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12+ Diabetes Mellitus Nursing Care Plans
Diabetes mellitus (DM) is a chronic disease characterized by insufficient production of insulin in the pancreas or when the body cannot efficiently use the insulin it produces. This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is characterized by disturbances in carbohydrate, protein, and fat metabolism.
Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.
Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose and decrease complications using insulin replacement, balanced diet, and exercise. The nurse should stress the importance of complying with the prescribed treatment program. Tailor your teaching to the patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control on long-term health.
Here are 13 nursing care plans (NCP) and nursing diagnoses for diabetes mellitus (DM):
1. Risk for Unstable Blood Glucose
Risk for Unstable Blood Glucose: At risk for variation of blood glucose levels from the normal range that may compromise health.
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
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 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%.
| Nursing Interventions | Rationale |
|---|---|
| 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 results in increased thirst, hunger, and increased urination. The patient may also report nonspecific symptoms of fatigue and blurred vision. |
| Assess blood glucose level before meals and at bedtime. | Blood glucose should be between 140 to 180 mg/dL. Non-intensive care patients should be maintained at pre-meal levels <140 mg/dL. |
| Monitor 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. |
| Assess for anxiety, tremors, and slurring of speech. Treat hypoglycemia with 50% dextrose. | These are signs of hypoglycemia and D50 is treatment for it. |
| Assess feet for temperature, pulses, color, and sensation. | To monitor peripheral perfusion and neuropathy. |
| Assess the patient’s current knowledge and understanding about the prescribed diet. | Nonadherence to dietary guidelines can result in hyperglycemia. An individualized diet plan is recommended. |
| Assess the pattern of physical activity. | Physical activity helps lower blood glucose levels. Regular exercise is a core part of diabetes management and reduces risk for cardiovascular complications. |
| Monitor for signs of hypoglycemia. | A patient with type 2 DM 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 are the result of both increased adrenergic activity and decreased glucose delivery to the brain, therefore, the patient may experienced tachycardia, diaphoresis, dizziness, headache, fatigue, and visual changes. |
| Administer basal and prandial insulin. | Adherence to the therapeutic regimen promotes tissue perfusion. Keeping glucose in the normal range slows progression of microvascular disease. |
| Teach patient how to perform home glucose monitoring. | Blood glucose is monitored before meals and at bedtime. Glucose values are used to adjust insulin doses. |
| 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. |
| Instruct patient to avoid heating pads and always to wear shoes when walking. | Patients have decreased sensation in the extremities due to peripheral neuropathy. |
| 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. |
| Instruct patient to take oral hypoglycemic medications as directed: | |
| Stimulates insulin secretion by the pancreas. They also enhance cell receptor sensitivity to insulin and decrease the liver synthesis of glucose from amino acids and stored glycogen. |
| Stimulates insulin secretion by the pancreas. |
| These drugs decrease the amount of glucose produced by the liver and improve insulin sensitivity. They enhance muscle cell receptor sensitivity to insulin. |
| Stimulates rapid insulin secretion to reduce the increases in blood glucose that occur soon after eating. |
| Delays the absorption of glucose into the blood from the intestine. |
| Drugs decrease insulin resistance in peripheral tissues. |
| Increases insulin secretion and decreases glucagon secretion. |
| Instruct patient to take insulin as directed | |
| 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. |
| Has an onset of action within 30 minutes of administration; duration of action is 4 to 8 hours. |
| Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours. |
| Premixed concentration has an onset of action similar to that of rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin. |
| Have an onset of one hour after administration. Duration of action is 36 hours for Ultralente is 36 hours and for glargine is at least 24 hours. |
| Instruct the patient on the proper preparation and administration of insulin. | |
| Absorption of insulin is more consistent when insulin is always injected in the same anatomical site. Absorption if 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. |
| Injection of insulin in the same site over time will result in lipoatrophy and lipohypertrophy with reduced insulin absorption. |
