Diabetes Mellitus: Nursing Diagnoses, Care Plans, Assessment & Interventions

Diabetes Mellitus (DM) is a chronic metabolic disorder in which the body is unable to process carbohydrates, fats, and proteins due to the ineffective use of insulin within the body. This results in high blood glucose levels in the bloodstream.

Types of Diabetes Mellitus

Type 1 diabetes is though to be due to an autoimmune reaction that destroys the insulin-producing beta cells in the pancreas. Genetics and viruses may also play a role. 

Type 2 diabetes develops over time. It is the result of the body’s inability to use the insulin it produces in a manner that allows for normal blood glucose levels.

Gestational Diabetes develops during pregnancy in individuals that otherwise have never been diagnosed with diabetes in the past. It typically resolves after the woman gives birth; however, it increases her risk of developing type 2 diabetes mellitus later in life.

Prediabetes is a stage in which blood glucose levels are higher than the normal range but not high enough to be classified as type 2 diabetes mellitus. Prediabetes is a fasting blood glucose level of 100-125 mg/dL.

Hypoglycemia

Hypoglycemia is the medical term describing low blood glucose and is measured at a value below 70 mg/dL. If this occurs, it needs to be treated immediately; otherwise, it could develop into a medical emergency.

Causes of Hypoglycemia

There are a variety of circumstances that could cause an individual’s blood glucose level to become low, including: taking too much insulin, not eating enough carbohydrates, timing of insulin administration, physical activity, alcohol, weather (hot/humid), puberty, or menstruation.

Hyperglycemia

Hyperglycemia is the medical term for high blood glucose levels and occurs due to too little insulin in the patient’s blood. Hyperglycemia is a fasting blood glucose level greater than 125 mg/dL or a blood glucose level of 180 mg/dL one to two hours after eating.

Causes of Hyperglycemia

Hyperglycemia can result from various factors, including diet choices, activity levels, illness, stress, steroid use, or incorrect use of diabetic medications (insulin or oral medications).

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to diabetes mellitus.

Review of Health History

1. Assess the patient’s general symptoms.

The following signs and symptoms can be associated with hypoglycemia: 

• Heart palpitations
• Shaking
• Sweating
• Nervousness/anxiousness
• Confusion
• Dizziness
• Hunger

Signs and symptoms that can indicate hyperglycemia include: 

• Frequent urination (polyuria)
• Increased thirst (polydipsia)
• Increased feeling of hunger (polyphagia)
• Blurred vision
• Burning, tingling, or numbness in lower extremities 
• Fatigue
• Headaches
• Balanitis (inflammation of the penis head) in men

Women with gestational diabetes may be asymptomatic. If symptoms do appear, they resemble hyperglycemia:

• Increased urination
• Increased hunger 
• Increased thirst
• Blurred vision
• Nausea and vomiting

2. Ask the patient about the duration of diabetes.
Ask the patient about the duration of their diabetes and what treatment they are currently receiving or have tried in the past. Long-term complications of diabetes are correlated with the control of their glucose levels.

3. Inquire about the patient’s age at diagnosis.
Diabetes type 1 can develop at any age. However, it frequently begins in childhood or adolescence. Diabetes type 2 is more prevalent and typically presents in adults over age 40.

4. Investigate the patient’s risk factors.

Non-modifiable factors of diabetes:

• Family history increases the risk of diabetes. Specific genetic mutations may cause maturity-onset diabetes of the young (MODY) and neonatal diabetes.
• Race raises the likelihood of type 2 diabetes. Black, Hispanic, American Indian, and Asian Americans are more at risk.
• Age increases the incidence of prediabetes and type 2 diabetes.
• Autoimmune diseases cause the body’s immune system to attack the insulin-producing cells in the pancreas, causing latent autoimmune diabetes in adults (LADA) and type 1 DM.
• Hormonal imbalances are caused by the inability of the pancreas to sustain enough insulin to overcome insulin resistance leading to gestational diabetes and type 2 diabetes. 

Modifiable risk factors of diabetes:

• Obesity and an unhealthy diet increase the risk of developing diabetes due to high fat, calories, and cholesterol. Overweight or obese patients are more likely to develop prediabetes, type 2 diabetes, and gestational diabetes.
• Smoking puts the patient at higher risk. Compared to non-smokers, cigarette smokers have a 30%–40% increased risk of type 2 diabetes. Smokers with diabetes are more prone than non-smokers to experience difficulties with insulin doses in managing their condition.
• Alcohol consumption that is excessive can make the body less sensitive to insulin, leading to type 2 diabetes.
• Physical activity lowers insulin resistance. A sedentary lifestyle increases the risk of prediabetes and type 2 diabetes.
• Chronic conditions like high blood pressure increase the risk of complications from diabetes, while hyperlipidemia increases the risk of type 2 diabetes.

