may help prevent sepsis as patients with diabetes are
more prone to serious infectious diseases.

11. 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.

Risk for Disturbed Sensory Perception

Patients taking insulin or oral hypoglycemic agents are at risk for the
development of hypoglycemia. Too little food or excessive physical
activity also exacerbates this complication. Change in blood glucose
levels alters the level of consciousness and impairs the function of the
CNS.

Risk factors may include

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

Desired Outcomes
Maintain usual level of mentation.
Recognize and compensate for existing sensory impairments.

Nursing Assessment and Rationales

1. Maintain blood glucose levels within the normal range.
CNS changes occur when blood glucose levels are altered due to
hypoglycemia. Hypoglycemia results primarily from the mismatch
between insulin intake (including patients treated with oral
hypoglycemic agents), excessive physical activity, and carbohydrate
activity.

2. Monitor vital signs and mental status.

To provide a baseline from which to compare abnormal findings.

3. Call the patient by name, reorient as needed to place, person, and

time. Give short explanations, speak slowly and enunciate clearly.
Decreases confusion and helps maintain contact with reality.

4. Schedule and cluster nursing time and interventions.

To provide uninterrupted rest periods and promote restful sleep,
minimize fatigue and improve cognition.
5. Keep the patient’s routine as consistent as possible. Encourage
participation in activities of daily living (ADLs) as able.
Helps keep the patient in touch with reality and maintain orientation
to the environment.

6. 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.

7. Evaluate visual acuity as indicated.

Retinal edema or detachment, hemorrhage, presence of cataracts, or
temporary paralysis of extraocular muscles may impair vision,
requiring corrective therapy and/or supportive care.

8. Observe and investigate reports of hyperesthesia, pain, or sensory

loss in the feet or legs. Investigate and look for ulcers, reddened
areas, pressure points, loss of pedal pulses.
Peripheral neuropathies may result in severe discomfort, lack of or
distortion of tactile sensation, potentiating the risk of dermal injury
and impaired balance.

9. Monitor laboratory values: blood glucose, serum osmolality,

Hb/Hct, BUN/Cr.
Imbalances can impair mentation. Note: If the fluid is replaced too
quickly, excess water may enter brain cells and cause alteration in the
level of consciousness (water intoxication).

Nursing Interventions and Rationales

1. Provide bed cradle. Keep hands and feet warm, avoiding exposure
to cool drafts and/or hot water or use of a heating pad.
Reduces discomfort and potential for dermal injury.

2. Assist patient with ambulation or position changes.

Promotes patient safety, especially when the sense of balance is
affected.

3. Carry out the prescribed regimen for correcting DKA as indicated.

Alteration in thought processes or potential for seizure activity is
usually alleviated once the hyperosmolar state is corrected.

Powerlessness

Patients newly diagnosed with diabetes may feel like they have no
control over their situation (powerlessness). 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.

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 Assessment and Rationales

1. 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.

Nursing Interventions and Rationales

2. Acknowledge the normality of feelings.
Recognition that reactions are normal can help patients problem-
solve and seek help as needed. Diabetic control is a full-time job that
serves as a constant reminder of disease and threat to a patient’s
health.

3. 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.

4. Encourage patient and SO to express feelings about hospitalization

and disease in general.
Identifies concerns and facilitates problem-solving

5. 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.
6. Determine whether a change in relationship with SO has occurred.
Constant energy and thought required for diabetic control often shift
the focus of a relationship. The development of psychological
concerns affecting self-concept may add further stress.

7. Encourage the patient to make decisions related to care:

ambulation, schedule for activities, and so forth.
Communicates to the patient that some control can be exercised over
care.

8. Support participation in self-care and give positive feedback for

efforts.
Promotes a feeling of control over the situation.

Risk for Ineffective Therapeutic Regimen Management

It is the nurse’s responsibility to investigate the reasons for the
patient’s ineffective management of the therapeutic regimen when
problems related to impaired glucose control and/or the
development of preventable complications of diabetes occur.

