Diabetes Mellitus NANDA Nursing Diagnosis: Comprehensive Guide for Nurses

Diabetes Mellitus (DM) is a pervasive, chronic metabolic condition characterized by the body’s impaired ability to process carbohydrates, fats, and proteins effectively due to insulin resistance or deficiency. This dysfunction leads to hyperglycemia, or elevated blood glucose levels, posing significant health risks if not properly managed. For nurses, understanding the nuances of diabetes mellitus, including accurate diagnosis and effective care planning, is paramount in ensuring optimal patient outcomes. This article provides a comprehensive guide focusing on Diabetes Mellitus Nanda Nursing Diagnosis, encompassing its various facets, from types and complications to detailed nursing assessments and interventions. We aim to delve deeper than introductory materials, offering an enriched perspective tailored for healthcare professionals seeking to enhance their expertise in diabetes care.

Types of Diabetes Mellitus

Diabetes Mellitus is not a monolithic condition; it encompasses several distinct types, each with unique etiologies and management approaches. Recognizing these differences is crucial for targeted nursing care.

Type 1 Diabetes Mellitus: Characterized by an autoimmune reaction, Type 1 DM results in the destruction of insulin-producing beta cells in the pancreas. This autoimmune response leads to absolute insulin deficiency, necessitating lifelong insulin therapy. While the exact triggers are not fully understood, genetic predisposition and viral infections are considered potential contributing factors.

Type 2 Diabetes Mellitus: The most prevalent form of diabetes, Type 2 DM, is marked by insulin resistance, where the body’s cells do not respond effectively to insulin. Over time, the pancreas may also lose its capacity to produce sufficient insulin. Lifestyle factors, such as obesity, physical inactivity, and unhealthy diets, play a significant role in its development. Type 2 diabetes often develops gradually, and for many years, individuals may be unaware of their condition.

Gestational Diabetes Mellitus (GDM): This type of diabetes emerges during pregnancy in individuals without a prior history of diabetes. Hormonal changes during pregnancy can lead to insulin resistance. GDM typically resolves after childbirth, but it significantly elevates the mother’s risk of developing Type 2 DM later in life and poses risks to the newborn.

Prediabetes: Prediabetes represents an intermediate stage where blood glucose levels are higher than normal but do not meet the diagnostic criteria for Type 2 DM. It’s often defined by a fasting blood glucose level between 100-125 mg/dL. Prediabetes is a critical juncture; lifestyle modifications at this stage can often prevent or delay the progression to Type 2 diabetes.

Hypoglycemia: Recognizing and Responding to Low Blood Sugar

Hypoglycemia, or low blood glucose, is a potentially dangerous condition, especially for individuals managing diabetes. It is clinically defined as a blood glucose level below 70 mg/dL and requires prompt intervention to prevent severe complications.

Causes of Hypoglycemia

Numerous factors can precipitate hypoglycemia in individuals with diabetes. Excessive insulin dosage relative to food intake or physical activity is a primary cause. Skipping meals or inadequate carbohydrate consumption can also lead to a blood glucose drop. Furthermore, the timing of insulin administration, increased physical exertion, alcohol consumption (especially without food), hot and humid weather, puberty, and menstruation can all influence blood glucose levels and potentially trigger hypoglycemia. Certain medications, beyond insulin and oral hypoglycemics, can also contribute to lower blood sugar.

Hyperglycemia: Understanding High Blood Sugar

Hyperglycemia, the opposite of hypoglycemia, denotes elevated blood glucose levels. It occurs when there is insufficient insulin in the bloodstream relative to glucose levels. Hyperglycemia is generally defined as a fasting blood glucose level exceeding 125 mg/dL, or a blood glucose level above 180 mg/dL one to two hours post-meal.

Causes of Hyperglycemia

Hyperglycemia can stem from a variety of lifestyle and health-related factors. Dietary indiscretions, such as consuming excessive carbohydrates, and physical inactivity are common culprits. Illness, infection, and psychological stress can also elevate blood glucose levels. Certain medications, particularly steroids, can induce hyperglycemia. Moreover, improper use or inadequate dosage of diabetes medications (insulin or oral agents) is a significant cause of uncontrolled hyperglycemia.

