Comprehensive Guide to Nurse Diagnosis for Diabetes Mellitus: Assessment, Interventions, and Care Plans

Diabetes Mellitus (DM) is a prevalent, chronic metabolic condition characterized by the body’s impaired ability to metabolize carbohydrates, fats, and proteins effectively due to insufficient insulin action. This dysfunction leads to hyperglycemia, or elevated blood glucose levels, which can have significant health consequences if not properly managed. Effective nursing care is crucial in managing diabetes, and it begins with accurate nurse diagnoses.

Understanding Diabetes Mellitus

Diabetes mellitus arises from either the pancreas not producing enough insulin (Type 1) or the body becoming resistant to insulin (Type 2), or a combination of both. Insulin is a hormone produced by the pancreas that acts like a key, allowing blood sugar to enter cells for energy use. When insulin is deficient or ineffective, glucose accumulates in the bloodstream, leading to a cascade of metabolic disturbances.

Types of Diabetes Mellitus

• Type 1 Diabetes: Characterized by an autoimmune reaction where the body’s immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas. Genetic predisposition and viral infections are considered potential contributing factors.
• Type 2 Diabetes: The most common form, developing gradually over time. It results from insulin resistance, where the body’s cells do not respond effectively to insulin. The pancreas may initially overproduce insulin to compensate, but eventually, insulin production may decline.
• Gestational Diabetes: Occurs during pregnancy in women who have not previously been diagnosed with diabetes. Hormonal changes during pregnancy can lead to insulin resistance. Gestational diabetes usually resolves after childbirth but increases the mother’s risk of developing type 2 diabetes later in life and also affects the baby’s health.
• Prediabetes: A precursor to type 2 diabetes, where blood glucose levels are higher than normal but not yet high enough to be classified as type 2 diabetes. It is often defined by a fasting blood glucose level between 100-125 mg/dL. Prediabetes is a critical stage where lifestyle interventions can effectively prevent or delay the onset of type 2 diabetes.

Blood Glucose Imbalances: Hypoglycemia and Hyperglycemia

Maintaining stable blood glucose levels is a cornerstone of diabetes management. Imbalances in either direction, hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), can pose immediate and long-term health risks.

Hypoglycemia

Hypoglycemia, or low blood glucose, is defined as a blood glucose level below 70 mg/dL. It is a potentially dangerous condition that requires prompt treatment. If left unaddressed, severe hypoglycemia can lead to seizures, loss of consciousness, and even neurological damage.

Causes of Hypoglycemia

Several factors can trigger hypoglycemia in individuals with diabetes, including:

• Excessive Insulin Dosage: Taking too much insulin relative to food intake or activity level.
• Missed or Delayed Meals/Snacks: Insufficient carbohydrate intake to match insulin or medication effects.
• Intense Physical Activity: Exercise increases glucose utilization, potentially leading to hypoglycemia, especially without adjusting insulin or food intake.
• Alcohol Consumption: Alcohol can impair the liver’s ability to release glucose, particularly when consumed without food.
• Medication Interactions: Certain medications can potentiate the effects of insulin or oral hypoglycemic agents.
• Hormonal Fluctuations: Puberty and menstruation can affect insulin sensitivity and glucose levels.
• Weather Conditions: Hot and humid weather can increase insulin absorption.

Hyperglycemia

Hyperglycemia, or high blood glucose, occurs when there is insufficient insulin in the bloodstream or when the body is resistant to insulin’s effects. It is typically defined as a fasting blood glucose level greater than 125 mg/dL or a blood glucose level of 180 mg/dL or higher one to two hours after eating. Chronic hyperglycemia is the hallmark of diabetes and leads to long-term complications.

Causes of Hyperglycemia

Hyperglycemia can be caused by various factors, including:

• Dietary Indiscretions: Consuming excessive carbohydrates or sugary foods.
• Inadequate Insulin Dosage or Missed Doses: Not taking enough insulin or skipping doses of diabetes medications.
• Physical Inactivity: Lack of exercise reduces insulin sensitivity and glucose utilization.
• Illness and Infection: Stress hormones released during illness can raise blood glucose levels.
• Stress: Emotional and physical stress can elevate blood glucose.
• Steroid Medications: Corticosteroids can increase insulin resistance and blood glucose levels.
• Incorrect Medication Administration: Improper technique in insulin injection or oral medication timing.