5. Investigate if the patient has had a yeast infection.
Patients with diabetes frequently battle yeast infections. High glucose levels make it easy for yeast to proliferate. Excessive sugar in the blood leads to sugar in the urine (glycosuria), promoting yeast overgrowth.

6. Assess for present complications related to diabetes.
If left untreated or poorly managed, diabetes (type 1 and 2) can lead to other complications, including:

• Cardiovascular Disease: High blood glucose levels can damage blood vessels and nerves that affect the heart. This can result in hypertension and high cholesterol levels and puts the patient at risk of developing coronary artery disease, angina, myocardial infarction, and cerebrovascular accidents.
• Neuropathy: High blood glucose levels can also damage the walls of capillaries leading to nerve damage. It can cause tingling, numbness, or burning pain that begins in the extremities and causes poor balance, reduced sensations, and complications like wounds and limb amputation.
• Renal Disease: Diabetes can also damage the small vessels in the body’s filtering system, causing kidney damage that, if severe, can become permanent and require dialysis or a kidney transplant.
• Retinopathy: Diabetes can damage the blood vessels in the eyes, resulting in diabetic retinopathy. Individuals diagnosed with diabetes are at higher risk of developing glaucoma or cataracts. If left untreated, it can eventually lead to blindness.
• Foot Damage: This is common due to the nerve damage previously mentioned and poor blood circulation in the feet. It can ultimately lead to foot ulcers that heal slowly and increase the patient’s risk of infection.
• Depression: This is also common due to the complexity of managing diabetes. Depression can lead to additional stress, which can further challenge the management of blood glucose levels.

7. Ask the patient for records of blood glucose monitoring.
Patients with DM have home glucose monitoring devices that can reveal the past results of glucose testing to reveal hyper- and hypoglycemic trends.

Physical Assessment

Patients with well-controlled diabetes may not present with physical symptoms.

1. Monitor the blood pressure and respiratory rate. 
Hypertension is prevalent in patients with diabetes. Orthostatic hypotension may occur in people with autonomic neuropathy and established diabetes. Kussmaul respirations are rapid, deep breaths indicative of diabetic ketoacidosis (DKA). 

2. Palpate the lower extremity pulses.
Palpating for and recording the dorsalis pedis and posterior tibialis pulses is essential, as diabetes may contribute to vascular compromise.

3. Perform a foot assessment.
Because diminished sensitivity restricts the patient’s ability to protect the feet and lower legs, it is helpful to document lower-extremity sensory neuropathy in patients with foot ulcers. The Semmes Weinstein monofilament test can be used to measure this, as well as reflex testing, and vibration perception.

4. Assess weight gain. 
With type 1 diabetes, there isn’t enough insulin to move glucose into the cells, causing high glucose in the blood. The kidneys attempt to rid the body of this excess glucose, which can cause dehydration and weight loss. Most patients with type 2 diabetes are overweight or obese at diagnosis, as these are risk factors for the disease. Weight gain can make it even harder to control glucose levels. 

Diagnostic Procedures

1. Collect blood for glucose testing.
The diagnosis of DM is commonly based on history and blood glucose levels.

Type 1 DM:

• Fasting glucose greater than 126 mg/dL
• Random glucose above 200 mg/dL
• Hemoglobin A1C of 6.5% or greater

Type 2 DM:

• Fasting glucose levels 
• HbA1c testing 

Borderline:

• A glucose tolerance test can assess fasting glucose levels and serum response to an oral glucose tolerance test (OGTT)

Prediabetes:

• Fasting blood sugar (FBS) level of 100 to 125 mg/dL
• 2-hour post-oral glucose tolerance test (post-OGTT) glucose level of 140 to 200 mg/dL

Gestational diabetes:

• All pregnant patients undergo screening between 24 and 28 weeks of gestation. 
  • 1-hour fasting glucose challenge test to check for gestational diabetes
  • 3-hour fasting glucose challenge test to confirm a diagnosis if blood glucose levels are over 140 mg/dL initially. 

2. Monitor other lab results.
Testing for the following can detect DM complications earlier:

• Urine albumin detects early diabetic nephropathy in type 1 DM.
• Serum lipid monitoring is advised at diagnosis since patients with diabetes are also at risk for cardiovascular disease. 
• Thyroid level testing is advised once a year due to a higher prevalence of hypothyroidism.

