Portfolio I: Objective 2 Nursing Interventions The nurse has a major role in diabetes prevention, care, and management. Teaching is an integral nursing intervention for those with Type 2 Diabetes. The goal of diabetes treatment is maintaining blood glucose levels at a steady, normalized rate, thereby preventing complications such as retinopathy, neuropathy, and nephropathy (Smeltzer et al, 2008). Prevention of Type 2 Diabetes is attainable, and nurses can help patients at risk for developing diabetes by teaching lifestyle modifications. Regular exercise and weight loss for those who are overweight are the recommendations by the American Diabetes Association (2012). Often, newly diagnosed patients can avoid taking medications or insulin by simply changing their diet, losing weight, and exercising (Smeltzer et al., 2008). This may be a hurdle to many patients who do not have adequate nutritional education or who are psychologically adverse to changing their diet or lifestyle; nurses can help identify these issues and problem solve. The first thing the nurse should do with a newly diagnosed patient is assess. With a thorough assessment, the nurse can then plan interventions with the specific patient in mind. The nurse should assess learning needs, ask the patient and family what their concerns are, address fears, reiterate that feelings of shock and depression are normal at this time (Smeltzer et al., 2008). Patients may fear self-injection, but this task must be accomplished if the patient is going to need insulin in the home environment. The insulin protocol must be very clear, and patients can eventually learn to adjust insulin to their blood glucose readings over time. A major nursing intervention for the patient with Type 2 Diabetes is educating the patient and helping he or she develop self care management and skills. All patient teaching must be adapted to the individual, taking into consideration the progression of the disease, and any comorbidities. Teaching the newly diagnosed patient can be divided into two phases: basic/ initial information, and advanced/ continuing education (Smeltzer et al., 2008). The initial teaching includes the information the patient NEEDS to know to survive and is imperative for safety. The patient must know the basics, and have a knowledge base and understanding of the diabetic disease process. This includes the basic pathophysiology of diabetes, different treatment modalities, recognition and prevention of hypoglycemia and hyperglycemia complications, when to contact physician and where to buy and store supplies (Smeltzer et al., 2008). When the patient becomes more comfortable and accepting of the diabetes diagnosis, more in-depth teaching can occur. Self-monitoring of blood glucose levels is an extremely important step to attaining normalized levels and preventing complications of diabetes. The patient must also understand what increases and decreases the need for insulin, signs and symptoms of hypoglycemia and hyperglycemia, and proper foot, skin, and blood pressure care. The patient is taught about supplies, medications, self blood glucose monitoring, any special assistive devices needed, community resources and education tools. Also important are instructions regarding eye care, skin care, infection control, and general hygiene with an acknowledgment of understanding by the patient. The more the patient understands, the better he or she will be able to independently manage his or her health. For the hospitalized patient with newly diagnosed Type 2 Diabetes, the nurse maintains fluid and electrolyte balance, administering any IV fluids and electrolytes, measuring intake and output, assessing for signs and symptoms of dehydration. She monitors vital signs, lab values, edema, and cardiac status (Smeltzer et al., 2008). Control of blood glucose in the inpatient situation is extremely important to facilitate healing and prevent complications. One life-threatening complication of Type 2 Diabetes is Hyperglycemic Hyperosmolar State (HHS). Patients will have an extremely high blood glucose level (>600), leading to hyperosmolality, and resulting in osmotic diuresis. This produces profound dehydration, changes in level of consciousness, possible hypovolemic shock, and eventually coma if interventions do not occur. HHS can be hard to detect in diabetic patients because of its subtle onset, but nurses should watch for vision changes, weakness, weight loss, and polyuria in patients at risk. Nursing interventions include: administering the prescribed intravenous rehydration (large volume), insulin drip, supplemental potassium, monitoring BP, CVP, and HR in response to therapy, and watching for complications (Urden et al., 2010). For the nurse working in the hospital, many patients will have Type 2 Diabetes as a comorbidity of the primary diagnosis for their hospitalization. Many patients in the hospital may have unrecognized diabetes. A fasting blood glucose of 126 mg/dL or a random level of 200 mg/dL can be classified as diabetes and later confirmed following discharge. Nurses can identify patients with previously unrecognized diabetes and intervene to achieve normalized levels. Research has shown that nurse-driven protocols of titrating insulin in the hospital and close monitoring of blood glucose levels dramatically improves patient glycemic control and outcomes(Lange, 2010). Due to the adverse effects of hyperglycemia on healing and wellness, it is vital for every nurse to have diabetes knowledge and use the nursing process in the care of patients. The nurse should focus on