Diabetes Mellitus Nursing Diagnosis Care Plan: A Comprehensive Guide

Diabetes Mellitus (DM) is a prevalent chronic metabolic condition characterized by the body’s impaired ability to regulate blood glucose levels effectively. This impairment stems from issues with insulin production, insulin action, or both, leading to hyperglycemia – elevated blood sugar. Ineffective management of diabetes can result in significant health complications affecting various organ systems. Nurses play a crucial role in the holistic care of patients with diabetes, from initial assessment and diagnosis to the development and implementation of comprehensive care plans aimed at achieving glycemic control, preventing complications, and enhancing patient quality of life. This article provides an in-depth guide to diabetes mellitus, focusing on nursing diagnoses and the development of effective care plans.

Types of Diabetes Mellitus

Diabetes mellitus is not a singular disease but rather a group of metabolic disorders sharing the common feature of hyperglycemia. Understanding the different types is crucial for tailored nursing care.

Type 1 Diabetes Mellitus (T1DM): Characterized by an autoimmune destruction of the pancreatic beta cells, which are responsible for insulin production. This leads to absolute insulin deficiency. While it can occur at any age, T1DM is frequently diagnosed in childhood or adolescence. Genetic predisposition and environmental factors like viral infections are thought to contribute to its development.

Type 2 Diabetes Mellitus (T2DM): The most common form of diabetes, T2DM is characterized 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. T2DM is strongly linked to lifestyle factors such as obesity, physical inactivity, and unhealthy diets. It typically develops gradually, often in adulthood, but is increasingly seen in younger populations.

Gestational Diabetes Mellitus (GDM): Diabetes that develops during pregnancy in women who did not have diabetes prior to gestation. Hormonal changes during pregnancy can lead to insulin resistance. GDM usually resolves after childbirth, but it significantly increases the mother’s risk of developing T2DM later in life and can pose risks to the baby.

Prediabetes: A condition where blood glucose levels are higher than normal but not yet high enough to be diagnosed as T2DM. Prediabetes is a critical stage as it indicates an increased risk of progressing to T2DM, cardiovascular disease, and other health problems. It is often defined by a fasting blood glucose level between 100 and 125 mg/dL.

Understanding Hypoglycemia and Hyperglycemia

Maintaining blood glucose within a target range is paramount in diabetes management. Deviations from this range, either too low (hypoglycemia) or too high (hyperglycemia), require prompt recognition and intervention.

Hypoglycemia: Low Blood Glucose

Hypoglycemia occurs when blood glucose levels drop below 70 mg/dL. This is a potentially dangerous condition that requires immediate treatment to prevent neurological impairment and other serious complications.

Causes of Hypoglycemia:

• Excessive insulin or oral hypoglycemic agents: Taking too much medication can drive blood glucose too low.
• Missed or delayed meals: Insufficient carbohydrate intake can lead to a glucose deficit, especially in individuals taking insulin or certain oral medications.
• Increased physical activity: Exercise increases glucose uptake by muscles, and if not balanced with increased carbohydrate intake or reduced medication, it can cause hypoglycemia.
• Alcohol consumption: Alcohol can impair liver glucose production, increasing the risk of hypoglycemia, particularly when consumed on an empty stomach.
• Timing of insulin administration: Improper timing of insulin doses relative to meals can lead to mismatches between insulin action and glucose availability.
• Other factors: Hot and humid weather, puberty, and menstruation can also influence glucose levels and potentially contribute to hypoglycemia.

Hyperglycemia: High Blood Glucose

Hyperglycemia refers to elevated blood glucose levels, typically when fasting blood glucose is greater than 125 mg/dL or blood glucose is above 180 mg/dL one to two hours after eating. Chronic hyperglycemia is the hallmark of diabetes and leads to long-term complications.