Nursing Assessment for Diabetes Mellitus

A comprehensive nursing assessment is the cornerstone of effective diabetes care. It involves systematically gathering subjective and objective data to understand the patient’s condition, risk factors, and needs.

Review of Health History: Subjective Data Collection

1. General Symptom Assessment:

Nurses should meticulously inquire about symptoms associated with both hypoglycemia and hyperglycemia.

Hypoglycemia Symptoms:

• Heart palpitations (racing heart)
• Tremors or shaking
• Diaphoresis (excessive sweating)
• Anxiety or nervousness
• Confusion and difficulty concentrating
• Dizziness or lightheadedness
• Intense hunger

Hyperglycemia Symptoms:

• Polyuria (frequent urination)
• Polydipsia (increased thirst)
• Polyphagia (increased hunger)
• Blurred vision
• Paresthesia (burning, tingling, or numbness in extremities, particularly lower limbs)
• Fatigue and lethargy
• Headaches
• Balanitis (inflammation of the glans penis) in men, often due to yeast infections

Gestational Diabetes Symptoms: Women with GDM may be asymptomatic. When symptoms are present, they often mirror hyperglycemia:

• Increased urination
• Increased hunger
• Increased thirst
• Blurred vision
• Nausea and vomiting

2. Duration and Treatment History of Diabetes:

Elicit information regarding the duration of the patient’s diabetes diagnosis and current and past treatments. The duration of diabetes and the effectiveness of glucose control directly correlate with the risk of long-term complications.

3. Age at Diagnosis:

Determine the patient’s age at diabetes diagnosis. Type 1 DM is frequently diagnosed in childhood or adolescence, although it can occur at any age. Type 2 DM is more common in adults, typically over 40 years old. Age of onset can provide clues about the type of diabetes and potential risk factors.

4. Risk Factor Investigation:

Thoroughly assess both non-modifiable and modifiable risk factors for diabetes.

Non-modifiable Risk Factors:

• Family History: A family history of diabetes significantly increases the risk, suggesting genetic predispositions. Specific genetic mutations are linked to MODY (maturity-onset diabetes of the young) and neonatal diabetes.
• Race/Ethnicity: Certain racial and ethnic groups have a higher prevalence of Type 2 diabetes, including Black, Hispanic, American Indian, and Asian American populations.
• Age: Advancing age is a major non-modifiable risk factor for prediabetes and Type 2 diabetes.
• Autoimmune Diseases: The presence of other autoimmune conditions increases the risk of autoimmune-related diabetes, such as LADA (latent autoimmune diabetes in adults) and Type 1 DM.
• Hormonal Imbalances: Conditions leading to hormonal imbalances can contribute to insulin resistance, increasing the risk of gestational diabetes and Type 2 diabetes.

Modifiable Risk Factors:

• Obesity and Unhealthy Diet: Excess weight, particularly abdominal obesity, and diets high in fat, calories, and cholesterol are major modifiable risk factors for prediabetes, Type 2 diabetes, and gestational diabetes.
• Smoking: Cigarette smoking significantly elevates the risk of Type 2 diabetes (30-40% increased risk compared to non-smokers). Smokers with diabetes face greater challenges in managing their condition, including insulin resistance.
• Excessive Alcohol Consumption: Heavy alcohol intake can reduce insulin sensitivity, increasing the risk of Type 2 diabetes.
• Physical Inactivity: A sedentary lifestyle contributes to insulin resistance and increases the risk of prediabetes and Type 2 diabetes. Regular physical activity enhances insulin sensitivity.
• Chronic Conditions: Conditions like hypertension (high blood pressure) increase the risk of diabetes complications, while hyperlipidemia (high cholesterol) is a risk factor for Type 2 diabetes.