nutritional intake and diet teaching, with the overall goal of maintaining glucose at an acceptable level. After assessment of the patient’s diet, food preferences, weight and BMI, activity level, the nurse works with a dietician and diabetes educator to develop a plan of care for the diet. The nurse also manages insulin administration and coordination with food intake and blood glucose levels. The nurse explains the need for the prescribed diet and works in conjunction with the registered dietician. The recommended diet for Type 2 Diabetics is consistent, decreased quantities of carbohydrates and increased vegetables, fruits, and whole grains (Urden et al., 2010). The nurse needs to attend to the psychological needs of the newly diagnosed Type 2 Diabetics as well. Providing emotional support and listening to the patient, answering questions and working to reduce anxiety, can all help the patient work through the grief process due to loss of health. The nurse should encourage the patient and family to take an active part in care and perform the tasks they will need to accomplish at home. This empowers the patient to manage his or her care confidently. Case Study J.B., a 50 year old male, comes into the clinic for a checkup after taking a family trip across the country. His wife noticed they would have to stop almost every hour for J.B to use the restroom and purchase a sugary soda. He was consuming up to three 2-liters of soda throughout a day, and remarked about how hungry he had been lately. J.B is found to have a random blood glucose level of 270 mg/dL and 135 mg/dL on a later fasting blood glucose test. These results along with the classic symptoms of polydipsia, polyphagia, and polyuria J.B. has been experiencing are enough to diagnose him with Type 2 Diabetes. His history includes lifelong obesity, with a BMI of 34. J.B. works 50 hours or more a week in a sedentary occupation. J.B has no medical background, and hasn’t been to the doctor for a checkup in six years. His main concern is, “Do I have to give myself shots forever now?”The nurse completes the doctor’s orders of obtaining vital signs, weight, ordering labs for lipids and electrolytes, and other markers for complications of diabetes. The nurse begins the assessment by asking the client what his specific fears are concerning his diagnosis, and takes time to listen and answer any questions to decrease J.B.’s anxiety. The nurse explains that Type 2 Diabetes can often be managed by lifestyle modifications in diet and exercise, and does not necessarily mean that he will need to self inject insulin forever or even at all. She explains there are many oral antidiabetic agents that are now used if weight loss and activity alone do not help lower blood glucose levels. The nurse provides literature about diabetes, so that J.B. can take them home and read them when he has more time and is less emotionally overwhelmed. The nurse explains the basic pathophysiology of Type 2 Diabetes, what it means, how insulin and blood sugar are related, and the symptoms of the disease. The nurse marks the spots in the literature handouts referring to her verbal instructions for J.B. to study later. J.B. expresses understanding of the basic diabetes regime instructions. The nurse does a full assessment of the patient, paying special attention to the neurovascular, cardiac, and renal systems, as those are often affected by diabetes. The nurse checks the skin of the lower extremities, palpating pulses and checking capillary refill for blood flow, as poor blood flow in the extremities can occur in diabetes and will increase the risk for slow wound healing and ultimately put the patient at risk for amputation. J.B is found to have diminished sensation in his feet, a sign of a common complication, peripheral neuropathy. The nurse instructs J.B. to check his feet daily and avoid any breaks in the skin which can become a gateway for pathogens, leading to infection. The nurse stresses to J.B that he needs to employ proper hygiene measures like hand-washing. He should take care to avoid an infection which J.B. would have more difficulty overcoming because of decreased circulation, oxygen, and high blood glucose. J.B. is given an appointment for an eye exam, as retinopathy is a complication of diabetes and he mentions that he sometimes has blurred vision. The nurse ensures J.B. understands he needs to have all lab tests for renal function done per his physician recommendation. After the physical and learning needs assessment, the nurse prepares to provide initial, “survival” skills for J.B. to take home. The nurse instructs him in use of the blood glucose meter, and has him give a return demonstration. She tells him when he should test his blood glucose, as prescribed by his doctor; either daily, every morning/ night, with meals, etc. The nurse explains the parameters for the insulin dosages, and fully explains all equipment - syringes, insulin bottles and storage of those when open, sites of injection, and demonstrates drawing up the insulin and has J.B. return demonstration. The nurse allows J.B to practice on an object, and instructs on the importance of rotating sites. She also gives him written instruction for further clarification. The nurse tells J.B. to record his blood glucose levels in a log, and to notify the doctor if he gets a reading above 300 mg/dL or below 60 mg/dL, or per MD orders. She instructs in the signs and symptoms of hypoglycemia and treatment, actions to take if unable to eat due to sickness, how to take oral antidiabetics, and signs of complications. |
