Unit 4 Discussion 1- Diabetes Management. Due 29. 1000w. 4 references
You are seeing a 64-year-old Hispanic male for his diabetes management. He reports that his morning capillary blood sugar readings are ranging in the 150 to 190 range.
· Last month his Hgb A1C was 7.4
· He is on Metformin 1000mg twice a day and Glipizide 5mg daily.
· He walks a couple miles three to five times a week.
· A dietary review reveals that his daily total carbohydrate intake is in the range of 75 to 100 grams.
· Last eye exam did not reveal any problems. He wears reading glasses when needed.
· He does report some intermittent burning sensation in his feet.
· Ht 6’2”, Wt 200 lbs, BP 118/72, P 72, R 17
· Heart regular rhythm, without murmur or gallop
· Lungs clear
· Monifilament testing does not reveal any decreased sensation in the feet
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.
Initial Post
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note ( Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Subjective (S):
The patient is a 64-year-old Hispanic male who came to the clinic for diabetes management.
His capillary blood sugar readings in the mornings were reported to range from 150-190, and
last month, his Hgb A1C. He lives a healthy lifestyle and walks a couple of miles three to five
times a week. His dietary review showed that his daily total carbohydrate intake is 75 to 100
grams, and his last eye exam was normal, but he wears reading glasses when needed. He
reports that he has some intermittent burning sensations in his feet. He is a known type II
diabetic, and he is on Metformin 1000 mg BID and glipizide 5 mg daily.
Objective (O):
His vital signs were BP 118/72, P 72, R 17, Ht. 6’2”, and Wt. 200 lbs. His cardiovascular
exam revealed a regular rhythm, with no murmur or gallop. He had clear lung sounds, and
monofilament testing did not reveal any decreased sensations in the feet.
Assessment (A):
Uncontrolled diabetes mellitus with hyperglycemia
Plan (P):
Therapeutics: Goyal & Jialal (2018) highlighted that the goal of the therapy is to achieve a
HbA1C of less than or equal to 7.0% and prevent other organs damage or progression of the
damage. The patient is already on metformin and glipizide combined therapy, and he is
already having symptoms of diabetic neuropathy. I would consider increasing the current
metformin dosage to 1500 mg BID and revisiting the clinic after 14 days, where a HbA1C
will be rechecked. The patient will be started on gabapentin or pregabalin to control the
discomfort for the burning sensations in the feet.
Educational: The patient will be educated on the importance of continuing to exercise and
continue his sugar and carbohydrate intake monitoring since he is overweight and some of the
side effects of sulfonylureas are weight gain. The patient will be educated on the importance
of continuous glucose monitoring. According to Kirwan et al. (2017), exercise and diet are
very important in managing type 2 diabetes mellitus.
Consultation/Collaboration: The patient will be referred to a dietician and will require an
endocrine consultation if the blood sugar continues to elevate.
Chief Complaint- Diabetes Management
HPI- 64 yo Hispanic male presents for a visit for diabetes management. His morning capillary
blood sugar reading has been ranging 150-190. His Hgb A1C was 7.4 last month. His daily total
carbohydrate intake is 75 to 100 grams.
PMH
Diabetes
Allergies- Unknown
Medications
Metformin 1000mg BID
Glipizide 5mg daily
Social History
He walks a couple miles three to five times per week.
Family History-Unknown
ROS:
HEENT- He wears reading glasses when needed.
PV-Reports intermittent burning sensation in his feet
Health Promotion- Last eye exam did not reveal any problems. He wears reading glasses when
needed.
Physical Exam:
VS: BP 118/72, P 72, R 17, Ht 6’2”, Wt 200 lbs, BMI 25.7
Cardiac: Heart regular rhythm, no murmur or gallop
Respiratory: Lungs clear
PV: Monifilament testing does not reveal any decreased sensation in the feet
Assessment
1. E11.65 Diabetes Mellitus with hyperglycemia
Plan
Diagnostics Recommendations per ( Practice Guidelines for Family Nurse Practitioners,2020).
Fasting complete chemistry panel and lipid profile if indicated
Therapeutics Recommendations per ( Practice Guidelines for Family Nurse Practitioners,2020).
Discuss treatment goals and plan
Review food plan and carbohydrate counting
Discuss exercise and weight reduction plan; weight loss is indicated if BMI >25 kg/m
Address possible causes of noninsulin agent failures before altering treatment
Based upon shared decision making, adjust Glipizide to extended release (Glucotrol XL)
10 mg daily or maintain immediate-release, but increase dose to Glipizide 10mg daily.
Dose adjustments of Glipizide based on blood glucose should not be done more
frequently than every 7 days.
May consider addition of third agent (oral or insulin) if blood glucose goals aren’t
reached ( Practice Guidelines for Family Nurse Practitioners,2020).
