A patient with Type 2 Diabetes presents with numbness in the feet, blurred vision, and recurrent urinary tract infections. The nurse notes these symptoms and reviews the patient's laboratory results, including an HbA1c level of 9.2% and an elevated LDL cholesterol level of 160 mg/dL. Which of the following interventions should the nurse prioritize to address the patient's current complications and prevent further progression?

C) Educate the patient on the importance of strict blood glucose control to reduce the risk of neuropathy and retinopathy.

A) Increase the dosage of atorvastatin to lower the LDL cholesterol level.

B) Refer the patient to a podiatrist for specialized foot care to prevent ulcers.

C) Educate the patient on the importance of strict blood glucose control to reduce the risk of neuropathy and retinopathy.

D) Initiate a referral to a nephrologist for further evaluation of renal function.

A patient with Type 2 Diabetes presents with peripheral neuropathy, blurred vision, and recurrent urinary tract infections. The nurse notes the patient's HbA1c is 9.2%, LDL cholesterol is 160 mg/dL, and renal function tests show a creatinine level of 1.3 mg/dL and eGFR of 58 mL/min/1.73 m^2. Which intervention should the nurse prioritize to address the patient's complications and improve outcomes?

B) Recommend adding a GLP-1 receptor agonist to the patient's medication regimen.

A) Educate the patient on dietary changes and recommend increasing physical activity.

B) Recommend adding a GLP-1 receptor agonist to the patient's medication regimen.

C) Schedule regular ophthalmology and urology evaluations to monitor complications.

D) Review and adjust the current atorvastatin dose to better manage LDL cholesterol levels.

A patient with type 2 diabetes presents with a non-healing ulcer on the left foot and reports ongoing peripheral neuropathy. The patient's blood pressure is 150/90 mmHg, and the HbA1c is 8.6%. Which of the following interventions should the nurse prioritize to prevent further complications?

B) Refer the patient to a podiatrist for specialized wound care.

A) Increase dietary fiber intake to improve glycemic control.

B) Refer the patient to a podiatrist for specialized wound care.

C) Recommend the addition of an SGLT2 inhibitor for renal protection.

D) Encourage the patient to perform daily foot exercises to improve circulation.

A patient with a history of diabetes presents with a non-healing ulcer on the left foot and reports numbness and tingling in the extremities. Which nursing intervention should take priority to prevent further complications?

A) Educate the patient on daily foot care and proper footwear

B) Refer the patient to a dietitian for nutritional counseling

C) Schedule the patient for a routine follow-up in three months

D) Educate the patient on proper insulin injection techniques

A patient with a history of poorly controlled diabetes and hypertension presents with increased fatigue, shortness of breath, and mild lower extremity edema. The nurse notes a blood pressure of 160/95 mmHg, heart rate of 98 bpm, and a slight decrease in GFR to 55 mL/min/1.73 m². Based on these findings, which nursing intervention is the most appropriate to prioritize for this patient?

B) Educate the patient on reducing dietary sodium to manage fluid overload.

A) Encourage increased fluid intake to improve renal perfusion.

B) Educate the patient on reducing dietary sodium to manage fluid overload.

C) Initiate an exercise program to enhance cardiovascular function.

D) Recommend protein-rich snacks to address fatigue.

A patient with poorly controlled diabetes and hypertension presents with increased fatigue, shortness of breath, and mild edema. Recent diagnostic tests indicate decreased renal function, electrolyte imbalance, and signs of early heart failure. What is the most appropriate intervention to address both the cardiovascular and renal complications in this patient?

B) Add an ACE inhibitor to the current regimen to improve renal and cardiac outcomes.

A) Initiate a diuretic therapy to reduce fluid overload.

B) Add an ACE inhibitor to the current regimen to improve renal and cardiac outcomes.

C) Increase the current antihypertensive dosage to better control blood pressure.

D) Focus on lifestyle modifications such as diet and exercise as the primary intervention.

A patient with a history of hypertension and diabetes presents with worsening fatigue, pulmonary congestion, and elevated potassium levels after starting an ACE inhibitor. The nurse notes a further decline in renal function. Which nursing intervention is most appropriate to address the current clinical concerns?

C) Monitor the patient for signs of hyperkalemia and fluid overload after starting a loop diuretic.

A) Increase dietary potassium intake to counteract hyponatremia.

