A patient with type 2 diabetes presents with diminished sensation in the feet, elevated blood pressure despite antihypertensive therapy, and a BMI of 32. Laboratory tests reveal poor glycemic control and early signs of nephropathy. As the nurse, which of the following interventions should be prioritized to address the patient's current health issues?

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

A) Increase the dosage of the patient's current antihypertensive medication.

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

C) Recommend a low-carbohydrate diet to improve blood glucose levels.

D) Schedule an urgent nephrology consultation to address renal function.

A patient with type 2 diabetes presents with diminished sensation in the feet, elevated blood pressure, and poor glycemic control. Which of the following nursing interventions should be prioritized to address the patient's risk of complications?

A) Educate the patient on daily foot care and inspection to prevent foot ulcers.

B) Increase the patient's antihypertensive medication dosage to better control blood pressure.

C) Schedule a dietary consult to address obesity and improve insulin sensitivity.

D) Refer the patient to an ophthalmologist for evaluation of diabetic retinopathy.

A patient with poorly controlled diabetes and hypertension has been started on an SGLT2 inhibitor and switched to an ARB to manage glycemic levels and blood pressure. Which nursing intervention is most important to prioritize during the initial phase of this new treatment regimen?

A) Monitor blood glucose levels regularly to assess the efficacy of the SGLT2 inhibitor

B) Educate the patient about potential side effects of ARBs, such as dizziness and dry cough

C) Encourage increased fluid intake to prevent dehydration associated with SGLT2 inhibitors

D) Schedule regular foot examinations to monitor for signs of peripheral neuropathy

A patient with type 2 diabetes mellitus presents with an elevated fasting blood glucose of 225 mg/dL, HbA1c of 9.5%, and urine albumin-to-creatinine ratio of 65 mg/g. The patient is currently on metformin and an ACE inhibitor. The healthcare team plans to add an SGLT2 inhibitor to the treatment regimen. Which additional intervention should the nurse prioritize to address the progression of diabetic nephropathy and peripheral neuropathy?

A) Educate the patient about the importance of foot care to prevent neuropathic ulcers.

B) Recommend increasing dietary protein intake to support renal function.

C) Instruct the patient to reduce fluid intake to manage potential fluid retention.

D) Encourage the patient to perform weight-bearing exercises to improve circulation.

A patient with type 2 diabetes is experiencing persistent numbness and tingling in the feet, a modest improvement in glycemic control, and new episodes of dizziness upon standing. Which nursing intervention should be prioritized to address the patient's current symptoms and potential complications?

D) Advise the patient to rise slowly from a sitting or lying position to prevent dizziness and falls.

A) Educate the patient on the importance of foot care and daily foot inspections to prevent injury.

B) Instruct the patient to increase fluid intake to manage dizziness and potential orthostatic hypotension.

C) Encourage the patient to maintain regular exercise to further improve glycemic control and weight loss.

D) Advise the patient to rise slowly from a sitting or lying position to prevent dizziness and falls.

A patient with diabetes mellitus has shown a modest improvement in glycemic control and blood pressure management after a treatment adjustment. However, the patient reports dizziness upon standing. Which nursing intervention is most appropriate to address this new complication?

B) Instruct the patient to rise slowly from a sitting or lying position

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

B) Instruct the patient to rise slowly from a sitting or lying position

C) Suggest the patient reduce antihypertensive medication dose independently

D) Advise the patient to engage in more frequent, intense exercise to improve circulation

A patient with a history of hypertension and diabetes is experiencing orthostatic hypotension, hypokalemia, and a mild decline in renal function. Which nursing intervention is most appropriate to address the patient's current electrolyte imbalance and reduce the risk of further complications?

B) Educate the patient on consuming a diet high in potassium-rich foods to correct hypokalemia.

A) Encourage the patient to increase daily fluid intake to manage blood pressure fluctuations.

B) Educate the patient on consuming a diet high in potassium-rich foods to correct hypokalemia.

C) Advise the patient to avoid standing quickly to prevent dizziness and potential falls.

D) Instruct the patient to limit salt intake to prevent fluid retention and hypertension.

A patient with a history of hypertension and diabetes is experiencing orthostatic hypotension and hypokalemia after being on an antihypertensive regimen that includes a diuretic. The healthcare team decides to reduce the diuretic dose and consider adding a potassium-sparing agent. Which of the following nursing interventions is most appropriate to address the patient's current condition and prevent further complications?

A) Educate the patient on increasing dietary potassium intake and monitor blood pressure regularly.

B) Advise the patient to restrict fluid intake to prevent fluid overload and worsening renal function.

C) Encourage the patient to increase physical activity to improve cardiovascular health and reduce palpitations.

D) Instruct the patient to take the diuretic dose at bedtime to minimize nocturia and improve sleep quality.

A patient with a history of hypertension and declining renal function is started on an ACE inhibitor. During a follow-up assessment, which clinical finding would most concern the nurse regarding the patient's renal status?