Nursing Interventions

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with diabetes mellitus.

Control Glycemia

1. Encourage patient adherence.
Participation of patients is essential for management. Encourage the patient to adhere to follow-up appointments with all specialists, especially the provider that manages their diabetes, which may be a primary care provider or endocrinologist. Lifestyle choices can significantly impact the level of diabetes control that patients can achieve. It is vital to continue to emphasize diet and exercise adherence throughout therapy. 

2. Educate the patient.
Education on diabetes is critical. Inform the patients about their treatment options. Patients who understand how diet, stress, medications, and exercise affect their glucose levels can make informed choices. Consider a referral to a diabetes nurse educator for patients who require individualized education.

3. Teach the patient to use a home glucose monitoring device.
The treatment plan may require patients to check and record their blood sugar up to four times daily. Accurate home glucose monitoring can guarantee that their glucose levels stay within an optimal range.

Note: A continuous glucose monitor is an option, especially for children and those with an insulin pump. It uses a sensor under the skin to take blood sugar readings every few minutes and transmits the information to a smart device.

4. Maintain ideal glucose levels.
Maintain HbA1c under 7% and blood sugar levels between 90 and 130 mg/dL. Long-term glucose control is the best way to prevent complications.

5. Expect some differences in treatment for type 1 and 2 DM.
Depending on the kind of diabetes patients have, the treatment plan may include oral medications, insulin, and blood sugar monitoring.

Type 1 DM treatments:

• Insulin injections 
• Use of an insulin pump
• Routine blood sugar monitoring
• Carbohydrate counting
• Islet cell or a pancreas transplant 

Type 2 DM treatments:

• Dietary and lifestyle modifications
• Blood sugar monitoring
• Oral diabetic medications
• Insulin

6. Ask the patient to demonstrate proper insulin administration.
Proper insulin management is essential for patients to regulate their glucose levels. Various insulin types are available, such as short-acting (regular), rapid-acting, long-acting, and intermediate options. The nurse is vital in instructing on properly drawing up insulin for injection or using an insulin pen and assessing return demonstrations.

7. Assist with wearable insulin pumps.
The insulin pump is a small, externally worn device around the size of a compact telephone. A catheter implanted beneath the abdomen’s skin is connected by a tube to the insulin reservoir. Wireless pumps are also available and are attached to the skin. Pumps deliver fast-acting insulin frequently and can be adjusted to deliver a bolus following meals. 

8. Consider closed-loop insulin delivery.
Another name for closed-loop insulin delivery is an artificial pancreas. The implanted gadget connects an insulin pump to a continuous glucose monitor, which measures blood sugar levels every five minutes. The device automatically administers the appropriate dosage when the monitor shows that more insulin is required.

9. Educate on oral diabetes medications.
Patients with type 2 diabetes, prediabetes, and gestational diabetes benefit the most from oral diabetic medications. In patients with diabetes who still produce some insulin, oral medications regulate glucose levels. There are many types, including:

• Alpha-glucosidase inhibitors prevent the digestive system’s metabolism of starches and some types of sugar. 
• Biguanides (metformin) reduce the amount of glucose the liver makes and distributes into the bloodstream.
• Bile acid sequestrants (BASs) decrease cholesterol, which may also aid in lowering blood sugar levels.
• Dopamine-2 agonists restore the hypothalamic circadian rhythm, which obesity impairs. The circadian rhythm reset reduces the generation of glucose in the liver and aids in reversing insulin resistance.
• DPP-4 inhibitors (gliptins) stop the body from breaking down GLP-1.
• Meglitinides (glinides) stimulate the pancreas to secrete insulin. 
• SGLT2 inhibitors force excess glucose from the body through the urine.
• Sulfonylureas induces the pancreas to release more insulin.
• Thiazolidinediones (TZDs) increase the sensitivity of muscle and fat tissue to insulin.

10. Discuss a pancreas transplant for type 1 DM.
A pancreas transplant is typically reserved for those who cannot control their diabetes or who also require a kidney transplant. If a pancreas transplant is successful, insulin therapy would be unnecessary. However, transplants carry significant risks, and immunosuppressants must be taken continuously to prevent organ rejection. 

11. Assist the patient in meal planning.
Diabetes requires adhering to a diabetic diet; reducing carbohydrates, processed foods, and sugar. The patient may need education on how carbohydrates (pasta, bread, rice) become glucose once digested. Instruct on increasing fruits, vegetables, lean proteins, and whole grains. These are nutrient-dense foods with a high fiber content and are lower in fat and calories. Involve the patient in creating a meal plan to increase commitment to the recommended diet.

