Diabetes Mellitus (DM) is a pervasive chronic metabolic disorder characterized by the body’s impaired ability to metabolize carbohydrates, fats, and proteins effectively due to insulin resistance or deficiency. This metabolic dysfunction leads to hyperglycemia, or elevated blood glucose levels, which, if poorly managed, can result in severe health complications. For nurses, understanding the nuances of diabetes and its related nursing diagnoses is paramount to providing effective patient care and improving health outcomes.
Types of Diabetes Mellitus
Diabetes Mellitus is not a singular disease but rather a group of metabolic diseases, each with distinct etiologies and characteristics. Recognizing these different types is crucial for targeted nursing interventions and patient education.
Type 1 Diabetes Mellitus: This type is characterized by an autoimmune reaction where the body’s immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas. The result is an absolute deficiency of insulin. While the exact trigger remains unclear, genetic predisposition and viral infections are considered potential contributing factors. Type 1 diabetes typically manifests in childhood or adolescence but can occur at any age.
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. Initially, the pancreas may compensate by producing more insulin, but over time, insulin production can decline, leading to hyperglycemia. Type 2 diabetes is strongly linked to lifestyle factors such as obesity, physical inactivity, and unhealthy diets, and it typically develops gradually over time, often in adults over 40.
Gestational Diabetes Mellitus (GDM): This type of diabetes develops during pregnancy in women who have not previously been diagnosed with diabetes. Hormonal changes during pregnancy can lead to insulin resistance. GDM usually resolves after childbirth, but it significantly increases the mother’s risk of developing type 2 diabetes later in life and poses risks to the fetus, including macrosomia (large birth weight) and hypoglycemia after birth.
Prediabetes: Prediabetes is an intermediate stage where blood glucose levels are higher than normal but do not yet meet the diagnostic criteria for type 2 diabetes. It is characterized by a fasting blood glucose level between 100 and 125 mg/dL. Prediabetes is a critical window of opportunity for intervention, as lifestyle modifications can often prevent or delay the progression to type 2 diabetes.
Understanding Hypoglycemia and Hyperglycemia
Managing diabetes effectively requires a thorough understanding of the two primary glucose imbalances: hypoglycemia and hyperglycemia.
Hypoglycemia: Low Blood Glucose
Hypoglycemia refers to abnormally low blood glucose levels, typically defined as below 70 mg/dL. It’s a potentially dangerous condition that requires prompt treatment to avoid serious complications such as seizures, loss of consciousness, and even brain damage.
Causes of Hypoglycemia
Several factors can contribute to hypoglycemia in individuals with diabetes, including:
- Excessive Insulin or Diabetes Medication: Taking too much insulin or certain oral diabetes medications can drive blood glucose levels too low.
- Missed or Delayed Meals: Insufficient carbohydrate intake or skipping meals can deplete glucose reserves.
- Strenuous Physical Activity: Exercise increases glucose utilization by muscles and can lead to hypoglycemia, especially if not properly managed with food intake or medication adjustments.
- Alcohol Consumption: Alcohol can impair the liver’s ability to release glucose into the bloodstream, particularly when consumed without food.
- Timing of Insulin Administration: Improper timing of insulin injections in relation to meals can lead to mismatches between insulin action and glucose absorption.
- Other Factors: Hot and humid weather, puberty, and menstruation can also influence glucose levels and potentially contribute to hypoglycemia.
Hyperglycemia: High Blood Glucose
Hyperglycemia signifies elevated blood glucose levels, resulting from insufficient insulin in the bloodstream or insulin resistance. It is diagnosed when fasting blood glucose exceeds 125 mg/dL or when blood glucose levels are 180 mg/dL or higher one to two hours after eating. Chronic hyperglycemia is the hallmark of diabetes and the primary driver of long-term diabetic complications.
Causes of Hyperglycemia
Hyperglycemia can be triggered by various factors, including:
- Dietary Indiscretions: Consuming excessive amounts of carbohydrates, especially sugary drinks and processed foods.