| Insulin should be refrigerated at 2º to 8º C (36º to 46º F). Unopened vials may be stored until their expiration date. 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. |
2. Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- - Unfamiliarity with insulin injection
- - Dietary modifications
- - Exercise for normoglycemia
- - Unfamiliarity with information
- - Interpretation
Possibly 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 Interventions | Rationale |
|---|---|
| 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 over 24 hours. |
| 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 actual amount of food ingested because rapid acting insulins can be given after a meal. |
| 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. |
| Teach patient to rotate insulin injection sites. | Multiple injections in the same site may cause fat deposits. |
| Explain the importance of inserting the needle perpendicular to the skin. | This ensures deep subcutaneous administration of insulin. |
| 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 the insulin dosage. |
| Teach patient to follow a diet that is 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 is recommended. Refined and simple sugars should be reduced, and complex carbohydrates, such as cereals, rice, should be increased. |
| Teach patient that anxiety, tremors, and slurred speech are signs of hypoglycemia. | These are indicators of hypoglycemia, which causes seizures, coma, and death. |
| Teach patient to treat hypoglycemia with crackers, a snack, or glucagon injection. | Hypoglycemia should be treated with a carbohydrate snack. If the patient is unconscious, glucagon should be given IM by a caregiver. |
3. Risk for Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Nursing Diagnosis
- - Risk for Infection
Risk factors may include
- - High glucose levels, decreased leukocyte function, alterations in circulation
- - Preexisting respiratory infection, or UTI
Possibly evidenced by
- [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]
Desired Outcomes
- - Identify interventions to prevent/reduce risk of infection.
- - Demonstrate techniques, lifestyle changes to prevent development of infection.
| Nursing Interventions | Rationale |
|---|---|
| Observe for the signs of infection and inflammation: fever, flushed appearance, wound drainage, purulent sputum, cloudy urine. | Patients with DM may be admitted with infection, which could have precipitated the ketoacidotic state. They may also develop nosocomial infection. |
| Teach and promote good hand hygiene. | Reduces risk of cross-contamination. |
| Maintain asepsis during IV insertion, administration of medications, and providing wound or site care. Rotate IV sites as indicated. | Increased glucose in the blood creates an excellent medium for bacteria to thrive. |
| Provide catheter or perineal care. Teach female patients to clean from front to back after elimination. | Minimizes risk of UTI. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract and/or vaginal yeast infections. |
| Provide meticulous skin care: gently massage bony areas, keep skin dry. Keep linens dry and wrinkle-free. | Peripheral circulation may be ineffective or impaired, placing the patient at increased risk for skin breakdown and infection. |
| Auscultate breath sounds. | Rhonchi may indicate accumulation of secretions possibly related to pneumonia or bronchitis. Crackles may results from pulmonary congestion or edema from rapid fluid replacement or heart failure. |
| Place in semi-Fowler’s position. | Facilitates lung expansion; reduces risk of aspiration. |
| Reposition and encourage coughing or deep breathing if patient is alert and cooperative. Otherwise, suction airway using sterile technique as needed. | Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection. |
| Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in proper handling of secretions. | To minimizes spread of infection. |
| Encourage and assist with oral hygiene. | Reduces risk of oral/gum disease. |
| Encourage adequate dietary and fluid intake (approximately 3000 mL/day if not contraindicated by cardiac or renal dysfunction), including 8 oz of cranberry juice per day as appropriate. | Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity, reducing bacteria growth and flushing organisms out of system. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall, reducing the risk of recurrent UTI. |
| Administer antibiotics as appropriate. | Early treatment may help prevent sepsis. |
4. Risk for Disturbed Sensory Perception
Risk for Disturbed Sensory Perception: At risk for change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
Nursing Diagnosis
- - Risk for Disturbed Sensory Perception
Risk factors may include
- - Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance
Possibly evidenced by
- [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.]
Desired Outcomes
- - Maintain usual level of mentation.