Risk factors
New-onset diabetes
Lack of knowledge about diabetes and its management
Complex medical regimen
Desired Outcomes
Patient will demonstrates knowledge of diabetes self-care measures.
Patient will verbalize understanding of the diabetes diseases process
and potential complications.
Patient will correctly perform necessary procedures and explain
reasons for the actions.

Nursing Assessment and Rationale

1. Investigate the patient’s prior efforts to manage the diabetes care
regimen.
It can provide an important starting point in understanding any
patient’s complexities or difficulties in his diabetes management
regimen. The patient may report experiences of being overwhelmed
by attempts to manage medications, diet, exercise, blood glucose
monitoring, and other measures to prevent complications.

2. Evaluate the patient’s self-management skills, including performing

procedures for blood glucose monitoring.
Self-management skills determine the amount and type of education
that needs to be provided.

3. Identify factors that may negatively affect success with following

the regimen.
Limited vision may impair the patient’s ability to prepare and
administer insulin accurately. Limited mobility and the loss of fine
motor control can interfere with the skills needed for insulin
administration and blood glucose monitoring. Additionally, limited
joint mobility or preexisting disability may impair the patient’s ability
to inspect the bottom of the feet.

4. Assess the patient’s financial resources for health care.

The cost of medication and supplies for blood glucose monitoring
may become barriers to the patient with limited financial resources.

Nursing Interventions and Rationale

1. Provide a simple explanation of the treatment regimen.
Information on diabetes management can be overwhelming and may
be difficult to follow for some patients.

2. Provide positive reinforcement of changed self-care behaviors.

Instead of focusing on neglected health behaviors, providing positive
reinforcement helps motivate the patient to continue the treatment
regimen. Avoid the use of fear or scare techniques to modify the
patient’s health or lifestyle behaviors.

3. Determine and ensure the patient’s knowledge about the

symptoms, causes, treatment, and prevention of hyperglycemia.
Elevated blood glucose levels in patients with previously diagnosed
diabetes indicate the need to evaluate diabetes management.

Risk for Injury

Neurological effects, sensory deficits, and impairment in mobility
from complications of diabetes are factors that affect the patient’s
risk for injury. Neuropathies alter the patient’s sensation, muscle
control, and gait. Visual deficits from retinopathy or cataracts greatly
put the patient at risk for injury. Hyperglycemia can alter the lenses of
the eye and result in blurred vision. Additionally, blood glucose levels
can change the patient’s level of consciousness and may cause
seizures, such as severe hypoglycemia.

Nursing Diagnosis: Risk for Injury

Risk Factors
Hyperglycemia
Hypoglycemia
Peripheral sensory neuropathy
Autonomic neuropathy
Immune system deficit
Vascular insufficiency
Blurred vision
Cataracts
Decreased tactile sensitivity
Desired Outcomes
Patient is free of injury.

Nursing Assessment and Rationale

1. Assess for the presence of contributing factors that increase the
risk for injury.
To provide baseline data necessary in developing individualized care.
Injury risk increases with the number of factors identified.

2. Assess the general appearance of the foot.

Foot lesions and associated wound infections are the most common
reason for hospitalization of the patient with DM. The patient’s feet
should be meticulously inspected at every visit. The patient may be
unaware of injuries to the feet due to decreased sensation from
peripheral neuropathy. Impaired vision from DM may decrease the
ability to inspect the feet.

3. Assess the status of the nails.

Fungal infections in nails serve as a portal of entry for bacteria. The
patient with diabetes has an increased risk for infection because of
impaired immunity. Patients with thickened or deformed nails should
be referred for treatment.

4. Assess the patient’s skin integrity.

Autonomic neuropathy leads to decreased perspiration, causing
excessive dryness and fissuring of the skin. Skin breakdown
predisposes the patient to infection.

