A patient with type 2 diabetes presents with increasing fatigue, intermittent blurred vision, polyuria, polydipsia, and tingling in the feet. Recent lab results show an HbA1c of 8.5%, elevated LDL cholesterol, triglycerides, and mild proteinuria. Which of the following interventions should be prioritized to address the patient's risk for both microvascular and macrovascular complications?

A) Introduce a GLP-1 receptor agonist to improve glycemic control and provide cardiovascular protection.

B) Increase the dose of atorvastatin to further reduce LDL cholesterol levels.

C) Add an ACE inhibitor to address elevated blood pressure and protect kidney function.

D) Implement intensive lifestyle modifications focusing on diet and exercise.

A 58-year-old male patient with type 2 diabetes presents with increasing fatigue, intermittent blurred vision, polyuria, polydipsia, and tingling in the feet. His blood pressure is 150/95 mmHg, and his recent HbA1c is 8.5%. The healthcare team is considering medication adjustments. Which intervention should the nurse prioritize to address both glycemic control and cardiovascular protection?

B) Add a GLP-1 receptor agonist to improve glycemic control and provide cardiovascular benefits.

A) Increase the dose of metformin to improve glycemic control.

B) Add a GLP-1 receptor agonist to improve glycemic control and provide cardiovascular benefits.

C) Initiate insulin therapy for tighter glycemic control.

D) Increase atorvastatin dosage to better manage lipid levels.

A patient with type 2 diabetes has been on a revised medication regimen including a GLP-1 receptor agonist and has made lifestyle changes. Despite some improvements, the patient continues to experience polyuria and tingling in the feet. The healthcare team is considering adding an ACE inhibitor or ARB to the patient's regimen. What is the primary rationale for adding this medication to the patient's treatment plan?

B) To address persistent proteinuria and protect renal function.

A) To further lower blood glucose levels and manage diabetes.

B) To address persistent proteinuria and protect renal function.

C) To alleviate the patient's symptoms of polyuria and tingling.

D) To improve the patient's lipid profile and reduce LDL cholesterol.

A patient with type 2 diabetes mellitus is experiencing persistent proteinuria despite lifestyle modifications and medication adjustments, including the addition of a GLP-1 receptor agonist. Which nursing intervention should be prioritized to address the risk of diabetic nephropathy progression?

A) Educate the patient on reducing sodium intake to help manage blood pressure.

B) Suggest adding a calcium channel blocker to the current antihypertensive regimen.

C) Recommend increasing the dose of the current statin to further lower LDL cholesterol.

D) Encourage the patient to increase fluid intake to flush the kidneys.

A patient with a history of diabetes and hypertension presents with increased fatigue, peripheral edema, and elevated blood pressure. Recent labs indicate worsening renal function and hyperkalemia. The healthcare team introduces an ACE inhibitor to improve renal outcomes. Which nursing intervention is most critical to perform when monitoring this patient's response to the new medication?

D) Check the patient's serum potassium levels to prevent complications related to hyperkalemia

A) Monitor the patient's blood glucose levels regularly for signs of hypoglycemia

B) Assess the patient's blood pressure daily to ensure effectiveness of the ACE inhibitor

C) Evaluate the patient's renal function through regular serum creatinine and eGFR tests

D) Check the patient's serum potassium levels to prevent complications related to hyperkalemia

A patient with a history of diabetes mellitus presents with increased fatigue, lower extremity edema, and poorly controlled hypertension. Recent lab results indicate worsening renal function and hyperkalemia. Which nursing intervention should be prioritized to address the patient's current condition and prevent further complications?

B) Instruct the patient to avoid foods high in potassium, such as bananas and oranges, to manage hyperkalemia.

A) Educate the patient on the importance of reducing sodium intake to manage hypertension.

B) Instruct the patient to avoid foods high in potassium, such as bananas and oranges, to manage hyperkalemia.

C) Encourage the patient to increase fluid intake to promote renal function and prevent dehydration.

D) Advise the patient to engage in daily physical activity to improve overall cardiovascular health.