- - Recognize and compensate for existing sensory impairments.
| Nursing Interventions | Rationale |
|---|---|
| Monitor vital signs and mental status. | To provide baseline from which to compare abnormal findings. |
| Call the patient by name, reorient as needed to place, person, and time. Give short explanations, speak slowly and enunciate clearly. | Decreases confusion and helps maintain contact with reality. |
| Schedule and cluster nursing time and interventions. | To provide uninterrupted rest periods and promote restful sleep, minimize fatigue and improve cognition. |
| Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. | Helps keep patient in touch with reality and maintain orientation to the environment. |
| Protect patient from injury by avoiding or limiting the use of restraints as necessary when LOC is impaired. Place bed in low position and pad bed rails if patient is prone to seizures. | Disoriented patients are prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration, and falls. |
| Evaluate visual acuity as indicated. | Retinal edema or detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care. |
| Observe and investigate reports of hyperesthesia, pain, or sensory loss in the feet or legs. Investigate and look for ulcers, reddened areas, pressure points, loss of pedal pulses. | Peripheral neuropathies may result in severe discomfort, lack of or distortion of tactile sensation, potentiating risk of dermal injury and impaired balance. |
| Provide bed cradle. Keep hands and feet warm, avoiding exposure to cool drafts and/or hot water or use of heating pad. | Reduces discomfort and potential for dermal injury. |
| Assist patient with ambulation or position changes. | Promotes patient safety, especially when sense of balance is affected. |
| Monitor laboratory values: blood glucose, serum osmolality, Hb/Hct, BUN/Cr. | Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication). |
| Carry out prescribed regimen for correcting DKA as indicated. | Alteration in thought processes or potential for seizure activity is usually alleviated once hyperosmolar state is corrected. |
5. Powerlessness
Powerlessness: The lived experience of lack of control over a situation, including a perception that one’s actions do not significantly affect an outcome.
Nursing Diagnosis
- - Powerlessness
May be related to
- - Long-term/progressive illness that is not curable
- - Dependence on others
Possibly evidenced by
- - Reluctance to express true feelings; expressions of having no control/influence over situation
- - Apathy, withdrawal, anger
- - Does not monitor progress, nonparticipation in care/decision making
- - Depression over physical deterioration/complications despite patient cooperation with regimen
Desired Outcomes
- - Acknowledge feelings of helplessness.
- - Identify healthy ways to deal with feelings.
- - Assist in planning own care and independently take responsibility for self-care activities.
| Nursing Interventions | Rationale |
|---|---|
| Encourage patient and/or SO to express feelings about hospitalization and disease in general. | Identifies concerns and facilitates problem solving. |
| Acknowledge normality of feelings. | Recognition that reactions are normal can help patient problem-solve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health. |
| Assess how patient has handled problems in the past. Identify locus of control. | Knowledge of individual’s style helps determine needs for treatment goals. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors. |
| Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful to patient. | Enhances sense of being involved and gives SO a chance to problem-solve solutions to help patient prevent recurrence. |
| Ascertain expectations and/or goals of patient and SO. | Unrealistic expectations or pressure from others or self may result in feelings of frustration and loss of control. These can impair coping abilities. |
| Determine whether a change in relationship with SO has occurred. | Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns affecting self-concept may add further stress. |
| Encourage patient to make decisions related to care: ambulation, schedule for activities, and so forth. | Communicates to patient that some control can be exercised over care. |
| Support participation in self-care and give positive feedback for efforts. | Promotes feeling of control over situation. |
6. Risk for Ineffective Therapeutic Regimen Management
Ineffective Therapeutic Regimen Management: At risk for pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals
Risk factors
- - New-onset diabetes
- - Lack of knowledge about diabetes and its management
- - Complex medical regimen
Desired Outcomes
- - Patient demonstrates knowledge of diabetes self-care measures
| Nursing Interventions | Rationale |
|---|---|
| Investigate the patient’s prior efforts to manage the diabetes care regimen. | Can provide an important starting point in understanding any complexities or difficulties the patient perceived 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. |
| Evaluate the patient’s self-management skills, including the ability to perform procedures for blood glucose monitoring. | Self-management skills determine the amount and type of education that needs to be provided. |
| Assess for 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 skills needed for insulin administration and blood glucose monitoring. |
| Assess the patien’s financial resource for health care. | Cost of medication and supplies for blood glucose monitoring may become barriers to the patient with limited financial resources. |
| Determine and ensure that 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. |
7. Risk for Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Risk Factors
- - Hyperglycemia
- - Peripheral sensory neuropathy
- - Autonomic neuropathy
- - Immune system deficit
- - Vascular insufficiency
Desired Outcomes
- - Patient is free of injury to feet.