5. Yeast Infection History:

Inquire about a history of yeast infections. Individuals with diabetes, particularly women, are more susceptible to yeast infections due to elevated glucose levels, which create a favorable environment for yeast proliferation. Glycosuria (glucose in the urine) further promotes yeast overgrowth.

6. Assessment for Diabetes-Related Complications:

Systematically assess for existing complications associated with diabetes, both Type 1 and Type 2, especially in cases of poorly managed or untreated diabetes.

• Cardiovascular Disease (CVD): Diabetes is a major risk factor for CVD. Hyperglycemia damages blood vessels and nerves controlling the heart, leading to hypertension, hyperlipidemia, and increased risk of coronary artery disease, angina, myocardial infarction (heart attack), and cerebrovascular accidents (stroke).
• Neuropathy (Nerve Damage): Diabetic neuropathy results from damage to capillaries supplying nerves due to chronic hyperglycemia. It manifests as tingling, numbness, burning pain, particularly in the extremities, leading to balance problems, reduced sensation, and foot complications.
• Nephropathy (Kidney Disease): Diabetes can damage small blood vessels in the kidneys, impairing their filtering function and leading to diabetic nephropathy. Severe kidney damage can progress to end-stage renal disease, requiring dialysis or kidney transplantation.
• Retinopathy (Eye Damage): Diabetic retinopathy is caused by damage to blood vessels in the retina. It increases the risk of glaucoma and cataracts and is a leading cause of blindness if untreated.
• Foot Damage: A combination of neuropathy and poor circulation in the feet makes individuals with diabetes prone to foot ulcers, infections, and slow wound healing, potentially leading to amputation.
• Depression: The chronic nature and management demands of diabetes can contribute to depression. Depression, in turn, can exacerbate diabetes management due to increased stress and reduced self-care.

7. Review of Blood Glucose Monitoring Records:

Request and review the patient’s blood glucose monitoring records from home glucometers or continuous glucose monitors (CGMs). These records provide valuable insights into glucose trends, patterns of hypo- and hyperglycemia, and adherence to monitoring regimens.

Physical Assessment: Objective Data Collection

Physical examination findings in patients with well-controlled diabetes may be minimal or absent. However, specific assessments are crucial.

1. Blood Pressure and Respiratory Rate Monitoring:

• Hypertension: Frequently assess blood pressure, as hypertension is common in diabetic patients and exacerbates cardiovascular risk.
• Orthostatic Hypotension: Monitor for orthostatic hypotension (drop in blood pressure upon standing), which may indicate autonomic neuropathy, a complication of diabetes.
• Kussmaul Respirations: Observe respiratory rate and depth. Kussmaul respirations (deep, rapid breathing) are a sign of diabetic ketoacidosis (DKA), a severe hyperglycemic emergency.

2. Palpation of Lower Extremity Pulses:

Palpate and document dorsalis pedis and posterior tibial pulses. Diminished or absent pulses may indicate peripheral artery disease, a common complication of diabetes, compromising blood flow to the lower extremities.

3. Foot Assessment:

Conduct a thorough foot examination. Assess for:

• Skin integrity: lesions, ulcers, infections
• Sensation: using monofilament testing to detect neuropathy
• Reflexes: testing deep tendon reflexes
• Vibration perception: using a tuning fork to assess vibratory sensation

Reduced sensation (neuropathy) increases the risk of foot injuries and ulcerations.

4. Weight Assessment:

Assess for weight changes.

• Type 1 DM: Unexplained weight loss can occur in Type 1 DM due to glycosuria and fluid loss as the body attempts to eliminate excess glucose.
• Type 2 DM: Obesity is a major risk factor for Type 2 DM. Weight gain in patients with Type 2 DM can worsen insulin resistance and glucose control.

Diagnostic Procedures

1. Blood Glucose Testing:

Blood glucose levels are fundamental in diagnosing diabetes and monitoring its management.

Diagnostic Criteria for Diabetes Mellitus:

• Type 1 DM:

  • Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)
  • Random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) in patients with classic hyperglycemia symptoms
  • Hemoglobin A1c (HbA1c) ≥ 6.5%

• Type 2 DM:

  • Diagnosis relies on fasting glucose and HbA1c testing, similar to Type 1 DM, but often considered in the context of risk factors and clinical presentation.