Nursing Assessment in Diabetes Mellitus

The nursing assessment is the initial and crucial step in providing effective care for patients with diabetes. It involves a comprehensive gathering of subjective and objective data to identify patient needs and formulate appropriate nurse diagnoses for diabetes. This assessment encompasses physical, psychosocial, emotional, and diagnostic aspects.

Review of Health History (Subjective Data)

Collecting a thorough health history is paramount in understanding the patient’s experience with diabetes. This involves asking specific questions to elicit relevant subjective data.

1. General Symptoms Review:

Inquire about symptoms associated with both hypoglycemia and hyperglycemia. Recognizing these symptoms is vital for early detection and intervention.

• Hypoglycemia Symptoms:

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

• Hyperglycemia Symptoms:

  • Frequent urination (polyuria), especially at night
  • Excessive thirst (polydipsia)
  • Increased hunger (polyphagia)
  • Blurred vision
  • Burning, tingling, or numbness in the extremities (neuropathy symptoms)
  • Unexplained fatigue
  • Headaches
  • Recurrent infections, such as balanitis (inflammation of the penis head) in men and yeast infections in women.

• Gestational Diabetes Symptoms:

  • Often asymptomatic.
  • If symptoms are present, they often mirror hyperglycemia: increased urination, thirst, hunger, blurred vision, nausea, and vomiting.

2. Duration of Diabetes:

Determine how long the patient has been diagnosed with diabetes and the types of treatments they have received or are currently using. The duration of diabetes and the level of glucose control are directly linked to the risk of long-term complications.

3. Age at Diagnosis:

Ask about the patient’s age when they were initially diagnosed with diabetes. Type 1 diabetes often manifests in childhood or adolescence, although it can occur at any age. Type 2 diabetes is more commonly diagnosed in adults, particularly those over 40.

4. Risk Factor Assessment:

Investigate both non-modifiable and modifiable risk factors for diabetes. Understanding these factors helps tailor preventative and management strategies.

• Non-Modifiable Risk Factors:

  • Family History: A family history of diabetes significantly increases the risk. Specific genetic mutations are linked to certain types of diabetes, such as Maturity-Onset Diabetes of the Young (MODY) 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: The risk of prediabetes and type 2 diabetes increases with age.
  • Autoimmune Conditions: Conditions like autoimmune diseases can trigger the immune system to attack pancreatic beta cells, leading to Latent Autoimmune Diabetes in Adults (LADA) and type 1 DM.
  • Hormonal Imbalances: Hormonal conditions can lead to insulin resistance, predisposing individuals to gestational diabetes and type 2 diabetes.

• Modifiable Risk Factors:

  • Obesity and Unhealthy Diet: Excess weight and diets high in fat, calories, and cholesterol increase the risk of insulin resistance and diabetes. Overweight and obese individuals are more prone to prediabetes, type 2 diabetes, and gestational diabetes.
  • Smoking: Cigarette smoking significantly elevates the risk of type 2 diabetes. Smokers are also more likely to experience difficulties managing their diabetes with insulin.
  • Excessive Alcohol Consumption: Heavy alcohol intake can reduce insulin sensitivity, increasing the risk of type 2 diabetes.
  • Sedentary Lifestyle: Lack of physical activity contributes to insulin resistance. Regular exercise improves insulin sensitivity and reduces diabetes risk.
  • Chronic Conditions: Conditions like hypertension and hyperlipidemia increase the risk of diabetes and its complications.

5. History of Yeast Infections:

Inquire about a history of yeast infections, particularly in women. Elevated glucose levels create a favorable environment for yeast overgrowth. Glycosuria (glucose in the urine) due to hyperglycemia promotes yeast proliferation.

6. Diabetes-Related Complications:

Assess for any existing complications associated with diabetes. Poorly managed diabetes can lead to a range of serious complications.