5. Note the presence of callus formation or corns.

Pressure over bony prominences leads to callus formation; may lead
to the development of skin breakdown.

6. Assess for evidence of infection.

Infection may be the initiating event for eventual amputation.
Symptoms of pain and tenderness may be absent because of
neuropathy. Look for redness, drainage, and swelling.

7. Monitor for signs of ketone accumulation and DKA.

Ketones are byproducts of fat breakdown and accumulate in the
blood and urine. Ketones detected in urine mean insulin is deficient.
When this process continues, the risk of DKA increases. The body
then starts to break down stored fat for energy.

8. Assess for edema.

Edema is a major predisposing factor to ulceration. Autonomic
neuropathy results in the loss of vasomotor reflexes and swelling in
the foot.

Nursing Interventions and Rationale

1. Instruct the patient in the hygiene principle: wash the feet daily in
warm water using mild soap; avoid soaking the feet. Dry carefully and
gently, especially between toes. Use moisturizing lotion at least once
daily. Avoid the area between the toes.
Maceration between the toes predisposes the patient to infection.
The use of lotion replaces the moisturizing effects lost by autonomic
neuropathy. The patient should select a lotion with a low alcohol
content to prevent drying.

2. Instruct the patient to inspect the feet daily for cuts, scratches, and
blisters. A mirror may be necessary to assess the bottom of the foot.
Instruct to use both visual inspection and touch.
All surfaces of the foot need to be examined, including the skin
between toes. Touch will identify skin surface alterations that are not
evident by sight.

3. Teach the patient to inspect the shoes daily by feeling the inside of
the shoe for irregularities or sharp objects.
Reduces the risk of injury to the foot.

4. Instruct the patient always to wear protective footwear; never go

barefoot.
Keeping the feet covered to prevent injuries to the foot.

5. Instruct the patient to trim nails straight across and to file sharp
corners to match the contour of the toe.
It helps avoid injury to the toes when self-care cannot be provided.

6. Instruct the patient to wear clean, well-fitting stockings made from

soft cotton, synthetic blend, or wool.
Soft cotton or wool absorbs moisture from perspiration and
discourages an environment in which fungus can thrive.
7. Perform urine ketone testing, as indicated.
For patients with type 1 diabetes presenting with persistent
glycosuria and hyperglycemia, urine ketone testing should be
initiated.

Imbalanced Nutrition: Less Than Body Requirements

Nutrition plays an important role in the management and treatment
of diabetes. Diabetes requires a balance between the intake of
nutrients, expenditure of energy, and timing and dose of insulin or
oral antidiabetic agents.

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 Assessment and Interventions

1. Weigh daily or as ordered.
Weighing serves as an assessment tool to determine the adequacy of
nutritional intake.

2. Ascertain the patient’s dietary program and usual pattern, then

compare with recent intake.
Identifies deficits and deviations from therapeutic needs to reinforce
teaching and provide positive feedback.

3. Ascertain understanding of individual nutritional needs.

To determine what information to be provided to the client or SO.

4. Discuss eating habits and encourage a diabetic diet (balanced diet)

as prescribed by the doctor.
To achieve the health needs of the patient with the proper food diet
for his condition.

5. Review the patient’s diet history.

To help identify the patient’s eating habits and lifestyle that could be
incorporated into the meal plan. Consider the patient’s food
preferences, eating times, food values, special needs, ethnic and
cultural backgrounds. Explore the patient’s need for weight
management (weight loss, weight gain, or weight maintenance).

6. Review meal plan with the client that focuses on the recommended
distribution of calories from carbohydrates, fats, proteins, and other
sources.

6.1. 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.
6.2. 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.
6.3. 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.
Note: Protein intake should be reduced in patients with early signs of
renal disease.
6.4. 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.
7. Document, actual weight, do not estimate. Note total daily intake,
including patterns and time of eating.
Patients may be unaware of their actual weight or weight loss due to
the estimation of weight.