Education Recommendations per ( Practice Guidelines for Family Nurse Practitioners,2020).
Notify the provider if there are any changes by the patient in the treatment plan; problems
with adherence or medication dose adjustments
Symptoms suggesting development of complications of DM and hypo/hyperglycemia
symptoms
Tips for effective SMBG; 1 or 2hr PP testing may be helpful 2 to 3 times per week to
allow patient to see the effects of a particular type of food on blood glucose levels, record
all test results so a day-to-day comparison can be made, the patient should know how to
respond appropriately to SMBG results by making adjustments in the diet
Possible causes of noninsulin agent failures (overeating at night, poor compliance, stress,
inadequate drug dosage, decreasing beta-cell function or increasing insulin resistance
Taking an “extra” dose to cover excess food intake is ineffective and may be harmful
Diet management is of utmost importance; poor eating habits will lessen or negate efforts
to achieve lower blood glucose levels
o Promote and support healthy eating habits (nutrient-dense foods and portions)
o Provide adequate calories to achieve and maintain healthy body weight
o Eat three balanced meals qd, 4 to 5 hours apart
o Include a bedtime snack
o Avoid high-sugar foods and drinks
o Appropriate adjustments for hyperglycemia, hypoglycemia, illness, and exercise
Pre-prandial blood glucose goals should be 70 to 130 mg/dL unless otherwise specified
Address cultural considerations; disease management, insulin use, treatment goals
Insulin may eventually be required for patients who are not controlled on oral agents
Recommend PPSV23 to all patients with DM 2-64 years of age ( Practice Guidelines for
Family Nurse Practitioners,2020).
Consultation/Collaboration Recommendations per ( Practice Guidelines for Family Nurse
Practitioners,2020).
Diabetes Education Program
Follow-up office visit in 3 months
Endocrinologist if unable to obtain glycemic control ( Practice Guidelines for Family
Nurse Practitioners,2020).
References
Cash, J., & Glass, C. (2018). Family Practice Guidelines. 4th ed. Springer Publishing. (Version
6.8.4625) [Mobile App].
Fenstermacher, K., & Hudson, B. T. (2020). Practice Guidelines for Family Nurse Practitioners
(5th ed.). Elsevier.
CHAPTER 82 Diabetes Mellitus
Management
Diabetes mellitus is a metabolic disorder
resulting from either an inadequate production
of insulin (type 1) or an inability of the body’s
cells to respond to insulin that is present (type 2).
Type 1 diabetes mellitus is an autoimmune
dysfunction involving the destruction of beta
cells, which produce insulin in the islets of
Langerhans of the pancreas. Immune system
cells and antibodies are present in circulation
and can also be triggered by certain genetic
tissue types or viral infections.
Type 2 diabetes mellitus is a progressive
condition due to increasing inability of cells
to respond to insulin (insulin resistance) and
decreased production of insulin by the beta
cells. It is linked to obesity, sedentary lifestyle,
and heredity. Metabolic syndrome often
precedes type 2 diabetes mellitus.
Diabetes mellitus has wide ranging systemic
effects and is a contributing factor to
development of cardiovascular disease,
hypertension, kidney disease, neuropathy,
retinopathy, peripheral vascular disease,
and stroke.
Diabetes mellitus is significantly more prevalent
in African American, Native American, and
Hispanic populations and is more common in
males than females.
HEALTH PROMOTION AND
DISEASE PREVENTION
●● Diabetes mellitus type 1 cannot be prevented. Lifestyle
modifications can reduce the risk of diabetes mellitus
type 2, and minimize the risk of complications for
clients who develop diabetes mellitus.
●● Try to maintain weight appropriate for body build
and height.
Diabetic screening
●● Screen clients who have a BMI above 25 and one or more
of these factors.
◯◯ A first-degree relative who has diabetes mellitus
◯◯ Age 45 years or older
◯◯ Report of sedentary lifestyle
◯◯ History of vascular disease, polycystic ovary
syndrome, gestational diabetes, or giving birth to an
infant weighing more than 9 lb
◯◯ Reports African, Hispanic, Asian, American Indian, or
Pacific Islander heritage
◯◯ Has a blood pressure consistently greater than
140/90 mm Hg
◯◯ HgA1C greater than 5.7%, impaired fasting glucose, or
impaired glucose tolerance
◯◯ HDL level less than 35 mg/dL or triglyceride level
greater than 250 mg/dL
●● Screening is done with fasting blood glucose levels or
glycosylated hemoglobin (A1C).
CLIENT EDUCATION
●● Exercise and good nutrition are necessary for preventing
or controlling diabetes.