C) Serum creatinine increased to 2.0 mg/dL

A) Blood pressure stabilized at 120/78 mmHg

B) Serum potassium level increased to 4.5 mEq/L

C) Serum creatinine increased to 2.0 mg/dL

D) Occasional premature ventricular contractions (PVCs)

A patient with a history of hypertension and declining renal function is being managed with a potassium-sparing agent and has been initiated on an ACE inhibitor. The nurse is educating the patient about the potential side effects of these medications. Which symptom reported by the patient should prompt the nurse to prioritize immediate intervention?

D) Lightheadedness upon standing

diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance - In Type 1 diabetes, the immune system attacks and destroys insulin-producing beta cells in the pancreas, leading to insulin deficiency. In Type 2 diabetes, the body becomes resistant to insulin, and the pancreas cannot produce enough insulin to overcome this resistance.

• Secondary mechanism: Impaired glucose uptake - Due to insufficient insulin action, glucose cannot efficiently enter cells, particularly muscle and fat cells. This leads to elevated blood glucose levels (hyperglycemia) and triggers the liver to release more glucose, exacerbating the problem.

• Key complication: Chronic hyperglycemia - Persistent high blood glucose levels damage blood vessels and nerves over time, leading to complications such as neuropathy, retinopathy, nephropathy, and increased risk of cardiovascular disease.

Patient Profile

Demographics:

52-year-old male, office manager

History:

• Key past medical history: Diagnosed with type 2 diabetes 8 years ago, hypertension for 5 years, and mild neuropathy

• 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: Increasing fatigue and intermittent blurry vision

• Key symptoms: Numbness and tingling in feet, increased thirst, frequent urination, and 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.

Section 1

During the initial assessment, the healthcare team focused on the patient's presenting symptoms and medical history. The physical examination revealed diminished sensation in the feet upon monofilament testing, consistent with worsening peripheral neuropathy. Fundoscopic examination noted microaneurysms, suggesting early signs of diabetic retinopathy. The patient's blood pressure remained elevated at 145/90 mmHg despite antihypertensive therapy, indicating suboptimal control. Given the patient's BMI of 32, obesity was identified as a contributing factor to the insulin resistance and hypertension.

Laboratory tests showed an elevated fasting blood glucose level of 210 mg/dL and an HbA1c of 9.2%, indicating poor long-term glycemic control. The lipid profile revealed LDL cholesterol at 130 mg/dL, slightly above the target for diabetic patients, despite current statin therapy, suggesting a need for further lipid management. Elevated creatinine levels at 1.4 mg/dL and a urine albumin-to-creatinine ratio of 45 mg/g pointed to early diabetic nephropathy, requiring close monitoring and potential adjustment of medications.

The team discussed the need for a comprehensive management plan that includes dietary modifications, potential intensification of the current diabetes medication regimen, and reinforcement of lifestyle changes. A referral to an ophthalmologist was made for further evaluation of the retinal changes, and a nephrology consult was considered to address the renal findings. The primary care provider emphasized the importance of regular follow-ups and adherence to prescribed treatments, recognizing that early intervention could prevent further complications and improve the patient's overall health outcomes.

Section 2

Two weeks after the initial assessment, the patient returned for a follow-up visit. During this visit, additional diagnostic tests were performed to further evaluate the patient’s condition. The new results revealed a slight increase in the patient's fasting blood glucose level to 225 mg/dL, indicating a continued trend of poor glycemic control despite prior dietary counseling and medication adjustments. The patient's HbA1c remained elevated at 9.5%, and the urine albumin-to-creatinine ratio increased to 65 mg/g, suggesting a progression of diabetic nephropathy. Blood pressure measurements showed readings of 150/92 mmHg, reinforcing the need for a reassessment of the antihypertensive regimen. During the physical examination, the patient reported increased frequency and intensity of numbness and tingling in the feet, consistent with worsening peripheral neuropathy.

In light of these findings, the healthcare team held a multidisciplinary meeting to reevaluate the patient's management plan. The decision was made to intensify the diabetes treatment regimen by adding a sodium-glucose co-transporter-2 (SGLT2) inhibitor, which could also provide renal protective benefits. The team also considered switching to a different class of antihypertensive medication, such as an angiotensin receptor blocker (ARB), to better manage the patient's blood pressure and address the renal complications. Additionally, the patient was referred to a diabetes educator to reinforce dietary modifications and promote a structured exercise plan aimed at weight reduction, recognizing that lifestyle changes could significantly impact both glycemic and blood pressure control.

The team also scheduled a nephrology consult to address the progression of nephropathy and to explore potential interventions to slow further renal decline. Emphasizing the importance of adherence to the new treatment regimen and lifestyle changes, the primary care provider planned more frequent follow-ups to closely monitor the patient’s response to the interventions. These steps aimed to mitigate the risk of further complications, improve the patient's overall health status, and enhance quality of life, while also preparing for any additional adjustments needed based on future clinical outcomes.