8. Auscultate bowel sounds. Note reports of abdominal pain, bloating,

nausea, vomiting of undigested food. Maintain NPO status as
indicated.
Hyperglycemia and fluid and electrolyte disturbances can decrease
gastric motility and/or function (due to distention or ileus), affecting
the 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.

Nursing Interventions and Rationales

1. Review the carbohydrate counting method with the patient.
Carbohydrate counting involves counting the number of grams of
carbohydrate in a meal and matching that to your dose of insulin.
Detailed information on carbohydrate counting can be found here.

2. Educate the patient on the dangers of consumption of alcohol with

diabetes mellitus.
Note that moderation is recommended in alcohol consumption.
Similar alcohol consumption precautions by people without diabetes
apply to people with diabetes. When consumed, alcohol is absorbed
first before other nutrients. Consuming large amounts can be
converted to fats, increasing the risk for DKA. Alcohol may also impair
the body’s production of glucose that can lead to hypoglycemia.
Additionally, excessive alcohol intake may impair the patient’s ability
to recognize signs and symptoms of hypoglycemia.

3. Provide liquids containing nutrients and electrolytes as soon as the

patient can tolerate oral fluids, then progress to a portion of more
solid food as tolerated.
The oral route is preferred when the patient is alert, and bowel
function is restored.

4. Identify food preferences, including ethnic and cultural needs.

If the patient’s food preferences can be incorporated into the meal
plan, cooperation with dietary requirements may be facilitated after
discharge.

5. Include SO in meal planning as indicated.

To promote a sense of involvement and provide information to the
SO to understand the patient’s nutritional needs. Note: Various
methods available or dietary planning include exchange list, point
system, glycemic index, or pre-selected menus.

6. Observe for signs of hypoglycemia: changes in LOC, cold and

clammy skin, rapid pulse, hunger, irritability, anxiety, headache,
lightheadedness, shakiness.
Hypoglycemia can occur once blood glucose level is reduced,
carbohydrate metabolism resumes, and insulin is given. If the patient
is comatose, hypoglycemia may occur without a notable change in
LOC. This potentially life-threatening emergency should be assessed
and treated quickly per protocol. Note: People with type 1 diabetes
long-standing may not display usual signs of hypoglycemia because
the normal response to low blood sugar may be diminished.
7. Perform fingerstick glucose testing.
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 a 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.

8. Administer regular insulin by intermittent or continuous IV method:

IV bolus followed by a continuous drip via the pump of approximately
5–10 U/hr so that glucose is reduced by 50 mg/dL/hr.
Regular insulin has a rapid onset and thus quickly helps move glucose
into cells. The IV route is the initial route of choice because
absorption from subcutaneous tissues may be erratic. Many believe
the continuous method is the optimal way to facilitate the transition
to carbohydrate metabolism and reduce the incidence of
hypoglycemia.

9. Administer glucose solutions: dextrose and half-normal saline.

Glucose solutions may be added after insulin and fluids have brought
the blood glucose to approximately 400 mg/dL. As carbohydrate
metabolism approaches normal, care must be taken to avoid
hypoglycemia.

10. Provide a diet of approximately 60% carbohydrates, 20% proteins,

20% fats in the designated number of meals and snacks.
Complex carbohydrates (apples, broccoli, peas, dried beans, 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
responses. Note: A snack at bedtime of complex carbohydrates is
significant (if insulin is given in divided doses) to prevent
hypoglycemia during sleep and potential Somogyi response.

11. Administer other medications as indicated: metoclopramide

(Reglan); tetracycline.
It may be useful in treating symptoms related to autonomic
neuropathies affecting the GI tract, thus enhancing oral intake and
absorption of nutrients.

