A 52-year-old patient with Type 2 Diabetes presents with an HbA1c level of 9.2%, elevated urine microalbumin levels, and signs of diabetic retinopathy. Which nursing intervention is most appropriate to prioritize in this patient's care plan?

D) Discuss with the healthcare provider the possibility of initiating insulin therapy to improve glycemic control.

A) Encourage the patient to monitor blood glucose levels twice a day and report any significant changes.

B) Educate the patient about proper foot care and the importance of daily foot inspections.

C) Refer the patient to a nephrologist for further evaluation and management of potential renal complications.

D) Discuss with the healthcare provider the possibility of initiating insulin therapy to improve glycemic control.

A 52-year-old patient with Type 2 Diabetes has an HbA1c level of 9.2%, elevated urine microalbumin levels, deteriorating visual acuity, and signs of peripheral neuropathy. Which nursing intervention is most critical to prioritize in this patient's care plan to prevent further complications?

C) Consult with a nephrologist to assess and manage kidney function.

A) Refer the patient to a dietitian for diabetes meal planning.

B) Schedule regular foot examinations to monitor for neuropathy-related injuries.

C) Consult with a nephrologist to assess and manage kidney function.

D) Educate the patient on the importance of regular ophthalmology visits.

A patient with stage 3 chronic kidney disease (CKD) and hypertension presents with a blood pressure of 150/95 mmHg. Her serum creatinine has increased to 1.4 mg/dL, and her GFR has declined to 55 mL/min/1.73m². Which adjustment to her antihypertensive therapy would be most appropriate to provide renal protection and better control of her hypertension?

C) Switch to or add an ACE inhibitor or angiotensin receptor blocker.

A) Increase the dose of her current calcium channel blocker.

B) Add a thiazide diuretic to her current regimen.

C) Switch to or add an ACE inhibitor or angiotensin receptor blocker.

D) Initiate a beta-blocker therapy.

A patient with stage 3 chronic kidney disease (CKD) and hypertension presents with a blood pressure of 150/95 mmHg and an increased serum creatinine level. Which nursing intervention is most appropriate to address the patient's renal and cardiovascular risks?

A) Educate the patient on the importance of sodium restriction to help control blood pressure.

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

C) Recommend the patient to consume a high-protein diet to support kidney health.

D) Advise the patient to avoid physical activity to prevent further renal damage.

A patient with stage 3 CKD, diabetes, and persistent hypertension despite ACE inhibitor therapy presents with orthostatic hypotension and elevated HbA1c. Which of the following nursing interventions is most critical in managing this patient's condition?

B) Advise the patient to monitor blood glucose levels closely and report any signs of hypoglycemia.

A) Educate the patient on the importance of a low-sodium diet to manage hypertension.

B) Advise the patient to monitor blood glucose levels closely and report any signs of hypoglycemia.

C) Recommend the patient to take multiple small meals throughout the day to prevent dizziness.

D) Suggest the patient increase fluid intake to manage dizziness and lightheadedness.

A patient with stage 3 CKD and type 2 diabetes presents with persistent hypertension, dizziness, and increased serum creatinine levels. Which of the following interventions should the nurse prioritize to address the patient's persistent hypertension and declining renal function?

C) Introduce a calcium channel blocker to the regimen.

A) Increase the dose of the current ACE inhibitor.

B) Initiate a low sodium diet and increase fluid intake.

C) Introduce a calcium channel blocker to the regimen.

D) Educate the patient on the importance of weight loss and physical activity.

A patient with hypertension and diabetes is on a treatment regimen that includes an ACE inhibitor, beta-blocker, and basal insulin. She reports episodes of mild hypoglycemia, which she managed with glucose tablets. Her blood glucose logs show variability, with occasional readings in the low 70s mg/dL. Her HbA1c remains elevated at 8.3%. What is the most appropriate nursing intervention to help manage her diabetes while minimizing the risk of hypoglycemia?