- Physical Inactivity: Lack of exercise reduces glucose utilization and insulin sensitivity.
- Illness and Infection: Stress hormones released during illness can counter insulin’s effects and raise blood glucose.
- Stress: Similar to illness, emotional stress can also elevate blood glucose levels.
- Steroid Medications: Corticosteroids can increase insulin resistance and glucose production.
- Improper Diabetes Medication Management: Incorrect dosage or timing of insulin or oral diabetes medications, or missed doses, can lead to hyperglycemia.
Nursing Assessment in Diabetes Mellitus
A comprehensive nursing assessment is the foundation of effective diabetes care. It involves gathering subjective and objective data to understand the patient’s condition, identify potential nursing diagnoses, and tailor interventions accordingly.
Review of Health History: Subjective Data
Obtaining a detailed health history is crucial for understanding the patient’s diabetes and risk factors. This includes:
1. General Symptoms: Assess for common symptoms of hypo- and hyperglycemia:
- Hypoglycemia Symptoms: Inquire about symptoms like heart palpitations, tremors, sweating, anxiety, confusion, dizziness, and hunger.
- Hyperglycemia Symptoms: Ask about frequent urination (polyuria), increased thirst (polydipsia), increased hunger (polyphagia), blurred vision, tingling or numbness in extremities, fatigue, headaches, and, in men, balanitis.
- Gestational Diabetes Symptoms: For pregnant women, inquire about symptoms similar to hyperglycemia, although many may be asymptomatic. These include increased urination, thirst, hunger, blurred vision, nausea, and vomiting.
2. Duration of Diabetes: Determine how long the patient has had diabetes and their past and current treatment regimens. The duration and control of diabetes are directly related to the risk of long-term complications.
3. Age at Diagnosis: Inquire about the age of diagnosis, as this can provide clues about the type of diabetes. Type 1 often presents in childhood or adolescence, while type 2 is more common in adults over 40.
4. Risk Factors: Investigate both non-modifiable and modifiable risk factors for diabetes:
- Non-modifiable Risk Factors:
- Family History: Diabetes, especially type 2, has a strong genetic component.
- Race/Ethnicity: Certain racial and ethnic groups, including Black, Hispanic, American Indian, and Asian Americans, have a higher prevalence of type 2 diabetes.
- Age: The risk of prediabetes and type 2 diabetes increases with age.
- Autoimmune Diseases: Conditions like autoimmune thyroid disease increase the risk of type 1 diabetes and LADA.
- Hormonal Imbalances: Polycystic ovary syndrome (PCOS) is linked to insulin resistance and increased diabetes risk.
- Modifiable Risk Factors:
- Obesity and Unhealthy Diet: Excess weight and diets high in fat, calories, and processed foods significantly increase diabetes risk.
- Smoking: Smoking increases the risk of type 2 diabetes and makes managing diabetes more challenging.
- Excessive Alcohol Consumption: Chronic heavy alcohol use can impair insulin sensitivity.
- Physical Inactivity: A sedentary lifestyle increases insulin resistance.
- Chronic Conditions: Hypertension and hyperlipidemia are associated with increased diabetes risk and complications.
5. History of Yeast Infections: Frequent yeast infections, particularly in women, can be a sign of diabetes due to elevated glucose levels promoting yeast overgrowth.
6. Present Complications: Assess for any existing diabetes-related complications:
- Cardiovascular Disease: Inquire about chest pain, shortness of breath, leg swelling, and symptoms of heart attack or stroke.
- Neuropathy: Ask about tingling, numbness, burning pain, balance problems, and foot problems.
- Renal Disease: Assess for changes in urine output, swelling, fatigue, and signs of kidney dysfunction.
- Retinopathy: Inquire about vision changes, blurred vision, floaters, and any history of eye problems.
- Foot Damage: Assess for foot ulcers, infections, pain, and any history of foot problems.