◯◯ Carbohydrates: 45% of total daily intake
◯◯ Protein: 15% to 20% of total daily intake, depending
upon kidney function
◯◯ Unsaturated and polyunsaturated fats: 20% to 35% of
total daily intake
●● Consistency in the amount of food consumed and
regularity in meal times promotes blood glucose control.
●● Consume a diet low in saturated fats to decrease
low‑density lipoprotein (LDL), assist with weight loss
for secondary prevention of diabetes, and reduce risk of
heart disease.
●● Modify the diet to include sources of omega‑3 fatty
acids and fiber to lower cholesterol, improve blood
glucose for clients who have diabetes, for secondary
prevention of diabetes, and to reduce the risk of
heart disease.
●● Perform physical activity at least three times per week
(150 min/week).
ASSESSMENT
Clients are considered to have prediabetes when the
glucose level is above the expected range and below levels
that indicate diabetes mellitus (impaired fasting glucose
or impaired glucose tolerance).
RIS K FACTORS
Metabolic syndrome
The presence of at least three factors that increase the
client’s risk for cardiovascular events and developing
diabetes mellitus type 2.
●● Central obesity: waist circumference greater than
100 cm (40 in) for males; greater than 88 cm (35 in)
for females
●● Hyperlipidemia: triglyceride level greater than
150 mg/dL or taking medication for triglycerides;
decreased HDL level (less than 50 mg/dL for females;
less than 40 mg/dL for males)
●● Blood pressure consistently greater than 130 mm Hg
systolic, or 85 mm Hg diastolic; taking medication for
hypertension
●● Hyperglycemia (fasting blood glucose at or greater than
100 mg/dL, or taking medication for hyperglycemia)
Insulin resistance: Impaired fasting glucose levels
100 to 125 mg/dL, impaired glucose tolerance 140 mg/dL,
or A1C level 5.7% to 6.4%
Pancreatitis and Cushing’s syndrome: Secondary causes
of diabetes
Age
●● Older adult clients might not be able to drive to the
provider’s office, grocery store, or pharmacy. Assess
support systems available for older adult clients.
●● Older adults are at risk for altered metabolism of
medication due to decreased kidney and liver function
because of the aging process.
●● Older adults can have vision alterations (yellowing
of lens, decreased depth perception, cataracts),
which can affect ability to read information and
administer mediation.
●● Vision and hearing deficits can interfere with the
understanding of teaching, reading of materials, and
preparation of medications.
●● Tissue deterioration secondary to aging can affect
the client’s ability to prepare food, care for self,
perform ADLs, perform foot/wound care, and perform
glucose monitoring.
●● A fixed income can mean that there are limited funds for
buying diabetic supplies, wound care supplies, insulin,
and medications. This can result in complications.
EXPECTE D FIN DINGS
Polyuria: Excess urine production and frequency from
osmotic diuresis
Polydipsia: Excessive thirst due to dehydration
●● Loss of skin turgor, skin warm and dry
●● Dry mucous membranes
●● Weakness and malaise
●● Rapid weak pulse and hypotension
Polyphagia: Excessive hunger and eating caused from
inability of cells to receive glucose (because of a lack
of insulin or cellular resistance to available insulin)
and the body’s use of protein and fat for energy (which
causes ketosis)
●● The client can display weight loss.
Kussmaul respirations: Increased respiratory rate and
depth in attempt to excrete carbon dioxide and acid due to
metabolic acidosis
Recurrent infections: Ask clients about the occurrence of
vaginal yeast infections
OTHER MANIFESTATIONS: Acetone/fruity breath odor
(due to accumulation of ketones), headache, nausea,
vomiting, abdominal pain, inability to concentrate,
fatigue, weakness, vision changes, slow healing of wounds,
decreased level of consciousness, seizures leading to coma
LA BORATOR Y TESTS
Diagnostic criteria for diabetes include two findings (on
separate days) of at least one of the following.
●● Manifestations of diabetes plus casual blood glucose
concentration greater than 200 mg/dL (without regard
to time since last meal)
●● Fasting blood glucose greater than 126 mg/dL (no caloric
intake within 8 hr of testing)
●● 2‑hr glucose greater than 200 mg/dL with oral glucose
tolerance test
●● Glycosylated hemoglobin (A1C) greater than 6.5%
Fasting blood glucose
NURSING ACTIONS: Postpone administration of
antidiabetic medication until after the level is drawn.
CLIENT EDUCATION: Fast (no food or drink other than
water) for the 8 hr prior to the blood test.
Oral glucose tolerance test
●● This test is often used to diagnose gestational diabetes
mellitus during pregnancy.
●● This is not generally used for routine diagnosis.
●● A fasting blood glucose level is drawn at the start of the
test. The client is then instructed to consume a specified
amount of glucose. Blood glucose levels are obtained
every 30 min for 2 hr. The clients must be assessed for
hypoglycemia throughout the procedure.
