A 58-year-old male with a history of type 2 diabetes presents with numbness and tingling in his feet, decreased sensation to monofilament testing, slow-healing sores on his feet, and a hemoglobin A1c of 8.5%. His blood pressure is 145/90 mmHg, and fasting blood glucose is 180 mg/dL. Which nursing intervention is the priority to prevent further complications in this patient?

A) Educate the patient on proper foot care and daily inspection.

B) Recommend dietary changes to lower LDL cholesterol levels.

C) Instruct the patient to increase physical activity to improve glycemic control.

D) Administer prescribed antihypertensive medication to manage blood pressure.

A patient with diabetes mellitus presents with numbness and tingling in the feet, decreased sensation, and slow-healing sores. Laboratory tests reveal an elevated hemoglobin A1c of 8.5%, LDL cholesterol level of 130 mg/dL, and a urine albumin-to-creatinine ratio of 35 mg/g. Which nursing intervention is most appropriate to address the potential complications of diabetic neuropathy and nephropathy?

A) Instruct the patient on the importance of daily foot care and regular podiatry visits.

B) Educate the patient to increase dietary sodium to manage blood pressure.

C) Advise the patient to limit daily physical activity to reduce the risk of hypoglycemia.

D) Recommend the patient to delay lipid-lowering medication until the next follow-up visit.

A patient with type 2 diabetes mellitus presents with persistent numbness in the feet and occasional dizziness upon standing, along with a recent increase in urine albumin-to-creatinine ratio. In revising the care plan, which intervention should the nurse prioritize to address these symptoms and prevent further complications?

C) Initiate an ACE inhibitor to manage nephropathy and potential orthostatic hypotension.

A) Increase the patient's insulin dosage to achieve tighter glucose control.

B) Educate the patient on proper foot care and schedule regular podiatry visits.

C) Initiate an ACE inhibitor to manage nephropathy and potential orthostatic hypotension.

D) Adjust the statin dosage to target elevated LDL cholesterol levels.

A patient with type 2 diabetes presents with persistent numbness in the feet and occasional dizziness upon standing. Considering the reassessment findings, which nursing intervention is most appropriate to prioritize in the patient's care plan?

B) Initiate fall precautions and educate on strategies to manage orthostatic hypotension.

A) Educate the patient on carbohydrate counting to improve blood glucose control.

B) Initiate fall precautions and educate on strategies to manage orthostatic hypotension.

C) Reinforce daily foot care routines to prevent complications associated with neuropathy.

D) Collaborate with the dietitian to further reduce LDL cholesterol levels through dietary changes.

A patient with diabetes returns to the clinic with increased urination, excessive thirst, and fatigue, despite adherence to an adjusted insulin regimen. Lab results show elevated fasting blood glucose and hemoglobin A1c, increased urine albumin-to-creatinine ratio, and a rise in creatinine level. What is the most appropriate nursing intervention to prioritize in this scenario?

B) Collaborate with the healthcare team to adjust the patient's insulin regimen for better glycemic control.

A) Educate the patient on the importance of fluid restriction to manage excessive thirst.

B) Collaborate with the healthcare team to adjust the patient's insulin regimen for better glycemic control.

C) Encourage the patient to increase physical activity to help reduce blood glucose levels.

D) Advise the patient to reduce protein intake to decrease kidney workload.

A patient with type 2 diabetes presents with increased frequency of urination, excessive thirst, and fatigue. Recent lab results show elevated fasting blood glucose and urine albumin-to-creatinine ratio, along with increased creatinine levels. Which of the following interventions should the nurse prioritize to address the possible worsening of diabetic nephropathy and insulin resistance?

C) Facilitate the initiation of a basal-bolus insulin regimen and discuss potential SGLT2 inhibitor therapy with the healthcare provider.

A) Encourage the patient to increase fluid intake to prevent dehydration.

B) Educate the patient on strict adherence to a low-protein diet to reduce kidney strain.

C) Facilitate the initiation of a basal-bolus insulin regimen and discuss potential SGLT2 inhibitor therapy with the healthcare provider.