- Depression: Screen for symptoms of depression, as it is common in people with diabetes and can impact self-management.
7. Blood Glucose Monitoring Records: If available, review the patient’s home glucose monitoring records to identify patterns of hypo- or hyperglycemia and assess their glucose control.
Physical Assessment: Objective Data
The physical assessment provides objective data to complement the health history. Key areas to assess include:
1. Vital Signs: Monitor blood pressure and respiratory rate. Hypertension is common in diabetes. Orthostatic hypotension may indicate autonomic neuropathy. Kussmaul respirations (deep, rapid breathing) may suggest diabetic ketoacidosis (DKA).
2. Peripheral Pulses: Palpate and document dorsalis pedis and posterior tibial pulses to assess for peripheral vascular disease, a common complication of diabetes.
3. Foot Assessment: Conduct a thorough foot exam, including:
- Inspection: Look for deformities, ulcers, calluses, infections, and skin changes.
- Sensory Testing: Use a Semmes-Weinstein monofilament to assess for protective sensation and vibration perception to detect neuropathy.
- Reflexes: Check ankle reflexes.
4. Weight: Assess for weight changes. Unexplained weight loss can occur in type 1 diabetes due to glycosuria and dehydration. Weight gain is common in type 2 diabetes and can worsen insulin resistance.
Diagnostic Procedures
Diagnostic tests are essential for confirming diabetes and monitoring its management.
1. Blood Glucose Tests:
- Fasting Plasma Glucose (FPG): Measures blood glucose after at least 8 hours of fasting. ≥126 mg/dL indicates diabetes.
- Random Plasma Glucose (RPG): Blood glucose measured at any time of day without regard to meals. ≥200 mg/dL with symptoms of hyperglycemia suggests diabetes.
- Hemoglobin A1c (HbA1c): Reflects average blood glucose levels over the past 2-3 months. ≥6.5% indicates diabetes.
- Oral Glucose Tolerance Test (OGTT): Measures blood glucose levels 2 hours after drinking a sugary drink. ≥200 mg/dL indicates diabetes.
- Prediabetes Diagnosis:
- Fasting blood sugar (FBS) level of 100 to 125 mg/dL.
- 2-hour post-oral glucose tolerance test (post-OGTT) glucose level of 140 to 200 mg/dL.
- Gestational Diabetes Screening:
- 1-hour glucose challenge test (GCT) between 24-28 weeks gestation. If ≥140 mg/dL, a 3-hour OGTT is performed.
- 3-hour OGTT confirms GDM diagnosis based on specific glucose thresholds.
2. Other Lab Tests:
- Urine Albumin: Detects early diabetic nephropathy, especially in type 1 diabetes.
- Serum Lipids: Assess cholesterol and triglyceride levels due to increased cardiovascular risk in diabetes.
- Thyroid Function Tests: Screen for hypothyroidism, which is more prevalent in people with diabetes.
Nursing Interventions for Diabetes Mellitus
Nursing interventions are crucial for managing diabetes, preventing complications, and empowering patients to self-manage their condition effectively.
Controlling Glycemia
1. Promote Patient Adherence: Emphasize the importance of patient participation in diabetes management. Encourage adherence to medical appointments, especially with diabetes specialists. Highlight the significant impact of lifestyle choices on glucose control.
2. Diabetes Education: Provide comprehensive diabetes education covering:
- Disease process and types of diabetes.
- Treatment options (medications, lifestyle modifications).
- The impact of diet, stress, exercise, and medications on glucose levels.
- Self-monitoring of blood glucose (SMBG) techniques and interpretation of results.
- Hypoglycemia and hyperglycemia: recognition, treatment, and prevention.
- Sick day management.
- Foot care.
Refer patients to certified diabetes educators (CDEs) for individualized education and support.