●● The fasting glucose should be less than 110 mg/d; less
than 180 mg/dL at 1 hr; and less than 140 mg/dL at 2 hr.
CLIENT EDUCATION
●● Consume a balanced diet for 3 days prior to the test.
Then, fast for 10 to 12 hr prior to the test.
●● Only water can be taken during the testing period. Food
or other liquids will affect the test results.
Glycosylated hemoglobin (HbA1c)
●● The expected reference range is 4% to 6%, but an
acceptable reference range for clients who have diabetes
can be 6.5% to 8%, with a target goal of less than 7%.
●● HbA1c is the best indicator of the average blood glucose
level for the past 120 days. It assists in evaluating
treatment effectiveness and compliance.
CLIENT EDUCATION
●● The test evaluates treatment effectiveness
and compliance.
●● The test is recommended quarterly or twice yearly
depending on the glycemic levels.
Urine ketones
●● Ketones accumulate in the blood due to breakdown of
fatty acids when insulin is not available.
●● High ketones in the urine associated with
hyperglycemia (exceed 300 mg/dL) is a
medical emergency.
Lipid profile
Obtain a baseline measurement at diagnosis, then every 1
to 2 years.
Other laboratory testing
C-peptide levels, autoantibodies for insulin, islet cells,
and glutamic acid decarboxylase
DIAGNOSTIC PROCE DURES
Self‑monitored blood glucose (SMBG)
NURSING ACTION: Ensure that the client follows the
proper procedure for blood sample collection and use of a
glucose meter. Supplemental short‑acting insulin can be
prescribed for elevated premeal glucose levels.
CLIENT EDUCATION
●● Check the accuracy of the strips with the control
solution provided.
●● Use the correct code number in the meter to match the
strip bottle number.
●● Store strips in the closed container in a dry location.
●● Obtain an adequate amount of blood sample when
preforming the test.
●● Perform appropriate hand hygiene.
●● Use fresh lancets, and avoid sharing glucose monitoring
equipment to prevent infection.
●● Keep a record of the SMBG that includes time, date,
blood glucose level, insulin dose, food intake, and
other events that can alter glucose metabolism (activity
level, illness).
MEDICATIONS
Antidiabetic medications are started at a low dose and
increased every few weeks until effective control or
maximum dosage is reached. Additional medications are
added as needed.
●● Insulin regimens are established for clients who have
type 1 diabetes mellitus.
◯◯ More than 1 type of insulin: rapid‑, short‑,
intermediate‑, and long‑acting
◯◯ Given one or more times a day based on blood
glucose results
●● Insulin can be required by some clients who have type 2
diabetes or gestational diabetes if glycemic control is not
obtained with diet, exercise, and oral hypoglycemic agents.
◯◯ Continuous infusion of insulin can be accomplished
using a small pump that is worn externally. The pump
is programmed to deliver insulin through a needle in
subcutaneous tissue. The needle should be changed at
least every 2 to 3 days to prevent infection.
◯◯ Complications of the insulin pump are accidental
cessation of insulin administration, obstruction of the
tubing/needle, pump failure, and infection.
●● Insulin pens are prefilled cartridges of 150 to 300 units of
insulin in a programmable device with disposable needles.
◯◯ Convenient for travel
◯◯ Used for clients who have vision impairment or
problems with dexterity
●● Oral antidiabetic medications are used, along with diet
and exercise, by clients who have type 2 diabetes to
regulate blood glucose.
Insulin
Also see the RN PHARMACOLOGY REVIEW MODULE:
CHAPTER 39: DIABETES MELLITUS .
A normally functioning pancreas releases insulin
continuously (basal) and as needed following carbohydrate
intake (prandial). Insulin therapy is prescribed to mimic
the pancreas.
Therapy can range from a single daily injection containing
an intermediate- to long-acting insulin, to two injections
daily with combination insulins, to an intense regime of
a basal insulin dose and subsequent injections for meal
intake and glucose levels.
Rapid‑acting insulin: Insulin lispro, insulin aspart,
insulin glulisine, inhaled human insulin
●● Administer before meals to control postprandial rise in
blood glucose.
●● Onset is rapid (10 to 30 min), depending on which
insulin is administered.
●● Administer in conjunction with intermediate‑ or
long‑acting insulin to provide glycemic control between
meals and at night.
Short‑acting insulin: Regular insulin
●● Administer 30 to 60 min before meals to control
postprandial hyperglycemia.
●● Regular insulin is available in two concentrations.
◯◯ U‑500 is reserved for the client who has insulin
resistance. It is never administered IV.
◯◯ U‑100 is prescribed for most clients and can be
administered IV.