• Prediabetes:

  • Fasting blood sugar (FBS) 100 to 125 mg/dL (5.6 to 6.9 mmol/L)
  • 2-hour post-oral glucose tolerance test (OGTT) glucose level 140 to 200 mg/dL (7.8 to 11.1 mmol/L)

• Gestational Diabetes:

  • Screening is typically performed between 24-28 weeks of gestation.
  • 1-hour glucose challenge test: a screening test; if the blood glucose level is ≥ 140 mg/dL, a 3-hour OGTT is performed for confirmation.
  • 3-hour OGTT: diagnostic test.

2. Other Laboratory Tests:

Additional lab tests help detect diabetes complications early.

• Urine Albumin: Microalbuminuria (elevated urine albumin) is an early indicator of diabetic nephropathy, particularly in Type 1 DM.
• Serum Lipids: Lipid profile (cholesterol, triglycerides) monitoring is crucial at diagnosis and regularly thereafter, as individuals with diabetes have a heightened risk of cardiovascular disease.
• Thyroid Function Tests: Annual thyroid level testing is recommended due to the increased prevalence of hypothyroidism in individuals with diabetes.

Nursing Interventions for Diabetes Mellitus

Nursing interventions are vital for managing diabetes, controlling glycemia, preventing complications, and empowering patients to effectively self-manage their condition.

Control of Glycemia: Therapeutic Nursing Interventions

1. Patient Adherence and Engagement:

Patient participation is paramount for successful diabetes management. Nurses play a key role in:

• Encouraging adherence to scheduled follow-up appointments with healthcare providers, including primary care physicians and endocrinologists or diabetologists.
• Reinforcing the critical role of lifestyle modifications, emphasizing diet and exercise adherence as integral components of diabetes therapy.

2. Diabetes Education:

Education is foundational to diabetes self-management. Nurses should:

• Provide comprehensive education about diabetes, including the disease process, treatment options, self-management techniques, and complication prevention.
• Ensure patients understand how diet, stress, medications, and exercise impact blood glucose levels to enable informed decision-making.
• Consider referrals to certified diabetes nurse educators (CDNEs) for individualized, in-depth education and support.

3. Home Glucose Monitoring Instruction:

Teach patients how to effectively use home glucose monitoring devices (glucometers). This includes:

• Proper technique for blood glucose testing.
• Understanding target blood glucose ranges.
• Accurate recording of blood glucose readings.
• Interpreting blood glucose results and adjusting management strategies as needed, in consultation with their healthcare provider.
• For suitable patients, discuss continuous glucose monitors (CGMs) as an option, especially for children, insulin pump users, and those with labile glucose levels. Explain the benefits of CGMs, such as real-time glucose readings, trend alerts, and reduced need for fingersticks.

4. Maintaining Ideal Glucose Levels:

Collaborate with the healthcare team to achieve and maintain optimal glycemic control. Target goals generally include:

• HbA1c below 7%.
• Pre-meal blood glucose between 90-130 mg/dL.
• Post-meal (1-2 hours after starting meal) blood glucose below 180 mg/dL.
• Emphasize that consistent, long-term glucose control is the most effective strategy for preventing or delaying diabetes complications.

5. Type-Specific Treatment Approaches:

Recognize and implement treatment strategies tailored to the specific type of diabetes.

Type 1 DM Treatment:

• Insulin Therapy: Insulin injections or insulin pump therapy are essential for survival in Type 1 DM.
• Routine Blood Glucose Monitoring: Frequent self-monitoring is critical.
• Carbohydrate Counting: Essential for matching insulin doses to carbohydrate intake.
• Pancreas or Islet Cell Transplantation: In select cases, transplantation may be considered.

Type 2 DM Treatment:

• Lifestyle Modifications: Diet and exercise are the cornerstones of initial management.
• Blood Glucose Monitoring: Regular monitoring is important, frequency varies.
• Oral Diabetes Medications: Various classes of oral agents are available to improve insulin sensitivity or increase insulin secretion.
• Insulin Therapy: May be required if oral medications and lifestyle changes are insufficient to achieve glycemic control.