B) Educate the patient to consume a consistent carbohydrate intake at each meal.

A) Increase her basal insulin dose and add a rapid-acting insulin before meals.

B) Educate the patient to consume a consistent carbohydrate intake at each meal.

C) Recommend stopping the beta-blocker to avoid masking hypoglycemic symptoms.

D) Advise the patient to decrease her physical activity to prevent hypoglycemic episodes.

A patient with hypertension and type 2 diabetes mellitus is being treated with an ACE inhibitor, a beta-blocker, and a new basal insulin regimen. She experiences two episodes of mild hypoglycemia and her HbA1c remains elevated at 8.3%. What is the most appropriate nursing intervention to address both her blood pressure and glucose variability effectively?

B) Educate the patient on recognizing early signs of hypoglycemia and appropriate actions.

A) Increase the basal insulin dosage to lower the HbA1c more rapidly.

B) Educate the patient on recognizing early signs of hypoglycemia and appropriate actions.

C) Recommend discontinuing the beta-blocker to prevent hypoglycemia.

D) Suggest a carbohydrate-controlled diet to manage blood glucose levels more effectively.

A patient with diabetes mellitus presents with increased fatigue, occasional dizziness, and numbness in the feet. Her recent laboratory results indicate increased urine microalbumin levels. Which nursing action is most appropriate to address the patient's risk of nephropathy progression?

B) Educate the patient on the importance of maintaining optimal blood pressure and glycemic control

A) Encourage the patient to increase fluid intake to dilute urine

B) Educate the patient on the importance of maintaining optimal blood pressure and glycemic control

C) Advise the patient to limit protein intake to reduce kidney workload

D) Suggest the patient take over-the-counter diuretics to manage blood pressure

A patient with a history of diabetes and hypertension presents with increased fatigue, morning dizziness, and recent reports of nocturnal hypoglycemia. Her urine microalbumin levels have also increased. What is the most appropriate nursing intervention to address these findings?

B) Educate the patient on the importance of bedtime snacks to prevent nocturnal hypoglycemia.

A) Encourage the patient to increase fluid intake to manage dizziness.

B) Educate the patient on the importance of bedtime snacks to prevent nocturnal hypoglycemia.

C) Advise the patient to perform daily foot exercises to improve circulation.

D) Suggest the patient take their antihypertensive medications at night to prevent morning dizziness.

diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance impairs glucose uptake, leading to hyperglycemia. In type 1 diabetes, autoimmune destruction of pancreatic beta cells reduces insulin production. In type 2, cells become resistant to insulin, often compounded by obesity and sedentary lifestyle.

• Secondary mechanism: Hyperglycemia causes osmotic diuresis, leading to dehydration and electrolyte imbalances. High blood glucose levels also initiate non-enzymatic glycation of proteins, affecting blood vessel and nerve function.

• Key complication: Chronic hyperglycemia damages small and large blood vessels, leading to complications like retinopathy, nephropathy, neuropathy, and increased risk of cardiovascular diseases. These complications underscore the importance of managing blood glucose levels to prevent further systemic damage.

Patient Profile

Demographics:

52-year-old female, office administrator

History:

• Key past medical history: Diagnosed with Type 2 Diabetes 8 years ago, hypertension, hyperlipidemia

• Current medications: Metformin 1000 mg twice daily, Lisinopril 20 mg daily, Atorvastatin 20 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent fatigue and worsening vision

• Key symptoms: Increased thirst, frequent urination, tingling sensation in feet, blurry vision

• Vital signs: Blood pressure 150/95 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose 210 mg/dL

Section 1

As the primary care team continues to monitor the 52-year-old patient with Type 2 Diabetes, her recent laboratory results reveal further insight into her condition. The HbA1c level has returned at 9.2%, significantly above the recommended target of less than 7%, indicating poor long-term glucose control. Additionally, urine microalbumin levels are elevated, suggesting early signs of diabetic nephropathy. Serum creatinine is at the upper limit of normal, and a glomerular filtration rate (GFR) test indicates a mild decrease in kidney function. These findings highlight a potential progression towards renal complications, likely exacerbated by her longstanding hypertension and hyperlipidemia.