Causes of Hyperglycemia:

• Insufficient insulin: Inadequate insulin dosage or missed doses can result in glucose buildup in the bloodstream.
• Dietary indiscretion: Consuming excessive carbohydrates, especially simple sugars, can cause rapid and significant increases in blood glucose.
• Physical inactivity: Lack of exercise reduces glucose utilization by muscles, contributing to hyperglycemia.
• Illness and infection: Stress hormones released during illness can counteract insulin and elevate blood glucose.
• Stress: Emotional or physical stress can also trigger hormonal responses that lead to hyperglycemia.
• Steroid use: Corticosteroids can increase insulin resistance and promote glucose production by the liver.
• Incorrect use of diabetic medications: Improper administration techniques or incorrect dosages of insulin or oral medications can lead to hyperglycemia.

Nursing Assessment for Diabetes Mellitus

A comprehensive nursing assessment is the foundation for developing individualized care plans for patients with diabetes. This assessment encompasses subjective and objective data collection, focusing on identifying risk factors, current health status, and potential complications.

Review of Health History (Subjective Data)

1. Elicit General Symptoms:

• Hypoglycemia Symptoms: Nurses should ask patients about symptoms suggestive of hypoglycemia, such as:

  • Heart palpitations
  • Tremors or shaking
  • Sweating (diaphoresis)
  • Anxiety or nervousness
  • Confusion or difficulty concentrating
  • Dizziness or lightheadedness
  • Intense hunger

• Hyperglycemia Symptoms: Inquire about symptoms indicative of hyperglycemia:

  • Polyuria (frequent urination)
  • Polydipsia (increased thirst)
  • Polyphagia (increased hunger)
  • Blurred vision
  • Paresthesia (burning, tingling, or numbness in extremities)
  • Fatigue or unexplained weakness
  • Headaches
  • Balanitis (inflammation of the glans penis) in men
  • Recurrent infections, particularly yeast infections or skin infections

• Gestational Diabetes Symptoms: Women with GDM may be asymptomatic. If symptoms are present, they often resemble hyperglycemia:

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

2. Determine Diabetes Duration and Treatment History:

• Ask about the duration of the diabetes diagnosis and past and current treatments. This helps assess the patient’s experience with diabetes management and identify potential challenges. Longer duration of diabetes, especially with poor glycemic control, increases the risk of complications.

3. Identify Age at Diagnosis:

• The age of diagnosis can provide clues about the type of diabetes. Type 1 DM often presents in childhood or adolescence, while Type 2 DM is more common in adults over 40, though this is changing with rising rates of childhood obesity.

4. Investigate Risk Factors:

• Non-modifiable Risk Factors:

  • Family history: A family history of diabetes significantly increases risk. Specific genetic mutations are associated with MODY and neonatal diabetes.
  • Race/Ethnicity: Certain racial and ethnic groups have a higher prevalence of T2DM, including Black, Hispanic, American Indian, and Asian Americans.
  • Age: The risk of prediabetes and T2DM increases with age.
  • Autoimmune diseases: Presence of other autoimmune conditions increases the risk of T1DM and LADA.
  • Hormonal imbalances: Conditions like polycystic ovary syndrome (PCOS) are linked to insulin resistance and increased diabetes risk.

• Modifiable Risk Factors:

  • Obesity and Unhealthy Diet: Excess weight, especially abdominal obesity, and diets high in fat, calories, and processed foods are major risk factors for insulin resistance and T2DM.
  • Smoking: Smoking significantly increases the risk of T2DM and worsens diabetes management. Smokers with diabetes experience more difficulty controlling blood glucose.
  • Excessive Alcohol Consumption: Chronic heavy alcohol use can impair insulin sensitivity.
  • Physical Inactivity: Sedentary lifestyles contribute to insulin resistance and increase the risk of prediabetes and T2DM.
  • Chronic Conditions: Conditions like hypertension and hyperlipidemia are often comorbid with diabetes and increase the risk of complications.