6. Insulin Administration Education and Assessment:

Provide thorough instruction on proper insulin administration techniques. This includes:

• Types of insulin (rapid-acting, short-acting, intermediate-acting, long-acting, premixed).
• Insulin storage and handling.
• Drawing up insulin from vials or using insulin pens.
• Injection sites and rotation.
• Assessing and documenting return demonstrations to ensure competency.

7. Insulin Pump Management:

For patients using wearable insulin pumps, nurses should:

• Provide education on pump operation, settings, and troubleshooting.
• Assist with pump initiation and ongoing management.
• Educate patients about bolus dosing for meals and correction boluses for hyperglycemia.
• Explain the benefits and limitations of insulin pump therapy.

8. Closed-Loop Insulin Delivery Systems (Artificial Pancreas):

For patients using or considering closed-loop systems:

• Explain how these systems integrate a CGM with an insulin pump to automatically adjust insulin delivery based on real-time glucose readings.
• Discuss the potential benefits, such as improved glucose control and reduced hypoglycemia.
• Provide education on system components and management.

9. Oral Diabetes Medication Education:

Educate patients about oral diabetes medications, including:

• Alpha-glucosidase inhibitors: (e.g., acarbose, miglitol) – slow carbohydrate absorption.
• Biguanides: (e.g., metformin) – reduce hepatic glucose production and improve insulin sensitivity.
• Bile acid sequestrants (BASs): (e.g., colesevelam) – lower cholesterol and may have a modest glucose-lowering effect.
• Dopamine-2 agonists: (e.g., bromocriptine) – mechanism in diabetes not fully understood, may improve glucose control.
• DPP-4 inhibitors (gliptins): (e.g., sitagliptin, linagliptin) – enhance incretin hormones, increasing insulin release and decreasing glucagon secretion.
• Meglitinides (glinides): (e.g., repaglinide, nateglinide) – stimulate rapid insulin release from the pancreas.
• SGLT2 inhibitors: (e.g., canagliflozin, empagliflozin) – increase glucose excretion in the urine.
• Sulfonylureas: (e.g., glipizide, glimepiride) – stimulate insulin release from the pancreas.
• Thiazolidinediones (TZDs): (e.g., pioglitazone, rosiglitazone) – improve insulin sensitivity in peripheral tissues.
• For each medication class, explain the mechanism of action, common side effects, and administration guidelines.

10. Pancreas Transplantation:

Discuss pancreas transplantation as a treatment option for select individuals with Type 1 DM, particularly those with end-stage renal disease or frequent severe hypoglycemia. Explain:

• It can restore insulin independence if successful.
• It is a major surgical procedure with significant risks.
• Lifelong immunosuppression is required to prevent organ rejection.

11. Meal Planning Guidance:

Provide education and support for diabetic meal planning, emphasizing:

• Reducing intake of carbohydrates, processed foods, and sugary drinks.
• Understanding how carbohydrates affect blood glucose levels.
• Increasing consumption of fruits, vegetables, lean proteins, and whole grains.
• Portion control and consistent meal timing.
• Involve patients in creating personalized meal plans to enhance adherence.

12. Referral to Dietitian/Nutritionist:

Refer patients to a registered dietitian or nutritionist for comprehensive medical nutrition therapy (MNT). Dietitians can:

• Develop individualized meal plans tailored to patient preferences, lifestyle, and health goals.
• Provide carbohydrate counting education, especially for Type 1 DM and insulin users.
• Offer ongoing dietary counseling and support.

13. Promoting Physical Activity:

Educate patients about the benefits of regular physical activity in diabetes management.

