NURSING
PROCESS: THE PATIENT WITH DIABETES AS A SECONDARY DIAGNOSIS
People
with diabetes frequently seek medical attention for prob-lems not directly
related to blood glucose control. However, dur-ing the course of treatment for
the primary medical diagnosis, blood glucose control may worsen. In addition,
the only oppor-tunity for some patients with diabetes to update their knowledge
about diabetes self-care and prevention of complications is during
hospitalization. Therefore, it is important for the nurse caring for the
patient with diabetes to focus attention on diabetes, regard-less of the primary
problem. Further, control of blood glucose levels is important because
hyperglycemia impairs resistance to certain infections and impedes wound
healing.
Assessment
of the patient with diabetes with a primary problem such as cardiac disease, renal
disease, cerebrovascular disease, pe-ripheral vascular disease, surgery, or any
other type of illness is the same as that for a nondiabetic patient. In
addition to nursing assessment for the primary problem, assessment of the
patient with diabetes must also focus on hypoglycemia and hyperglycemia, skin
breakdown, and dia-betes self-care skills, including survival skills and
measures for prevention of long-term complications. In addition, the patient is
asked about use of alternative or complementary therapies; studies have
demonstrated that patients with diabetes are twice as likely as other patients
to use these therapies, and some may be harmful (Egede et al., 2002).
The
patient is assessed for hypoglycemia and hyperglycemia with frequent blood
glucose monitoring (usually prescribed be-fore meals and at bedtime) and with
monitoring for signs and symptoms of hypoglycemia or prolonged hyperglycemia
(includ-ing DKA or HHNS), as described in previous sections.
Careful
assessment of the skin, especially at pressure points and on the lower
extremities, is important. The skin is assessed for dryness, cracks, skin
breakdown, and redness. The patient is asked about symptoms of neuropathy, such
as tingling and pain or numbness of the feet. Deep tendon reflexes are
assessed.
Assessment
of diabetes self-care skills is performed as early as possible to determine
whether the patient requires further dia-betes teaching. The nurse observes the
patient preparing and in-jecting the insulin, monitoring blood glucose, and
performing foot care. (Simply questioning the patient about these skills
with-out actually observing performance of the skills is not sufficient.)
Knowledge about diet can be assessed with the help of the di-etitian through
direct questioning and review of patient choices on the menu. The patient is
questioned regarding signs, treat-ment, and prevention of hypoglycemia and
hyperglycemia. The patient’s knowledge of risk factors for macrovascular
disease, in-cluding hypertension, increased lipids, and smoking, is assessed.
The patient is asked the date of the last eye examination (in-cluding dilation
of the pupil). It is also important to assess the patient’s use of preventive
health measures: annual influenza vaccination (flu shot), date of last
pneumonia vaccine (ADA, Immunization and the Prevention of Influenza and
Pneumo-coccal Disease in People With Diabetes, 2003), daily dose of aspirin
(unless contraindicated) (ADA, Aspirin Therapy in Diabetes, 2003), and smoking
cessation (ADA, Smoking and Diabetes, 2003).
Based
on the assessment data, the patient’s major nursing diag-noses may include:
· Imbalanced nutrition
related to increase in stress hormones (caused by primary medical problem) and
imbalances in in-sulin, food, and physical activity
· Risk for impaired skin
integrity related to immobility and lack of sensation (caused by neuropathy)
· Deficient knowledge
about diabetes self-care skills (caused by lack of basic diabetes education or
lack of continuing in-depth diabetes education)
Based
on the assessment data, potential complications may include:
· Inadequate control of
blood glucose levels (hyperglycemia, hypoglycemia)
· DKA and HNNS
The
major goals for the patient may include improved nutritional status,
maintenance of skin integrity, ability to perform basic di-abetes self-care
skills as well as preventive care for the avoidance of chronic diabetes
complications, and absence of complications.
The
patient’s diet is planned with the primary goal of glucose control; however,
the dietary prescription must also consider the patient’s primary health
problem in addition to lifestyle, cultural background, activity level, and food
preferences. If alterations are needed in the patient’s diet because of the
primary health prob-lem (eg, GI problems), alternative strategies to ensure
adequate nutritional intake must be implemented. The patient’s nutri-tional
intake is monitored carefully along with blood glucose, urine ketones, and
daily weight. Blood glucose records are assessed for patterns of hypoglycemia
and hyperglycemia at the same time of day, and findings are reported to the
physician for alteration in insulin orders. In the patient with elevated blood
glucose levels that are prolonged, laboratory values and the patient’s physical
condition are monitored for signs of DKA or HHNS.
The
skin is assessed daily for dryness or breaks. The feet are cleaned with warm
water and soap. Excessive soaking of the feet is avoided. The feet are dried
thoroughly, especially between the toes, and lotion is applied to the entire
foot except between the toes. For bedridden patients (especially those with a history
of neuropathy), the heels are elevated off the bed with a pillow placed under
the lower legs and the heels resting over the edge of the pillow. Dermal ulcers
are treated as indicated and prescribed. The nurse promotes optimal blood
glucose control in patients with skin breakdown.