• Cardiovascular Disease: Hyperglycemia damages blood vessels and nerves affecting the heart, increasing the risk of hypertension, hyperlipidemia, coronary artery disease, angina, myocardial infarction, and cerebrovascular accidents (stroke).
• Neuropathy: Nerve damage caused by high blood glucose can result in tingling, numbness, burning pain, poor balance, reduced sensation, and foot problems, potentially leading to wounds and amputations.
• Renal Disease (Nephropathy): Damage to the small blood vessels in the kidneys can impair kidney function, potentially leading to chronic kidney disease, requiring dialysis or kidney transplantation.
• Retinopathy: Damage to blood vessels in the retina can cause diabetic retinopathy, increasing the risk of glaucoma, cataracts, and blindness if untreated.
• Foot Damage: Nerve damage and poor circulation in the feet increase the risk of foot ulcers, infections, and slow healing, potentially leading to amputations.
• Depression: The challenges of managing diabetes can contribute to depression, which can further complicate diabetes management by increasing stress levels.

7. Blood Glucose Monitoring Records:

If available, review the patient’s home blood glucose monitoring records. These records provide valuable information about glucose trends, patterns of hypo- and hyperglycemia, and adherence to monitoring schedules.

Physical Assessment (Objective Data)

The physical assessment provides objective data that complements the subjective health history. While patients with well-controlled diabetes may not exhibit obvious physical signs, a thorough examination is essential.

1. Vital Signs:

• Blood Pressure and Respiratory Rate: Monitor blood pressure for hypertension, which is common in diabetes. Assess for orthostatic hypotension, which can occur due to autonomic neuropathy. Observe respiratory rate and pattern; Kussmaul respirations (deep, rapid breathing) may indicate diabetic ketoacidosis (DKA).

2. Peripheral Pulses:

Palpate and document the dorsalis pedis and posterior tibialis pulses in the lower extremities. Reduced or absent pulses can indicate peripheral artery disease, a common complication of diabetes.

3. Foot Assessment:

Conduct a comprehensive foot examination. Assess for:

• Skin integrity: Look for ulcers, blisters, cuts, redness, or swelling.
• Sensation: Evaluate sensory neuropathy using the Semmes-Weinstein monofilament test, reflex testing, and vibration perception testing. Diminished sensation increases the risk of foot injuries going unnoticed.
• Foot deformities: Note any structural abnormalities that may predispose to pressure points and ulceration.

4. Weight Assessment:

Assess for weight changes. Weight loss can occur in type 1 diabetes due to glucose loss and dehydration. Weight gain is more common in type 2 diabetes and can exacerbate insulin resistance.

Diagnostic Procedures

Diagnostic tests are essential to confirm diabetes, assess glucose control, and screen for complications.

1. Blood Glucose Testing:

Blood glucose levels are the primary diagnostic criteria for diabetes.

• Type 1 DM Diagnostic Criteria:

  • Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)
  • Random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) in patients with classic symptoms of hyperglycemia or hyperglycemic crisis.
  • HbA1c ≥ 6.5% (48 mmol/mol)

• Type 2 DM Diagnostic Criteria:

  • Primarily diagnosed using fasting plasma glucose and HbA1c testing.

• Borderline Diabetes/Impaired Glucose Tolerance:

  • Oral Glucose Tolerance Test (OGTT) is used to assess glucose response.

• Prediabetes Diagnostic Criteria:

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

• Gestational Diabetes Screening:

  • All pregnant women are screened between 24 and 28 weeks of gestation.
  • 1-hour glucose challenge test: A level of 140 mg/dL or higher indicates the need for a 3-hour OGTT.
  • 3-hour OGTT confirms gestational diabetes diagnosis.

2. Other Laboratory Tests:

• Urine Albumin: Detects early diabetic nephropathy, particularly in type 1 DM.
• Serum Lipid Profile: Assesses cardiovascular risk; recommended at diagnosis due to the increased risk of cardiovascular disease in diabetes.
• Thyroid Function Tests: Recommended annually due to a higher prevalence of hypothyroidism in individuals with diabetes.

