Nursing Care Plan for Diabetes Mellitus (DM)

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Pathophysiology

Diabetes Mellitus is when blood glucose (sugar in the blood) is unable to move into the cells and help in the making of ATP…AKA energy. The body makes insulin to assist with this process. Insulin is a hormone that allows the sugar in the blood to move across the cell wall so the body can use to to produce ATP. There are two types of diabetes. Type I and Type II.

Type I is an autoimmune disorder where the cells attack the insulin producing cells in the pancreas. Thus the body is producing very little or no insulin leaving the sugar in the blood and the cells starve.

Type II is when the cells don’t respond to the insulin trying to get sugar into them, called insulin resistance. Thus the sugar stays in the blood and the cells starve.

Etiology

The cause for Type I diabetes is unknown, but hypothesized to be potentially genetic or triggered by a virus. The cause for Type II diabetes is caused by a storm of events culminating such as weight gain, lack of activity, genetics, and stress levels.

Desired Outcome

Blood sugar control with minimal side effects.

Diabetes Mellitus Nursing Care Plan

Subjective Data:

  • Hyperglycemia: BG >180 mg/dL
  • Polydipsia
  • Polyphagia
  • Polyuria
  • Blurred vision
  • Dry mouth
  • Increased tiredness
  • Leg pain
  • Nausea/Vomiting

Hypoglycemia: <70 mg/dL

  • Confusion
  • Weakness
  • Numbness around the mouth
  • Nervousness/Anxiety
  • Hungry
  • Headaches
  • Nightmares
  • Groggy

Objective Data:

Hyperglycemia:

  • -Hot and Dry, Sugar High.

Hypoglycemia:

  • -Cold and clammy give them some candy!
  • Sweaty
  • Tachycardia
  • Irritability
  • Slurring words

Nursing Interventions and Rationales

  • Blood sugar monitoring: Normal range 70-180 mg/dL *patient may have a different target blood sugar level, make sure to know what each patient’s target is.

 

  • The physician will make a target blood glucose level. Teach the patient that they need to monitor their blood glucose.They need to call their primary care physician if they have blood glucose levels higher than their target for multiple days or if they have 2 readings of greater than 300 mg/dL.
  • Teach the patient how to use their glucometer and record their results.

 

  • Insulin administration -Rapid Acting: Humalog Novolog -Fast/short Acting: Regular -Intermediate Action: NPH -Long Acting:’ Lantus Levemir

 

  • It is important to know which insulin to give and how they work. Each institution has guidelines and each insulin has guidelines. Following the guidelines, make sure you know the onset, peak and duration of each type of insulin.

-Rapid Acting
Onset: 10-30 minutes
Peak: 30 minutes- 3 hours
Duration: 3-5 hours

-Fast/short Acting
Onset: 30 minutes-1 hour
Peak: 2-5 hours
Duration: Up to 12 hours

-Intermediate Action
Onset:1.5-4 hours
Peak: 4-12 hours
Duration: Up to 24 hours

-Long Acting
Onset:1-4 hours
Peak: minimal peak
Duration: Up to 24 hours

  • To administer insulin, teach the patient to rotate injection sites and to clean the site with alcohol prior to inserting needle.

 

  • Educate about nutritional changes and monitoring

 

  • This would be a good time to get the dietician involved. The patient needs to learn at a minimum, how to count carbs and which foods to avoid such as beer.
  • A patient’s glucose should be checked once when the patient wakes up, before meals, and before going to bed.
  • If the patient is hypoglycemic, and they are able to eat or drink, give them some OJ and graham crackers with peanut butter.
  • Increase water intake if the patient has hyperglycemia

 

  • Monitor feet and educate about monitoring feet

 

  • Both decreased blood flow to the feet as well as neuropathy occur to make the feet something the patient really needs to watch. Wounds are hard to heal so if they are having a hard time feeling their feet and they become injured, the wounds will be worse than with someone without diabetes.
  • Teach the patient to check their feet everyday. Washing their feet, cutting their toenails straight across, and scrubbing off calluses gently are a couple of points to make with the patient.
  • The patient may have a podiatrist involved in their care as well.
  • As a nurse, you will need to be checking the patient’s feet as well and monitor any wounds.

 

  • Monitor Blood Pressure (BP) Normal Blood Pressure: 120/80 mmHg

 

  • It is vital to keep someone with diabetes within normal limits for their blood pressure.
  • Placing strain on the cardiovascular system wrecks havoc on other organ systems. Being diabetic makes the chances of that system having issues worse. A patient can lose their vision, kidney function, have a stroke or heart attack.

 

  • Educate about maintaining a healthy weight and keeping active

 

  • With a healthy weight, the patient is likely also implementing a healthy diet as well as implementing more movement. These three things (weight, diet, exercise) can help to manage or even reverse diabetes.
  • Healthy weights are calculated based on height and sex of the patient. Other ways to monitor the size of the patient is to use a BMI calculator or measure waist circumference.