A patient with a history of hypertension and diabetes mellitus reports occasional lightheadedness when standing after starting an ACE inhibitor. Which nursing intervention should be prioritized to address the patient's symptoms and prevent complications?

B) Instruct the patient to rise slowly from a sitting or lying position to reduce orthostatic changes.

A) Advise the patient to increase fluid intake to improve blood pressure.

B) Instruct the patient to rise slowly from a sitting or lying position to reduce orthostatic changes.

C) Recommend the patient to consume a high-sodium diet to counteract the effects of the medication.

D) Encourage the patient to perform leg exercises before standing to enhance circulation.

A patient with a history of diabetes and hypertension presents with lightheadedness upon standing, nocturia, and mild shortness of breath despite a recent change in medication to include an ACE inhibitor. Which nursing intervention is most appropriate to address the patient's symptom of lightheadedness?

B) Instruct the patient to rise slowly from sitting or lying positions to prevent orthostatic hypotension.

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

B) Instruct the patient to rise slowly from sitting or lying positions to prevent orthostatic hypotension.

C) Advise the patient to decrease sodium intake to reduce blood pressure further.

D) Suggest the patient engage in more physical activity to improve cardiovascular health.

A patient with diabetes and recent laboratory findings indicating worsening renal function and elevated BNP levels is experiencing orthostatic hypotension and tingling in the hands. Given these signs and symptoms, which nursing intervention should be prioritized to address the patient's current condition?

B) Educate the patient on slow position changes to manage orthostatic hypotension.

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

B) Educate the patient on slow position changes to manage orthostatic hypotension.

C) Recommend potassium-rich foods to address potential electrolyte imbalances.

D) Initiate a high-intensity exercise regimen to improve cardiac function.

A patient with a history of diabetes and newly diagnosed orthostatic hypotension presents with increased serum potassium levels, elevated creatinine, and reduced eGFR. Which nursing intervention is most appropriate to address these findings while preventing potential complications?

B) Educate the patient on reducing potassium-rich foods to prevent hyperkalemia.

A) Encourage increased fluid intake to improve renal function and reduce orthostatic hypotension.

B) Educate the patient on reducing potassium-rich foods to prevent hyperkalemia.

C) Advise the patient to limit physical activity to manage blood pressure changes.

D) Instruct the patient to take an extra dose of ACE inhibitor if blood pressure increases.

diabetes mellitus - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance occurs when body cells, particularly muscle, fat, and liver cells, do not respond effectively to insulin, leading to decreased glucose uptake and increased blood glucose levels. This is crucial in Type 2 diabetes development.

• Secondary mechanism: Impaired insulin secretion from pancreatic beta cells, which is often progressive, exacerbates hyperglycemia. Over time, beta cells may become dysfunctional or exhausted, further reducing insulin availability and worsening blood glucose control.

• Key complication: Chronic hyperglycemia can lead to microvascular complications such as retinopathy, nephropathy, and neuropathy, as well as macrovascular complications including cardiovascular disease, highlighting the importance of early detection and management to prevent these outcomes.

Patient Profile

Demographics:

56-year-old male, office manager

History:

• Key past medical history: Diagnosed with type 2 diabetes mellitus 10 years ago, hypertension, hyperlipidemia

• Current medications: Metformin, Lisinopril, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and intermittent blurred vision

• Key symptoms: Polyuria, polydipsia, tingling sensation in feet, occasional headaches

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

Section 1

During the initial assessment, the healthcare team noted the patient's chief complaints of increasing fatigue and intermittent blurred vision, alongside polyuria, polydipsia, and a tingling sensation in the feet. These symptoms raised concerns for potential complications related to chronic hyperglycemia. Upon further examination, the patient's blood pressure was elevated at 150/95 mmHg, which, combined with his history of hypertension and hyperlipidemia, increased his risk for cardiovascular events. The patient's blood glucose was notably high at 210 mg/dL, indicating suboptimal glycemic control despite ongoing metformin therapy. Physical examination revealed diminished sensation in the distal extremities, suggestive of peripheral neuropathy, a common microvascular complication of diabetes.