5. Assess for Yeast Infections:

• Recurrent yeast infections, particularly vaginal or penile yeast infections, can be a sign of undiagnosed or poorly controlled diabetes due to glycosuria (glucose in the urine) creating a favorable environment for yeast overgrowth.

6. Evaluate for Diabetes-Related Complications:

• Inquire about symptoms and history related to potential diabetes complications:
  • Cardiovascular Disease: Chest pain, shortness of breath, leg pain during exertion (claudication), symptoms of stroke (weakness, speech difficulties).
  • Neuropathy: Tingling, numbness, burning pain in hands and feet, foot deformities, balance problems.
  • Renal Disease (Nephropathy): Swelling in legs and feet (edema), changes in urine output, fatigue, loss of appetite.
  • Retinopathy: Changes in vision, blurred vision, floaters, difficulty seeing at night.
  • Foot Damage: Foot ulcers, slow-healing wounds, infections in the feet, history of foot problems.
  • Depression and Anxiety: Feelings of sadness, hopelessness, loss of interest in activities, anxiety, and stress related to diabetes management.

7. Review Blood Glucose Monitoring Records:

• If the patient performs home glucose monitoring, ask to review their records to identify patterns of hypo- or hyperglycemia, glycemic variability, and adherence to monitoring recommendations.

Physical Assessment (Objective Data)

Patients with well-managed diabetes may have few physical findings. However, a thorough physical exam can reveal signs of diabetes or its complications.

1. Monitor Vital Signs:

• Blood Pressure and Heart Rate: Hypertension is common in diabetes. Assess for hypertension and orthostatic hypotension (related to autonomic neuropathy). Tachycardia may be present in hypoglycemia or as a compensatory mechanism in decreased cardiac output.
• Respiratory Rate and Pattern: Assess for Kussmaul respirations (deep, rapid breathing), which can indicate diabetic ketoacidosis (DKA).

2. Palpate Peripheral Pulses:

• Assess and document the strength and quality of dorsalis pedis and posterior tibial pulses in both feet. Diminished or absent pulses can indicate peripheral artery disease (PAD), a common complication of diabetes.

3. Perform Foot Assessment:

• Skin and Nail Examination: Inspect the feet for skin changes (dryness, cracking, calluses, lesions), nail abnormalities (fungal infections, thickened nails), and deformities (bunions, hammertoes).
• Sensory Testing: Assess for peripheral neuropathy using the Semmes-Weinstein monofilament test to evaluate protective sensation. Also, assess vibration perception and reflexes.
• Foot Ulcers: Carefully examine for any existing foot ulcers, noting location, size, depth, and signs of infection.

4. Assess Weight:

• Note the patient’s weight and BMI. Weight loss can occur in uncontrolled T1DM due to glycosuria and catabolism. Weight gain is common in T2DM and can exacerbate insulin resistance.

Diagnostic Procedures

Diagnostic testing is essential to confirm diabetes, determine its type, and monitor glycemic control and complications.

1. Blood Glucose Tests:

• Fasting Plasma Glucose (FPG): Measures blood glucose after at least 8 hours of fasting. Diabetes is diagnosed if FPG is ≥ 126 mg/dL on two separate occasions. Prediabetes is diagnosed with FPG between 100-125 mg/dL.
• Random Plasma Glucose (RPG): Blood glucose measured at any time of day without regard to meals. Diabetes is diagnosed if RPG is ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia.
• Oral Glucose Tolerance Test (OGTT): Measures blood glucose levels at intervals after the patient drinks a standardized glucose solution. Diabetes is diagnosed if the 2-hour post-OGTT glucose is ≥ 200 mg/dL. Prediabetes is diagnosed with 2-hour post-OGTT glucose between 140-199 mg/dL.
• Hemoglobin A1c (Glycated Hemoglobin): Reflects average blood glucose levels over the past 2-3 months. Diabetes is diagnosed if A1c is ≥ 6.5%. An A1c between 5.7-6.4% indicates prediabetes.