Intermediate‑acting insulin: NPH insulin
●● Administered for glycemic control between meals
and at night
●● Not administered before meals to control postprandial
rise in blood glucose
●● Contains protamine (a protein), which causes a delay
in the insulin absorption or onset and extends the
duration of action of the insulin
●● Administered subcutaneous only and as the only insulin
to mix with short‑acting insulin
Long‑acting insulin: Insulin glargine, insulin detemir
●● Administer once daily, anytime during the day but
always at the same time each day.
●● Glargine insulin forms microprecipitates that dissolves
slowly over 24 hr and maintains a steady blood sugar
level with no peaks or troughs.
●● Insulin detemir has an added fatty‑acid chain that
delays absorption. Although it does not have a peak,
duration is dose‑dependent (12 to 24 hr).
●● Administer glargine insulin and insulin detemir
subcutaneous only. Never administer IV.
Ultra long-acting insulin: U-300 insulin glargine,
insulin degludec
●● Duration is longer than 24 hr.
●● Both medications are available only as a prefilled pen.
●● U-300 insulin glargine is three times more concentrated
than standard insulin glargine. It is useful for clients
who do not receive 24 hr effective glucose with the
standard concentration.
●● Insulin degludec comes in U-100 and U-200 concentrations.
NURSING ACTIONS
●● Observe the client perform self‑administration of
insulin, and offer additional instruction as indicated.
●● Monitor for hypoglycemic reactions (sweating,
weakness, dizziness, confusion, headache, tachycardia,
slurred speech) at insulin peak times.
●● Dosage can be adjusted when the client is scheduled for
procedures that require fasting.
CLIENT EDUCATION
●● Perform self‑administration of subcutaneous
insulin injections.
◯◯ Rotate injection sites (to prevent lipohypertrophy)
within one anatomic site (to prevent day‑to‑day
changes in absorption rates).
◯◯ Inject at a 90° angle (45° angle if the client is thin).
Aspiration for blood is not necessary.
◯◯ When mixing a rapid‑ or short‑acting insulin with
a longer‑acting insulin, draw up the shorter‑acting
insulin into the syringe first and then the
longer‑acting insulin. This reduces the risk of
introducing the longer‑acting insulin into the
shorter‑acting insulin vial.
●● Perform self-administration of inhaled human insulin.
◯◯ Cartridges containing the powdered insulin are
available in 4, 8, or 12 units.
◯◯ Use multiple cartridges if needed to administer the
prescribed dose.
●● Eat at regular intervals, avoid alcohol intake, and adjust
insulin to exercise and diet to avoid hypoglycemia.
●● Wear a medical identification wristband.
Oral antidiabetics
Biguanides: Metformin
●● Reduces the production of glucose by the liver
(gluconeogenesis)
●● Increases tissue sensitivity to insulin
●● Slows carbohydrate absorption in the intestines
NURSING ACTIONS
◯◯ Monitor significance of gastrointestinal (GI) effects
(flatulence, anorexia, nausea, vomiting).
◯◯ Monitor for lactic acidosis, especially in clients who
have kidney disorders or liver dysfunction.
◯◯ Stop medication for 24 to 48 hr before any type of
elective radiographic test with iodinated contrast dye
and restart 48 hr after (can cause lactic acidosis due
to acute kidney injury).
CLIENT EDUCATION
◯◯ Take with food to decrease adverse GI effects.
◯◯ Take vitamin B12 and folic acid supplements.
◯◯ Contact the provider if manifestations of lactic
acidosis develop (myalgia, sluggishness, somnolence,
and hyperventilation).
Second‑generation sulfonylureas: Glipizide,
glimepiride, glyburide
●● Stimulates insulin release from the pancreas causing a
decrease in blood sugar levels
●● Increases tissue sensitivity to insulin following
long‑term use
NURSING ACTIONS
◯◯ Monitor for hypoglycemia.
◯◯ Beta‑blockers can mask tachycardia typically seen
during hypoglycemia.
CLIENT EDUCATION
◯◯ Administer 30 min before meals.
◯◯ Monitor for hypoglycemia and report frequent
episodes to the provider.
◯◯ Avoid alcohol due to disulfiram effect.
◯◯ Avoid alcohol consumption while taking metformin to
reduce the risk for lactic acidosis.
Meglitinides: Repaglinide, nateglinide
●● Stimulates insulin release from pancreas
●● Administered for post‑meal hyperglycemia
NURSING ACTIONS: Monitor for hypoglycemia.
CLIENT EDUCATION
◯◯ Take within 30 min before meals.
◯◯ Omit the dose if skipped a meal to prevent
hypoglycemic crisis.
Thiazolidinediones: Pioglitazone
●● Reduces the production of glucose by the liver
(gluconeogenesis)
●● Increases tissue sensitivity to insulin
NURSING ACTIONS
◯◯ Monitor for fluid retention, especially in clients who
have a history of heart failure.
