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
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