2. Gestational Diabetes Screening:

• Glucose Challenge Test (GCT): A 1-hour screening test performed between 24-28 weeks of gestation. If the 1-hour glucose level is ≥ 140 mg/dL, a 3-hour OGTT is performed.
• 3-hour Oral Glucose Tolerance Test (3-hour OGTT): Used to diagnose GDM. Specific glucose thresholds must be met or exceeded at two or more time points during the 3-hour test for a diagnosis of GDM.

3. Other Laboratory Tests:

• Urine Albumin: Detects microalbuminuria, an early sign of diabetic nephropathy, particularly in T1DM.
• Serum Lipid Panel: Assesses cholesterol and triglyceride levels. Patients with diabetes are at increased risk for dyslipidemia and cardiovascular disease.
• Thyroid Function Tests (TSH): Screen for hypothyroidism, which is more prevalent in individuals with diabetes.

Nursing Interventions for Diabetes Mellitus

Nursing interventions for diabetes are multifaceted and aim to achieve glycemic control, prevent acute and chronic complications, and empower patients to effectively manage their condition.

Glycemic Control

1. Promote Patient Adherence and Engagement:

• Emphasize the importance of patient participation in diabetes management. Encourage adherence to scheduled appointments with healthcare providers, including endocrinologists, primary care physicians, and diabetes educators.
• Reinforce the critical role of lifestyle modifications, including diet and exercise, in achieving and maintaining glycemic control.

2. Provide Comprehensive Diabetes Education:

• Educate patients about all aspects of diabetes, including:
  • The pathophysiology of diabetes and its types.
  • The importance of blood glucose monitoring and target ranges.
  • Medication management (insulin and oral agents), including proper administration techniques, dosages, and side effects.
  • Dietary management, including carbohydrate counting, meal planning, and healthy food choices.
  • Exercise recommendations and the benefits of physical activity.
  • Recognition, treatment, and prevention of hypoglycemia and hyperglycemia.
  • Foot care and skin care guidelines.
  • Sick day management strategies.
  • Importance of regular eye exams, dental checkups, and kidney function monitoring.
• Consider referral to a certified diabetes care and education specialist (CDCES) for individualized and in-depth education.

3. Teach Home Glucose Monitoring:

• Instruct patients on how to use a blood glucose meter accurately, including:
  • Proper technique for obtaining a blood sample.
  • Calibration and maintenance of the meter.
  • Recording and interpreting blood glucose results.
  • Understanding target blood glucose ranges.
• Discuss the use of continuous glucose monitors (CGMs) as an option, especially for patients with T1DM, those using insulin pumps, or those with hypoglycemia unawareness. Explain the benefits and limitations of CGM technology.

4. Maintain Optimal Glucose Levels:

• Collaborate with the healthcare team to establish individualized glycemic targets for each patient, considering factors like age, diabetes type, duration, comorbidities, and risk of hypoglycemia.
• Aim for an HbA1c level below 7% for most non-pregnant adults, as recommended by the American Diabetes Association.
• Encourage pre-meal blood glucose levels in the range of 80-130 mg/dL and post-meal (1-2 hours after starting the meal) levels below 180 mg/dL.

5. Tailor Treatment Plans for Diabetes Type:

• Type 1 DM Management:

  • Insulin therapy is essential for survival in T1DM. Educate patients on different types of insulin (rapid-acting, short-acting, intermediate-acting, long-acting), injection techniques, and insulin regimens (basal-bolus, premixed).
  • Insulin pump therapy may be appropriate for some patients. Provide education on pump operation, insulin delivery settings, and troubleshooting.
  • Emphasize carbohydrate counting to match insulin doses to carbohydrate intake.
  • Islet cell or pancreas transplantation are considered in select cases.