• Exercise lowers blood glucose by increasing glucose uptake by muscles.
• It enhances insulin sensitivity.
• Recommend at least 150 minutes of moderate-intensity aerobic activity per week, spread over at least 3 days, with no more than 2 consecutive days without activity.
• Encourage resistance training 2-3 times per week.
• Advise patients to consult their healthcare provider before starting a new exercise program, especially if they have pre-existing health conditions.
• Educate patients about monitoring blood glucose before, during, and after exercise and adjusting insulin or carbohydrate intake as needed.

14. Weight Management:

For overweight or obese patients with Type 2 DM or prediabetes, emphasize the importance of weight loss.

• Even modest weight loss (5-7% of body weight) can significantly improve glucose control, insulin sensitivity, and reduce the risk of diabetes complications.
• Combine dietary modifications and increased physical activity for effective weight management.

15. Gestational Diabetes Management:

Manage blood sugar levels during pregnancy in women with GDM.

• Treatment may include dietary changes, exercise, blood glucose monitoring, and insulin or oral hypoglycemic agents (e.g., metformin, glyburide – although insulin is often preferred).
• Closely monitor blood glucose levels during labor and delivery.
• Be aware of the risk of neonatal hypoglycemia in infants born to mothers with GDM due to fetal hyperinsulinemia in response to maternal hyperglycemia.

16. Diabetes Prevention Strategies:

For individuals with prediabetes or at high risk of developing Type 2 DM, implement prevention strategies.

• Intensify lifestyle modifications, including weight loss (if overweight), healthy eating, and increased physical activity.
• Consider metformin therapy for high-risk individuals, particularly those with prediabetes and obesity, as evidence suggests it can delay or prevent the onset of Type 2 diabetes.

17. Referral to Endocrinologist/Diabetologist:

Refer patients to an endocrinologist or diabetologist for specialized diabetes care, especially in cases of:

• Complex diabetes management issues.
• Difficulty achieving glycemic control.
• Presence of diabetes complications.
• Type 1 diabetes.
• Unclear diabetes diagnosis.

Prevention of Diabetes Complications: Proactive Nursing Interventions

1. Medical Alert Identification:

Advise patients to wear a medical alert bracelet or necklace or carry a medical ID card indicating they have diabetes. This is crucial for emergency situations, such as hypoglycemia or DKA, to ensure prompt and appropriate medical care.

2. Ophthalmologic Care Referrals:

Recommend annual eye examinations by an ophthalmologist. Early detection and treatment of diabetic retinopathy, cataracts, and glaucoma can prevent vision loss.

3. Vaccination Recommendations:

Encourage up-to-date vaccinations, including annual influenza vaccine and pneumococcal vaccine (especially for older adults and those with comorbidities). Individuals with diabetes may have an increased risk of infections and complications.

4. Foot Care Education and Regular Exams:

Emphasize daily foot care and regular foot examinations to prevent foot complications.

• Instruct patients (or family members/caregivers) to inspect feet daily for any redness, swelling, cuts, blisters, or sores.
• Advise washing feet daily with lukewarm water and mild soap.
• Thoroughly dry feet, especially between toes, and avoid applying lotion between toes (to prevent fungal infections).
• Recommend professional podiatric care for nail trimming, callus management, and routine foot exams, especially for patients with neuropathy or foot deformities.

5. Blood Pressure and Cholesterol Management:

Promote strategies to manage blood pressure and cholesterol levels.

• Encourage regular exercise, a heart-healthy diet (low in saturated and trans fats, cholesterol, and sodium), and weight management.
• Ensure adherence to prescribed antihypertensive and lipid-lowering medications.

6. Oral Hygiene Education:

Educate patients about good oral hygiene practices to prevent periodontal disease, which is more common and severe in people with diabetes.

• Advise brushing teeth at least twice daily and flossing daily.
• Recommend regular dental check-ups and professional cleanings.

7. Smoking Cessation Encouragement:

Strongly encourage smoking cessation. Smoking significantly increases the risk of diabetes complications, particularly cardiovascular disease and peripheral artery disease. Provide resources and support for quitting smoking.

8. Moderate Alcohol Consumption Guidance:

If patients choose to consume alcohol, educate them about moderate alcohol intake and its effects on blood glucose.

