DIABETES MELLITUS/DIABETIC KETOACIDOSIS

Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5) stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.

CARE SETTING

Although DKA may be encountered in any setting and mild DKA may be managed at the community level, severe metabolic imbalance requires inpatient acute care on a medical unit.

RELATED CONCERNS

Amputation

Fluid and electrolyte imbalances

Metabolic acidosis (primary base bicarbonate deficit)

Psychosocial aspects of care

Patient Assessment Database

Data depend on the severity and duration of metabolic imbalance, length/stage of diabetic process, and effects on other organ function.

ACTIVITY/REST

May report: Sleep/rest disturbances

Weakness, fatigue, difficulty walking/moving

Muscle cramps, decreased muscle strength

May exhibit: Tachycardia and tachypnea at rest or with activity

Lethargy/disorientation, coma

Decreased muscle strength/tone

CIRCULATION

May report: History of hypertension; acute myocardial infarction (MI)

Claudication, numbness, tingling of extremities (long-term effects)

Leg ulcers, slow healing

May exhibit: Tachycardia

Postural BP changes; hypertension

Decreased/absent pulses

Dysrhythmias

Crackles; jugular venous distension (JVD) (if heart failure [HF] present)

Hot, dry, flushed skin; sunken eyeballs

EGO INTEGRITY

May report: Stress; dependence on others

Life stressors including financial concerns related to condition

May exhibit: Anxiety, irritability

ELIMINATION

May report: Change in usual voiding pattern (polyuria), nocturia

Pain/burning, difficulty voiding (infection), recent/recurrent urinary tract infection (UTI)

Abdominal tenderness, bloating

Diarrhea

May exhibit: Pale, yellow, dilute urine; polyuria (may progress to oliguria/anuria if severe hypovolemia occurs)

Cloudy, odorous urine (infection)

Abdomen firm, distented

Bowel sounds diminished or hyperactive (diarrhea)

FOOD/FLUID

May report: Loss of appetite; nausea/vomiting

Not following diet; increased intake of glucose/carbohydrates

Weight loss over a period of days/weeks

Thirst

Use of medications exacerbating dehydration, such as diuretics

May exhibit: Dry/cracked skin, poor skin turgor

Abdominal rigidity/distension

Thyroid may be enlarged (increased metabolic needs with increased blood sugar)

Halitosis/sweet, fruity odor (acetone breath)

NEUROSENSORY

May report: Fainting spells/dizziness

Headaches

Tingling, numbness, weakness in muscles

Visual disturbances

May exhibit: Confusion/disorientation; drowsiness, lethargy, stupor/coma (later stages)

Memory impairment (recent, remote)

Deep tendon reflexes (DTRs) decreased (coma)

Seizure activity (late stages of DKA or hypoglycemia)

PAIN/DISCOMFORT

May report: Abdominal bloating/pain (mild/severe)

May exhibit: Facial grimacing with palpation; guarding

RESPIRATION

May report: Air hunger (late stages of DKA)

Cough, with/without purulent sputum (infection)

May exhibit: Increased respiratory rate (tachypnea); deep, rapid (Kussmaul’s) respirations (metabolic acidosis)

Rhonchi, wheezes

Yellow or green sputum (infection)

SAFETY

May report: Dry, itching skin; skin ulcerations

Paresthesia (diabetic neuropathy)

May exhibit: Fever, diaphoresis

Skin breakdown, lesions/ulcerations

Decreased general strength/ROM

Weakness/paralysis of muscles, including respiratory musculature (if potassium levels are markedly decreased)

SEXUALITY

May report: Vaginal discharge (prone to infection)

Problems with impotence (men); orgasmic difficulty (women)

TEACHING/LEARNING

May report: Familial risk factors: diabetes mellitus (DM), heart disease, strokes, hypertension

Slow/delayed healing

Use of drugs, e.g., steroids, thiazide diuretics, phenytoin (Dilantin), and phenobarbital (can increase glucose levels)

May/may not be taking diabetic medications as ordered

Discharge plan DRG projected mean length of inpatient stay: 5.9 days

considerations: May need assistance with dietary regimen, medication administration/supplies, self-care, glucose monitoring

Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

Serum glucose: Increased 200–1000 mg/dL or more.