• Type 2 DM Management:

  • Lifestyle modification (diet and exercise) is the cornerstone of T2DM management.
  • Oral hypoglycemic agents are often used to improve insulin sensitivity, increase insulin secretion, or reduce glucose production. Educate patients about different classes of oral medications, their mechanisms of action, side effects, and administration guidelines.
  • Insulin therapy may be necessary in T2DM if glycemic control cannot be achieved with lifestyle modifications and oral agents.

6. Ensure Proper Insulin Administration Technique:

• Provide thorough instruction and hands-on training on insulin administration, including:
  • Choosing appropriate injection sites (abdomen, thigh, arm) and rotating sites.
  • Using correct injection technique (subcutaneous injection, avoiding intramuscular injection).
  • Proper disposal of sharps.
  • Safe storage of insulin.
• Assess and document the patient’s ability to correctly draw up insulin (if using vials and syringes) or use insulin pens. Provide return demonstrations and correct any errors in technique.

7. Assist with Insulin Pump Management:

• For patients using insulin pumps, provide education on:
  • Pump components and operation.
  • Setting basal and bolus insulin rates.
  • Carbohydrate ratio and correction factor calculations.
  • Site changes and infusion set insertion.
  • Troubleshooting pump alarms and malfunctions.
• Collaborate with the diabetes team to ensure appropriate pump settings and ongoing support.

8. Explain Oral Diabetes Medications:

• Educate patients about their prescribed oral diabetes medications, including:
  • Name and class of medication.
  • Mechanism of action.
  • Dosage and timing of administration.
  • Potential side effects and how to manage them.
  • Drug interactions.
• Emphasize the importance of taking medications as prescribed and not discontinuing them without consulting their healthcare provider.

9. Discuss Pancreas Transplant for Type 1 DM (if applicable):

• For eligible patients with T1DM, provide information about pancreas transplantation as a potential treatment option.
• Explain the benefits and risks of transplantation, including the need for lifelong immunosuppression to prevent organ rejection.

10. Guide Meal Planning and Dietary Modifications:

• Emphasize the importance of a balanced and healthy diet in diabetes management.
• Educate patients on:
  • Carbohydrate counting and portion control.
  • Choosing complex carbohydrates over simple sugars.
  • Increasing intake of fruits, vegetables, and whole grains.
  • Selecting lean protein sources.
  • Limiting saturated and trans fats.
  • Reducing sodium intake.
• Involve patients in meal planning and encourage them to make gradual, sustainable dietary changes.

11. Refer to a Registered Dietitian or Nutritionist:

• Recommend consultation with a registered dietitian or nutritionist for personalized meal planning and dietary counseling.
• Dietitians can provide expertise in carbohydrate counting, meal pattern management, and addressing individual dietary needs and preferences.

12. Promote Regular Physical Activity:

• Advise patients to engage in at least 150 minutes of moderate-intensity aerobic exercise per week, spread over at least 3 days, with no more than 2 consecutive days without exercise.
• Encourage strength training exercises at least 2 times per week.
• Educate patients on:
  • The benefits of exercise for glycemic control, weight management, and cardiovascular health.
  • Safe exercise practices, including warming up and cooling down.
  • Monitoring blood glucose before, during, and after exercise, and adjusting food or medication as needed.
  • Choosing enjoyable and sustainable forms of physical activity.
• Advise patients to obtain medical clearance from their healthcare provider before starting a new exercise program.

13. Achieve and Maintain a Healthy Weight:

• For overweight or obese patients with T2DM or prediabetes, emphasize the benefits of weight loss, even a modest 5-10% reduction in body weight, for improving insulin sensitivity and glycemic control.
• Support weight loss efforts through dietary modifications, increased physical activity, and behavioral strategies.

14. Manage Blood Glucose During Pregnancy (Gestational Diabetes):

• For women with GDM, provide education on:
  • Blood glucose monitoring and target ranges during pregnancy.
  • Medical nutrition therapy tailored for pregnancy.
  • Insulin or oral hypoglycemic agents if needed.
• Monitor blood glucose levels closely during labor and delivery.
• Be aware of the risk of neonatal hypoglycemia in infants born to mothers with GDM.