◯◯ Monitor for elevation of ALT, LDH, and
triglycerides levels.
◯◯ Monitor for hepatotoxicity.
CLIENT EDUCATION
◯◯ Report rapid weight gain, shortness of breath,
decreased exercise tolerance, jaundice, or dark urine.
◯◯ Use additional contraception methods because
the medication reduces the blood levels of oral
contraceptives and stimulate ovulation.
◯◯ Have liver function tests at baseline and every
3 to 6 months thereafter.
Alpha‑glucosidase inhibitors: Acarbose, miglitol
●● Slow carbohydrate absorption from the intestinal tract
●● Reduces post‑meal hyperglycemia
NURSING ACTIONS
◯◯ Monitor liver function every 3 months.
◯◯ Treat hypoglycemia with glucose, not table sugar
(prevents table sugar from breaking down).
●● CLIENT EDUCATION
◯◯ Have liver function tests performed every 3 months or
as prescribed.
◯◯ Take the medication with the first bite of each meal in
order for the medication to be effective.
◯◯ GI discomfort is common with these medications.
Dipeptidyl peptidase‑4 (DPP‑4) inhibitors: Sitagliptin,
saxagliptin, linagliptin, alogliptin
●● Augments naturally occurring intestinal incretin
hormones, which promote release of insulin and
decrease secretion of glucagon
●● Lowers fasting and postprandial glucose levels
●● Few adverse effects, but upper respiratory manifestations
(nasal and throat inflammation) and pancreatitis can occur.
CLIENT EDUCATION
◯◯ Report persistent upper respiratory manifestations.
◯◯ Report severe abdominal pain, with or without emesis.
◯◯ Medication only works when blood sugar is rising.
82.3 Insulin
Sodium‑glucose cotransporter 2 inhibitors: Canagliflozin,
dapagliflozin
●● Blocks reabsorption of glucose by kidneys, thus
increasing urinary glucose excretion so that glucose is
excreted in the urine
NURSING ACTIONS
◯◯ Monitor for development of urinary tract infections
and genital yeast infection.
◯◯ Monitor for postural hypotension in older adult clients,
especially if taking diuretics concurrently.
CLIENT EDUCATION
◯◯ Take the medication before the first meal of the day.
◯◯ Change positions slowly.
◯◯ Monitor and report genital burning, itching, or
increased drainage.
Non-insulin injectable medications
Incretin mimetic: Exenatide, liraglutide
●● Mimics the function of intestinal incretin hormone
by decreasing glucagon secretion, promoting insulin
release, and gastric emptying
●● Decreases insulin demand by reducing fasting and
postprandial hyperglycemia
NURSING ACTIONS
◯◯ Administer exenatide subcutaneously 60 min before
morning and evening meal.
◯◯ Monitor for gastrointestinal distress.
CLIENT EDUCATION
◯◯ Do not administer after a meal.
◯◯ Oral medications should never be taken within 1 hr of
oral exenatide or 2 hr after an injection of exenatide
because it will decrease effectiveness. Use caution,
particularly with oral contraceptives and antibiotics.
◯◯ Decreased appetite and weight loss can occur.
◯◯ Report severe abdominal pain, with or without emesis,
as a possible indication of pancreatitis.
Amylin mimetic: Pramlintide
●● A synthetic amylin hormone found in the beta cells
of the pancreas, suppresses glucagon secretion and
controls postprandial blood glucose levels
●● Used for clients who are taking insulin, to provide more
effective glucose control
●● The provider should reduce the premeal doses of rapidor
short‑acting insulins by 50% when pramlintide
therapy begins to reduce risk of hypoglycemia.
NURSING ACTIONS
◯◯ Administer subcutaneously immediately before each
major meal.
◯◯ Do not administer if client has hypoglycemia
unawareness, or noncompliance/poor adherence to
treatment regimens and self‑monitoring blood glucose.
CLIENT EDUCATION
◯◯ Monitor and report frequent periods of hypoglycemia.
◯◯ Administer the injection at least 5 cm (2 in) from any
insulin injection given at the same time. Monitor for
injection site reactions.
PATIENT‑CENTERED CARE
NURSING CARE
●● Monitor the following.
◯◯ Blood glucose levels and factors affecting levels
(other medications)
◯◯ I&O and weight
◯◯ Skin integrity and healing status of any wounds for
presence of recurrent infections (feet and folds of the
skin should be monitored)
◯◯ Sensory alterations (tingling, numbness)
◯◯ Visual alterations
◯◯ Dietary practices
◯◯ Exercise patterns
◯◯ SMBG skill proficiency
◯◯ Self‑medication administration proficiency
●● Adjustments to the client’s antidiabetic therapy might
be required if the client is placed NPO, on a clear liquid
diet, or is receiving enteral or parenteral nutrition.