Serum acetone (ketones): Strongly positive.

Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

Serum osmolality: Elevated but usually less than 330 mOsm/L.

Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.

Glycosylated hemoglobin (HbA_1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.

Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.

Electrolytes:

Sodium: May be normal, elevated, or decreased.

Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.

Phosphorus: Frequently decreased.

Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO₃ (metabolic acidosis) with compensatory respiratory alkalosis.

CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal perfusion).

Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.

Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.

Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.

Cultures and sensitivities: Possible UTI, respiratory or wound infections.

NURSING PRIORITIES

1. Restore fluid/electrolyte and acid-base balance.

2. Correct/reverse metabolic abnormalities.

3. Identify/assist with management of underlying cause/disease process.

4. Prevent complications.

5. Provide information about disease process/prognosis, self-care, and treatment needs.

DISCHARGE GOALS

1. Homeostasis achieved.

2. Causative/precipitating factors corrected/controlled.

3. Complications prevented/minimized.

4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.

5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Fluid Volume deficient [specify] May be related to Osmotic diuresis (from hyperglycemia) Excessive gastric losses: diarrhea, vomiting Restricted intake: nausea, confusion Possibly evidenced by Increased urinary output, dilute urine Weakness; thirst; sudden weight loss Dry skin/mucous membranes, poor skin turgor Hypotension, tachycardia, delayed capillary refill DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Fluid Balance (NOC) Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.

ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) Independent Obtain history from patient/SO related to duration/intensity of symptoms such as vomiting, excessive urination. Monitor vital signs: Note orthostatic BP changes; Respiratory pattern, e.g., Kussmaul’s respirations, acetone breath; Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis; Temperature, skin color/moisture.

RATIONALE Assists in estimation of total volume depletion. Symptoms may have been present for varying amounts of time (hours to days). Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses. Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when patient’s systolic BP drops more than 10 mm Hg from a recumbent to a sitting/standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate. Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Acetone breath is due to breakdown of acetoacetic acid and should diminish as ketosis is corrected. Correction of hyperglycemia and acidosis will cause the respiratory rate and pattern to approach normal. In contrast, increased work of breathing; shallow, rapid respirations; and presence of cyanosis may indicate respiratory fatigue and/or that patient is losing ability to compensate for acidosis. Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin may reflect dehydration.

ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) Independent Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Monitor I&O; note urine specific gravity. Weigh daily. Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed. Promote comfortable environment. Cover patient with light sheets. Investigate changes in mentation/sensorium. Collaborative Administer fluids as indicated: Isotonic (0.9%) or lactated Ringer’s solution without additives; Albumin, plasma, dextran. Insert/maintain indwelling urinary catheter. Monitor laboratory studies, e.g.: Hct; BUN/creatinine (Cr); Serum osmolality;

RATIONALE Indicators of level of hydration, adequacy of circulating volume. Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. Provides the best assessment of current fluid status and adequacy of fluid replacement. Maintains hydration/circulating volume. Avoids overheating, which could promote further fluid loss. Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose patient to aspiration. Type and amount of fluid depend on degree of deficit and individual patient response. Note: Patients with DKA often severely dehydrated and commonly need 5–10 L of isotonic saline (2–3 L within first 2 hr of treatment). Plasma expanders may occasionally be needed if the deficit is life-threatening/BP does not normalize with rehydration efforts. Provides for accurate/ongoing measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder (urinary retention/overflow incontinence). May be removed when patient is stable to reduce risk of infection. Assesses level of hydration and is often elevated because of hemoconcentration associated with osmotic diuresis. Elevated values may reflect cellular breakdown from dehydration or signal the onset of renal failure. Elevated because of hyperglycemia and dehydration.

ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) Collaborative Sodium; Potassium. Administer potassium and other electrolytes via IV and/or by oral route as indicated. Administer bicarbonate if pH is less than 7.1. Insert NG tube and attach to suction as indicated.