15. Prevent Diabetes Development (Prediabetes Management):

• For individuals with prediabetes, implement lifestyle interventions to prevent progression to T2DM:
  • Weight loss (if overweight or obese).
  • Healthy eating habits.
  • Regular physical activity.
• Discuss the potential role of metformin in preventing T2DM in high-risk individuals with prediabetes, particularly those with obesity and a strong family history of diabetes.

16. Refer to a Diabetologist or Endocrinologist:

• Refer patients to a diabetologist or endocrinologist for specialized diabetes care, particularly for complex cases, T1DM management, insulin pump therapy, and management of diabetes complications.

Prevention of Complications

1. Recommend Wearing a Medical Alert ID:

• Advise patients to wear a medical alert bracelet or necklace indicating they have diabetes. This provides crucial information to emergency personnel in case of hypoglycemia, DKA, or other medical emergencies.

2. Refer to an Ophthalmologist for Regular Eye Exams:

• Emphasize the importance of annual dilated eye exams by an ophthalmologist to screen for diabetic retinopathy, cataracts, and glaucoma. Early detection and treatment of retinopathy can prevent vision loss.

3. Promote Up-to-Date Vaccinations:

• Encourage patients to receive recommended vaccinations, including annual influenza vaccine and pneumococcal vaccine, as people with diabetes are at increased risk for infections and complications.

4. Emphasize Regular Foot Care and Foot Exams:

• Educate patients on daily foot care practices:
  • Inspect feet daily for cuts, blisters, redness, swelling, or sores.
  • Wash feet daily with lukewarm water and mild soap.
  • Dry feet thoroughly, especially between the toes.
  • Apply lotion to dry skin, avoiding between the toes.
  • Trim toenails straight across and file edges.
  • Avoid walking barefoot.
  • Wear comfortable, well-fitting shoes.
• Encourage regular podiatry visits, especially for patients with neuropathy, foot deformities, or a history of foot ulcers.

5. Manage Blood Pressure and Cholesterol Levels:

• Implement strategies to manage hypertension and hyperlipidemia, common comorbidities in diabetes, to reduce cardiovascular risk:
  • Lifestyle modifications (diet, exercise, weight management, smoking cessation).
  • Antihypertensive and lipid-lowering medications as prescribed.

6. Educate on Oral and Dental Care:

• Advise patients to practice good oral hygiene to prevent gum disease and infections:
  • Brush teeth at least twice daily with fluoride toothpaste.
  • Floss daily.
  • Schedule regular dental checkups and cleanings.

7. Encourage Smoking Cessation:

• Strongly advise patients who smoke to quit. Provide resources and support for smoking cessation, as smoking significantly increases the risk of diabetes complications.

8. Moderate Alcohol Consumption:

• If patients choose to drink alcohol, advise them to do so in moderation and with food.
• Educate them on the potential effects of alcohol on blood glucose levels (hypoglycemia or hyperglycemia) and the importance of monitoring glucose when consuming alcohol.

9. Promote Stress Management Techniques:

• Educate patients on the impact of stress on blood glucose levels.
• Encourage stress-reducing activities such as exercise, relaxation techniques, mindfulness, and adequate sleep.

10. Coordinate with a Diabetes Nurse Educator:

• Refer patients to a diabetes nurse educator for ongoing support, education reinforcement, and assistance with diabetes self-management skills.

11. Seek Diabetes Self-Management Education and Support (DSMES) Programs:

• Recommend participation in DSMES programs, which have been shown to improve glycemic control, reduce complications, and enhance quality of life for people with diabetes.

Diabetes Mellitus Nursing Care Plans: Examples

Nursing care plans provide a structured framework for delivering patient-centered care. Here are examples of nursing care plans for common nursing diagnoses in patients with diabetes mellitus.