| Nursing Interventions | Rationale |
|---|---|
| Assess the general appearance of the foot. | Foot lesions and associated wound infections are teh 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 as a result of decreased sensation from peripheral neuropathy. Impaired vision from DM may decrease the ability to inspect the feet. |
| 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. |
| 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. |
| Note the presence of callus formation or corns. | Pressure over bony prominences lead to callus formation; may lead to the development of skin breakdown. |
| Assess for evidence of infection. | Infection may be the initiating even for eventual amputation. Symptoms of pain and tenderness may be absent because of neuropathy. Look for redness, drainage, and swelling. |
| 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. |
| Instruct the patient in the principle of hygiene: 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 low alcohol content to prevent drying. |
| 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. |
| Teach the patient to inspect the shoes daily by feeling the inside of the shoe for irregularities or sharp objects. | Reduces the risk for injury to the foot. |
| Instruct the patient to always wear protective footwear; never go barefoot. | Keeping the feet covered prevent injuries to the foot. |
| Instruct the patient to trim nails straight across and to file sharp corners to match the contour of the toe. | Helps avoid injury to the toes when self-care cannot be provided. |
| 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 enviroment in which fungus can thrive. |
8. Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.
Nursing Diagnosis
- - Imbalanced Nutrition: Less Than Body Requirements
May be related to
- - Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)
- - Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
- - Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process
Possibly evidenced by
- - Increased urinary output, dilute urine
- - Reported inadequate food intake, lack of interest in food
- - Recent weight loss; weakness, fatigue, poor muscle tone
- - Diarrhea
- - Increased ketones (end product of fat metabolism)
Desired Outcomes
- - Ingest appropriate amounts of calories/nutrients.
- - Display usual energy level.
- - Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
| Nursing Interventions | Rationale |
|---|---|
| Weigh daily or as ordered. | Weighing serves as an assessment tool to determine the adequacy of nutritional intake. |
| Ascertain patient’s dietary program and usual pattern then compare with recent intake. | Identifies deficits and deviations from therapeutic needs. |
| Ascertain understanding of individual nutritional needs. | 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. | 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. | 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. | To reveal changes that should be made in the client’s dietary intake. For greater understanding and further assessment of specific foods. |
| Auscultate bowel sounds. Note reports of abdominal pain, bloating, nausea, vomiting of undigested food. Maintain NPO status as indicated. | Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility and/or function (due to distention or ileus) affecting choice of interventions. Note: Chronic difficulties with decreased gastric emptying time and poor intestinal motility may suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment. |
| Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. | Oral route is preferred when patient is alert and bowel function is restored. |
| Identify food preferences, including ethnic and cultural needs. | If patient’s food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge. |
| Include SO in meal planning as indicated. | To promote sense of involvement and provide information to the SO to understand the nutritional needs of the patient. Note: Various methods available or dietary planning include exchange list, point system, glycemic index, or pre selected menus. |
| Observe for signs of hypoglycemia: changes in LOC, cold and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. | Hypoglycemia can occur once blood glucose level is reduced and carbohydrate metabolism resumes and insulin is being given. If the patient is comatose, hypoglycemia may occur without notable change in LOC. This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished. |
| Perform fingerstick glucose testing. | Beside analysis of serum glucose is more accurate than monitoring urine sugar. Urine glucose is not sensitive enough to detect fluctuations in serum levels and can be affected by patient’s individual renal threshold or the presence of urinary retention. Note: Normal levels for fingerstick glucose testing may vary depending on how much the patient ate during his last meal. In general: 80–120 mg/dL (4.4–6.6 mmol/L) before meals or when waking up; 100–140 mg/dL (5.5–7.7 mmol/L) at bedtime. |
| Administer regular insulin by intermittent or continuous IV method: IV bolus followed by a continuous drip via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr. | Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia. |
| Administer glucose solutions: dextrose and half-normal saline. | Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia. |
| Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals and snacks. | Complex carbohydrates (apples, broccoli, peas, dried beads, carrots, peas, oats) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics and individual patient response. Note: A snack at bedtime of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. |
| Administer other medications as indicated: metoclopramide (Reglan); tetracycline. | May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients. |
| Instruct the patient to exercise regularly. | |
| Specific exercises can be prescribed based on any physical limitations the diabetic patient may have. |
| Warm-ups and stretching helps prevent muscle injury. |
| Dehydration can hasten hypoglycemia, especially in hot weather. Patients may need to add a snack before exercising if they experience hypoglycemia. |
9. Risk for Deficient Fluid Volume
Risk for Deficient Fluid Volume: At risk for decreased intravascular, interstitial, and intracellular fluid.