RATIONALE May be decreased, reflecting shift of fluids from the intracellular compartment (osmotic diuresis). High sodium values reflect severe fluid loss/dehydration or sodium reabsorption in response to aldosterone secretion. Initially, hyperkalemia occurs in response to metabolic acidosis, but as this potassium is lost in the urine, the absolute potassium level in the body is depleted. As insulin is replaced and acidosis is corrected, serum potassium deficit becomes apparent. Potassium should be added to the IV (as soon as urinary flow is adequate) to prevent hypokalemia. Note: Potassium phosphate may be drug of choice when IV fluids contain sodium chloride in order to prevent chloride overload. Given with caution to help correct acidosis in the presence of hypotension or shock, lactic acidosis, or severe hyperkalemia. Decompresses stomach and may relieve vomiting.

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements May be related to Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism) Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process Possibly evidenced by Increased urinary output, dilute urine Reported inadequate food intake, lack of interest in food Recent weight loss; weakness, fatigue, poor muscle tone Diarrhea Increased ketones (end product of fat metabolism) DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status (NOC) Ingest appropriate amounts of calories/nutrients. Display usual energy level. Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.

ACTIONS/INTERVENTIONS Hyperglycemia Management (NIC) Independent Weigh daily or as indicated. Ascertain patient’s dietary program and usual pattern; compare with recent intake. Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food. Maintain nothing by mouth (NPO) status as indicated. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to more solid food as tolerated. Identify food preferences, including ethnic/cultural needs. Include SO in meal planning as indicated. Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. Collaborative Perform fingerstick glucose testing.

RATIONALE Assesses adequacy of nutritional intake (absorption and utilization). Identifies deficits and deviations from therapeutic needs. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function (distension or ileus), affecting choice of interventions. Note: Long-term difficulties with decreased gastric emptying and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment. Oral route is preferred when patient is alert and bowel function is restored. If patient’s food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge. Promotes sense of involvement; provides information for SO to understand nutritional needs of patient. Note: Various methods available or dietary planning include exchange list, point system, glycemic index, or preselected menus. Once carbohydrate metabolism resumes (blood glucose level reduced) and as insulin is being given, hypoglycemia can occur. If patient is comatose, hypoglycemia may occur without notable change in level of consciousness (LOC). This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished. Bedside analysis of serum glucose is more accurate (displays current levels) than monitoring urine sugar, which is not sensitive enough to detect fluctuations in serum levels and can be affected by patient’s individual renal threshold or the presence of urinary retention/renal failure. Note: Some studies have found that a urine glucose of 20% may be correlated to a blood glucose of 140–360 mg/dL.

ACTIONS/INTERVENTIONS Hyperglycemia Management (NIC) Collaborative Monitor laboratory studies, e.g., serum glucose, acetone, pH, HCO3. Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a continuous drip via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr. Administer glucose solutions, e.g., dextrose and half-normal saline. Consult with dietitian for initiation of resumption of oral intake. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/snacks. Administer other medications as indicated, e.g., metoclopramide (Reglan); tetracycline.

RATIONALE Blood glucose will decrease slowly with controlled fluid replacement and insulin therapy. With the administration of optimal insulin dosages, glucose can then enter the cells and be used for energy. When this happens, acetone levels decrease and acidosis is corrected. Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia. Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia. Useful in calculating and adjusting diet to meet patient’s needs; answer questions and assist patient/SO in developing meal plans. Complex carbohydrates (e.g., corn, peas, carrots, broccoli, dried beans, oats, apples) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics (e.g., peak effect) and individual patient response. Note: A snack at bedtime (hs) of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients.

NURSING DIAGNOSIS: Infection, risk for [sepsis] Risk factors may include High glucose levels, decreased leukocyte function, alterations in circulation Preexisting respiratory infection, or UTI Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Infection Control (NOC) Identify interventions to prevent/reduce risk of infection. Demonstrate techniques, lifestyle changes to prevent development of infection.