 


References

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Video Transcript

All right, let’s work through an example Nursing Care Plan for a patient with Diabetes Mellitus. So again, we’re working through a hypothetical patient here and we’re just going to say that diabetes as a whole is the only problem they have. Okay. So what kind of data are we going to see on a patient who has diabetes? Well, the number one really obvious one is they’re going to have an increased BGL or blood glucose. So their sugars are going to be high, right? So we’re going to be hyperglycemic. You may actually, sometimes, depending on what’s going on, you may actually see hypoglycemia in a patient with diabetes, just depending, maybe they took too much insulin, right? So you’re going to see blood sugar issues. And then what are the other things? The three P’s, right? Your most classic signs of diabetes where you have polydipsia or excess thirst. You have polyphagia with a g, is excess hunger, or you have polyuria, which is excess urination. So most of these are subjective. You may actually be able to count their urine output to see the Polyuria, but most of those will be subjective. 

Let’s see. They’re going to have neuropathies, especially those who’ve had diabetes for quite a while, especially if they’re not very well controlled, they’re definitely going to have some neuropathies usually in their hands and feet. Now, speaking of control, how do we know whether or not they’re controlled? We look at their hemoglobin A1c, right? So if they’re poorly controlled, we might see a high hemoglobin A1c and then we also know because of these neuropathies and all the vascular issues, they may have some wounds or some also barriers. And if that’s the case and they’ve got some wounds and some authors, we’re going to see problems with healing, right?

We’re going to see slow wound healing. We might even see some wound infections, right? Just depending on what’s going on. So these are all things you might see with a patient. If you’ve got a patient who is leaning towards like a hypoglycemia, then of course you’ll have symptoms of that. If you have high blood sugar, then those are gonna be your three Ps. So there’s a lot of other little details that you might actually see with this patient in addition to the ones that are specific to diabetes. So let’s just go with these. This is our hypothetical patient. This is what they look like. They’ve got sugars all over the place. They’ve got an A1c that’s like 8.2 – really high. They’ve got all the three PS. And then of course if you’ve got a severe case, you might see some signs of DKA or HHNS just depending.

This is where we start to get into those complications, right? That if things get worse, then you start leaning into these more complicated processes. So we’ve got it all our data, we’ve picked out the relevant information, and now we’re gonna choose our problems and prioritize. So what is the problem for this patient? Well, we know that this patient is not able to appropriately regulate their blood glucose levels, right? They’re struggling to regulate their blood sugars appropriately. We know that they are at risk for skin problems, risk for wounds and ulcers and risk for poor wound healing and poor circulation. And the other thing that we know is that they’re at risk for fluid and electrolyte issues. We know that when they get that really, really high sugar they get hyperosmolar and their fluids will shift everywhere. They get cellular dehydration like crazy.

And then with that you start to see some potassium changes with their insulin. So definitely things that we need to be watching for for this patient because they’re showing this dehydration issue. So things that can be improved probably their fluid status, definitely their blood glucose levels, right? So priority, honestly for any patient with diabetes, their priority is going to be regulation of that blood glucose level. Because the high glucose was really what impacts everything else that goes on with this patient. Right? So we start asking our how questions so that we can plan, implement and evaluate. We start linking our data together so that we know what was the problem and how did I know it was a problem. Then we’re going to figure out how to address it. So what kinds of things are we going to do for this patient? Well, we definitely, we’ve already talked about it a bajillion times.

We’ve got to monitor that blood glucose level. We’re probably also going to give insulin. We’re going to give insulin as ordered cause we were really trying to control that sugar. Let’s see, what else are we going to monitor? We might monitor potassium levels. We might then replace potassium if necessary. Let’s say they got a lot of insulin. Their potassium level went really low. What else are we gonna monitor? We’re also gonna watch their feet, right? We’re going to do a skin assessment, watch their feet, watch their wounds, watch their ulcers, make sure that we know where they’re at. We’re going to do wound care if we need to for their skin. We’re also going to educate, right? We’re going to educate them on a diet. We’re going to educate them on wound care for their feet, and we’re going to educate them on how to handle their blood sugars depending on what’s going on, right?

So there’s all these things that we can do for this patient. We’re also going to monitor or assess for signs and symptoms of dehydration, or even you could say for DKA or HHS, because all of those things are going to be fluid related is what you’re going to see is that dehydration. So how do I know it gets better? Well, you always look back at your original data. How did I know it was a problem? Tells me how I’m going to know it got better. So my BGL is going to be regulated within a target, right? Cause you have a diabetic, you’re not necessarily looking for everyone to be less than a hundred. Maybe your target is less than 140. So whatever your target range is, you’re gonna try to get your sugar there. But that’s more of a short term, isn’t it? Right.

So long term we might look at their hemoglobin A1c this is going to tell me they have better overall regulation, wounds. We’re going to say my wounds heal, right? Without complication. What about the dehydration? We can literally just say no signs and symptoms of dehydration or even no signs and symptoms of DKA or HHS. So the thing that told us it was a problem is going to also be the thing that tells us that it gets better. So time to translate it. Let’s get these into these high level nursing concepts that we could really focus our priorities. So our number one thing here, we already said this is going to be our glucose regulation or our glucose metabolism. We’ve got to make sure that we’re taking care of that glucose.

