Diabetes Mellitus (DM), particularly Type 2, is a prevalent chronic metabolic disorder characterized by the body’s ineffective use of insulin, leading to hyperglycemia. Unlike Type 1 diabetes, which is often autoimmune, Type 2 diabetes develops gradually, primarily due to insulin resistance. Effective management of Type 2 diabetes is crucial to prevent complications and improve patient outcomes. This article provides a comprehensive guide for nurses on nursing diagnoses, assessments, interventions, and care plans specifically tailored for patients with Type 2 Diabetes Mellitus.
Understanding Type 2 Diabetes Mellitus
Type 2 Diabetes Mellitus is characterized by the body’s cells becoming resistant to insulin. Initially, the pancreas attempts to compensate by producing more insulin, but over time, it may not be able to produce enough insulin to maintain normal blood glucose levels. Several factors contribute to the development of Type 2 diabetes, including genetics, lifestyle, and environmental factors. It is often associated with modifiable risk factors like obesity, physical inactivity, unhealthy diet, and age. Understanding the pathophysiology of Type 2 diabetes is fundamental for nurses to provide targeted and effective care.
Nursing Assessment for Type 2 Diabetes
A thorough nursing assessment is the cornerstone of developing an effective care plan for patients with Type 2 diabetes. This assessment includes both subjective and objective data collection.
Subjective Data: Health History Review
1. Presenting Symptoms:
While some individuals with Type 2 diabetes may be asymptomatic initially, many present with classic symptoms of hyperglycemia. Nurses should inquire about:
- Polydipsia (increased thirst): Excessive thirst due to fluid loss from frequent urination.
- Polyuria (frequent urination): The kidneys attempt to excrete excess glucose, leading to increased urine production.
- Polyphagia (increased hunger): Despite eating more, patients may experience persistent hunger as glucose is not effectively entering cells for energy.
- Unexplained weight loss: In some cases, despite polyphagia, patients might experience weight loss due to the body breaking down fat and muscle for energy.
- Fatigue: Lack of glucose in cells leads to decreased energy levels and fatigue.
- Blurred vision: High blood glucose can affect the lens of the eye, causing temporary blurred vision.
- Frequent infections: Hyperglycemia can impair immune function, leading to increased susceptibility to infections, particularly yeast infections and skin infections.
- Slow-healing sores: Impaired circulation and immune function can delay wound healing.
- Numbness or tingling in hands and feet (paresthesia): Early signs of neuropathy due to nerve damage from prolonged hyperglycemia.
2. Duration and Management of Diabetes:
- Duration of diagnosis: Knowing how long the patient has had diabetes helps assess the potential for long-term complications.
- Current treatment regimen: This includes medications (oral hypoglycemic agents, insulin), diet, and exercise plan.
- Past treatments and their effectiveness: Understanding what has worked or not worked in the past is crucial for tailoring the current care plan.
- Adherence to treatment plan: Assess factors affecting adherence, such as understanding of the disease, self-management skills, and psychosocial factors.
3. Age at Diagnosis and Risk Factors:
- Age at diagnosis: Type 2 diabetes is more common in adults, particularly those over 40, but it is increasingly seen in younger populations.
- Family history of diabetes: Genetic predisposition is a significant non-modifiable risk factor.
- Ethnicity: Certain ethnicities, including Black, Hispanic, American Indian, and Asian Americans, have a higher prevalence of Type 2 diabetes.
- Lifestyle risk factors:
- Obesity and unhealthy diet: Excess weight, high-fat, high-calorie diets are major modifiable risk factors.
- Physical inactivity: Sedentary lifestyles increase insulin resistance.
- Smoking: Smokers have a significantly higher risk of developing Type 2 diabetes and its complications.
- Excessive alcohol consumption: Can impair insulin sensitivity.
- History of gestational diabetes: Women with gestational diabetes have a higher risk of developing Type 2 diabetes later in life.