Further examination reveals a deterioration in her visual acuity, with ophthalmoscopy showing signs consistent with diabetic retinopathy, including microaneurysms and possible macular edema. These ocular changes correlate with her complaint of worsening vision and are indicative of the chronic microvascular damage that can occur with persistent hyperglycemia. The tingling sensation in her feet, coupled with a decreased vibratory sensation on examination, suggests peripheral neuropathy, another common complication of poorly controlled diabetes.

Given these findings, the healthcare team needs to re-evaluate her management plan to address the multifactorial challenges presented by her condition. This will include optimizing glycemic control through potential adjustments in her medication regimen, enhanced dietary and lifestyle interventions, and possibly introducing insulin therapy if necessary. Collaborative care involving a nephrologist and an ophthalmologist may be warranted to manage her kidney function and retinal health, respectively. Additionally, patient education focusing on the importance of blood pressure control, cholesterol management, and regular follow-up appointments will be vital in preventing further progression of diabetic complications.

Section 2

As the healthcare team implements the revised management plan, the patient returns for a follow-up visit four weeks later. During this appointment, the initial assessment findings indicate some subtle but concerning changes in her condition. Her blood pressure is measured at 150/95 mmHg, revealing inadequate control despite current antihypertensive therapy. This elevation could further exacerbate her renal and cardiovascular risks. Her weight remains stable, but the patient reports feeling increasingly fatigued and experiencing frequent episodes of nocturia, which may suggest worsening renal function or fluid balance issues.

Laboratory results from this visit reveal a further increase in her serum creatinine to 1.4 mg/dL, surpassing the upper normal limit, and her GFR has declined to 55 mL/min/1.73m², indicating a progression to stage 3 chronic kidney disease (CKD). This deterioration highlights the potential need for a more aggressive approach to her blood pressure and blood glucose management. Additionally, although her lipid profile shows slight improvement with LDL reduced to 105 mg/dL, the need for tighter control remains crucial to mitigate cardiovascular risks associated with diabetic nephropathy.

The clinical team deliberates on the necessity of adjusting her therapeutic regimen to include either an additional antihypertensive agent or a switch to a combination therapy with an ACE inhibitor or angiotensin receptor blocker, which could offer renal protective benefits. The possibility of initiating a basal insulin regimen is also considered, given her persistently elevated HbA1c levels and the need for improved glycemic control. These decisions will require careful monitoring and patient education to ensure adherence and address any potential side effects, emphasizing the importance of regular follow-ups to prevent further complications.

Section 3

Four weeks after the introduction of the revised management plan, the patient returns for another follow-up appointment. During this visit, the healthcare team notes some concerning changes in her clinical status. The patient's blood pressure remains elevated at 148/92 mmHg, despite the addition of an ACE inhibitor to her antihypertensive regimen. This persistent hypertension calls for a reevaluation of her current treatment strategy, considering the potential for further renal compromise. Additionally, the patient reports increased episodes of dizziness and lightheadedness, particularly upon standing, which suggests the possibility of orthostatic hypotension, a side effect that may warrant a dosage adjustment or change in her medication plan.

Laboratory tests reveal further deterioration in renal function, with her serum creatinine increasing to 1.6 mg/dL and her GFR declining to 50 mL/min/1.73m². This progression to more advanced stage 3 CKD highlights the critical need for intensified management of her blood pressure and blood glucose levels to slow the decline in kidney function. Furthermore, her HbA1c remains elevated at 8.5%, indicating that her current oral hypoglycemic agents are insufficient for optimal glycemic control. The clinical team must now consider initiating a basal insulin regimen to achieve tighter glucose regulation, while carefully monitoring for hypoglycemic episodes, especially given her potential for orthostatic hypotension.