12. Instruct the patient to exercise regularly:

Refer the patient to an exercise physiologist, physical therapist, or

cardiac rehabilitation nurse for specific exercise instructions.
Specific exercises can be prescribed based on any physical limitations
the diabetic patient may have.
Instruct to do warm-ups and cool-downs for at least 30 to 60 minutes.
Warm-ups and stretching helps prevent muscle injury.
Instruct patient in the methods to maintain hydration and avoid
hypoglycemia during exercise.
Dehydration can hasten hypoglycemia, especially in hot weather.
Patients may need to add a snack before exercising if they experience
hypoglycemia.

13. Consult a dietician and/or physician for further assessment and

recommendation regarding food preferences and nutritional support.
To reveal changes that should be made in the client’s dietary intake.
For greater understanding and further assessment of specific foods.
Risk for Fluid Volume Deficit
Hyperglycemia leads to excessive urination and excessive thirst in an
attempt of the body to rid excess glucose, water, and electrolytes,
putting the patient at risk for fluid volume deficit.

Nursing Diagnosis: Risk for Fluid Volume Deficit

Risk factors
Polyuria
Osmotic diuresis (from hyperglycemia)
Excessive gastric losses: diarrhea, vomiting
Restricted intake: nausea, confusion
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 Assessment and Rationale

1. Assess the patient’s history related to duration or intensity of

symptoms such as vomiting, excessive urination.
Assists in the estimation of total volume depletion. Symptoms may
have been present for varying amounts of time (hours to days). The
presence of the infectious process results in fever and
hypermetabolic state, increasing insensible fluid losses.

2. Monitor vital signs:

Note orthostatic BP changes.

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.
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.
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.
Although fever, chills, and diaphoresis are common with infectious
process, fever with flushed, dry skin and decreased skin turgor may
reflect dehydration.
3. Assess peripheral pulses, capillary refill, and mucous membranes.
Indicators of the level of hydration, adequacy of circulating volume.

4. Monitor I&O and note urine-specific gravity.

Provides an ongoing estimate of volume replacement needs, kidney
function, and effectiveness of therapy.

5. Weigh daily.
Provides the best assessment of current fluid status and adequacy of
fluid replacement.

Nursing Interventions and Rationale

1. Maintain fluid intake of at least 2500 mL/day within cardiac
tolerance when oral intake is resumed.
Maintains hydration and circulating volume.

2. Promote a comfortable environment—cover patient with light

sheets.
Avoids overheating, which could promote further fluid loss.

3. Investigate changes in mentation and level of consciousness.

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 a patient to aspiration.

4. Insert and maintain indwelling urinary catheter, as necessary.

Provides accurate ongoing measurement of urinary output, especially
if autonomic neuropathies result in the neurogenic bladder (urinary
retention/overflow incontinence). It may be removed when the
patient is stable to reduce the risk of infection.

Fatigue
Fatigue is a common complaint distressing people with diabetes and
can likely affect their daily activities and self-care towards diabetes
management and treatment.
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 Assessment and Interventions
1. Assess response and tolerance to activity.
Response to an activity can be evaluated to achieve the desired level
of tolerance.

2. Assess muscle strength of the patient and functional level of

activity.
To determine the level of activity.

3. Monitor pulse, respiration rate, and blood pressure before and

after activity.
Indicates physiological levels of activity tolerance. Tolerance develops
by adjusting frequency, duration, and intensity until the desired level
is achieved.

Nursing Interventions and Interventions

1. Discuss with the patient the need for activity. Plan schedule with
the patient and identify activities that lead to fatigue.
Education may motivate to increase activity level even though the
patient may feel too weak initially.

2. Alternate activity with periods of rest and uninterrupted sleep.

To prevent excessive fatigue.

3. Discuss ways of conserving energy while bathing, transferring, and

so on.
The patient will be able to accomplish more with a decreased
expenditure of energy.

4. Increase patient participation in ADLs as tolerated.

Increases confidence level, self-esteem, and tolerance level.

5. Discuss with the patient the need for activity.

Education may motivate to increase activity level even though the
patient may feel too weak initially.

6. Alternate activity with periods of rest or uninterrupted sleep.

Prevents excessive fatigue. Indicates physiological levels of tolerance.