Ensure clients who are prescribed clear liquids have
sufficient calorie intake.
◯◯ Clients who have diabetes mellitus type 1 will
need continued insulin administration while NPO
to prevent diabetic ketoacidosis. This can include
elimination of rapid-acting insulin but continuing to
provide a basal insulin dose.
◯◯ Monitor blood glucose levels consistently; the timing
should coincide with meal or intermittent feeding
administration.
◯◯ Short-acting insulin is often given at the time of
clear liquid meals or enteral feedings to prevent
hyperglycemia.
◯◯ Clients receiving continuous feeding (enteral or
parenteral) require blood glucose monitoring and
possible insulin injections at evenly spaced times
(every 6 hr).
●● Teach the client to follow facility policies or
recommendations of a podiatrist for nail care. Some
protocols allow for trimming toenails straight across
with clippers and filing edges with an emery board
or nail file to prevent soft tissue injury. If clippers or
scissors are contraindicated, the client should file the
nails straight across.
CLIENT EDUCATION
●● Practice appropriate techniques for SMBG, including
obtaining blood samples, recording and responding to
results, and correctly handling supplies and equipment.
●● Perform self‑administration of insulin.
●● Rotate injection sites to prevent lipohypertrophy
(increased swelling of fat) or lipoatrophy (loss of fat
tissue) within one anatomic site (prevents day‑to‑day
changes in absorption rates).
Foot care
CLIENT EDUCATION
●● Inspect feet daily. Wash feet daily with mild soap and
warm water. Test water temperature with the arms or a
thermometer before washing feet. Do not soak the feet.
●● Pat feet dry gently, especially between the toes, and
avoid lotions between toes to decrease excess moisture
and prevent infection.
●● Use mild foot powder (powder with cornstarch) on
sweaty feet.
●● Do not use commercial remedies for the removal of
calluses or corns, which can increase the risk for tissue
injury and infection.
●● Consult a podiatrist.
●● Separate overlapping toes with cotton or lamb’s wool.
●● Avoid open‑toe, open‑heel shoes. Leather shoes are
preferred to plastic. Wear shoes that fit correctly. Wear
slippers with soles. Do not go barefoot.
●● Wear clean, absorbent socks or stockings that are made
of cotton or wool and have not been mended. Wear
socks at night if the feet get cold.
●● Do not use hot water bottles or heating pads to warm
feet. Wear socks for warmth.
●● Avoid prolonged sitting, standing, and crossing of legs.
●● Cleanse cuts with warm water and mild soap, gently
dry, and apply a dry dressing. Monitor healing and seek
intervention promptly.
Nutritional guidelines
CLIENT EDUCATION
●● Consult a dietitian for collaborative education with the
client and family on meal planning to include food
intake, weight management, and lipid and glucose
management.
●● Plan meals to achieve appropriate timing of food intake,
activity, onset, and peak of insulin. Calories and food
composition should be similar each day. Eat at regular
intervals, and do not skip meals.
●● Count grams of carbohydrates consumed for
glycemic control.
●● 15 g carbohydrates is equal to 1 carbohydrate exchange.
●● Restrict calories and increase physical activity as
appropriate to facilitate weight loss (for clients who are
overweight or obese) or to prevent obesity.
●● Include fiber in the diet to increase carbohydrate
metabolism and to help control cholesterol levels.
●● Use artificial sweeteners. If caloric sweeteners are used,
add this to daily carbohydrate intake.
●● Read and interpret fat content information on food
labels. Reduce intake of saturated and trans fats.
Exercise
CLIENT EDUCATION
●● Only exercise when glucose levels are between 80 to
250 mg/dL; do not exercise if ketones are present in
the urine.
●● If more than 1 hr has passed since eating and
high‑intensity exercise is planned, consume a
carbohydrate snack first.
●● Wear comfortable shoes, and always carry identification
information regarding diabetic status.
●● Check blood glucose more often 24 hr after intensive
exercise; a reduced medication dose might be required.
Illness
CLIENT EDUCATION
●● Notify the provider when ill.
●● Monitor blood glucose every 2 to 4 hr.
●● Continue to take insulin or oral hypoglycemic agents.
●● Consume 8 to 12 oz (240 to 260 mL) of sugar‑free,
noncaffeinated liquid every hour to prevent dehydration.
If the blood glucose is below the prescribed range,
drinking fluids containing sugar is acceptable.
●● Meet carbohydrate needs through soft food (custard,
cream soup, gelatin, graham crackers) six to eight times
per day, if possible. If not, consume liquids equal to
usual carbohydrate content.
●● Test urine for ketones as prescribed and report to
provider if they are outside the expected reference
range. Testing is recommended every 3 to 4 hr or if the
blood glucose exceeds 240 mg/dL.