- Other medical conditions: Conditions like hypertension and hyperlipidemia increase the risk of Type 2 diabetes and its complications.
4. History of Yeast Infections:
- Recurrent yeast infections, especially vaginal yeast infections in women, can be a sign of poorly controlled diabetes due to glycosuria (sugar in the urine), which promotes yeast growth.
5. Presence of Diabetes Complications:
Assess for existing complications, which are more common with longer duration and poor glycemic control in Type 2 diabetes:
- Cardiovascular disease: Angina, myocardial infarction, stroke, peripheral artery disease.
- Neuropathy: Peripheral neuropathy (numbness, tingling, pain in extremities), autonomic neuropathy (orthostatic hypotension, gastroparesis).
- Nephropathy: Kidney disease, proteinuria, edema.
- Retinopathy: Vision changes, blurred vision, floaters.
- Foot problems: Foot ulcers, infections, pain, deformities.
- Depression and anxiety: The burden of managing a chronic condition can impact mental health.
6. Blood Glucose Monitoring Records:
- Review patient’s blood glucose logs from home monitoring to identify patterns of hypo- and hyperglycemia and assess overall glycemic control.
Objective Data: Physical Assessment
1. Vital Signs:
- Blood Pressure: Hypertension is common in Type 2 diabetes. Assess for elevated BP and orthostatic hypotension, which can indicate autonomic neuropathy.
- Respiratory Rate: Kussmaul respirations (deep, rapid breathing) are a sign of diabetic ketoacidosis (DKA), although less common in Type 2 diabetes than Type 1, it can occur in certain situations.
2. Peripheral Vascular Assessment:
- Palpate peripheral pulses: Assess dorsalis pedis and posterior tibial pulses for strength and presence. Diminished or absent pulses can indicate peripheral artery disease.
- Skin assessment: Note skin color, temperature, and texture. Cool, clammy skin, pallor, or cyanosis can indicate poor perfusion. Assess for dryness, lesions, or ulcers, especially on the feet and lower legs.
- Capillary refill: Prolonged capillary refill (>3 seconds) can suggest impaired peripheral circulation.
3. Foot Assessment:
- Comprehensive foot exam: Inspect feet for deformities, calluses, blisters, ulcers, infections, and nail abnormalities.
- Sensory testing: Use Semmes-Weinstein monofilament to assess for protective sensation. Test vibration perception and reflexes.
- Assess for signs of infection: Redness, warmth, swelling, drainage, odor.
4. Weight Assessment:
- Assess BMI and weight history. Obesity is a major risk factor for Type 2 diabetes. Note any recent unexplained weight loss or gain.
Diagnostic Procedures
1. Blood Glucose Tests:
- Fasting Plasma Glucose (FPG): Fasting glucose level ≥126 mg/dL on two separate occasions is diagnostic for diabetes.
- Hemoglobin A1c (HbA1c): HbA1c ≥6.5% indicates diabetes. This test reflects average blood glucose levels over the past 2-3 months.
- Random Plasma Glucose (RPG): Random glucose ≥200 mg/dL with classic hyperglycemia symptoms can diagnose diabetes.
- Oral Glucose Tolerance Test (OGTT): A 2-hour plasma glucose ≥200 mg/dL during an OGTT confirms diabetes.
2. Other Laboratory Tests:
- Lipid panel: Assess cholesterol and triglyceride levels, as dyslipidemia is common in Type 2 diabetes and increases cardiovascular risk.
- Urine albumin: To screen for early diabetic nephropathy.
- Renal function tests: Serum creatinine and eGFR to assess kidney function.
- Thyroid function tests: Screen for hypothyroidism, which is more prevalent in individuals with diabetes.
A blood glucose monitoring device is essential for managing diabetes, enabling patients to regularly check and record their blood sugar levels at home.
Nursing Diagnoses for Type 2 Diabetes Mellitus
Based on the nursing assessment, common nursing diagnoses for patients with Type 2 diabetes may include:
- Risk for Unstable Blood Glucose Level: Related to insufficient knowledge of diabetes management, medication management, dietary management, and/or physical activity management.