Nurse Diagnosis for Diabetes Mellitus: Common Diagnoses

Based on the comprehensive nursing assessment, several nurse diagnoses for diabetes may be identified. These diagnoses guide the development of individualized care plans. Common nursing diagnoses in diabetes mellitus include:

• Risk for Unstable Blood Glucose Level: This diagnosis is applicable to all patients with diabetes due to the inherent challenges in maintaining glycemic control.
• Ineffective Tissue Perfusion (Peripheral): Relevant due to the microvascular and macrovascular complications of diabetes that impair blood flow, particularly to the extremities.
• Decreased Cardiac Output: Diabetes increases the risk of cardiovascular disease and diabetic cardiomyopathy, potentially leading to reduced cardiac function.
• Risk for Infection: Hyperglycemia impairs immune function, increasing susceptibility to infections.
• Risk for Injury: Neuropathy can reduce sensation in the extremities, increasing the risk of unnoticed injuries, especially to the feet.
• Deficient Knowledge: Many patients, especially newly diagnosed, require education about diabetes management.
• Impaired Skin Integrity: Poor circulation and neuropathy increase the risk of skin breakdown and foot ulcers.
• Disturbed Sensory Perception (Tactile): Diabetic neuropathy can cause altered sensation, increasing risk of injury and impacting quality of life.
• Risk for Impaired Vision: Diabetic retinopathy is a major cause of vision loss in people with diabetes.
• Ineffective Health Management: This diagnosis addresses challenges in adhering to the complex self-management regimen required for diabetes.
• Anxiety and/or Fear: Living with a chronic condition like diabetes and managing its complexities can lead to anxiety and fear.
• Depression: Diabetes is associated with an increased risk of depression, impacting self-care and overall well-being.

Nursing Interventions for Diabetes Mellitus

Nursing interventions are crucial for managing diabetes, preventing complications, and improving patient outcomes. These interventions are tailored to the individual patient’s needs based on their nurse diagnoses for diabetes.

Glycemic Control Interventions

Effective glycemic control is the primary goal of diabetes management.

1. Promote Patient Adherence:

• Encourage active participation: Emphasize the importance of patient involvement in managing their diabetes.
• Follow-up appointments: Stress adherence to scheduled appointments with healthcare providers, including endocrinologists or primary care physicians specializing in diabetes.
• Lifestyle modifications: Continuously reinforce the importance of diet and exercise in diabetes management.

2. Provide Diabetes Education:

• Treatment options: Educate patients about their specific treatment plan, including medications, lifestyle modifications, and monitoring.
• Impact of lifestyle: Explain how diet, stress, medications, and exercise directly affect blood glucose levels.
• Referral to Diabetes Nurse Educator: Recommend consultation with a certified diabetes nurse educator for personalized education and support.

3. Home Glucose Monitoring Instruction:

• Glucometer use: Teach patients how to use a home glucose monitoring device correctly, including proper technique, frequency of testing, and recording results.
• Continuous Glucose Monitoring (CGM): Discuss CGM options, especially for patients with type 1 diabetes, insulin pumps, or those with frequent hypo/hyperglycemia. Explain the benefits of real-time glucose data.

4. Maintain Target Glucose Levels:

• HbA1c goals: Reinforce the goal of maintaining HbA1c below 7% (or individualized target).
• Blood glucose targets: Educate on target blood glucose ranges (e.g., 90-130 mg/dL pre-meal).
• Long-term benefits: Emphasize that consistent glucose control is the most effective way to prevent long-term complications.

5. Type 1 vs. Type 2 DM Treatment Differences:

• Explain treatment variations: Clarify that treatment approaches differ between type 1 and type 2 diabetes.
• Type 1 DM treatments: Detail insulin injections, insulin pumps, blood sugar monitoring, carbohydrate counting, and in some cases, islet cell or pancreas transplantation.
• Type 2 DM treatments: Explain lifestyle modifications, blood sugar monitoring, oral medications, and potentially insulin therapy.

6. Insulin Administration Education:

• Proper technique: Instruct patients on the correct method for insulin injection, including site rotation, needle disposal, and medication storage.
• Insulin types: Educate about different types of insulin (rapid-acting, short-acting, intermediate-acting, long-acting) and their onset, peak, and duration of action.
• Insulin pens vs. syringes: Provide instruction on using both insulin pens and syringes.
• Return demonstration: Assess the patient’s ability to correctly prepare and administer insulin through return demonstration.

7. Wearable Insulin Pump Assistance:

• Pump function: Explain how insulin pumps work, including continuous basal rate and bolus doses for meals.
• Pump management: Provide education on pump site changes, troubleshooting, and adjusting basal and bolus rates as needed (under healthcare provider guidance).
• Wireless pumps: Discuss the option of wireless insulin pumps.

