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NURSING PROCESS: THE PATIENT NEWLY DIAGNOSED WITH DIABETES MELLITUS
The history and physical assessment focus on the signs and symp-toms of prolonged hyperglycemia and on physical, social, and emotional factors that may affect the patient’s ability to learn and perform diabetes self-care activities. The patient is asked to de-scribe symptoms that preceded the diagnosis of diabetes, such as polyuria, polydipsia, polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing ulcers. The blood glucose and, for patients with type 1 diabetes, urine ketone levels are measured.
Patients with type 1 diabetes are assessed for signs of DKA, in-cluding ketonuria, Kussmaul respirations, orthostatic hypoten-sion, and lethargy. The patient is questioned about symptoms of DKA, such as nausea, vomiting, and abdominal pain. Laboratory values are monitored for metabolic acidosis (ie, decreased pH and decreased bicarbonate level) and for electrolyte imbalance. Patients with type 2 diabetes are assessed for signs of HHNS, in-cluding hypotension, altered sensorium, seizures, and decreased skin turgor. Laboratory values are monitored for hyperosmolality and electrolyte imbalance.
If the patient exhibits signs and symptoms of DKA or HHNS, nursing care first focuses on treatment of these acute complica-tions, as outlined in previous sections. Once these complications are resolving, nursing care then focuses on long-term manage-ment of diabetes, as discussed in this section.
Then the patient is assessed for physical factors that may im-pair his or her ability to learn or perform self-care skills, such as:
• Visual deficits (the patient is asked to read numbers or words on the insulin syringe, menu, newspaper, or written teaching materials)
• Deficits in motor coordination (the patient is observed eating or performing other tasks or handling a syringe or finger-lancing device)
• Neurologic deficits (eg, due to stroke, other neurologic dis-orders; other disabling conditions) (from history in chart; the patient is assessed for aphasia or decreased ability to fol-low simple commands)
The nurse evaluates the patient’s social situation for factors that may influence the diabetes treatment and education plan, such as:
• Low literacy level (may be evaluated while assessing for visual deficits by having the patient read from teaching materials)
• Limited financial resources or lack of health insurance
• Presence or absence of family support
• Typical daily schedule (patient is asked about timing and number of usual daily meals, work and exercise schedule, plans for travel)
The patient’s emotional status is assessed by observing general demeanor (eg, withdrawn, anxious) and body language (eg, avoids eye contact). The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any mis-conceptions or misinformation regarding diabetes. Coping skills are assessed by asking how the patient has dealt with difficult situations in the past.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
• Risk for fluid volume deficit related to polyuria and dehy-dration
• Imbalanced nutrition related to imbalance of insulin, food, and physical activity
• Deficient knowledge about diabetes self-care skills/infor-mation
• Potential self-care deficit related to physical impairments or social factors
• Anxiety related to loss of control, fear of inability to man-age diabetes, misinformation related to diabetes, fear of di-abetes complications
Based on assessment data, potential complications may include:
• Fluid overload, pulmonary edema, heart failure
• Hyperglycemia and ketoacidosis
• Cerebral edema
The major goals for the patient may include maintenance of fluid and electrolyte balance, optimal control of blood glucose levels, reversal of weight loss, ability to perform survival diabetes skills and self-care activities, decreased anxiety, and absence of complications.
Intake and output are measured. IV fluids and electrolytes are administered as prescribed, and oral fluid intake is encouraged when it is permitted. Laboratory values of serum electrolytes (especially sodium and potassium) are monitored. Vital signs are monitored for signs of dehydration (tachycardia, orthostatic hypotension).
The diet is planned with the control of glucose as the primary goal. It must take into consideration the patient’s lifestyle, cul-tural background, activity level, and food preferences. An appro-priate caloric intake allows the patient to achieve and maintain the desired body weight. The patient is encouraged to eat full meals and snacks as prescribed per the diabetic diet. Arrange-ments are made with the dietitian for extra snacks before in-creased physical activity. It is important for the nurse to ensure that insulin orders are altered as needed for delays in eating be-cause of diagnostic and other procedures.
The nurse provides emotional support and sets aside time to talk with the patient who wishes to express feelings, cry, or ask ques-tions about this new diagnosis. Any misconceptions the patient or family may have regarding diabetes are dispelled (see Table 41-7). The patient and family are assisted to focus on learning self-care behaviors. The patient is encouraged to perform the skills that are feared most and must be reassured that once a skill such as self-injection or lancing a finger for glucose monitoring is performed for the first time, anxiety will decrease. Positive reinforcement is given for the self-care behaviors attempted, even if the technique is not yet completely mastered.
