Diabetes Pt 4 - The Nursing Process Flashcards
Nursing Assessment
Past health history
- Viral infections, trauma, infection, stress, pregnancy (delivering infant weighing >9 lbs), chronic pancreatitis, Cushing syndrome, acromegaly, fhx of DM
Medications
- Insulin, OAs, corticosteroids, diuretics, phenytoin (Dilantin)
Recent surgery
Subjective data
- Malaise
- Obesity, wt loss (type 1) or gain (type 2)
- Thirst, hunger, n/v
- Poor healing
- Dietary compliance
- Constipation/diarrhea
- Frequent urination, bladder infections
- Nocturia, urinary incontinence
- Muscle weakness, fatigue
- Abd pain, HA, blurred vision
- Numbness/tingling, pruritus
- Impotence, freq vaginal infections
- Decreased libido
- Depression, irritability, apathy
- Commitment to lifestyle changes
Objective data
- Soft, sunken eyeballs*
- Vitreal hemorrhages, cataracts
- Dry, warm, inelastic skin
- Pigmented lesions (on legs)
- Ulcers (esp on feet)
- Loss of hair on toes; acanthosis nigricans
- Rapid, deep respirations (Kussmaul respirations)*
- Hypotension*
- Weak, rapid pulse*
(*) = indicates manifestations of diabetic ketoacidosis
- Dry mouth
- Vomiting*
- Fruity breath*
- Altered reflexes, restlessness
- Confusion, stupor, coma
- Muscle wasting
- Serum electrolyte abnormalities
- Fasting BG lvl of 126 mg/dL or higher
- OGTT and/or random glucose lvl exceeding 200 mg/dL
- Leukocytosis
- ↑ BUN, creatinine
- ↑ TGs, cholesterol, LDL, VLDL
- ↓ HDL
- Hgb A1C value >6.0%
- Glycosuria; ketonuria; albuminuria; acidosis
Nursing Diagnoses
- Ineffective self-health management
- Risk for unstable blood glucose levels r/t inadequate blood glucose monitoring & lack of adherence to diabetes management plan
- Risk for injury r/t decreased tactile sensation, episodes of hypoglycemia
- Risk for peripheral neurovascular dysfunction r/t vascular effects of diabetes
Planning
Overall goals
- Active patient participation
- Few or no episodes of acute hyperglycemic emergencies or hypoglycemia
- Maintain normal BG lvls
- Prevent or minimize chronic complications
- Adjust lifestyle to accommodate diabetes regimen w/a minimum of stress
Nursing Implementation
Health promotion
- Identify, monitor, & teach pts @ risk
- Obesity = primary risk factor
- Routine screening for all overweight adults & those older than 45
- Diabetes risk test
Acute intervention
! Hypoglycemia
! DKA
! HHNS
Acute illness, injury, & surgery
- ↑ BG lvl secondary to counter-regulatory hormones
- Freq monitoring of BG
- Ketone testing if glucose lvl exceeds 240 mg/dL
- Report glucose lvls exceeding 300 mg/dL for 2 tests or moderate to high ketone lvls
- Increase insulin for type 1 DM (to prevent DKA)
- Type 2 DM may necessitate insulin therapy
Acute illness
- Maintain normal diet if able
- Increase noncaloric fluids
- Continue taking anti-diabetic medications
- If normal diet is not possible, supplement w/CHO-containing fluids while continuing medications
Intraoperative period
- IV fluids & insulin
- Freq monitoring of BG
Ambulatory & home care
- Overall goal is to enable pt or caregiver to reach an optimal level of independence
- Use services of CDE
- Establish individualized goals for teaching
- Include family & caregivers
- Assess pt’s ability to perform SMBG & insulin injection
- Utilize assistive devices as needed
- Assess pt/caregiver knowledge & ability to manage diet, medication, & exercise therapy
- Teach manifestations & how to treat hypoglycemia & hyperglycemia
- Frequent oral care
Foot care
* Inspect daily
* Avoid going barefoot
* Proper footwear
* How to treat cuts
Travel needs
* Medication, supplies, food, activity
- MedicAlert bracelet
Evaluation: Expected outcomes
- Verbalizes key elements of the therapeutic regimen, incl knowledge of dz & treatment plan
- Describes self-care measures that may prevent or dec progression of chronic complications
- Maintains a balance of nutrition, activity, & insulin availability that results in stable, normal BG lvls
- Experiences no injury resulting from dec sensation in feet
- Experiences no injury resulting from hypoglycemia
- Verbalizes effects of DM on peripheral artery circulation
- Implements measures to inc peripheral circulation