The other thing we’ve talked about a lot is their skin, right?  So we want to make sure that they don’t get these wounds. We want to make sure if they have them that they heal. So this tissue and skin integrity becomes a big thing for your patients with diabetes. And then the other thing I think we’ve focused on a lot is our fluid and electrolyte balance. So we know they’re at high risk for cellular dehydration. We know they’re going to pee a lot. And so it was really, really important that we’re watching that fluid electrolyte balance. So time to transcribe. Let’s get this on paper. Top three priorities, glucose, metabolism, tissue, skin integrity, and fluid and electrolyte balance. Let’s look at these things. Let’s link everything together. What’s my problem and how do I know, what am I going to do about it and why? And how am I going to know it’s better? So Glucose metabolism, my three P’s, Polydipsia, polyuria, Polyphagia, those are telling me that I’m living with some pretty high blood sugars.

I’m also going to see those high blood sugars. Or again, sometimes you can see hypoglycemia, maybe they got too much insulin, right? And then we’re going to see that elevated hemoglobin A1c, remember this tells us how well we’re controlled over the last 90 days. Okay? So it’s kind of an average. So interventions, monitor your blood glucose levels, administer insulin as ordered. Remember when you’re writing a care plan, if it’s anything that has to do with medications, you typically want to write as prescribed or as ordered, right? And then we’re going to educate this patient on managing their sugars. So the reason why we need to do this, obviously we need to detect any changes. Sorry, this is supposed to be a triangle. So detect any changes and treat them early. So the sooner we can detect problems we can get them treated.

Insulin obviously is going to help us get control and educating the patient is so important because they’re going to be managing their blood sugars by themselves most of the time. So they need to know what to do. What do I do if my sugar’s too high? What do I do if my sugar is too low? So what outcomes are we going to look for? Again, we’re looking back at what, what told us that there was a problem and that’s what’s going to allow us to know whether or not it got better. So first thing on a short term level, we can say we have a blood glucose level that’s within target range. Again for diabetics, a lot of times we’re looking for something like less than 140, maybe less than 120. Usually we’re not trying to get them all the way down to 100. Right? We know they’re going to be a little bit higher. 

Long term. We want to see that hemoglobin A1c within target range. Now for most diabetics, if we can get them to around 6.5, we are super happy. Okay. So let’s look at tissue and skin integrity. Neuropathies. If I can’t feel my skin, I can’t feel my feet. I’m definitely at risk for getting these skin issues because I might get a tiny little ulceration and then it gets really, really bad because I had no idea it was even there. So again, wounds and ulcers that are going to be slow healing and giving us a lot of problems. So interventions and we’re going to monitor my feet, and any other wounds and ulcers I have and I’m going to educate that patient on foot care. So again, decreased sensation means there’s more likelihood for them to develop these wounds without even knowing.

And then they have slow wound healing and they’re high risk for infection. Bacteria love sugar, right? They love to consume the sugar. They love to be around the sugar. And so you get high sugar means lots of bacteria in these wounds. Poor circulation because of all the vascular issues means slow wound healing. So how am I going to know that it’s better? Well, short term, I can’t in one day completely heal a wound, right? But short term I can say, hey, my wounds not getting any worse, we’re not getting any worse. We’re not getting infected, which is a great sign. And long term I want to see those wounds heal without complication. So let’s look at fluid and electrolytes. So how do I know? Well signs of cellular dehydration are definitely gonna tell me I’ve got a fluid problem. Low Potassium, if they’re getting a lot of insulin and possibly even a high potassium if they’re acidotic.

So if we have this patient go into DKA, then that potassium is going to go really high. So either way, we need to watch my fluid and electrolyte balance. So I’m gonna Monitor that potassium level. I’m going to monitor for signs and symptoms of dehydration and signs and symptoms of things like DKA or HHNS. So why would monitor k? Well we just said potassium decreases with insulin and increases in acidosis and that cellular dehydration happens a lot if we have the hyperosmolarity from the hyperglycemia. So how do I know if it gets better? Well, my potassium levels are within normal limits and I have no signs and symptoms of dehydration. Super easy. What told us it was a problem is also what this is going to tell us it was better. 

So just a recap of the five steps for writing a care plan.  We’re going to collect all of our information and we’re going to analyze that information, determine what’s relevant, what tells us we have a problem and decide what our priorities are. We’re going to ask our how questions so we can plan, implement and determine how to evaluate. Again, remember evaluation is usually looking back at what told us we had a problem and seeing it fixed. We’re going to translate that. We’re going to get our concise terms. We’re going to make sure we know what our high level priorities are, and then we’re going to get it all on paper. We’re going to transcribe it, use whatever form or template you need to use, but just get it on paper so that you can communicate it well. All right guys, I hope that was helpful. Just a little review of a diabetic care plan. Again, your patient’s likely going to have more than just diabetes as their problem, so make sure you’re looking holistically and prioritizing their problems as a whole. All right. Make sure you check out all the rest of the examples in this course, as well as our nursing care plan library. Now go out and be your best self today and as always, happy nursing.

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