Patient teaching is the major strategy used to prepare the pa-tient for self-care. Special equipment may be needed for instruc-tion on diabetes survival skills, such as a magnifying glass for insulin preparation or an injection-aid device for insulin injec-tion. Low-literacy information and literature in other languages can be obtained from the ADA. The family is also taught so that they can assist in diabetes management by, for instance, prefill-ing syringes or monitoring the blood glucose level. The diabetes specialist is consulted regarding various blood glucose monitors and other equipment for use by patients with physical impair-ments. The patient is assisted in identifying community resources for education and supplies as needed. Other members of the health care team are informed about variations in the timing of meals and the work schedule (eg, if the patient works at night or in the evenings and sleeps during the day) so that the diabetes treatment regimen can be adjusted accordingly.
Fluid overload can occur because of the administration of a large volume of fluid at a rapid rate that is often required to treat the patient with DKA or HHNS. This risk is increased in elderly pa-tients and in those with preexisting cardiac disease. To avoid fluid overload and resulting congestive heart failure and pul-monary edema, the nurse monitors the patient closely during treatment by measuring vital signs at frequent intervals. Central venous pressure monitoring and hemodynamic monitoring may be initiated to provide additional measures of the fluid status. Physical examination focuses on assessment of cardiac rate and rhythm, breath sounds, venous distention, skin turgor, and urine output. The nurse monitors fluid intake and keeps careful records of IV and other fluid intake, along with urine output measurements.
As previously described, hypokalemia is a potential complication during the treatment of DKA as potassium is lost from body stores. Low serum potassium levels may result from rehydration, increased urinary excretion of potassium, and movement of potassium from the extracellular fluid into the cells with insulin administration. Prevention of hypokalemia includes cautious re-placement of potassium; before its administration, however, it is important to ensure that the patient’s kidneys are functioning. Because of the adverse effects of hypokalemia on cardiac function, monitoring of the cardiac rate, cardiac rhythm, electrocardio-gram, and serum potassium levels is essential.
Although the hyperglycemia and ketoacidosis that may have led to the new diagnosis of diabetes may be resolved, the patient is at risk for their subsequent recurrence. Therefore, blood glucose levels and urine ketones are monitored, and medications (insulin, oral antidiabetic agents) are administered as prescribed. The pa-tient is monitored for signs and symptoms of impending hyper-glycemia and ketoacidosis; if they occur, insulin and IV fluids are administered.
Hypoglycemia may occur if the patient skips or delays meals or does not follow the prescribed diet or greatly increases the amount of exercise without modifying diet and insulin. Also, the hospitalized patient or outpatient who fasts in preparation for di-agnostic testing is at risk for hypoglycemia. Juice or glucose tablets are used for treatment of hypoglycemia. The patient is en-couraged to eat full meals and snacks as prescribed per the dia-betic diet. If hypoglycemia is a recurrent problem, the total therapeutic regimen should be re-evaluated.
Because of the risk of hypoglycemia, especially with intensive insulin regimens, it is important for the nurse to review with the patient its signs and symptoms, possible causes, and measures to prevent and treat it. The nurse stresses to the patient and family the importance of having information on diabetes at home for reference.
Although the cause of cerebral edema is unknown, it is thought to be caused by rapid correction of hyperglycemia, resulting in fluid shifts. Cerebral edema can be prevented by gradual reduc-tion in the blood glucose level (ADA, Hyperglycemic Crises in Patients With Diabetes Mellitus, 2003). An hourly flow sheet is used to enable close monitoring of the blood glucose level, serum electrolyte levels, urine output, mental status, and neurologic signs. Precautions are taken to minimize activities that could in-crease intracranial pressure.
The patient is taught survival skills, including simple pathophys-iology; treatment modalities (insulin administration, monitoring of blood glucose, and, for type 1 diabetes, urine ketones, and diet); recognition, treatment, and prevention of acute complica-tions (hypoglycemia and hyperglycemia); and practical informa-tion (where to obtain supplies, when to call the physician). If the patient has signs of long-term diabetes complications at the time of diagnosis of diabetes, teaching about appropriate preventive behaviors (eg, foot care or eye care) should be included at this time (Chart 41-10).
Follow-up education is arranged with a home care nurse or an outpatient diabetes education center. This is particularly impor-tant for the patient who has had difficulty coping with the diag-nosis, the patient who has limitations that may affect his or her ability to learn or to carry out the management plan, or the patient without any family or social supports.