3. Home Glucose Monitoring: Teach patients how to use a home glucose monitor accurately and record results. Explain the importance of regular monitoring, often multiple times daily, to guide treatment decisions. Discuss continuous glucose monitoring (CGM) as an option, particularly for those on insulin or with frequent hypoglycemia.
4. Maintain Target Glucose Levels: Work with patients to achieve and maintain individualized glycemic targets, generally aiming for an HbA1c below 7% and pre-meal glucose levels between 90-130 mg/dL. Emphasize that tight glucose control reduces long-term complications.
5. Tailored Treatment Plans: Recognize that treatment varies based on diabetes type:
- Type 1 DM: Requires insulin therapy (injections or pump), SMBG, carbohydrate counting, and potentially islet cell or pancreas transplantation.
- Type 2 DM: Initial management often involves lifestyle modifications, SMBG, and oral medications. Insulin may be needed as the disease progresses.
6. Insulin Administration Education: Provide thorough education on insulin administration techniques, including:
- Proper drawing up of insulin from vials or using insulin pens.
- Injection sites and rotation.
- Insulin storage and handling.
- Different types of insulin (rapid-acting, short-acting, intermediate-acting, long-acting, and premixed) and their action profiles.
- Assessing and documenting return demonstrations of insulin injection technique.
7. Insulin Pump Management: For patients using insulin pumps, provide education on:
- Pump operation and settings.
- Insertion site care and pump maintenance.
- Troubleshooting pump problems.
- Adjusting basal and bolus rates.
- The benefits and limitations of pump therapy.
8. Closed-Loop Insulin Delivery (Artificial Pancreas): Explain the concept of closed-loop systems, which automate insulin delivery based on CGM readings. Discuss the benefits and availability of these systems.
9. Oral Diabetes Medications Education: Educate patients on oral diabetes medications, including:
- Types of medications (biguanides, sulfonylureas, DPP-4 inhibitors, SGLT2 inhibitors, etc.).
- Mechanism of action of each medication class.
- Proper dosage and timing.
- Potential side effects and how to manage them.
- Importance of adherence.
10. Pancreas Transplant Discussion: For select individuals with type 1 diabetes, particularly those with kidney failure, discuss pancreas transplantation as a potential option. Explain the benefits (insulin independence) and risks (rejection, immunosuppression).
11. Meal Planning and Dietary Guidance: Collaborate with patients to develop individualized meal plans that are:
- Balanced and nutritious.
- Lower in carbohydrates, especially refined carbohydrates and sugary drinks.
- Rich in fruits, vegetables, lean proteins, and whole grains.
- Consistent with their lifestyle, cultural preferences, and health goals.
12. Nutritionist/Dietitian Referral: Refer patients to registered dietitians or nutritionists for comprehensive medical nutrition therapy (MNT). Dietitians can provide personalized meal plans, carbohydrate counting education, and address specific dietary needs and challenges.
13. Promote Physical Activity: Encourage regular physical activity, aiming for at least 150 minutes of moderate-intensity exercise per week. Explain the benefits of exercise in improving insulin sensitivity and lowering blood glucose. Advise patients to consult their healthcare provider before starting a new exercise program.
14. Weight Management: For overweight or obese patients with type 2 diabetes or prediabetes, emphasize the benefits of even modest weight loss (5-7% of body weight) in improving glucose control and reducing diabetes risk.
15. Gestational Diabetes Management: Manage gestational diabetes with:
- Blood glucose monitoring.
- Medical nutrition therapy.
- Regular physical activity.
- Insulin or oral hypoglycemic agents if needed.
- Close monitoring of blood glucose during labor and delivery.
- Postpartum screening for type 2 diabetes.
16. Diabetes Prevention: For individuals with prediabetes, emphasize lifestyle modifications (weight loss, healthy diet, exercise) to prevent or delay the onset of type 2 diabetes. Discuss the potential role of metformin in diabetes prevention for high-risk individuals.
17. Specialist Referral: Refer patients to endocrinologists or diabetologists for specialized diabetes care, particularly for complex cases or when optimal glucose control is not achieved with primary care management.