New diagnostic results were ordered to gain a clearer picture of the patient's condition. An HbA1c test was performed, revealing a level of 8.5%, indicating poor long-term glucose control over the past three months. Additionally, a lipid panel showed elevated LDL cholesterol and triglycerides, despite atorvastatin therapy, heightening the risk for macrovascular complications. A urine microalbumin test indicated mild proteinuria, raising concerns for early nephropathy. The ophthalmologic exam confirmed mild non-proliferative diabetic retinopathy, correlating with the patient's blurred vision complaints.

These findings prompted the healthcare team to re-evaluate the patient's management plan. It became clear that more aggressive interventions were needed to mitigate the risk of further complications. This included intensifying the patient's diabetes management through the potential addition of a GLP-1 receptor agonist or SGLT2 inhibitor to better control blood glucose levels and provide cardiovascular protection. The patient's antihypertensive regimen may also be adjusted to achieve better blood pressure control, and dietary and lifestyle modifications were recommended to address lipid abnormalities. Close monitoring and follow-up were emphasized to assess the effectiveness of these interventions and to prevent the progression of diabetic complications.

Section 2

Following the intensified management plan, the patient returned for a follow-up appointment after eight weeks. He reported adherence to his revised medication regimen, which now included the addition of a GLP-1 receptor agonist. He also implemented recommended dietary changes and increased physical activity. The patient noted a slight improvement in energy levels and stabilization in his vision, but he continued to experience polyuria and occasional tingling in his feet.

During the follow-up assessment, his vital signs showed a blood pressure reading of 140/88 mmHg, reflecting improved but still suboptimal control. A repeat HbA1c test revealed a modest decrease to 7.9%, suggesting some improvement in glycemic control, though further progress was needed. The lipid panel showed a reduction in LDL cholesterol to 110 mg/dL, indicating a positive response to lifestyle modifications and medication adjustments. However, repeat urine microalbumin tests showed persistent proteinuria, raising ongoing concerns about diabetic nephropathy.

Given these mixed results, the healthcare team discussed the potential need to further adjust the patient's antihypertensive therapy, perhaps adding an ACE inhibitor or ARB to better protect renal function. Continued emphasis was placed on the importance of lifestyle modifications, particularly focusing on weight management and consistent exercise, to enhance cardiovascular and metabolic outcomes. The team also stressed the need for regular follow-up appointments to closely monitor the patient's response to interventions and to prevent any further complications. The patient was encouraged and felt motivated by the slight improvements, agreeing to maintain adherence and work towards better management of his diabetes and associated risks.

Section 3

Two months after the previous follow-up, the patient returns to the clinic with new complaints of increased fatigue and swelling in his lower extremities. On assessment, vital signs reveal a blood pressure of 148/92 mmHg, suggesting a regression in blood pressure control. His heart rate is 82 beats per minute, and respiratory rate is 18 breaths per minute. Physical examination reveals 2+ pitting edema in both ankles and diminished sensation in the feet, indicating potential progression of peripheral neuropathy. The patient reports that, despite adhering to his medication regimen, he has experienced increasing nocturia and has gained five pounds since his last visit.

New laboratory results show an HbA1c of 8.2%, indicating a slight deterioration in glycemic control since the last visit. Additionally, serum creatinine levels have risen to 1.5 mg/dL from a previous 1.2 mg/dL, and his estimated glomerular filtration rate (eGFR) has decreased to 58 mL/min/1.73m², further pointing towards declining kidney function. Urine microalbumin tests continue to show elevated protein levels, and new findings include mild hyperkalemia, with a serum potassium level of 5.5 mmol/L.