D) Advise the patient to monitor blood pressure daily and report any significant changes.

A patient with type 2 diabetes has been on a basal-bolus insulin regimen and an SGLT2 inhibitor for two weeks. Despite some improvement in symptoms, the patient's hemoglobin A1c remains unchanged, and there is an increase in the urine albumin-to-creatinine ratio. Which of the following nursing interventions is most appropriate to address these findings?

C) Collaborate with the healthcare team to initiate a dietary and exercise plan to address insulin resistance.

A) Increase the dose of the SGLT2 inhibitor to improve glycemic control.

B) Encourage the patient to increase fluid intake to assist kidney function.

C) Collaborate with the healthcare team to initiate a dietary and exercise plan to address insulin resistance.

D) Discontinue the ACE inhibitor due to potential nephrotoxicity.

A patient with type 2 diabetes has been on a basal-bolus insulin regimen and an SGLT2 inhibitor for two weeks but is experiencing persistent fatigue and an increased urine albumin-to-creatinine ratio. Which nursing intervention should be prioritized to address the underlying issue of kidney stress in this patient?

B) Encourage dietary modifications to reduce protein intake.

A) Increase the insulin dosage to achieve better glycemic control.

B) Encourage dietary modifications to reduce protein intake.

C) Emphasize the importance of consistent blood glucose monitoring.

D) Initiate a patient education session on the benefits of exercise.

A patient with progressive diabetic nephropathy presents with mild ankle swelling, occasional shortness of breath, elevated blood pressure, and elevated LDL cholesterol levels. Which of the following nursing interventions should be prioritized to address the patient's current symptoms and prevent further complications?

A) Educating the patient on dietary sodium restriction to reduce fluid retention

B) Encouraging the patient to increase fluid intake to support kidney function

C) Advising the patient to perform high-intensity exercise to improve cardiovascular health

D) Monitoring the patient's blood glucose levels more frequently to control diabetes

A patient with diabetes presents with mild ankle swelling, occasional shortness of breath during exertion, and elevated blood pressure. Recent lab results indicate increased urine albumin-to-creatinine ratio, decreased eGFR, and elevated LDL cholesterol. Which nursing intervention is most important to prioritize in managing this patient's condition?

A) Educate the patient on the importance of reducing dietary sodium intake.

B) Advise the patient to increase fluid intake to improve kidney function.

C) Recommend the patient to avoid physical activity to prevent further cardiovascular strain.

D) Suggest the patient to reduce protein intake to alleviate renal function decline.

diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance leads to impaired glucose uptake into cells, resulting in elevated blood glucose levels. In Type 1 diabetes, autoimmune destruction of pancreatic beta cells causes insulin deficiency. In Type 2 diabetes, insulin resistance occurs, often associated with obesity and lifestyle factors.

• Secondary mechanism: Chronic hyperglycemia triggers metabolic stress and inflammation, damaging blood vessels and nerves over time. This process contributes to microvascular complications like retinopathy, nephropathy, and neuropathy, as well as macrovascular complications such as cardiovascular disease.

• Key complication: Persistent high blood glucose levels can cause diabetic ketoacidosis in Type 1 diabetes, characterized by the accumulation of ketones leading to metabolic acidosis. In Type 2 diabetes, hyperosmolar hyperglycemic state can occur, marked by severe dehydration and altered consciousness.

Patient Profile

Demographics:

52-year-old male, office manager

History:

• Type 2 diabetes diagnosed 10 years ago, hypertension, hyperlipidemia

• Metformin, Lisinopril, Atorvastatin, Aspirin

• Allergic to penicillin

Current Presentation:

• Chief complaint: Increasing numbness and tingling in feet

• Key symptoms: Fatigue, blurred vision, frequent urination, slow-healing sores on feet

• Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose 180 mg/dL fasting

Section 1

Upon initial assessment, the healthcare team noted several key findings that suggested the progression of diabetic neuropathy and potential complications. The patient reported increasing numbness and tingling in his feet, which upon examination, revealed decreased sensation to monofilament testing and diminished vibratory sense. Additionally, the slow-healing sores on his feet raised concerns about potential diabetic foot ulcers, compounded by the patient's slightly elevated blood pressure of 145/90 mmHg and fasting blood glucose level of 180 mg/dL. These factors suggested suboptimal glycemic and blood pressure control, which are critical in managing diabetes complications.