7. Perform activities slowly with frequent rest periods.

Interventions should be directed at delaying the onset of fatigue and
optimizing muscle efficiency.

8. Promote energy conservation techniques by discussing conserving

energy while bathing, transferring, and performing ADLs.
Symptoms of fatigue are alleviated with rest. Also, the patient will be
able to accomplish more with a decreased expenditure of energy.

9. Provide adequate ventilation.

For proper oxygenation.

10. Instruct the patient to perform deep breathing exercises.

Helps promote relaxation.

11. Provide comfort and safety measures.

To be free from injury during activity.

12. Administer oxygen as ordered.

To provide proper ventilation.
Risk for Impaired Skin Integrity
Neuropathies from diabetes complications can result in decreased or
absent sensation, ultimately putting the patient at risk of altered skin
integrity.

Risk factors
Decreased circulation and sensation caused by peripheral neuropathy
and arterial obstruction.
Diabetic neuropathies
Desired outcomes
Patient’s skin on legs and feet remains intact while the patient is
hospitalized.
Patient will demonstrate proper foot care.

Nursing Assessment and Rationales

1. Conduct thorough baseline and ongoing assessment of the
following:

(1) lesions, fissures, dryness, blisters, redness, cellulitis, or gangrene

of the lower extremities;
(2) musculoskeletal assessment of the foot, ankle, joint of range
motion, bone abnormalities;
(3) neurological assessment including sensations of touch, pain, and
temperature;
(4) vascular examination of the lower extremities, the temperature of
the skin, lesions, capillary refill;
(5) and hydration status.
Peripheral neuropathies put people with diabetes at greater risk of
lower extremity gangrene due to alterations in the perception of
pain, pressure, and temperature. Lesions on the skin, dryness,
hydration of the skin can potentiate infections and delayed healing.

2. Assess the integrity of the skin. Assess knee and deep tendon
reflexes and proprioception.
These are assessments for neuropathy. The skin on lower extremity
pressure points is at great risk for ulceration.

3. Inspect feet daily for erythema or trauma.

These are signs that the skin needs preventive care.

Nursing Interventions and Rationales

1. Use a foot cradle on the bed. Use space boots on ulcerated heels,
elbow protectors, and pressure-relief mattresses.
To prevent pressure on pressure-sensitive points.

2. Wash feet daily with mild soap and warm water. Check the water
temperature before immersing feet in the water.
Decreased sensation increases the risk for burns and dermal injury.

3. Change socks or stockings daily. Encourage the patient to wear

white cotton socks.
To prevent infection from moisture. The white fabric enables easy
visualization of blood or exudates.

4. Use gentle moisturizers on the feet.

Moisturizers soften and lubricate dry skin, preventing skin cracking.

5. Cut toenails straight across after softening toenails with a bath.

This action prevents ingrown toenails, which could cause infection.

6. The patient should not walk barefoot.

This is a high risk for trauma and may result in ulceration and
infection.

7. Implement and teach foot hygiene by washing the feet daily with
lukewarm water and mild soap.
Proper foot hygiene can significantly reduce the chance of infection.

8. Reinforce that all cuts and blisters need to be cleaned and treated
with an antiseptic preparation.
Prompt wound treatment helps prevent infection. If the wound
appears infected, encourage the patient to notify the primary health
care provider immediately.

9. Instruct the patient to avoid very hot baths.

Patients with peripheral neuropathy are at risk for burn injury due to
a decrease in temperature sensation.

10. Discuss the need for smoking cessation if applicable.

Smoking can cause vasoconstriction that can impair blood supply to
the feet.

Assignment

Drug calculations, Sliding scale in surgical ICU.

REFERENCES

•Hinkle, J.L., Cheever, K.H. (2014).Management of patients with

Endocrine Disorders. Wolters Kluver publication.

 https://nurseslabs.com/diabetes-mellitus/