- Ineffective Tissue Perfusion (Peripheral): Related to hyperglycemia, peripheral vascular disease, and/or neuropathy.
- Risk for Infection: Related to impaired immune function secondary to hyperglycemia, and/or impaired skin integrity.
- Deficient Knowledge: Related to newly diagnosed diabetes, lack of information regarding disease process, self-management skills, and/or treatment regimen.
- Imbalanced Nutrition: More Than Body Requirements: Related to excessive intake in relation to metabolic needs, and/or sedentary lifestyle.
- Risk for Injury: Related to peripheral neuropathy, visual impairment, and/or hypoglycemia.
- Disturbed Sensory Perception (Tactile): Related to peripheral neuropathy.
- Readiness for Enhanced Self-Health Management: Expressed desire to manage diabetes and prevent complications.
Nursing Interventions and Care Plan for Type 2 Diabetes
The nursing care plan for Type 2 diabetes is multifaceted, focusing on glycemic control, complication prevention, patient education, and promoting self-management.
Goals of Care
- Achieve and maintain optimal blood glucose levels within target range.
- Prevent or delay the onset and progression of diabetes complications.
- Promote patient knowledge and self-management skills.
- Improve overall health and quality of life.
Nursing Interventions
1. Glycemic Control:
- Medication Management:
- Administer oral hypoglycemic agents and/or insulin as prescribed. Understand the different classes of oral medications (e.g., metformin, sulfonylureas, DPP-4 inhibitors, SGLT2 inhibitors, TZDs) and their mechanisms of action, side effects, and nursing considerations.
- Educate patients on proper medication administration, timing, and potential side effects.
- For patients on insulin, teach injection techniques, insulin types, storage, and rotation of injection sites.
- Emphasize medication adherence and address barriers to adherence.
- Blood Glucose Monitoring:
- Educate patients on how to use a blood glucose meter accurately and record results.
- Discuss target blood glucose ranges and frequency of monitoring based on individual needs and treatment regimen.
- Explain the importance of monitoring before meals, 2 hours after meals, and at bedtime, as well as when experiencing symptoms of hypo- or hyperglycemia.
- Consider continuous glucose monitoring (CGM) for select patients to improve glucose control and reduce hypoglycemia.
- Dietary Management:
- Collaborate with a registered dietitian to develop an individualized meal plan.
- Educate patients on carbohydrate counting, portion control, and healthy food choices.
- Emphasize a balanced diet rich in fruits, vegetables, whole grains, and lean proteins, and low in saturated and trans fats, and added sugars.
- Provide guidance on meal planning for special occasions and dining out.
- Physical Activity:
- Encourage regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week.
- Advise patients to check blood glucose before, during, and after exercise, especially when starting a new exercise program.
- Educate on adjusting medication or carbohydrate intake as needed for exercise.
- Recommend activities the patient enjoys and can sustain long-term.
- Hypoglycemia and Hyperglycemia Management:
- Educate patients on recognizing the signs and symptoms of hypoglycemia and hyperglycemia.
- Teach the “15-15 rule” for treating hypoglycemia (consume 15 grams of fast-acting carbohydrates, wait 15 minutes, recheck blood glucose).
- Instruct on appropriate treatment for hyperglycemia and when to seek medical attention.
- Develop an action plan for sick days, including guidelines for blood glucose monitoring, medication adjustments, and fluid intake.
2. Complication Prevention:
- Cardiovascular Risk Reduction:
- Encourage smoking cessation.
- Promote management of hypertension and hyperlipidemia through lifestyle modifications and medications as prescribed.
- Educate on the importance of regular cardiovascular check-ups.
- Neuropathy Prevention and Management:
- Emphasize strict glycemic control to prevent or slow nerve damage.
- Educate on foot care to prevent foot ulcers and infections (see detailed foot care instructions below).