The healthcare team recognizes these changes as signs of worsening diabetic nephropathy and possibly heart failure. They decide to adjust the patient's antihypertensive therapy by introducing an ACE inhibitor to improve renal outcomes and control blood pressure more effectively. Additionally, they emphasize the importance of maintaining strict blood glucose control and suggest a referral to a nephrologist for further evaluation of renal health. The team also recommends dietary modifications to manage potassium levels and prevent further complications. The patient is counseled on the implications of these findings and the importance of frequent monitoring, as well as adherence to the revised management plan to prevent further deterioration of his condition.

Section 4

Two weeks after the implementation of the revised management plan, the patient returns to the clinic for a follow-up visit. During this assessment, the patient reports feeling slightly less fatigued but still experiences nocturia and mild shortness of breath upon exertion. Physical examination reveals a reduction in the pitting edema of the lower extremities to 1+, suggesting a partial response to the introduction of the ACE inhibitor. However, the patient continues to exhibit diminished sensation in the feet, with monofilament testing confirming persistent peripheral neuropathy. Vital signs show a slight improvement in blood pressure, now at 142/88 mmHg, and a stable heart rate of 80 beats per minute. Despite these changes, the patient mentions occasional lightheadedness, particularly when standing up, which may indicate orthostatic hypotension as a side effect of the new medication regimen.

New laboratory results provide further insight into the patient's current status. The HbA1c level has shown a marginal improvement, now at 8.0%, reflecting a minor enhancement in glycemic control. Serum creatinine remains elevated at 1.5 mg/dL, with no significant change in the eGFR, which remains at 58 mL/min/1.73m². Urine microalbumin levels persist in showing elevated protein excretion, confirming ongoing renal impairment. Serum potassium levels have decreased slightly to 5.3 mmol/L following dietary modifications, yet they remain above the normal range, indicating a need for continued monitoring and dietary adjustments. These results suggest initial stabilization but highlight the need for ongoing vigilance in managing renal function and cardiovascular health.

The healthcare team discusses these findings with the patient, emphasizing the importance of regular follow-up appointments to closely monitor renal function and electrolyte balance. They educate the patient on recognizing symptoms of electrolyte imbalances and orthostatic hypotension, stressing the importance of adhering to dietary recommendations and medication adjustments. The team considers the potential need for further medications to optimize blood pressure control and mitigate the risk of cardiovascular complications. The patient is encouraged to maintain lifestyle modifications and is scheduled for another follow-up in four weeks to evaluate the effectiveness of the current management plan and make any necessary adjustments.

Section 5

Four weeks later, the patient returns for a follow-up appointment, presenting with new symptoms that suggest further complications. The patient reports increased episodes of dizziness and occasional heart palpitations, particularly in the morning. During this visit, the patient's blood pressure is measured at 136/82 mmHg while seated, but drops to 110/68 mmHg upon standing, confirming orthostatic hypotension. Heart rate remains stable at 78 beats per minute. The patient's weight has decreased slightly, suggesting a potential benefit from the dietary modifications, yet the patient notes a persistent sensation of tingling in the hands, raising concerns about potential peripheral neuropathy progression or the onset of new neuropathic symptoms.

Laboratory results further illuminate the patient's condition. The HbA1c level has improved to 7.8%, indicating better glycemic control, yet serum potassium levels have slightly increased again to 5.5 mmol/L, despite dietary interventions. Serum creatinine has risen to 1.6 mg/dL, and eGFR has decreased to 55 mL/min/1.73m², suggesting a potential decline in renal function. Additionally, a new finding of elevated BNP levels at 120 pg/mL raises concerns regarding cardiac function, possibly indicating early signs of heart failure.

The healthcare team thoroughly discusses these findings, emphasizing the importance of managing both renal and cardiovascular health. They consider initiating a diuretic to address fluid retention and prevent further cardiac complications, while also monitoring for potential exacerbation of electrolyte imbalances. The patient is advised to continue monitoring blood pressure at home, particularly postural changes, and to report any worsening symptoms immediately. A referral to a cardiologist is considered to evaluate the need for further cardiac assessment. The patient leaves with a plan for more frequent monitoring and a follow-up appointment scheduled in two weeks to reassess the response to these interventions and to address any further complications that may arise.