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

• Explain technology: Describe closed-loop systems that integrate CGM and insulin pumps to automate insulin delivery.
• Benefits: Discuss the potential benefits of improved glucose control and reduced burden of manual adjustments.

9. Oral Diabetes Medication Education:

• Medication classes: Educate patients on different classes of oral diabetes medications, including:
  • Alpha-glucosidase inhibitors
  • Biguanides (metformin)
  • Bile acid sequestrants (BASs)
  • Dopamine-2 agonists
  • DPP-4 inhibitors (gliptins)
  • Meglitinides (glinides)
  • SGLT2 inhibitors
  • Sulfonylureas
  • Thiazolidinediones (TZDs)
• Mechanism of action: Explain how each class of medication works to lower blood glucose.
• Side effects and precautions: Discuss potential side effects, drug interactions, and important precautions for each medication.

10. Pancreas Transplant Discussion (Type 1 DM):

• Transplant option: For eligible patients with type 1 DM, discuss pancreas transplantation as a potential treatment, especially for those with poor glucose control or who also need a kidney transplant.
• Risks and benefits: Explain the risks of transplantation, including surgery and immunosuppression, as well as the potential benefits of insulin independence.

11. Meal Planning Guidance:

• Diabetic diet principles: Educate patients on the principles of a diabetic diet: reduced carbohydrates, limited processed foods and sugary drinks, and emphasis on whole foods.
• Carbohydrate counting: Teach carbohydrate counting, especially for patients on insulin, to match insulin doses to carbohydrate intake.
• Nutrient-dense foods: Encourage increased intake of fruits, vegetables, lean proteins, and whole grains.

12. Referral to Nutritionist/Dietitian:

• Personalized meal plans: Recommend consultation with a registered dietitian or nutritionist to develop individualized meal plans tailored to patient preferences, lifestyle, and health goals.
• Carbohydrate counting education: Dietitians provide in-depth education on carbohydrate counting.

13. Promote Physical Activity:

• Benefits of exercise: Explain how exercise lowers blood glucose by increasing glucose uptake by muscles and improving insulin sensitivity.
• Exercise recommendations: Recommend at least 150 minutes of moderate-intensity physical activity per week.
• Healthcare provider clearance: Advise patients to get medical clearance from their healthcare provider before starting a new exercise program.

14. Weight Management:

• Weight loss benefits: For overweight or obese patients with type 2 DM or prediabetes, emphasize that even modest weight loss (e.g., 7%) can significantly improve blood glucose control.
• Weight management strategies: Discuss strategies for achieving and maintaining a healthy weight, including diet, exercise, and behavior modification.

15. Gestational Diabetes Management:

• Treatment approaches: Explain that gestational diabetes management may include blood glucose monitoring, dietary modifications, exercise, oral hypoglycemic agents (some), or insulin therapy.
• Intrapartum monitoring: Emphasize the importance of blood glucose monitoring during labor.
• Neonatal hypoglycemia risk: Educate about the risk of hypoglycemia in newborns of mothers with gestational diabetes and the need for monitoring after delivery.

16. Diabetes Prevention (Prediabetes):

• Lifestyle interventions: Reinforce that healthy lifestyle changes are the cornerstone of prediabetes management to prevent progression to type 2 diabetes.
• Medication considerations: Discuss medications like metformin, statins, and antihypertensives that may be beneficial for some individuals with prediabetes, especially those with cardiovascular risk factors.

17. Referral to Diabetologist/Endocrinologist:

• Specialized care: Recommend referral to a diabetologist or endocrinologist for complex cases, unclear diagnoses, or when specialized management is needed. Explain their expertise in diabetes management.

Complication Prevention Interventions

Preventing or delaying diabetes complications is crucial for maintaining long-term health and quality of life.

1. Medical Alert Identification:

• Medical ID bracelet/necklace: Advise patients to wear a medical alert ID indicating they have diabetes. This is vital for emergency situations, especially for hypoglycemia or DKA.

2. Ophthalmologist Referrals:

• Annual eye exams: Emphasize the need for annual dilated eye exams by an ophthalmologist to screen for diabetic retinopathy, cataracts, and glaucoma.

3. Vaccination Promotion:

• Recommended vaccines: Advise patients to receive recommended vaccinations, including influenza and pneumococcal vaccines, as diabetes can weaken the immune system.