• Advise limiting alcohol intake to no more than one drink per day for women and two drinks per day for men.
• Recommend consuming alcohol with food to minimize the risk of hypoglycemia.
• Warn about the potential for alcohol to mask symptoms of hypoglycemia.

9. Stress Management Techniques:

Educate patients about stress management techniques. Chronic stress can elevate blood glucose levels. Encourage:

• Prioritizing tasks and setting realistic goals.
• Engaging in relaxation techniques (deep breathing, meditation, yoga).
• Ensuring adequate sleep.
• Participating in enjoyable hobbies and activities.
• Seeking social support.

10. Diabetes Nurse Educator (DNE) Coordination:

Coordinate referrals to diabetes nurse educators (DNEs). DNEs are valuable resources for:

• Comprehensive diabetes education.
• Self-management training.
• Ongoing support and counseling.

11. Diabetes Self-Management Education and Support (DSMES) Program Referral:

Refer patients to recognized Diabetes Self-Management Education and Support (DSMES) programs. DSMES programs provide structured education and support to empower individuals with diabetes to:

• Improve self-care behaviors.
• Enhance coping skills.
• Prevent or delay diabetes complications.
• Improve quality of life.

NANDA Nursing Care Plans for Diabetes Mellitus

Once nursing diagnoses are identified, NANDA nursing care plans guide the prioritization of assessments and interventions to achieve both short-term and long-term patient care goals. Examples of nursing care plans relevant to diabetes mellitus include:

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to cellular dysfunction secondary to insulin resistance or uncontrolled blood glucose levels.

Related Factors:

• Elevated blood glucose levels
• Impaired myocardial contractility
• Increased afterload
• Decreased myocardial oxygenation
• Increased cardiac inflammation

As Evidenced By:

• Tachycardia
• Tachypnea
• Dyspnea
• Orthopnea
• Reduced oxygen saturation
• Hypotension
• Decreased central venous pressure
• Dysrhythmia
• Fatigue
• Change in level of consciousness
• Anxiety/Restlessness
• Decreased activity tolerance
• Edema
• Decreased peripheral pulses
• Decreased urine output

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Systolic BP within 20 mmHg of baseline
  • Heart rate 60-100 bpm with regular rhythm
  • Respiratory rate 12-20 breaths/min
  • Urine output 0.5-1.5 cc/kg/hour
  • Strong peripheral pulses
• Patient will report absence of dyspnea, heart palpitations, or altered mentation.
• Patient will maintain skin integrity without wounds or breakdown.

Nursing Assessments:

1. Monitor heart rate and blood pressure: Assess for tachycardia and hypotension, compensatory responses to reduced cardiac output.
2. Assess EKG rhythms: Continuous telemetry may be indicated to monitor for arrhythmias.
3. Daily weight monitoring: Assess for fluid retention, a sign of compromised cardiac output.
4. Assess cardiac history: Diabetes can exacerbate pre-existing cardiac conditions, increasing cardiovascular risks.

Nursing Interventions:

1. Administer supplemental oxygen: Improve myocardial oxygen availability, especially in hypoxemia.
2. Promote rest: Reduce physical and emotional stress to decrease oxygen demand.
3. Assist with echocardiography: Diagnostic tool for structural cardiac abnormalities like diabetic cardiomyopathy.
4. Administer medications as ordered: SGLT2 inhibitors may be prescribed for heart failure in diabetic patients, offering cardioprotective benefits.
5. Educate on diabetes and cardiac dysfunction: Enhance patient understanding of the link between diabetes and cardiac health to improve adherence to treatment and lifestyle modifications.

Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to endothelial damage from chronic hyperglycemia, leading to impaired oxygen transport and blood flow.

Related Factors:

• Impaired oxygen transport
• Interruption in arterial blood flow
• Elevated blood glucose levels
• Neuropathy
• Peripheral vascular disease
• Insufficient knowledge of diabetes and its management

As Evidenced By:

• Weak or absent peripheral pulses
• Numbness
• Pain in extremities
• Cool, clammy skin
• Difference in BP between extremities
• Prolonged capillary refill
• Delayed wound healing
• Altered sensation

Expected Outcomes:

• Patient will maintain optimal peripheral tissue perfusion, evidenced by:
  • Strong, palpable peripheral pulses
  • Warm and dry extremities
  • Capillary refill time < 3 seconds
• Patient will report absence of burning or numbness in extremities.