Section 3

Three months after the multidisciplinary meeting and subsequent treatment adjustments, the patient returned for a follow-up evaluation. During this visit, the healthcare team was eager to assess the patient's response to the intensified diabetes management plan and lifestyle modifications. The patient reported feeling more energetic and had managed to lose five pounds through regular exercise and improved dietary habits. However, the patient still experienced persistent numbness and tingling in the feet, which occasionally affected mobility, indicating ongoing peripheral neuropathy.

The clinical assessment revealed a modest improvement in glycemic control, with the fasting blood glucose level reduced to 180 mg/dL and HbA1c decreased to 8.7%. While these numbers showed progress, they remained above the target range, necessitating continued focus on optimizing the treatment regimen. Additionally, the urine albumin-to-creatinine ratio had stabilized at 60 mg/g, and the patient’s blood pressure had improved to 140/88 mmHg following the switch to an angiotensin receptor blocker. These findings suggested a positive response to the new medications, yet highlighted the need for ongoing vigilance to prevent further nephropathy progression and maintain blood pressure control.

Despite these improvements, the patient reported a new complication: occasional episodes of dizziness, particularly upon standing. This prompted the healthcare team to investigate potential causes such as orthostatic hypotension, a side effect of the antihypertensive treatment. A plan was devised to monitor blood pressure changes with positional adjustments and consider dosage modifications if necessary. Meanwhile, the nephrology consult was scheduled to ensure comprehensive management of renal health. The team emphasized the importance of adherence to the treatment plan and lifestyle modifications, reiterating the need for regular follow-up visits to tailor interventions and maximize the patient's quality of life.

Section 4

Two months later, the patient returned for another follow-up appointment, presenting with new symptoms of increased fatigue and occasional palpitations. During the initial assessment, the healthcare team noted that the patient’s blood pressure was now 130/80 mmHg when seated, but it dropped to 110/70 mmHg upon standing, confirming orthostatic hypotension. This change was likely contributing to the patient's dizziness and palpitations. The patient also reported experiencing nocturia, which raised concerns about potential fluid balance issues or worsening renal function.

The team decided to perform additional diagnostic tests to further investigate the underlying causes of these symptoms. A comprehensive metabolic panel revealed that the patient's serum potassium level had dropped to 3.2 mEq/L, indicating hypokalemia, possibly linked to the diuretic component of the patient's antihypertensive regimen. The estimated glomerular filtration rate (eGFR) had decreased slightly to 58 mL/min/1.73 m², suggesting a mild decline in renal function. Additionally, a 24-hour Holter monitor was ordered to evaluate the frequency and pattern of the palpitations for any underlying arrhythmias.

These new findings prompted an adjustment in the patient's treatment plan. The healthcare team decided to modify the antihypertensive therapy by reducing the diuretic dose to address the orthostatic hypotension and hypokalemia. A potassium-sparing agent was considered to help manage the electrolyte imbalance. The nephrologist's input was sought to optimize renal protection strategies, emphasizing the importance of maintaining adequate hydration and monitoring renal function closely. The patient was counseled on recognizing symptoms of electrolyte disturbances and instructed to report any new or worsening symptoms promptly. These steps aimed to stabilize the patient's condition while minimizing risks of further complications, ensuring a comprehensive approach to their ongoing diabetes management.

Section 5

Following the adjustments to the antihypertensive regimen and the inclusion of a potassium-sparing agent, the patient returned for a follow-up appointment two weeks later. During the visit, the patient reported a slight improvement in dizziness, though occasional palpitations persisted. The healthcare team conducted a comprehensive physical assessment and noted that the patient's blood pressure had stabilized at 120/78 mmHg while seated, with a milder drop to 115/75 mmHg upon standing. The patient appeared less fatigued, and nocturia had reduced to once per night, suggesting a partial improvement in fluid balance.

However, new laboratory results revealed an emerging complication. The patient's serum potassium level had increased to 4.0 mEq/L, falling within the normal range, but the comprehensive metabolic panel indicated a rise in serum creatinine to 1.5 mg/dL, with a corresponding eGFR of 52 mL/min/1.73 m². These findings suggested a continued decline in renal function, prompting further investigation. In addition, the results from the 24-hour Holter monitor indicated episodes of premature ventricular contractions (PVCs), potentially linked to the previous hypokalemia and current electrolyte adjustments.

The nephrologist recommended initiating an ACE inhibitor to provide renal protection and address the declining kidney function, while carefully monitoring blood pressure and electrolytes. The patient was advised to maintain a balanced diet with adequate hydration, avoiding excessive potassium intake. Education on recognizing symptoms of renal impairment was reinforced, and the importance of timely follow-up was emphasized. These strategies aimed to stabilize the patient's renal function and manage cardiovascular risks, ensuring a proactive approach to their diabetes care. The healthcare team planned for close monitoring of renal parameters and electrolyte levels to mitigate the risk of further complications, setting the stage for ongoing management and adjustment of the treatment plan as needed.