Nursing Diagnosis
- - Risk for Deficient Fluid Volume
Risk factors
- - 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.]
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 | Rationale |
|---|---|
| Assess patient’s history related to duration or intensity of symptoms such as vomiting, excessive urination. | 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: | |
| 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. |
| 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. |
| 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. |
| 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. | Indicators of level of hydration, adequacy of circulating volume. |
| Monitor I&O and note urine specific gravity. | Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. |
| Weigh daily. | 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. | Maintains hydration and circulating volume. |
| Promote comfortable environment. Cover patient with light sheets. | Avoids overheating, which could promote further fluid loss. |
| Investigate changes in mentation and LOC. | 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. | 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. |
10. Fatigue
Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level
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 | Rationale |
|---|---|
| Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue. | 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. | To prevent excessive fatigue. |
| Monitor pulse, respiratory rate, and BP before and after activity. | Indicates physiological levels of tolerance. |
| Discuss ways of conserving energy while bathing, transferring, and so on. | Patient will be able to accomplish more with a decreased expenditure of energy. |
| Increase patient participation in ADLs as tolerated. | Increases confidence level, self-esteem and tolerance level. |
| Assess response to activity. | Response to an activity can be evaluated to achieve desired level of tolerance. |
| Assess muscle strength of patient and functional level of activity. | To determine the level of activity. |
| Discuss with patient the need for activity. | Education may provide motivation to increase activity level even though patient may feel too weak initially. |
| Alternate activity with periods of rest or uninterrupted sleep. | Prevents excessive fatigue. Indicates physiological levels of tolerance. |
| Monitor pulse, respiration rate and blood pressure before and after activity. | Tolerance develops by adjusting frequency, duration and intensity until desired level is achieved. |
| Perform activities slowly with frequent rest periods. | Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. |
| Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and performing ADLs. | Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more with a decreased expenditure of energy. |
| Provide adequate ventilation. | For proper oxygenation. |
| Instruct patient to perform deep breathing exercises. | Helps promote relaxation. |
| Provide comfort and safety measures. | To be free from injury during activity. |
| Administer oxygen as ordered. | To provide proper ventilation. |
11. Risk for Impaired Skin Integrity
Risk for Impaired Skin Integrity: Altered epidermis and/or dermis.
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 | Rationale |
|---|---|
| Assess integrity of the skin. Assess knee and deep tendon reflexes and proprioception. | 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. | 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. | Decreased sensation increases the risk for burns. |
| Inspect feet daily for erythema or trauma. | These are signs that the skin needs preventive care. |
| Change socks or stockings daily. Encourage the patient to wear white cotton socks. | To prevent infection from moisture. White fabric enables easy visualization of blood or exudates. |
| Use gentle moisturizers on the feet. | Moisturizers soften and lubricate dry skin, preventing skin cracking. |
| Cut toenails straight across after softening toenails with a bath. | This action prevents ingrown toenails, which could cause infection. |
| The patient should not walk barefoot. | This is a high risk for trauma and may result in ulceration and infection. |
12. Other Possible Nursing Care Plans
Here are other possible diabetes mellitus nursing care plans:
- 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.
References and Sources : nurseslabs.com
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