A patient with a history of poorly controlled type 2 diabetes presents with bilateral peripheral neuropathy, early diabetic retinopathy, and signs of nephropathy. Which nursing intervention should the nurse prioritize to address the current complications and prevent further deterioration?

B) Refer the patient to a dietitian for dietary modifications to control blood glucose levels.

A) Educate the patient on the importance of daily foot inspections and proper footwear.

B) Refer the patient to a dietitian for dietary modifications to control blood glucose levels.

C) Schedule regular ophthalmology appointments to monitor and manage diabetic retinopathy.

D) Initiate a smoking cessation program to reduce cardiovascular risk.

A 58-year-old patient with type 2 diabetes presents with bilateral peripheral neuropathy, early diabetic retinopathy, elevated fasting blood glucose, and elevated HbA1c. Laboratory results also show slightly elevated creatinine and elevated urine microalbumin levels. Which nursing intervention is MOST appropriate to prioritize in the management of this patient?

B) Refer the patient to an ophthalmologist for comprehensive eye care.

A) Educate the patient on the importance of daily blood glucose monitoring.

B) Refer the patient to an ophthalmologist for comprehensive eye care.

C) Encourage the patient to increase physical activity to at least 150 minutes per week.

D) Initiate dietary counseling focusing on reducing carbohydrate intake.

A patient with type 2 diabetes mellitus presents with worsening peripheral neuropathy and signs of diabetic nephropathy. The healthcare team is considering adding a sodium-glucose co-transporter-2 (SGLT2) inhibitor to the treatment plan. Which of the following is the most important consideration for the nurse when educating the patient about this new medication?

B) The potential for increased risk of urinary tract infections.

A) The need for increased fluid intake to prevent dehydration.

B) The potential for increased risk of urinary tract infections.

C) The possibility of experiencing hypoglycemia as a side effect.

D) The importance of monitoring blood pressure regularly.

A patient with type 2 diabetes mellitus is experiencing symptoms of peripheral neuropathy and signs of diabetic nephropathy. The healthcare team is considering adding an SGLT2 inhibitor to the patient's treatment plan. Which of the following nursing interventions is most appropriate when initiating this medication?

A) Educate the patient about the importance of monitoring blood pressure regularly.

B) Instruct the patient to increase protein intake to support kidney function.

C) Advise the patient to limit fluid intake to prevent dehydration.

D) Encourage the patient to perform daily foot inspections and proper foot care.

A patient with diabetes mellitus and recent orthostatic hypotension is being managed with an ACE inhibitor for diabetic nephropathy. Which nursing intervention is most appropriate to address the patient's orthostatic hypotension while continuing to protect renal function?

B) Advise the patient to rise slowly from sitting or lying positions to prevent dizziness.

A) Encourage the patient to decrease fluid intake to reduce blood pressure variability.

B) Advise the patient to rise slowly from sitting or lying positions to prevent dizziness.

C) Suggest increasing the dose of the ACE inhibitor to enhance renal protection.

D) Recommend the patient to avoid all physical activities to prevent hypotensive episodes.

A patient with type 2 diabetes and diabetic nephropathy is experiencing dizziness and lightheadedness due to orthostatic hypotension after starting an ACE inhibitor. Which nursing intervention is most appropriate to address the patient's symptoms while maintaining renal protection?

B) Educate the patient on the importance of rising slowly from a sitting or lying position and ensure adequate hydration.

A) Discontinue the ACE inhibitor immediately and monitor the patient's symptoms.

B) Educate the patient on the importance of rising slowly from a sitting or lying position and ensure adequate hydration.

C) Increase the dosage of the ACE inhibitor to improve renal protection and monitor for side effects.

D) Recommend the patient avoid any physical activity until symptoms completely resolve.

A patient with diabetes presents with worsening peripheral neuropathy and an increase in serum creatinine levels. Which intervention should the nurse prioritize to address the patient's symptoms while considering renal function?

A) Initiate gabapentin therapy for neuropathic pain management.

B) Recommend increasing fluid intake to improve kidney function.

C) Educate the patient on daily foot care and regular exercise.

D) Suggest reducing protein intake to alleviate kidney strain.

A patient with diabetes presents with recent worsening of peripheral neuropathy symptoms and a slight increase in serum creatinine. Which nursing intervention is most appropriate to address the progression of these complications?

B) Educate the patient on regular foot inspections and proper foot care.

A) Encourage increased protein intake to support renal function.

B) Educate the patient on regular foot inspections and proper foot care.

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

D) Recommend reducing physical activity to prevent further nerve damage.

A patient being treated with gabapentinoids for neuropathic pain management presents with increased fatigue, difficulty concentrating, and a slight increase in serum creatinine levels. What is the most appropriate nursing action to address the patient's current condition?

B) Educate the patient on dietary modifications to support renal function.

A) Increase the gabapentinoid dosage to enhance pain control.