4. Foot Care Education and Exams:

• Daily foot inspection: Instruct patients and family members to inspect feet daily for any signs of injury, redness, swelling, or sores.
• Proper foot hygiene: Advise washing feet daily with lukewarm water, drying thoroughly (especially between toes), and using moisturizer (avoiding between toes).
• Podiatry referrals: Recommend regular visits to a podiatrist, especially for patients with neuropathy or difficulty with foot care.

5. Blood Pressure and Cholesterol Management:

• Lifestyle and medications: Educate on the importance of managing blood pressure and cholesterol through diet, exercise, and medications as prescribed to prevent cardiovascular disease.

6. Oral Hygiene Education:

• Regular dental care: Emphasize the importance of good oral hygiene, including brushing and flossing at least twice daily and regular dental checkups, due to increased risk of gum infections in diabetes.

7. Smoking Cessation Encouragement:

• Risks of smoking: Strongly encourage smoking cessation due to the significantly increased risk of diabetes complications and cardiovascular disease in smokers with diabetes.

8. Moderate Alcohol Consumption:

• Alcohol and blood glucose: Educate about the effects of alcohol on blood glucose levels (can cause both hypo- and hyperglycemia).
• Recommendations: Advise moderation (no more than one drink per day for women, two for men), and to consume alcohol with food.

9. Stress Management Techniques:

• Stress and glucose: Explain how chronic stress can negatively impact blood glucose control.
• Stress-reduction strategies: Recommend stress-reducing activities, relaxation techniques, adequate rest, and prioritizing tasks.

10. Diabetes Nurse Educator Coordination:

• Ongoing support: Coordinate with diabetes nurse educators for ongoing education, support, and self-management training.

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

• Program benefits: Recommend participation in DSMES programs, which have been shown to improve health outcomes, self-efficacy, coping skills, and quality of life in people with diabetes, while reducing hospitalizations and complications.

Nursing Care Plans for Diabetes Mellitus: Examples

Nursing care plans for diabetes mellitus are essential tools for organizing and delivering individualized care. They are developed based on the identified nurse diagnoses for diabetes and prioritize assessments and interventions to achieve both short-term and long-term goals. Here are examples of nursing care plans for common diabetes-related diagnoses:

Nursing Care Plan Example 1: Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to cellular dysfunction secondary to insulin resistance or uncontrolled blood glucose levels, as evidenced by tachycardia, tachypnea, dyspnea, orthopnea, reduced oxygen saturation, hypotension, dysrhythmia, fatigue, edema, and decreased peripheral pulses.

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 and heart palpitations.
• Patient will maintain clear mentation.
• Patient will maintain intact skin without breakdown.

Nursing Assessments:

1. Monitor heart rate and blood pressure: To detect compensatory tachycardia and hypotension indicative of reduced cardiac output.
2. Assess EKG rhythm: To identify arrhythmias; continuous telemetry may be indicated.
3. Monitor daily weight: To assess for fluid retention related to decreased cardiac output.
4. Assess for history of cardiac conditions: To identify pre-existing conditions exacerbated by diabetes.
5. Auscultate lung sounds: To assess for adventitious breath sounds indicative of fluid overload.

Nursing Interventions:

1. Administer supplemental oxygen as ordered: To increase myocardial oxygen supply and relieve hypoxemia.
2. Promote physical and emotional rest: To reduce cardiac workload and oxygen demand.
3. Assist with diagnostic tests (e.g., echocardiography): To diagnose structural cardiac abnormalities like diabetic cardiomyopathy.
4. Administer medications as prescribed (e.g., SGLT2 inhibitors): SGLT2 inhibitors can improve heart failure in diabetic patients by multiple mechanisms.
5. Educate patient on the link between diabetes and cardiac dysfunction: To enhance understanding and adherence to treatment and lifestyle modifications.
6. Monitor fluid intake and output: To assess fluid balance and guide fluid management.
7. Elevate legs when resting: To promote venous return and reduce edema.

Nursing Care Plan Example 2: Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to endothelial damage from chronic hyperglycemia, neuropathy, and peripheral vascular disease, as evidenced by weak or absent peripheral pulses, numbness, pain, cool and clammy skin, prolonged capillary refill, and delayed healing.