Nursing Care Plan 1: Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to cellular dysfunction secondary to insulin resistance and/or uncontrolled blood glucose levels, as evidenced by tachycardia, dyspnea, edema, and fatigue.

Related Factors:

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

Defining Characteristics:

• 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 blood pressure within 20 mmHg of baseline.
  • Heart rate 60-100 beats/min with regular rhythm.
  • Respiratory rate 12-20 breaths/min.
  • Urine output 0.5-1.5 mL/kg/hour.
  • Strong, palpable peripheral pulses.
• Patient will report absence of dyspnea and heart palpitations.
• Patient will maintain baseline mental status.
• Patient will not develop new wounds or skin breakdown related to poor perfusion.

Nursing Assessments:

1. Monitor heart rate and blood pressure: Rationale: Tachycardia and hypotension are compensatory mechanisms for decreased cardiac output.
2. Assess EKG rhythms: Rationale: Continuous telemetry monitoring can detect arrhythmias, which may compromise cardiac output.
3. Monitor daily weight at the same time: Rationale: Fluid retention secondary to decreased cardiac output can be detected by daily weight monitoring.
4. Assess for history of cardiac conditions: Rationale: Diabetes increases the risk of cardiovascular disease, and pre-existing cardiac conditions can be exacerbated by diabetes.
5. Auscultate lung sounds: Rationale: Crackles or wheezes may indicate fluid overload due to heart failure.

Nursing Interventions:

1. Administer supplemental oxygen as ordered: Rationale: Supplemental oxygen increases oxygen availability to the myocardium and alleviates hypoxemia.
2. Promote physical and emotional rest: Rationale: Rest reduces myocardial oxygen demand.
3. Assist with diagnostic modalities (e.g., echocardiography): Rationale: Echocardiography can identify structural cardiac abnormalities such as diabetic cardiomyopathy.
4. Administer medications as prescribed: Rationale: Medications such as SGLT2 inhibitors may be used to manage heart failure in patients with diabetes.
5. Educate patient on the relationship between diabetes and cardiac dysfunction: Rationale: Understanding the link between diabetes and heart disease promotes adherence to treatment and lifestyle modifications.
6. Monitor fluid intake and output: Rationale: Provides data on fluid balance and kidney function, which are affected by cardiac output.
7. Elevate legs when sitting or resting: Rationale: Promotes venous return and reduces edema.

Nursing Care Plan 2: Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to endothelial damage from chronic hyperglycemia, as evidenced by weak peripheral pulses, numbness in extremities, and delayed healing.

Related Factors:

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

Defining Characteristics:

• Weak or absent peripheral pulses
• Numbness in extremities
• Pain in extremities (intermittent claudication or rest pain)
• Cool, clammy skin
• Difference in blood pressure in opposite extremities
• Prolonged capillary refill (>3 seconds)
• Delayed wound healing
• Altered sensation in extremities

Expected Outcomes:

• Patient will maintain optimal peripheral tissue perfusion as 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 or reduced severity.
• Patient will demonstrate proper foot care practices.

Nursing Assessments:

1. Monitor blood pressure for orthostatic changes: Rationale: Orthostatic hypotension may indicate autonomic neuropathy and contribute to decreased perfusion.
2. Assess peripheral pulses using Doppler ultrasound if needed: Rationale: Doppler can detect blood flow when pulses are difficult to palpate.
3. Assess skin texture and integrity, especially on lower extremities and feet: Rationale: Arterial insufficiency can cause thin, shiny skin, hair loss, and ulcerations.
4. Evaluate sensation in extremities using monofilament testing: Rationale: Detects peripheral neuropathy, a major risk factor for foot ulcers.
5. Monitor for signs of infection in extremities: Rationale: Poor perfusion impairs healing and increases infection risk.

