Diabetes Mellitus Nursing Care

 

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

Possibly evidenced by

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

Risk factors may include

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

Possibly evidenced by

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

May be related to

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

Possibly evidenced by

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

May be related to

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

Possibly evidenced by

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

May be related to

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

Possibly evidenced by

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

Possibly evidenced by

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

Monitor vital signs: 

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

May be related to

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

Possibly evidenced by

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

Possibly evidenced by

  • Elevated temperature
  • Increased urine output
  • Sweating
  • Thirst
  • Exhaustion
  • Weight loss
  • Dry skin and/or mucous membrane
Desired outcomes
  • Patient will verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications.
  • Patient will improve or maintain fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane, and stable vital signs.
Nursing Interventions
  • Establish rapport
    • Rationale: Friendly and trusting relationship with patient and to be able to understand each other’s concern.
  • Take and record vital signs.
    • Rationale: To obtain baseline data.
  • Monitor the temperature.
    • Rationale: To monitor changes in temperature.
  • Assess skin turgor and mucous membranes for signs of dehydration.
    • Rationale: Dry mucous membranes are signs of dehydration.
  • Monitor intake and output
    • Rationale: To assess for signs of dehydration.
  • Encourage patient to increase fluid intake as tolerated.
    • Rationale: To replace fluid loss and prevent dehydration.
  • Administer IVF as ordered.
    • Rationale: To replace lost electrolytes and fluids.
Nursing Diagnosis
  • Imbalanced Nutrition: less than body requirement r/t insulin deficiency

Possibly evidenced by

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

Risk factors

  • Chronic hyperglycemia
  • Neurogenic bladder
  • Peripheral vascular disease

Possibly evidenced by

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

Risk factors

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

Possibly evidenced by

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