Laboratory results further illuminated the patient's condition. His hemoglobin A1c was notably elevated at 8.5%, indicating poor long-term blood glucose control. Lipid panel results showed an LDL cholesterol level of 130 mg/dL, higher than the target for patients with diabetes, suggesting a need for more aggressive lipid management. The urine albumin-to-creatinine ratio was slightly elevated at 35 mg/g, suggesting early signs of nephropathy. These findings highlighted the interconnected nature of diabetic complications, where poor glucose control can exacerbate vascular damage, leading to both microvascular and macrovascular complications.

Faced with these assessment and diagnostic findings, the healthcare team recognized the need for a comprehensive intervention plan. This plan would aim to tighten glycemic control, potentially through adjustments in medication or lifestyle changes, and address hypertension and hyperlipidemia more aggressively. Patient education on foot care and regular screenings for neuropathy and retinopathy were also emphasized. The team also scheduled follow-up appointments to closely monitor the patient's response to interventions and to prevent further deterioration of his condition. This approach aimed to mitigate the risk of new complications and improve the patient's overall management of his diabetes.

Section 2

Following the comprehensive intervention plan, the patient returned for a follow-up appointment six weeks later. During the visit, the healthcare team conducted a thorough reassessment to evaluate the patient's response to the interventions. The patient reported being more consistent with his medication regimen and had incorporated suggested dietary changes, including reducing carbohydrate intake and increasing fiber-rich foods. However, he noted persistent numbness in his feet and occasional dizziness upon standing, raising concerns about potential orthostatic hypotension.

Vital signs revealed a blood pressure of 138/85 mmHg, indicating some improvement from the previous visit. Fasting blood glucose levels had decreased slightly to 160 mg/dL, demonstrating better but still suboptimal glycemic control. Repeat laboratory tests showed a hemoglobin A1c of 8.1%, suggesting a modest improvement in long-term glucose management. Nevertheless, the LDL cholesterol level remained elevated at 128 mg/dL, prompting consideration of further lipid-lowering strategies. The urine albumin-to-creatinine ratio had increased to 40 mg/g, signaling a progression in nephropathy that warranted closer monitoring and possibly an adjustment in the patient's antihypertensive regimen to include an ACE inhibitor or ARB.

The patient's ongoing symptoms and lab values led the healthcare team to reassess the current management plan. They decided to intensify the pharmacological approach by optimizing the patient's insulin regimen, aiming for tighter glucose control. Additionally, they increased the dosage of his statin medication to address the persistent hyperlipidemia. The team also emphasized the importance of continued foot care and scheduled a referral to a nephrologist for a more detailed evaluation of kidney function. This approach aimed to prevent further complications and stabilize the patient's condition, setting the stage for ongoing management and monitoring in the next phase of his diabetes care.

Section 3

Two weeks after the intensified interventions, the patient returned to the clinic reporting new symptoms that had developed over the past few days. He experienced increased frequency of urination, excessive thirst, and fatigue, despite adherence to the adjusted insulin regimen and medication plan. Concerned about these developments, the healthcare team conducted a more detailed assessment to determine the underlying cause.

Vital signs revealed a slight increase in blood pressure to 142/88 mmHg, suggesting the potential impact of ongoing nephropathy despite the introduction of an ACE inhibitor. Fasting blood glucose had risen unexpectedly to 185 mg/dL, indicating a potential mismatch in insulin dosage or adherence issues. A repeat hemoglobin A1c test showed minimal change, holding at 8.2%, hinting at ongoing challenges in achieving optimal glycemic control. Further laboratory tests revealed a rise in urine albumin-to-creatinine ratio to 50 mg/g, signaling a concerning progression of kidney involvement. Moreover, a comprehensive metabolic panel detected an elevated creatinine level of 1.5 mg/dL, underscoring the need for urgent nephrology input.