Referral to social services and community resources (eg, centers for the visually impaired) may be needed, depending on the patient’s financial circumstances and physical limitations. The importance of self-monitoring and of monitoring and follow-up by primary health care providers is reinforced, and the patient is reminded about the importance of keeping follow-up appointments. The patient who is newly diagnosed with diabetes is also reminded about the importance of participating in other health promotion activities and health screening. Chart 41-11 is a checklist of home care skills.
Expected patient outcomes may include:
• Achieves fluid and electrolyte balance
a) Demonstrates intake and output balance
b) Exhibits electrolyte values within normal limits
c) Exhibits vital signs that remain stable with resolution of orthostatic hypotension and tachycardia
• Achieves metabolic balance
a) Avoids extremes of glucose levels (hypoglycemia or hy-perglycemia)
b) Demonstrates rapid resolution of hypoglycemic episodes
c) Avoids further weight loss (if applicable) and begins to approach desired weight
• Demonstrates/verbalizes diabetes survival skills
a) Defines diabetes as a condition in which high blood glu-cose levels are present
b) States normal and target blood glucose ranges
c) Identifies factors that cause the blood glucose level to fall (insulin, exercise, some oral anti-diabetes medications)
d) Identifies factors that cause the blood glucose level to rise (food, illness, stress, and infections)
e) Describes the major treatment modalities: diet, exercise, monitoring, medication, education
f) Demonstrates proper technique for drawing up and in-jecting insulin (including mixing two types of insulin if necessary)
g) States dose and timing of injections, peak action, dura-tion, and adverse effects of insulin
h) Verbalizes plan for rotating insulin injection sites
i) States dose, timing, peak action, and duration of pre-scribed oral agents
j) Verbalizes understanding of food group classifications (depending on system used)
k) Verbalizes appropriate schedule for eating snacks and meals; orders appropriate foods on menus; identifies foods that may be substituted for one another on the meal plan
l) Demonstrates proper technique for monitoring blood glucose, including using finger-lancing device; obtain-ing a drop of blood; applying blood properly to strip; obtaining value of blood glucose; and recording blood glucose value. Also, is able to calibrate and clean meter, change batteries, identify alarms and warnings on meter, and use control solutions to validate strips.
m) Demonstrates proper technique for disposing of lancets and needles used for blood glucose monitoring and in-sulin injections (discarding them into hard plastic con-tainer such as empty bleach or detergent container or medical waste containers)
n) Demonstrates proper technique for urine ketone testing (for patients with type 1 diabetes) and verbalizes appro-priate times to assess for ketones (when ill or when blood glucose test results are repeatedly and inexplicably more than 250 to 300 mg/dL [13.8 to 16.6 mmol/L])
o) Identifies community, outpatient resources for obtain-ing further diabetes education
p) Identifies acute complications (hypoglycemia and hyper-glycemia)
q) Verbalizes symptoms of hypoglycemia (shakiness, sweat-ing, headache, hunger, numbness or tingling of lips or fingers, weakness, fatigue, difficulty concentrating, change of mood) and dangers of untreated hypo-glycemia (seizures and coma)
r) Identifies appropriate treatment of hypoglycemia, in-cluding 15 g simple carbohydrate (eg, two to four glu-cose tablets, 4 to 6 oz juice or soda, 2 to 3 teaspoons sugar, or 6 to 10 hard candies) followed by a snack of protein and carbohydrate (eg, cheese and crackers or milk) or by a regularly scheduled meal
s) States potential causes of hypoglycemia (too much in-sulin, delayed or decreased food intake, increased phys-ical activity) and verbalizes preventive behaviors, such as frequent monitoring of blood glucose when daily schedule is changed and eating a snack before exercise
t) Verbalizes importance of wearing medical identification and carrying a source of simple carbohydrate at all times
u) Verbalizes symptoms of prolonged hyperglycemia (in-creased thirst and urination)
v) Verbalizes rules for sick day management
w) Describes where to purchase and store insulin, syringes, and glucose monitoring supplies
x) Identifies appropriate circumstances for calling the physi-cian (when ill, when glucose levels repeatedly exceed a certain level [per physician guidelines], or when skin wounds fail to heal) and also identifies name of physi-cian (or other health care team member) and 24-hour phone number
• Absence of complications
a) Exhibits normal cardiac rate and rhythm and normal breath sounds
b) Exhibits jugular venous pressure and distention within normal limits
c) Exhibits blood glucose and urine ketone levels within normal limits
d) Exhibits no manifestations of hypoglycemia or hyper-glycemia
e) Shows improved mental status without signs of cerebral edema
f) States measures to prevent complications
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