B) Educate the patient on dietary modifications to support renal function.

C) Discontinue gabapentinoids and start an alternative medication immediately.

D) Recommend the patient to rest more frequently to manage fatigue.

A patient with neuropathic pain managed by gabapentinoids presents with increased fatigue and difficulty concentrating. Recent laboratory results show elevated serum creatinine and trace proteinuria, indicating early nephropathy. Which nursing intervention is most appropriate to address both the symptoms and potential renal complications in this patient?

B) Recommend the patient reduce sodium and protein intake while maintaining a balanced diet.

A) Encourage the patient to increase fluid intake to flush out the kidneys.

B) Recommend the patient reduce sodium and protein intake while maintaining a balanced diet.

C) Advise the patient to increase their gabapentinoid dosage to manage neuropathy symptoms.

D) Suggest the patient discontinue all medications to prevent further renal damage.

diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency/resistance - In Type 1 diabetes, autoimmune destruction of pancreatic beta cells leads to insufficient insulin production. In Type 2 diabetes, cells exhibit insulin resistance, reducing glucose uptake despite adequate insulin levels.

• Secondary mechanism: Hyperglycemia - Resulting from impaired insulin action, glucose accumulates in the bloodstream, as cells cannot effectively use it for energy, leading to elevated blood sugar levels.

• Key complication: Vascular damage - Chronic hyperglycemia causes damage to blood vessels, increasing the risk of cardiovascular disease, neuropathy, nephropathy, and retinopathy, highlighting the importance of glycemic control.

Patient Profile

Demographics:

58 years old, male, construction worker

History:

• Type 2 Diabetes diagnosed 8 years ago, hypertension, dyslipidemia

• Metformin 1000 mg twice daily, Lisinopril 10 mg daily, Atorvastatin 20 mg daily, Insulin glargine 20 units at bedtime

• Allergic to penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and blurred vision

• Key symptoms: Polyuria, polydipsia, tingling in feet, occasional dizziness

• Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, BMI 32 kg/m²

Section 1

Upon initial assessment, the patient's condition reveals several areas of concern that warrant further investigation. Physical examination notes the presence of bilateral peripheral neuropathy, as indicated by diminished sensation in the feet upon monofilament testing. Additionally, there is evidence of early diabetic retinopathy, with retinal examination revealing microaneurysms and mild non-proliferative changes. Laboratory results show a fasting blood glucose level of 210 mg/dL and an HbA1c of 9.2%, indicating suboptimal glycemic control. Creatinine levels are slightly elevated at 1.4 mg/dL, suggesting the onset of diabetic nephropathy, while urine microalbumin levels are elevated at 45 mg/L, further substantiating this finding.

These assessment findings highlight the progression of diabetes-related complications, emphasizing the need for a revised management plan to address both hyperglycemia and its sequelae. The presence of diabetic neuropathy and nephropathy indicates microvascular damage, likely exacerbated by poor blood pressure and lipid control. The patient's current medication regimen may need adjustment, potentially increasing insulin dosage or adding a GLP-1 receptor agonist, to achieve better glycemic control and mitigate further vascular damage. Additionally, the development of retinopathy necessitates referral to an ophthalmologist for comprehensive eye care.

Given these findings, it is clear that the patient requires a multifaceted approach to management, integrating lifestyle modifications with pharmacological interventions. Emphasis should be placed on dietary counseling, regular physical activity, and smoking cessation to enhance cardiovascular health. The healthcare team must engage in regular monitoring and follow-up to assess the effectiveness of interventions, address any barriers to adherence, and prevent the progression of complications. This integrated strategy will be critical in improving the patient's quality of life and preventing further deterioration of health.

Section 2

Following the initial assessment and implementation of a revised management plan, the patient returns for a follow-up appointment six weeks later. During this visit, the healthcare team notes a mild improvement in glycemic control, with the patient's fasting blood glucose level now at 180 mg/dL and HbA1c reduced to 8.6%. Despite these advancements, the patient reports persistent tingling and numbness in the feet, with increased difficulty in maintaining balance, particularly when walking on uneven surfaces. These symptoms suggest a progression of peripheral neuropathy, prompting further evaluation and consideration of additional interventions.

A comprehensive neurological examination reveals worsened proprioception and an increase in the monofilament test score, indicating heightened sensory loss. Furthermore, new laboratory results show a slight increase in serum creatinine to 1.6 mg/dL, alongside the continued presence of elevated urine microalbumin at 55 mg/L. These findings suggest progression in diabetic nephropathy, necessitating a reassessment of renal protective strategies, including the potential introduction of an ACE inhibitor or ARB to manage blood pressure and minimize kidney damage.