ACTIONS/INTERVENTIONS Infection Control (NIC) Independent Observe for signs of infection and inflammation, e.g., fever, flushed appearance, wound drainage, purulent sputum, cloudy urine. Promote good handwashing by staff and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance/site care. Rotate IV sites as indicated. Provide catheter/perineal care. Teach the female patient to clean from front to back after elimination. Provide conscientious skin care; gently massage bony areas. Keep the skin dry, linens dry and wrinkle-free. Auscultate breath sounds. Place in semi-Fowler’s position. Reposition and encourage coughing/deep breathing if patient is alert and cooperative. Otherwise, suction airway, using sterile technique, as needed. Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in proper handling of secretions. Encourage/assist with oral hygiene. Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or renal dysfunction), including 8 oz of cranberry juice per day as appropriate. Collaborative Obtain specimens for culture and sensitivities as indicated. Administer antibiotics as appropriate.

RATIONALE Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. Reduces risk of cross-contamination. High glucose in the blood creates an excellent medium for bacterial growth. Minimizes risk of UTI. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract/vaginal yeast infections. Peripheral circulation may be impaired, placing patient at increased risk for skin irritation/breakdown and infection. Rhonchi indicate accumulation of secretions possibly related to pneumonia/bronchitis (may have precipitated the DKA). Pulmonary congestion/edema (crackles) may result from rapid fluid replacement/HF. Facilitates lung expansion; reduces risk of aspiration. Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection. Minimizes spread of infection. Reduces risk of oral/gum disease. Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity, reducing bacteria growth and flushing organisms out of system. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall, reducing the risk of recurrent UTI. Identifies organism(s) so that most appropriate drug therapy can be instituted. Early treatment may help prevent sepsis.

NURSING DIAGNOSIS: Sensory Perception, risk for disturbed (specify) Risk factors may include Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance Possibly evidenced by [Not applicable; presence of signs and symptoms establishes and actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Neurological Status (NOC) Maintain usual level of mentation. Recognize and compensate for existing sensory impairments.

ACTIONS/INTERVENTIONS Neurological Monitoring (NIC) Independent Monitor vital signs and mental status. Address patient by name; reorient as needed to place, person, and time. Give short explanations, speaking slowly and enunciating clearly. Schedule nursing time to provide for uninterrupted rest periods. Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. Protect patient from injury (avoid/limit use of restraints as able) when level of consciousness is impaired. Place bed in low position. Pad bed rails and provide soft airway if patient is prone to seizures. Evaluate visual acuity as indicated. Investigate reports of hyperesthesia, pain, or sensory loss in the feet/legs. Look for ulcers, reddened areas, pressure points, loss of pedal pulses.

RATIONALE Provides a baseline from which to compare abnormal findings, e.g., fever may affect mentation. Decreases confusion and helps maintain contact with reality. Promotes restful sleep, reduces fatigue, and may improve cognition. Helps keep patient in touch with reality and maintain orientation to the environment. Disoriented patient is prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration. Retinal edema/detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care. Peripheral neuropathies may result in severe discomfort, lack of/distortion of tactile sensation, potentiating risk of dermal injury and impaired balance. Note: Mononeuropathy affects a single nerve (most often femoral or cranial), causing sudden pain and loss of motor/sensory function along affected nerve path.

ACTIONS/INTERVENTIONS Neurological Monitoring (NIC) Independent Provide bed cradle. Keep hands/feet warm, avoiding exposure to cool drafts/hot water or use of heating pad. Assist with ambulation/position changes. Collaborative Carry out prescribed regimen for correcting DKA as indicated. Monitor laboratory values, e.g., blood glucose, serum osmolality, Hb/Hct, BUN/Cr.

RATIONALE Reduces discomfort and potential for dermal injury. Note: Sudden development of cold hands/feet may reflect hypoglycemia, suggesting need to evaluate serum glucose level. Promotes patient safety, especially when sense of balance is affected. Alteration in thought processes/potential for seizure activity is usually alleviated once hyperosmolar state is corrected. Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication).