Nursing Assessments:

1. Monitor for orthostatic hypotension: May indicate early neuropathy and hypertension risk.
2. Assess peripheral pulses with Doppler: If pulses are weak or impalpable, use Doppler ultrasound to assess blood flow.
3. Assess skin texture: Note abnormalities like thin, shiny skin, hair loss, brittle nails, and ulcerations, indicative of arterial insufficiency.

Nursing Interventions:

1. Maintain glycemic control: Essential for preventing perfusion complications. Educate on glucose monitoring and medication adherence.
2. Encourage compression stockings: Improve venous return and reduce edema.
3. Provide meticulous foot care and podiatry referral: Prevent foot ulcers, especially in patients with neuropathy.
4. Counsel on smoking cessation: Smoking exacerbates vascular damage and impairs perfusion.
5. Educate on lifestyle factors for tissue perfusion: Emphasize healthy diet and exercise to manage diabetes, cholesterol, and hypertension.

Risk for Unstable Blood Glucose Level

Nursing Diagnosis: Risk for Unstable Blood Glucose Level related to insufficient knowledge or inadequate diabetes management.

Related Factors:

• Alterations in physical activity
• Unfamiliarity with diagnosis
• Excessive weight gain or loss
• Inadequate glucose monitoring
• Incorrect insulin administration
• Poor adherence to antidiabetic medication regimen
• Insufficient dietary intake
• Pregnancy
• Illness

As Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcomes:

• Patient will achieve and maintain blood glucose levels within acceptable range.
• Patient will verbalize factors that may cause fluctuations in glucose levels.
• Patient will verbalize signs and symptoms of hypoglycemia and hyperglycemia.

Nursing Assessments:

1. Assess for hypo- and hyperglycemia symptoms: Monitor for signs like shakiness, dizziness (hypoglycemia) or thirst, headache (hyperglycemia).
2. Assess physical activity levels: Physical activity impacts glucose utilization. Inquire about exercise routines and glucose monitoring practices related to exercise.
3. Review HbA1c levels: Assess long-term glycemic control.
4. Evaluate diabetes knowledge: Determine the patient’s understanding of diabetes management to tailor education.
5. Assess support system: Identify support needs, especially for those who may struggle with self-management due to cognitive or physical limitations.

Nursing Interventions:

1. Administer diabetic medications as prescribed: Ensure timely and accurate medication administration, adjusting insulin doses as needed, especially during hospitalization.
2. Educate on carbohydrate counting: Teach patients how carbohydrate intake affects blood glucose and how to adjust insulin doses accordingly.
3. Instruct on blood glucose monitoring: Ensure patient competency in using a glucometer and interpreting results. Consider CGM for complex regimens.
4. Teach hypoglycemia treatment: Educate patients on recognizing and treating hypoglycemia promptly with fast-acting glucose sources.
5. Refer to Diabetes Self-Management Education (DSME): Recommend DSME programs for comprehensive diabetes education and support, particularly for newly diagnosed patients.

References

• American Diabetes Association. (2023). Standards of Medical Care in Diabetes—2023. Diabetes Care, 46(Supplement_1), S1-S291.
• NANDA International, Inc. (2018). Nursing diagnoses: Definitions and classification 2018-2020. Eleventh Edition. Thieme Medical Publishers, Inc.

Alt Text: A close-up view of a blood glucose meter displaying a numerical reading, likely indicating a blood sugar level, used for monitoring diabetes.

Alt Text: A nurse providing diabetes education to a patient, possibly discussing diet, medication, or lifestyle modifications for managing their condition.

Alt Text: A visible diabetic foot ulcer on a patient’s toe, highlighting a serious complication of diabetes requiring careful wound care and management.