In response to these developments, the healthcare team decides to intensify the patient's treatment regimen. This includes optimizing the current pharmacological approach by considering the addition of a sodium-glucose co-transporter-2 (SGLT2) inhibitor, which has demonstrated renal protective effects and may further improve glycemic control. The patient is also referred to a podiatrist for specialized foot care and to a physical therapist to address balance issues through targeted exercises. These adjustments aim to slow the progression of complications, improve the patient's functional capacity, and enhance overall quality of life. Regular follow-ups are planned to monitor progress and ensure adherence to the revised management strategy.

Section 3

Three months after the intensified treatment regimen was implemented, the patient returns for another follow-up appointment. During this visit, the healthcare team observes a notable improvement in the patient's glycemic control, as evidenced by a fasting blood glucose level reduced to 150 mg/dL and an HbA1c of 7.9%. Despite these positive changes, the patient reports occasional dizziness and lightheadedness, especially upon standing, which raises concerns about potential orthostatic hypotension. A review of the patient's current medications reveals the recent addition of an ACE inhibitor to manage diabetic nephropathy, which may be contributing to these symptoms.

A thorough assessment is conducted, including vital signs taken in both supine and standing positions. The patient's blood pressure is 125/80 mmHg while lying down but drops to 100/70 mmHg upon standing, confirming the presence of orthostatic hypotension. Additionally, the neurological examination shows mild improvement in proprioception and a slight decrease in the monofilament test score, suggesting some stabilization of peripheral neuropathy symptoms. However, the patient's serum creatinine remains at 1.6 mg/dL, with urine microalbumin slightly reduced to 50 mg/L, indicating that renal function has not significantly worsened.

Based on these findings, the healthcare team decides to adjust the patient's medication regimen to address the orthostatic hypotension while continuing to provide renal protection. The dosage of the ACE inhibitor is reviewed and adjusted cautiously, and the patient is educated on lifestyle modifications such as rising slowly from sitting or lying positions and maintaining adequate hydration. The team also emphasizes the importance of ongoing monitoring of blood pressure and renal function, with plans for regular follow-ups to ensure the patient remains stable and to assess the effectiveness of the revised management plan. This approach aims to balance the management of existing complications while minimizing the risk of new side effects, guiding the patient toward improved stability and quality of life.

Section 4

Two months after the adjustments to the patient's medication regimen, the patient returns for a scheduled follow-up appointment. During this visit, the healthcare team notes that the patient’s orthostatic hypotension symptoms have slightly improved, with blood pressure readings now showing 120/78 mmHg while supine and 108/74 mmHg upon standing. The patient reports fewer episodes of dizziness and lightheadedness, indicating a positive response to the modifications in medication and lifestyle adjustments.

However, new concerns arise as the patient describes experiencing more frequent episodes of numbness and tingling in their feet, particularly at night. A detailed neurological examination reveals diminished vibratory sensation and a further decrease in the monofilament test score, suggesting a progression of peripheral neuropathy despite stable glycemic control. Additionally, recent lab results show a slight increase in serum creatinine to 1.8 mg/dL, raising concerns about potential renal function decline, even though urine microalbumin levels remain stable.

The healthcare team recognizes the need for further intervention to address these emerging complications. They discuss the possibility of introducing a medication specifically aimed at neuropathic pain management, such as a gabapentinoid, while continuing to monitor renal function closely. Education is reinforced around foot care and the importance of regular exercise to improve circulation. Scheduled follow-ups are planned to reassess the effectiveness of the new interventions and to ensure comprehensive management of the patient’s diabetes and associated complications. Through careful monitoring and tailored interventions, the team aims to prevent further progression of complications and enhance the patient's quality of life.

Section 5

Two weeks after the introduction of the gabapentinoid for neuropathic pain management, the patient returns for a follow-up appointment. Initially, the patient reports a noticeable reduction in the intensity and frequency of numbness and tingling in their feet, indicating a positive response to the medication. However, the patient also mentions experiencing increased fatigue and occasional difficulty concentrating, which raises concerns about possible side effects of the new medication. The healthcare team decides to adjust the gabapentinoid dosage to balance efficacy with tolerability, while also considering non-pharmacological interventions such as physical therapy to support nerve health and function.

During this visit, a repeat set of laboratory tests is conducted to monitor renal function and overall metabolic status. The results reveal a slight increase in serum creatinine to 2.0 mg/dL, suggesting a continuing decline in renal function. In addition, a new finding of a trace amount of protein in the urine indicates early signs of nephropathy. These results prompt the healthcare team to re-evaluate the patient's medication regimen, particularly the use of any nephrotoxic agents, and to reinforce the importance of optimal blood pressure and glycemic control to preserve kidney function.

The patient is counseled on dietary modifications, such as reducing sodium and protein intake, to alleviate stress on the kidneys. The team emphasizes the importance of maintaining a balanced diet and regular physical activity to manage weight and improve circulation, which is critical for both neuropathy and kidney health. Follow-up appointments are scheduled more frequently to closely monitor the patient's progress and to adjust treatment plans as needed. Through a proactive and holistic approach, the healthcare team aims to mitigate further complications and support the patient's overall well-being.