12. Refer to a nutritionist or dietitian.
Learning what to eat and how much to consume might take time and effort. The patient can develop a meal plan that suits their lifestyle, food preferences, and health goals with the guidance of a registered nutritionist or dietitian. For type 1 diabetes or those requiring insulin as part of their treatment, a nutritionist or dietitian will educate them about carbohydrate counting.

13. Promote physical activities.
The blood glucose level is lowered by exercise by allowing sugar to enter the cells, where it is converted to energy. The body becomes more insulin-sensitive during exercise, so less insulin is required by the body to deliver sugar to the cells. At least 150 minutes of moderate physical activity per week or 30 minutes or more of moderate activity most days of the week is recommended. Advise the patient to get permission to exercise from the healthcare provider first.

14. Maintain an ideal weight.
For patients with type 2 DM or prediabetes with an overweight status, even a 7% weight loss will help the patient control their blood sugar levels.

15. Manage blood sugar levels during pregnancy.
Gestational diabetes treatment may include blood sugar monitoring, oral hypoglycemic agents, or insulin. Throughout labor, monitor the blood sugar levels. The baby may produce a lot of insulin in response to maternal blood sugar levels, causing low fetal blood sugar soon after delivery.

16. Prevent the development of diabetes.
Healthy lifestyle choices are part of the treatment for prediabetes. Restore normal blood sugar levels by maintaining a healthy weight with exercise and a balanced diet. Some people with prediabetes and heart disease may benefit from medications like metformin, statins, and antihypertensives.

17. Refer the patient to a diabetologist or endocrinologist.
Endocrinologists identify, manage, and treat conditions affecting the endocrine glands and their hormones, including the adrenals, pancreas, pituitary, parathyroid, thyroid, ovaries, and testicles. Endocrinologists who specialize in treating DM are known as diabetologists. 

Prevent Complications

1. Advise the patient to wear a medical alert ID.
A diabetic medical ID gives emergency personnel vital details about the patient’s medical history if the patient is unresponsive, such as with DKA or hypoglycemia events.

2. Refer the patient to an ophthalmologist.
Refer the patient to an eye specialist (opthalmologist). The ophthalmologist will look for symptoms of retinal damage (retinopathy), cataracts, and glaucoma caused by complications from diabetes.

3. Promote up-to-date vaccinations.
The immune system may be weakened by high blood sugar. Advise the patient in getting vaccines as recommended. 

4. Emphasize the need for regular foot care and exams.
Advise the patient or a family member to inspect the feet daily for any redness, swelling, cuts, blisters, or sores. Use lukewarm water to wash the feet daily. Dry thoroughly between the toes and avoid applying lotion between the toes. Patients with difficulty trimming their toenails or neuropathy should receive regular podiatry visits. 

5. Manage blood pressure and cholesterol levels.
Regular exercise, a healthy diet, and medications can help lower cholesterol and blood pressure to prevent the development of atherosclerosis and vascular diseases, which are further complicated by diabetes.

6. Enlighten the patient about mouth care.
The chance of severe gum infections may increase in diabetes. Advise the patient to floss and brush their teeth at least twice daily and plan routine dental exams. 

7. Encourage smoking cessation.
The chance of developing various diabetic problems rises when smoking. Compared to non-smokers with diabetes, smokers with diabetes are more likely to die from cardiovascular disease.

8. Consume alcohol moderately.
Blood sugar levels can be raised or lowered by alcohol. The amount of drink and whether food is eaten simultaneously will determine the effect of alcohol. It is recommended to consume no more than two drinks daily for males, one for women, and always with meals.

9. Cope with stress appropriately.
Long-term stress may cause the body to produce hormones that interfere with insulin function. Glucose levels will increase, and the patient will feel even more stressed. Prioritize tasks and set limitations for yourself. Get plenty of rest and partake in stress-reducing activities.

10. Coordinate with a diabetes nurse educator.
Diabetes educators specialize in teaching people with diabetes how to manage their condition. The diabetes educator can educate those with diabetes and their family and caregivers on effectively managing DM.

11. Seek DSMES guidance.
Diabetes self-management education and support (DSMES) programs reduce hospital admissions and complications related to DM. DSMES programs improve health outcomes by increasing self-efficacy, coping, healthy eating, exercise, and quality of life.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for diabetes mellitus, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for diabetes mellitus.

References

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