Nursing Interventions:

1. Maintain controlled glucose levels: Rationale: Glycemic control is essential to prevent further endothelial damage and improve perfusion.
2. Encourage use of compression stockings (if appropriate and prescribed): Rationale: Compression stockings improve venous return and may enhance arterial blood flow in some patients.
3. Provide meticulous foot care and refer to podiatrist: Rationale: Prevents foot ulcers and complications in patients with neuropathy and impaired perfusion.
4. Instruct on smoking cessation: Rationale: Nicotine vasoconstricts blood vessels and worsens peripheral vascular disease.
5. Educate on lifestyle factors to improve tissue perfusion: Rationale: Healthy diet, exercise, and weight management improve overall circulation.
6. Promote proper positioning: Rationale: Avoid crossing legs and elevate legs slightly when sitting to improve circulation.
7. Advise against wearing tight clothing or restrictive footwear: Rationale: Restrictive clothing can impair circulation.

Nursing Care Plan 3: Risk for Unstable Blood Glucose Level

Nursing Diagnosis: Risk for Unstable Blood Glucose Level related to insufficient knowledge of diabetes management and lifestyle factors.

Related Factors:

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

Defining Characteristics:

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 target range.
• Patient will verbalize factors that can cause fluctuations in blood glucose levels.
• Patient will verbalize signs and symptoms of hypoglycemia and hyperglycemia and appropriate actions to take.
• Patient will demonstrate correct technique for blood glucose monitoring and medication administration (if applicable).

Nursing Assessments:

1. Assess for signs and symptoms of hypo- and hyperglycemia: Rationale: Early detection allows for prompt intervention.
2. Assess patient’s physical activity level and patterns: Rationale: Exercise affects glucose utilization.
3. Review patient’s HbA1c results and blood glucose logs: Rationale: Provides data on long-term and recent glycemic control.
4. Assess patient’s understanding of diabetes, self-management skills, and knowledge gaps: Rationale: Identifies areas for targeted education.
5. Assess patient’s support system and resources: Rationale: Social support is crucial for successful diabetes management.
6. Evaluate patient’s dietary habits and meal patterns: Rationale: Diet is a major factor influencing blood glucose levels.

Nursing Interventions:

1. Administer diabetic medications (oral and insulin) as prescribed and monitor effectiveness: Rationale: Medications are essential for glycemic control in many patients.
2. Instruct patient on carbohydrate counting and meal planning: Rationale: Dietary management is fundamental to blood glucose control.
3. Educate patient on proper blood glucose monitoring techniques and frequency: Rationale: Self-monitoring provides data for informed decision-making.
4. Teach patient how to recognize, treat, and prevent hypoglycemia: Rationale: Hypoglycemia is a potentially dangerous complication requiring patient education.
5. Educate patient on hyperglycemia causes, symptoms, and management: Rationale: Hyperglycemia needs to be addressed to prevent long-term complications.
6. Refer patient to Diabetes Self-Management Education (DSME) program: Rationale: DSME provides comprehensive education and support for diabetes self-management.
7. Provide individualized education based on identified learning needs and knowledge gaps: Rationale: Tailored education is more effective.
8. Encourage patient to establish a consistent meal and activity schedule: Rationale: Regular routines help stabilize blood glucose levels.

References

• American Diabetes Association. (2023). Standards of medical care in diabetes—2023 abridged for primary care providers. Clinical Diabetes, 41(1), 4-31.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Diabetes mellitus. Retrieved from https://www.niddk.nih.gov/health-information/diabetes
• Centers for Disease Control and Prevention (CDC). (2022). Diabetes. Retrieved from https://www.cdc.gov/diabetes/basics/index.html
• Powers, M. A., & Bardsley, J. K. (2022). Diabetes mellitus. In J. M. Butts & K. K. Rich (Eds.), Medical-surgical nursing: Pathophysiological concepts (5th ed., pp. 699-744). Elsevier.

---

Note: This article provides general information and should not be considered medical advice. Always consult with a qualified healthcare professional for diagnosis and treatment of diabetes mellitus.