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.
• Patient will demonstrate proper foot care practices.

Nursing Assessments:

1. Monitor blood pressure for orthostatic changes: To detect orthostatic hypotension related to neuropathy and hypertension.
2. Assess peripheral pulses using Doppler ultrasound if needed: To assess blood flow when pulses are difficult to palpate.
3. Assess skin texture and integrity, particularly on lower extremities and feet: To identify signs of arterial insufficiency and risk of ulceration.
4. Assess for pain, numbness, tingling in extremities: To monitor neuropathy symptoms.
5. Evaluate capillary refill time in nail beds: To assess peripheral circulation.

Nursing Interventions:

1. Maintain controlled glucose levels: To prevent further endothelial damage and improve perfusion. Educate on glucose monitoring and medication adherence.
2. Encourage use of compression stockings: To improve venous return and reduce edema in lower legs.
3. Provide meticulous foot care and refer to podiatrist as needed: To prevent foot ulcers and complications related to neuropathy and poor circulation.
4. Instruct patient to quit smoking: To improve blood vessel function and perfusion.
5. Educate on lifestyle factors to improve tissue perfusion: Emphasize healthy diet, exercise, and weight management to control diabetes, cholesterol, and blood pressure.
6. Encourage regular, non-weight-bearing exercise: To improve circulation without excessive pressure on feet.
7. Avoid crossing legs for prolonged periods: To prevent restricted blood flow.
8. Keep extremities warm, but avoid direct heat: To promote vasodilation without risk of burns due to neuropathy.

Nursing Care Plan Example 3: Risk for Unstable Blood Glucose Level

Nursing Diagnosis: Risk for Unstable Blood Glucose Level related to unfamiliarity with diagnosis, inadequate glucose monitoring, incorrect insulin administration, poor adherence to antidiabetic medication, insufficient dietary intake, alterations in physical activity, pregnancy, and illness.

Expected Outcomes:

• Patient will achieve and maintain blood glucose levels within acceptable target range.
• Patient will verbalize factors that can cause fluctuations in glucose levels.
• Patient will verbalize symptoms of hypoglycemia and hyperglycemia and appropriate actions.
• Patient will demonstrate correct techniques for blood glucose monitoring and medication administration.

Nursing Assessments:

1. Assess for signs and symptoms of hypo- and hyperglycemia: To detect current glucose imbalances and guide immediate interventions.
2. Assess patient’s physical activity level and patterns: To understand activity-related glucose fluctuations.
3. Review patient’s HbA1c results: To evaluate long-term glucose control.
4. Assess patient’s understanding and knowledge of diabetes management: To identify educational needs and tailor teaching strategies.
5. Assess patient’s support system: To identify available resources and potential need for caregiver involvement.
6. Review patient’s medication regimen and adherence: To identify potential issues with medication management.
7. Assess dietary intake patterns and knowledge of diabetic diet: To identify dietary factors contributing to glucose instability.

Nursing Interventions:

1. Administer diabetic medications (oral and insulin) as prescribed and monitor response: To manage hyperglycemia and prevent hypoglycemia. Monitor glucose levels before and after medication administration.
2. Instruct on carbohydrate counting: To help patient match insulin doses to carbohydrate intake and manage postprandial glucose levels.
3. Educate patient on home blood glucose monitoring: Provide detailed instruction and return demonstration on glucometer use and CGM if applicable.
4. Teach patient how to recognize and treat hypoglycemia: Explain symptoms of hypoglycemia and instruct on immediate treatment with fast-acting glucose sources (glucose tablets, juice, etc.).
5. Refer to Diabetes Self-Management Education (DSME): To provide comprehensive diabetes education and support to improve self-management skills.
6. Develop individualized meal plan in collaboration with dietitian: To address dietary needs and preferences and promote consistent carbohydrate intake.
7. Educate on sick-day management: Provide guidelines for managing diabetes during illness, including medication adjustments, monitoring frequency, and when to seek medical attention.
8. Encourage regular communication with healthcare provider: To address concerns, adjust treatment plan as needed, and prevent glucose instability.

By utilizing these nurse diagnoses for diabetes and implementing comprehensive nursing interventions and care plans, nurses play a pivotal role in empowering patients to effectively manage their diabetes, prevent complications, and improve their overall health and well-being.