NURSING DIAGNOSIS: Fatigue May be related to Decreased metabolic energy production Altered body chemistry: insufficient insulin Increased energy demands: hypermetabolic state/infection Possibly evidenced by Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone Impaired ability to concentrate, listlessness, disinterest in surroundings DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL Endurance (NOC) Verbalize increase in energy level. Display improved ability to participate in desired activities.

ACTIONS/INTERVENTIONS Energy Management (NIC) Independent Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue. Alternate activity with periods of rest/uninterrupted sleep. Monitor pulse, respiratory rate, and BP before/after activity.	RATIONALE Education may provide motivation to increase activity level even though patient may feel too weak initially. Prevents excessive fatigue. Indicates physiological levels of tolerance.
ACTIONS/INTERVENTIONS Energy Management (NIC) Independent Discuss ways of conserving energy while bathing, transferring, and so on. Increase patient participation in ADLs as tolerated.	RATIONALE Patient will be able to accomplish more with a decreased expenditure of energy. Increases confidence level/self-esteem and tolerance level. Note: Elderly patients may experience a “lag effect” in which exercise may precipitate hypoglycemia as late as 24 hr after exercising, leading to extensive fatigue and muscle tremors.

NURSING DIAGNOSIS: Powerlessness May be related to Long-term/progressive illness that is not curable Dependence on others Possibly evidenced by Reluctance to express true feelings; expressions of having no control/influence over situation Apathy, withdrawal, anger Does not monitor progress, nonparticipation in care/decision making Depression over physical deterioration/complications despite patient cooperation with regimen DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Health Beliefs: Perceived Control (NOC) Acknowledge feelings of helplessness. Identify healthy ways to deal with feelings. Assist in planning own care and independently take responsibility for self-care activities.

ACTIONS/INTERVENTIONS Self-Responsibility Facilitation (NIC) Independent Encourage patient/SO to express feelings about hospitalization and disease in general. Acknowledge normality of feelings. Assess how patient has handled problems in the past. Identify locus of control.

RATIONALE Identifies concerns and facilitates problem solving. Recognition that reactions are normal can help patient problem-solve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health/life. Knowledge of individual’s style helps determine needs for treatment goals. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors.

ACTIONS/INTERVENTIONS Self-Responsibility Facilitation (NIC) Independent Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful to patient. Ascertain expectations/goals of patient and SO. Determine whether a change in relationship with SO has occurred. Encourage patient to make decisions related to care, e.g., ambulation, time for activities, and so forth. Support participation in self-care and give positive feedback for efforts.

RATIONALE Enhances sense of being involved and gives SO a chance to problem-solve solutions to help patient prevent recurrence. Unrealistic expectations/pressure from others or self may result in feelings of frustration/loss of control and may impair coping abilities. Note: Even with rigid adherence to medical regimen, complications/setbacks may occur. Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns/visceral neuropathies affecting self-concept (especially sexual role function) may add further stress. Communicates to patient that some control can be exercised over care. Promotes feeling of control over situation.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge needs May be related to Lack of exposure/recall, information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions/request for information, verbalization of the problem Inaccurate follow-through of instructions, development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Diabetes Management (NOC) Verbalize understanding of disease process, potential complications. Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors. Correctly perform necessary procedures and explain reasons for the actions. Initiate necessary lifestyle changes and participate in treatment regimen.

ACTIONS/INTERVENTIONS Learning Facilitation (NIC) Independent Create an environment of trust by listening to concerns, being available. Work with patient in setting mutual goals for learning. Select a variety of teaching strategies, e.g., demonstrate needed skills and have patient do return demonstration, incorporate new skills into the hospital routine. Teaching: Disease Process (NIC) Discuss essential elements, e.g: What the normal blood glucose range is and how it compares with patient’s level, the type of DM patient has, the relationship between insulin deficiency and a high glucose level; Reasons for the ketoacidotic episode; Acute and chronic complications of the disease, including visual disturbances, neurosensory and cardiovascular changes, renal impairment/hypertension. Demonstrate fingerstick testing, or similar monitoring system, and have patient/SO return demonstration until proficient. Instruct patient to check urine ketones if glucose is higher than 250 mg/dL. Discuss dietary plan, limiting intake of sugar, fat, salt, and alcohol; eating complex carbohydrates, especially those high in fiber (fruits, vegetables, whole grains); and ways to deal with meals outside the home. Review medication regimen, including onset, peak, and duration of prescribed insulin, as applicable, with patient/SO.