●● Rest.
●● Call the provider for the following.
◯◯ Presence of moderate to large urine ketones or
ketonuria for more than 24 hr
◯◯ Blood glucose greater than 250 mg/dL that does not
resolve with treatment
◯◯ Fever greater than 38.6° C (101.5° F), does not respond
to acetaminophen, or lasts more than 24 hr
◯◯ Feeling disoriented or confused
◯◯ Experiencing rapid breathing
◯◯ Persistent nausea, vomiting, or diarrhea
◯◯ Inability to tolerate liquids
◯◯ Illness that lasts longer than 2 days
INTERPROFESSIONAL CARE
Refer the client to a diabetes educator for comprehensive
education in diabetes management.
COMPLICATIONS
Consistent maintenance of blood glucose within the
expected reference range is the best protection against
the complications of diabetes mellitus. Expected reference
ranges can vary.
Cardiovascular and cerebrovascular disease
Hypertension, myocardial infarction, and stroke
NURSING ACTIONS
●● Ensure the client’s blood pressure is measured at each
visit; the target blood pressure is less than 140/90 mm
Hg, or less than 130/80 mm Hg for young adult clients.
●● Facilitate tobacco cessation.
●● Promote adherence to prescriptions for lipid-lowering
medications and aspirin.
CLIENT EDUCATION
●● Perform checks of cholesterol (HDL, LDL, and
triglycerides) yearly and HbA1c every 3 months.
●● Participate in regular activity for weight loss
and control.
●● Consume a diet of low‑fat meals that are high in fruits,
vegetables, and whole grains.
●● Report shortness of breath, headaches (persistent and
transient), swelling of feet, and infrequent urination.
Diabetic retinopathy
Impaired vision and blindness
CLIENT EDUCATION
●● Perform yearly eye exams to ensure the health of the
eyes and to protect vision.
●● Conduct management of blood glucose levels.
●● Hypoglycemia causes temporary blurred vision;
report other vision changes that do not fluctuate with
glucose levels.
Diabetic neuropathy
Caused from damage to sensory nerve fibers resulting in
numbness and pain
●● Peripheral neuropathy includes focal neuropathies,
caused by acute ischemic damage or diffuse
neuropathies, which are more widespread and involve
slow, progressive loss. This can lead to complications
(foot deformities, ulcers).
●● Autonomic neuropathy can affect nerve conduction of
the heart (exercise intolerance, painless myocardial
infarction, altered left ventricular function, syncope),
gastrointestinal system (gastroparesis, reflux,
early satiety), and urinary tract (decreased bladder
sensation, urinary retention). It affects the autonomic
nervous system, which minimizes manifestations of
hypoglycemia (diaphoresis, tremors, palpitations), which
can be dangerous for the client.
NURSING ACTIONS
●● Monitor for tolerance to activity and other indicators of
cardiac insufficiency.
●● Administer medications to promote gastric motility as
prescribed (metoclopramide).
●● Check for urinary retention.
●● Provide foot care.
CLIENT EDUCATION
●● Conduct annual exams by a podiatrist.
●● Practice regular follow‑up with provider to assess and
treat neuropathy.
●● Report numbness and tingling, joint problems, or
difficulties with digestion or urinary elimination.
●● Traditional indication of a heart attack might not be
present (chest, back, or jaw pain). Monitor for and report
other manifestations.
●● If there is reduced awareness of hypoglycemia, monitor
blood glucose more carefully.
Diabetic nephropathy
Damage to the kidneys from prolonged elevated blood
glucose levels and dehydration. The blood vessels near the
kidneys become more permeable, allowing fluids to escape
and can become scarred over time.
NURSING ACTIONS
●● Monitor hydration and kidney function (I&O,
blood creatinine level).
●● Report an hourly output less than 30 mL/hr.
●● Monitor blood pressure.
CLIENT EDUCATION
●● Conduct yearly urine analysis, BUN, microalbumin, and
blood creatinine level.
●● Avoid soda, alcohol, and toxic levels of acetaminophen
or NSAIDs.
●● Consume 2 to 3 L/day of fluid from food and beverages
with artificial sweetener, and drink an adequate
amount of water.
●● Report decrease in output to the provider.
Sexual dysfunction
Damage to nerve and vascular tissue of the sexual organs
●● Females can experience decreased libido or
sexual response, or dyspareunia from decreased
vaginal secretions.
●● Males can experience retrograde ejaculation or
erectile dysfunction.
NURSING ACTIONS: Discuss sexual concerns and
recommend options or referral, if the client desires.
CLIENT EDUCATION: Report concerns or difficulties with
the provider.
Other complications
Periodontal disease, integumentary disorders (infections,
patchy color changes, sclerosing)