Hospital
admission of the patient with diabetes provides an ideal opportunity for the
nurse to assess the patient’s level of knowl-edge about diabetes and its
management. The nurse uses this opportunity to assess the patient’s
understanding of diabetes management, including blood glucose monitoring,
administra-tion of medications (ie, insulin, oral agents), dietary
requirements, exercise, and strategies to prevent long- and short-term compli-cations
of diabetes. The nurse also assesses the adjustment of the patient and family
to diabetes and its management and identifies any misconceptions they have.
Inadequate
control of blood glucose levels may hinder recovery from the immediate health
problem. Blood glucose levels are monitored, and insulin is administered as
prescribed. It is im-portant for the nurse to ensure that insulin prescribed is
modified as needed to compensate for changes in the patient’s schedule or
eating pattern. Treatment is given for hypoglycemia (with oral glucose) or
hyperglycemia (with supplemental regular insulin no more often than every 3 to
4 hours). Blood glucose records are as-sessed for patterns of hypoglycemia and
hyperglycemia at the same time of day, and findings are reported to the
physician for modification in insulin orders. In the patient with elevated
blood glucose levels that are prolonged, laboratory values and the pa-tient’s
physical condition are monitored for signs of DKA or HHNS.
Development
of acute complications of diabetes secondary to inadequate control of blood
glucose levels may be associated with other health care problems because of
changes in activity level and diet and physiologic alterations related to the
primary health problem itself. Therefore, the patient must be monitored for
acute complications (hyperglycemia, hypoglycemia) and measures must be
implemented for their prevention and early treatment.
Even
if the patient has had diabetes for many years, it is impor-tant to assess his
or her knowledge and adherence to the plan of care. It may be necessary to plan
and implement a teaching plan that includes basic information about diabetes,
its cause and symptoms, and acute and chronic complications and their
treat-ment. The nurse asks the patient to give repeated return demon-strations
of skills that were not performed correctly during the initial assessment. The
patient is taught self-care activities for the prevention of long-term
complications, including foot care, eye care, and risk factor management. The
nurse also reminds the pa-tient and family about the importance of health
promotion ac-tivities and recommended health screening.
The
patient who is hospitalized for another health problem may require referral for
home care for that problem or if gaps in knowledge about self-care are
uncovered. In either case, the home care nurse can use this opportunity to assess
the patient’s knowl-edge about diabetes management and the patient’s and
family’s ability to carry out that management. Teaching provided in the
hospital, clinic, office, or diabetes education center is reinforced by the
nurse. The home care environment is assessed to deter-mine its adequacy for
self-care and safety.
During
home care visits, the nurse assesses the patient for signs and symptoms of
long-term complications and assesses the pa-tient’s and family’s techniques in
blood glucose monitoring, in-sulin administration, and food selection. In
addition, the patient and family are reminded of the importance of
participating in health promotion activities as well as recommended health
screening.
Expected
patient outcomes may include:
1) Achieves optimal control
of blood glucose
a) Avoids extremes of
hypoglycemia and hyperglycemia
b) Takes steps to resolve
rapidly any hypoglycemic episodes
2)Maintains skin integrity
a) Demonstrates intact skin
without dryness and cracking
b) Avoids ulcers caused by
pressure and neuropathy
3)Demonstrates/verbalizes
diabetes survival skills and pre-ventive care
4)Understands treatment
modalities
a) Demonstrates proper
technique for administering in-sulin or oral antidiabetic medications and
assessing blood glucose
b) Demonstrates appropriate
knowledge of diet through proper menu selections and identification of pattern
used for selecting foods at home
c) Verbalizes signs,
appropriate treatment, and prevention of hypoglycemia and hyperglycemia
5)Demonstrate proper foot
care
a) Inspects feet (using
mirror if necessary to see bottom of foot), including inspection for cracks or
fungal infec-tions between toes
b) Washes feet with warm
water and soap; dries feet thoroughly
c) Applies lotion to entire
foot except between toes
d) Verbalizes behaviors
that decrease the risk of foot ul-cers, including wearing shoes at all times;
using hand or elbow, not foot, to test temperature of bath water; avoiding use
of heating pad on feet; avoiding constric-tive shoes; wearing new shoes for
brief periods; avoiding home remedies for treatment of corns and calluses;
having feet examined at every appointment with the physician; and consulting a
podiatrist for regular nail care if necessary
6)Takes steps to prevent
eye disease
a) Verbalizes need for
yearly or more frequent thorough dilated eye examinations by an ophthalmologist
(starting at 5 years after diagnosis for type 1 diabetes or the year of
diagnosis for type 2 diabetes)
b) Verbalizes that
retinopathy usually does not cause change in vision until serious damage to the
retina has occurred
c) States that early laser
treatment along with good control of blood glucose and blood pressure may
prevent visual loss from retinopathy
d) Identifies hypoglycemia
and hyperglycemia as two causes of temporary blurred vision
7)States measures to
control macrovascular risk factors
a) Smoking cessation
b) Limitation of fats and
cholesterol
c) Control of hypertension
d) Exercise
e) Regular monitoring of
renal function
8)Reports absence of acute
complications
a) Maintains blood glucose
and urine ketones within nor-mal limits
b) Experiences no signs or
symptoms of hypoglycemia or hyperglycemia
c) Identifies signs and
symptoms of hypoglycemia or hyper-glycemia
d) Reports appearance of
symptoms so that treatment can be initiated
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