The healthcare team determined that the patient's symptoms and lab findings indicated a potential worsening of diabetic nephropathy and possible insulin resistance. They decided to refine the insulin regimen further, considering a basal-bolus approach for more precise glucose management. Additionally, they initiated discussions about considering an SGLT2 inhibitor to address both glycemic control and renal protection. The team reinforced the importance of monitoring blood pressure and glucose levels closely, and they expedited the nephrology referral. This proactive strategy aimed to halt the progression of complications and stabilize the patient's condition, setting the stage for further adjustments in his long-term diabetes management.

Section 4

Two weeks after initiating the basal-bolus insulin regimen and introducing an SGLT2 inhibitor, the patient returned to the clinic for a follow-up appointment. During this visit, he reported some improvement in his thirst and urination frequency, yet he continued to experience persistent fatigue. The healthcare team conducted a thorough assessment to evaluate the effectiveness of the recent interventions and identify any emerging issues.

Vital signs revealed that blood pressure had slightly improved to 138/86 mmHg, indicating a positive response to the ACE inhibitor and enhanced blood pressure management. Blood glucose monitoring showed a modest decrease in fasting levels to 165 mg/dL, suggesting partial improvement in glycemic control. However, the hemoglobin A1c remained relatively unchanged at 8.0%, indicating that further adjustments might be needed to achieve optimal glycemic control. Despite these efforts, the urine albumin-to-creatinine ratio had increased to 60 mg/g, pointing to ongoing kidney stress. The patient's creatinine level remained elevated at 1.6 mg/dL, prompting the healthcare team to anticipate nephrology consultation results eagerly.

The team considered the potential for underlying insulin resistance and discussed the possibility of lifestyle modifications, including dietary adjustments and a tailored exercise program, to complement pharmacological interventions. They also emphasized the importance of consistent blood glucose monitoring and maintaining adherence to the medication regimen. Recognizing the need for a comprehensive approach, the team planned to collaborate closely with the nephrologist to refine the patient's management plan further, aiming to curb the progression of nephropathy while safeguarding overall health. The patient's journey underscored the complexity of diabetes management and highlighted the critical need for ongoing, multidisciplinary care to navigate the challenges of chronic complications.

Section 5

Two weeks following the initial follow-up, the patient returned to the clinic, reporting new symptoms of mild swelling in his ankles and an occasional shortness of breath during exertion. These changes raised concerns about potential fluid retention and cardiovascular involvement. The healthcare team conducted a detailed examination and noted that the patient's blood pressure had risen slightly to 142/88 mmHg. His heart rate was regular at 78 beats per minute, but the presence of peripheral edema was confirmed upon physical examination.

New diagnostic results from the nephrology consultation indicated a further increase in urine albumin-to-creatinine ratio to 75 mg/g, suggesting worsening renal function. The patient's estimated glomerular filtration rate (eGFR) had decreased to 45 mL/min/1.73m², reinforcing the suspicion of progressive diabetic nephropathy. Additionally, a recent lipid panel revealed elevated LDL cholesterol at 160 mg/dL, contrasting with the patient's prior stable levels, thereby compounding cardiovascular risk.

In response to these findings, the healthcare team recognized the need for an intensified therapeutic approach. Adjustments to the patient's medication regimen were discussed, including the potential introduction of a statin to address dyslipidemia and a diuretic to manage fluid overload. The team emphasized the importance of dietary sodium restriction and adherence to an exercise routine tailored to the patient's cardiovascular capacity. Collaborative discussions with the cardiologist and nephrologist were prioritized to integrate care strategies, aiming to stabilize renal function while mitigating cardiovascular complications. This phase of the patient's journey highlighted the intricate interplay between diabetes management and its systemic effects, underscoring the necessity for vigilant, interdisciplinary coordination.