RATIONALE Rapport and respect need to be established before patient will be willing to take part in the learning process. Participation in the planning promotes enthusiasm and cooperation with the principles learned. Use of different means of accessing information promotes learner retention. Provides knowledge base from which patient can make informed lifestyle choices. Knowledge of the precipitating factors may help avoid recurrences. Awareness helps patient be more consistent with care and may prevent/delay onset of complications. Self-monitoring of blood glucose four or more times a day allows flexibility in self-care, promotes tighter control of serum levels (e.g., 60–150 mg/dL), and may prevent/delay development of long-term complications. Note: Various new devices have been released or are in testing. Some use a laser perforator instead of a sharp lancet, others are bloodless. In addition to glucose levels, several devices can measure glocosylated albumin (fructosamine) in the home, providing a measure of blood glucose control over the past 7–10 days. Medical nutrition therapy for diabetes encourages patient to make meal choices based on individual unique needs and preferences. Awareness of importance of dietary control aids patient in planning meals/sticking to regimen. Fiber can slow glucose absorption, decreasing fluctuations in serum levels, but may cause GI discomfort, increase flatus, and affect vitamin/mineral absorption. Understanding all aspects of drug usage promotes proper use. Dose algorithms are created, taking into account drug dosages established during inpatient evaluation, usual amount and schedule of physical activity, and meal plan. Including SO provides additional support/resource for patient.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Review self-administration of insulin and care of equipment. Have patient demonstrate procedure (e.g., drawing up and injecting insulin, insulin pen technique, or use of continuous pump). Discuss timing of insulin injection and mealtime. Review individual’s target blood glucose levels. Stress importance and necessity of maintaining diary of glucose testing, medication dose/time, dietary intake, activity, feelings/sensations, life events. Discuss factors that play a part in diabetic control, e.g., exercise (aerobic versus isometric), stress, surgery, and illness. Review “sick day” rules.

RATIONALE Verifies understanding and correctness of procedure. Identifies potential problems (e.g., vision, memory, and so on) so that alternative solutions can be found for insulin administration. Note: If multiple daily injections are required, combinations of regular, intermediate, and long-acting insulin are used. If the pump method is used, patient programs his or her own basal and bolus settings. Only regular insulin is administered, with a basal dose throughout the day and bolus doses before meals and as needed. An insulin pump more closely mimics normal pancreatic activity because the basal rate may be changed relative to patient’s activity level, presence of stressors/infection or menstrual cycle. One of the many inconveniences people with diabetes cope with is having to decide at least 30–60 min in advance when they are going to have a meal for the timely administration of regular Humulin injections. A newer product, insulin lispro (Humalog), may be helpful because it works best when taken within 15 min of eating. With the onset twice as fast as regular human insulin and a duration approximately half as long, Humalog closely mimics pancreatic activity. However, hypoglycemia may develop more rapidly and be more severe than with use of regular insulin. A blood glucose level below 80 mg/dL indicates that insulin should be injected after eating rather than before the meal. Although this range varies per person, the ideal range for the adult diabetic is considered to be 80–120 mg/dL. Note: Patients with an insulin pump may maintain blood glucose levels between 120 mg/dL and 200 mg/dL with no urinary ketones. Aids in creating overall picture of patient situation to achieve better disease control, and promotes self-care/independence. This information promotes diabetic control and can greatly reduce the occurrence of ketoacidosis. Note: Aerobic exercise (e.g., walking, swimming) promotes effective use of insulin, lowering glucose levels, and strengthens the cardiovascular system. A “sick day” management plan helps maintain equilibrium during illness, minor surgery, severe emotional stress, or any condition that might send glucose spiraling upward.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Review effects of smoking on insulin use. Encourage cessation of smoking. Establish regular exercise/activity schedule and identify corresponding insulin concerns. Identify the symptoms of hypoglycemia (e.g., weakness, dizziness, lethargy, hunger, irritability, diaphoresis, pallor, tachycardia, tremors, headache, changes in mentation) and explain causes. Instruct in importance of routine examination of the feet and proper foot care. Demonstrate ways to examine feet; inspect shoes for fit; and care for toenails, calluses, and corns. Encourage use of natural fiber stockings. Demonstrate/discuss proper use of transcutaneous electrical nerve stimulator (TENS) unit. Identify safety concerns following local nerve block. Stress importance of regular eye examinations, especially for patients who have had type 1 diabetes for 5 yr or more. Arrange for vision aids when needed, e.g., magnifying sleeve for insulin syringe, large-print instructions, one-touch/talking glucose meters.