The patient's lipid profile shows further improvement with LDL reduced to 100 mg/dL, yet given her CKD and diabetes, the goal remains to bring LDL levels below 70 mg/dL to lessen cardiovascular risks. This situation necessitates a comprehensive review of her lifestyle modifications and adherence to prescribed medications. The team emphasizes the importance of patient education, particularly around recognizing symptoms of hypoglycemia and understanding the role of dietary changes in managing her condition. Regular follow-ups are planned to track her response to these interventions, adjust treatment as needed, and prevent the onset of additional complications.

Section 4

Response to Interventions:

Over the next two weeks, the healthcare team implements the adjusted treatment plan to address the patient's hypertension and glycemic control. The ACE inhibitor dosage is carefully titrated, and a beta-blocker is introduced to better manage her blood pressure, with close monitoring of her renal function. The patient also begins a basal insulin regimen to achieve tighter glucose regulation, initiated at a low dose to minimize the risk of hypoglycemia. Dietary consultations reinforce the importance of a low-sodium, carbohydrate-controlled diet to support her treatment goals.

At her subsequent follow-up visit, the patient's blood pressure shows signs of improvement, now averaging 135/85 mmHg. However, she reports experiencing two episodes of mild hypoglycemia, presenting with symptoms of shakiness and sweating, which she managed appropriately with glucose tablets. Her blood glucose logs reveal significant variability, with occasional readings dipping into the low 70s mg/dL. The clinical team recognizes the need to reassess her insulin dosing and oral hypoglycemic agents to strike a balance between effective glycemic control and minimizing hypoglycemia risk.

Laboratory tests show stabilization of her renal function, with serum creatinine holding steady at 1.6 mg/dL and GFR maintaining at 50 mL/min/1.73m². Despite this stability, her HbA1c remains elevated at 8.3%, indicating a need for further intervention to optimize her diabetes management. Additionally, her LDL has slightly decreased to 95 mg/dL, yet further reduction is necessary to reach the target goal. The healthcare team plans to explore additional lipid-lowering strategies, potentially incorporating a PCSK9 inhibitor, while continuing to emphasize the critical role of lifestyle changes in her therapeutic regimen. Regular follow-ups remain crucial to adjust her treatment plan and address any emerging complications promptly.

Section 5

Two weeks following the recent adjustments to her treatment regimen, the patient returns for another follow-up. The healthcare team notes that her blood pressure has improved further, averaging 130/80 mmHg, indicating a positive response to the modified antihypertensive therapy. However, she reports increased fatigue and occasional dizziness, particularly in the morning. A review of her blood glucose logs reveals persistent variability with frequent nocturnal hypoglycemia, suggesting that her basal insulin dose may still be too high. Consequently, the insulin regimen is further adjusted, reducing the bedtime dose slightly and emphasizing the importance of consistent bedtime snacks to prevent overnight drops in blood sugar.

New laboratory results reveal a concerning development: her urine microalbumin levels have increased from 150 mg/L to 210 mg/L, suggesting worsening nephropathy despite stable creatinine and GFR levels. This prompts the clinical team to intensify nephroprotective strategies, ensuring that her blood pressure and glycemic control are as optimal as possible. Additionally, her lipid profile, while improved, remains suboptimal, prompting the introduction of a PCSK9 inhibitor to better manage her LDL levels.

The patient also mentions the emergence of some numbness and tingling in her feet, raising suspicion for peripheral neuropathy, a common complication of poorly controlled diabetes. This new symptom prompts a comprehensive neurological assessment and the consideration of medications such as gabapentin for symptomatic relief. The team emphasizes the importance of regular foot care to prevent further complications. This multifaceted approach, combining medication adjustments, lifestyle interventions, and close monitoring, aims to mitigate the progression of her diabetes-related complications and improve her overall quality of life. The clinical team schedules more frequent follow-up visits to closely monitor her response to these interventions and make timely adjustments as needed.