Preventing Complications
Preventing or delaying diabetes complications is a major focus of nursing care.
1. Medical Alert Identification: Advise patients to wear a medical alert bracelet or necklace indicating they have diabetes. This is crucial for emergency situations, especially for hypoglycemia or DKA.
2. Ophthalmologist Referral: Recommend annual eye exams by an ophthalmologist to screen for diabetic retinopathy, cataracts, and glaucoma. Early detection and treatment can prevent vision loss.
3. Vaccination Promotion: Encourage recommended vaccinations, including annual influenza and pneumococcal vaccines, as people with diabetes are at higher risk of infections.
4. Foot Care Education: Provide comprehensive foot care education:
- Daily foot inspection for cuts, blisters, redness, or swelling.
- Washing feet daily with lukewarm water and mild soap.
- Drying feet thoroughly, especially between toes.
- Applying moisturizer to feet, avoiding between toes.
- Properly fitting shoes and socks.
- Avoiding walking barefoot.
- Promptly reporting any foot problems to their healthcare provider.
- Regular podiatry visits, especially for those with neuropathy or foot problems.
5. Blood Pressure and Cholesterol Management: Educate patients on the importance of managing blood pressure and cholesterol to reduce cardiovascular risk. Encourage healthy lifestyle habits and medication adherence as prescribed.
6. Oral Hygiene: Emphasize good oral hygiene, including:
- Brushing teeth twice daily and flossing daily.
- Regular dental checkups and cleanings.
- Reporting any gum problems to their dentist.
7. Smoking Cessation: Strongly advise smokers to quit smoking. Provide resources and support for smoking cessation. Highlight the increased risk of diabetes complications associated with smoking.
8. Moderate Alcohol Consumption: If patients choose to drink alcohol, advise moderation (up to one drink per day for women, two for men) and to consume alcohol with food. Explain the potential effects of alcohol on blood glucose levels.
9. Stress Management: Teach stress-coping techniques, such as exercise, relaxation techniques, mindfulness, and adequate sleep. Explain how stress can impact blood glucose control.
10. Diabetes Nurse Educator Collaboration: Coordinate with diabetes nurse educators to provide ongoing support, education, and self-management training to patients and their families.
11. Diabetes Self-Management Education and Support (DSMES): Refer patients to DSMES programs, which provide structured education and support to improve self-management skills, health outcomes, and quality of life.
Nursing Care Plans for Diabetes Mellitus
Nursing care plans are essential tools for organizing and delivering patient-centered care for individuals with diabetes. They are based on identified nursing diagnoses and guide nursing interventions to achieve specific patient outcomes. Here are examples of nursing care plans for common nursing diagnoses related to diabetes:
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, and edema.
Related Factors:
- Elevated blood glucose levels
- Impaired contractility
- Increased afterload
- Decreased myocardial oxygenation
- Increased cardiac inflammation
Defining Characteristics (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, 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, and strong peripheral pulses.
- Patient will report absence of dyspnea, heart palpitations, and altered mentation.
- Patient will maintain intact skin without wounds or breakdown.
Nursing Assessments:
- Monitor heart rate and blood pressure: Assess for tachycardia and hypotension, which are compensatory mechanisms in decreased cardiac output.
- Assess EKG rhythms: Continuous telemetry monitoring may be needed to detect arrhythmias.
- Monitor daily weight: Fluid retention due to decreased cardiac output can be detected by daily weight monitoring.
- Assess cardiac history: Diabetes exacerbates pre-existing cardiac conditions, increasing the risk of cardiovascular disease.
Nursing Interventions:
- Administer supplemental oxygen: Improve myocardial oxygen supply and relieve hypoxemia.
- Promote rest: Reduce cardiac workload and oxygen demand through physical and emotional rest.
- Assist with echocardiography: Echocardiography helps diagnose structural heart abnormalities like diabetic cardiomyopathy.
