Care Plan Nursing Diabetes Mellitus

CARE PLAN NURSING DIABETES MELLITUS DIABETES MELLITUS 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. Diabetes mellitus has a few types:  Type 1 diabetes is characterized by destruction of the pancreatic beta cells.  Types 2 diabetes involves insulin resistance and impaired insulin secretion.  Gestational diabetes mellitus is when a pregnant woman experiences any degree of glucose intolerance with the onset of pregnancy. Nursing Care Plans for Diabetes Mellitus 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 2. Deficient Knowledge 3. Risk for Infection 4. Risk for Disturbed Sensory Perception 5. Powerlessness 6. Risk for Ineffective Therapeutic Regimen Management 7. Risk for Injury 8. Imbalanced Nutrition: Less Than Body Requirements 9. Risk for Deficient Fluid Volume CARE PLAN NURSING DIABETES MELLITUS 10. Fatigue 11. Risk for Impaired Skin Integrity 12. Other Possible Nursing Care Plans Risk for Unstable Blood Glucose Nursing Diagnosis  Risk for Unstable Blood Glucose 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 Assess for signs of hyperglycemia. Rationale 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. CARE PLAN NURSING DIABETES MELLITUS Assess blood glucose levels 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 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. 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. 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 experience 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 the 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 CARE PLAN NURSING DIABETES MELLITUS 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:  Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta), glimepiride (Amaryl).  Meglitinides: repaglinide (Prandin)  Biguanides: metformin (Glucophage)  Phenylalanine derivatives: nateglinide (Starlix) Alpha-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset).  Thiazolidinediones: pioglitazone (Actos), rosiglitazone (Avandia)  Incretin modifier: sitagliptin phosphate (Januvia) Instruct patient to take insulin as directed  Rapid-acting insulin analogs: lispro insulin (Humalog), insulin aspart  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. 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 CARE PLAN NURSING DIABETES MELLITUS for aspart. Has an onset of action within 30 minutes of  Short-acting insulin: regular administration; duration of action is 4 to 8 hours.  Intermediate-acting insulin: neutral Onset of action for the intermediate-acting protamine Hagedorn (NPH), insulin zinc is one hour after administration; duration of suspension (Lente) action is 18 to 26 hours. Premixed concentration has an onset of  Intermediate and rapid: 70% NPH/30% action similar to that of a rapid-acting regular. insulin and a duration of action similar to that of intermediate-acting insulin. Have an onset of one hour after  Long-acting insulin: Ultralente, insulin administration. Duration of action is 36 glargine (Lantus) hours for Ultralente is 36 hours and glargine is at least 24 hours. Instruct the patient on the proper preparation and administration of insulin. The 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  Injection procedures. 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  Rotation of injection within one time will result in lipoatrophy and anatomical site. 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  Storage of insulin. 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.