RATIONALE Nicotine constricts the small blood vessels, and insulin absorption is delayed for as long as these vessels remain constricted. Note: Insulin absorption may be reduced by as much as 30% below normal in the first 30 min after smoking. Exercise times should not coincide with the peak action of insulin. A snack should be ingested before or during exercise as needed, and rotation of injection sites should avoid the muscle group that will be used in the activity (e.g., abdominal site is preferred over thigh/arm before jogging or swimming) to prevent accelerated uptake of insulin. May promote early detection and treatment, preventing/limiting occurrence. (However, approximately 30% of insulin-dependent patients are asymptomatic when hypoglycemic.) Note: Early morning hyperglycemia may reflect the “dawn phenomenon” (indicating need for additional insulin) or a rebound response to hypoglycemia during sleep (Somogyi effect), requiring a decrease in insulin dosage/change in diet (e.g., hs snack). Testing serum levels at 3 am aids in identifying the specific problem. Prevents/delays complications associated with peripheral neuropathies and/or circulatory impairment, especially cellulitis, gangrene, and amputation. Note: Studies show that approximately 15% of all patients with diabetes will develop a foot or leg ulcer during the course of the disease. Also 50% of all nontraumatic lower extremity amputations occur in people with diabetes. Prevention is therefore critical. May provide relief of discomfort associated with neuropathies. Changes in vision may be gradual and are more pronounced in persons with poorly controlled DM. Problems include changes in visual acuity and may progress to retinopathy and blindness. Adaptive aids have been developed in recent years to help the visually impaired manage their own DM more effectively.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Discuss sexual functioning and answer questions patient/SO may have. Stress importance of use of identification bracelet. Recommend avoidance of over-the-counter (OTC) drugs without prior approval of healthcare provider. Discuss importance of follow-up care. Review signs/symptoms requiring medical evaluation, e.g., fever; cold or flu symptoms; cloudy, odorous urine, painful urination; delayed healing of cuts/sores; sensory changes (pain or tingling) of lower extremities; changes in blood sugar level, presense of ketones in urine. Identify community resources, e.g., American Diabetic Association, Internet resources/online diabetes bulletin boards, visiting nurse, weight-loss/stop-smoking clinic, contact person/diabetic instructor.

RATIONALE Impotence may be first symptom of onset of DM. Note: Counseling and/or use of penile prosthesis may be of benefit. Can promote quick entry into the health system and appropriate care with fewer resultant complications in the event of an emergency. These products may contain sugars/interact with prescribed medications. Helps maintain tighter control of disease process and may prevent exacerbations of DM, retarding development of systemic complications. Prompt intervention may prevent development of more serious/life-threatening complications. Continued support is usually necessary to sustain lifestyle changes and promote well-being.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)

Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, economic concerns, perceived susceptibility (recurrence of problem).

Sensory Perception, disturbed: diabetic neuropathy/visual—endogenous chemical alternations (elevated glucose level).