- Administer medications as ordered: SGLT2 inhibitors may be prescribed for heart failure associated with diabetes, offering cardioprotective benefits.
- Educate on diabetes and cardiac dysfunction: Enhance patient understanding of the link between diabetes and heart disease to improve treatment adherence.
Ineffective Peripheral Tissue Perfusion
Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to endothelial damage from chronic hyperglycemia, as evidenced by weak peripheral pulses, numbness, and delayed healing.
Related Factors:
- Impaired oxygen transport
- Interruption in blood flow
- Elevated blood glucose level
- Neuropathy
- Peripheral vascular disease
- Insufficient knowledge of diabetes management
Defining Characteristics (As evidenced by):
- Weak or absent peripheral pulses
- Numbness
- Pain
- Cool, clammy skin
- Difference in BP in opposite extremities
- Prolonged capillary refill
- Delayed healing
- Altered sensation
Expected Outcomes:
- Patient will maintain optimal peripheral tissue perfusion, evidenced by strong, palpable pulses, warm and dry extremities, and capillary refill time <3 seconds.
- Patient will report absence of burning or numbness in extremities.
Nursing Assessments:
- Monitor orthostatic blood pressure: Assess for orthostatic hypotension, which can indicate neuropathy and hypertension.
- Assess peripheral pulses with Doppler: Use Doppler ultrasound if pulses are difficult to palpate.
- Assess skin texture: Observe for signs of arterial insufficiency, such as thin, shiny skin, hair loss, and ulcerations.
Nursing Interventions:
- Maintain controlled glucose levels: Achieving and maintaining target glucose levels is paramount to preventing perfusion complications.
- Encourage compression stockings: Improve venous return and reduce edema in lower extremities.
- Provide meticulous foot care: Prevent foot ulcers and complications through comprehensive foot care and podiatry referrals.
- Instruct on smoking cessation: Emphasize the detrimental effects of smoking on blood vessels and perfusion.
- Educate on lifestyle factors: Promote healthy eating and exercise to improve overall tissue perfusion.
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 diagnosis
- Excessive weight gain or loss
- Inadequate glucose monitoring
- Incorrect insulin administration
- Poor adherence to antidiabetic medication
- Insufficient dietary intake
- Pregnancy
- Illness
Defining Characteristics (As evidenced by):
- A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are focused on prevention.
Expected Outcomes:
- Patient will achieve and maintain blood glucose levels within acceptable target range.
- Patient will verbalize factors that cause glucose level variations.
- Patient will verbalize symptoms of hypoglycemia and hyperglycemia and appropriate actions.
Nursing Assessments:
- Assess for hypo- and hyperglycemia symptoms: Monitor for signs and symptoms of both high and low blood glucose.
- Assess physical activity levels: Understand the patient’s exercise routine and glucose monitoring practices related to activity.
- Assess HbA1c: Review HbA1c levels to evaluate long-term glucose control.
- Assess diabetes knowledge: Determine the patient’s understanding of diabetes self-management.
- Assess support system: Evaluate the availability of support for self-management, especially for patients with cognitive or physical limitations.
Nursing Interventions:
- Administer diabetic medications as prescribed: Ensure timely and accurate administration of insulin and oral medications.
- Instruct on carbohydrate counting: Educate on carbohydrate counting to match insulin doses to dietary intake.
- Educate on blood glucose monitoring: Teach proper SMBG techniques and CGM if appropriate.
- Teach hypoglycemia treatment: Educate patients on recognizing and treating hypoglycemia with readily available glucose sources.
- Refer to Diabetes Self-Management Education (DSME): Enroll newly diagnosed patients and those needing further education in DSME programs.
References
- American Diabetes Association. (2023). Standards of medical care in diabetes—2023 abridged for primary care providers. Clinical Diabetes, 41(1), 4–31.
- Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.
- Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry, M. A., Loketis, E. M., Romanick, K. J., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems (10th ed.). Elsevier.