- Discuss pain management strategies for neuropathic pain, including medications and non-pharmacological approaches.
- Nephropathy Prevention:
- Encourage blood pressure control and glycemic control to protect kidney function.
- Educate on the importance of regular urine albumin and renal function testing.
- Discuss dietary modifications, such as protein restriction if indicated.
- Retinopathy Prevention:
- Stress the importance of regular eye exams by an ophthalmologist.
- Emphasize glycemic and blood pressure control to reduce the risk of retinopathy progression.
- Foot Care Education:
- Daily foot inspection: Inspect feet daily for cuts, blisters, redness, swelling, or nail problems. Use a mirror to check the soles of feet if needed.
- Wash feet daily: Wash feet daily with lukewarm water and mild soap. Dry feet thoroughly, especially between the toes.
- Moisturize feet: Apply lotion to dry skin, but avoid applying lotion between the toes.
- Proper footwear: Wear well-fitting, supportive shoes and socks. Avoid walking barefoot.
- Protect feet from hot and cold: Avoid hot water, heating pads, and prolonged exposure to cold.
- Trim toenails carefully: Trim toenails straight across and file edges to prevent ingrown toenails. If unable to trim nails safely, seek podiatric care.
- Regular podiatry visits: Recommend regular foot exams by a podiatrist, especially for patients with neuropathy or foot deformities.
- Promptly report any foot problems: Instruct patients to seek immediate medical attention for any foot injuries, sores, or infections.
3. Patient Education and Self-Management:
- Diabetes Education: Provide comprehensive diabetes education covering:
- Disease process of Type 2 diabetes.
- Importance of glycemic control and lifestyle modifications.
- Medication management.
- Blood glucose monitoring.
- Healthy eating and meal planning.
- Physical activity.
- Hypoglycemia and hyperglycemia management.
- Complication prevention.
- Foot care.
- Sick day management.
- Stress management.
- Self-Management Skills Training:
- Teach problem-solving skills for managing diabetes in daily life.
- Enhance self-efficacy by providing positive reinforcement and support.
- Encourage patient participation in diabetes self-management education and support (DSMES) programs.
- Psychosocial Support:
- Assess for psychosocial factors that may impact diabetes management, such as depression, anxiety, stress, and social support.
- Provide emotional support and counseling or refer to mental health professionals as needed.
- Encourage patient involvement in support groups or online communities.
4. Health Promotion and Maintenance:
- Regular Healthcare Follow-up:
- Emphasize the importance of regular visits with primary care providers, endocrinologists, ophthalmologists, podiatrists, and other specialists as needed.
- Schedule regular HbA1c testing, lipid panels, renal function tests, and other recommended screenings.
- Promote annual influenza and pneumococcal vaccinations.
- Lifestyle Modifications:
- Reinforce healthy lifestyle behaviors at each encounter.
- Provide ongoing support and resources for maintaining healthy eating, physical activity, and smoking cessation.
- Address barriers to lifestyle changes and collaboratively develop strategies to overcome them.
Healthy eating is a cornerstone of diabetes management. A balanced diet, rich in vegetables, lean proteins, and whole grains, helps stabilize blood glucose levels.
Evaluation
Regularly evaluate the effectiveness of the care plan based on patient outcomes, including:
- Glycemic control (HbA1c levels, blood glucose monitoring records).
- Achievement of self-management goals.
- Prevention or early detection of diabetes complications.
- Patient satisfaction with care and quality of life.
Adjust the care plan as needed based on ongoing assessment and evaluation to ensure optimal outcomes for patients with Type 2 Diabetes Mellitus.
References
- American Diabetes Association. (2023). Standards of medical care in diabetes—2023 abridged for primary care providers. Clinical Diabetes, 41(1), 4-31.
- Centers for Disease Control and Prevention. (2022). National Diabetes Statistics Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
- Национальный институт диабета и болезней органов пищеварения и почек. (н.д.). Тип 2 диабета.