B) Educate the patient on reducing fluid intake to manage pulmonary congestion.

C) Monitor the patient for signs of hyperkalemia and fluid overload after starting a loop diuretic.

D) Encourage the patient to continue the ACE inhibitor to maintain blood pressure control.

A patient with a history of hypertension and chronic kidney disease presents with worsening pulmonary congestion despite recent adjustments to their treatment plan, including the initiation of an ACE inhibitor and dietary modifications. Given the recent laboratory findings of a declining GFR, mild hyponatremia, and worsening hyperkalemia, which action should the nurse prioritize during the follow-up care to address these changes effectively?

C) Collaborate with the healthcare team to revise the medication regimen, focusing on discontinuing the ACE inhibitor and starting a loop diuretic.

A) Continue monitoring the patient's blood pressure and heart rate closely without immediate changes.

B) Educate the patient on increasing dietary potassium intake to counteract hyponatremia.

C) Collaborate with the healthcare team to revise the medication regimen, focusing on discontinuing the ACE inhibitor and starting a loop diuretic.

D) Encourage the patient to increase fluid intake to manage the elevated blood pressure and support renal function.

A patient with a history of heart failure and diabetes has recently had their medication regimen adjusted to discontinue an ACE inhibitor and introduce a loop diuretic. The patient now reports muscle weakness and occasional palpitations. With laboratory results showing potassium at 5.3 mEq/L and sodium at 134 mEq/L, what should be the nurse's priority intervention?

C) Assess the patient's ECG for any signs of cardiac arrhythmias

A) Educate the patient on reducing potassium-rich foods in their diet

B) Administer a sodium supplement to address hyponatremia

C) Assess the patient's ECG for any signs of cardiac arrhythmias

D) Increase the patient's fluid intake to improve sodium levels

A patient with a history of heart failure and diabetes has recently had an ACE inhibitor discontinued and a loop diuretic initiated. The patient now presents with muscle weakness and occasional palpitations. Which intervention should the nurse prioritize to address the patient's current symptoms?

C) Monitor the patient's electrolyte levels and report significant changes to the healthcare provider.

A) Encourage the patient to increase their potassium intake through diet.

B) Educate the patient on the importance of reducing fluid intake to manage swelling.

C) Monitor the patient's electrolyte levels and report significant changes to the healthcare provider.

D) Suggest the patient take a magnesium supplement to prevent further muscle weakness.

Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: In Type 1 Diabetes, autoimmune destruction of pancreatic beta cells leads to insufficient insulin production, preventing glucose uptake by cells and resulting in hyperglycemia.

• Secondary mechanism: In Type 2 Diabetes, insulin resistance occurs when cells in muscles, fat, and liver do not respond well to insulin, causing the pancreas to produce more insulin until it can no longer keep up, leading to high blood glucose levels.

• Key complication: Chronic hyperglycemia from either type leads to vascular damage, increasing the risk of complications such as neuropathy, nephropathy, and retinopathy, which are crucial for nurses to monitor and manage.

Patient Profile

Demographics:

58-year-old male, office worker

History:

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

• Metformin, Lisinopril, Atorvastatin, Aspirin

• No known drug allergies

Current Presentation:

• Chief complaint: Increasing fatigue and numbness in feet

• Key symptoms: Blurred vision, recurrent urinary tract infections, occasional chest discomfort

• Vital signs: Blood pressure 150/95 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, BMI 28.5

Section 1

As the nurse conducts an initial assessment, several findings highlight the progression of the patient's complications. The numbness in the patient's feet is indicative of peripheral neuropathy, a common complication of prolonged hyperglycemia in Type 2 Diabetes. Upon further examination, there are noticeable signs of decreased sensation in the lower extremities, confirmed by a monofilament test. The patient's blurred vision prompts a referral to an ophthalmologist, suspecting diabetic retinopathy, which could be contributing to his visual disturbances. Moreover, the recurrent urinary tract infections raise concerns about potential autonomic neuropathy affecting bladder function, necessitating urological evaluation.

To further assess the patient's condition, a series of diagnostic tests are ordered. The HbA1c level returns at 9.2%, indicating poor long-term glucose control. A lipid panel reveals elevated LDL cholesterol at 160 mg/dL, despite atorvastatin therapy, suggesting the need for medication adjustment or increased lifestyle interventions. Renal function tests show a creatinine level of 1.3 mg/dL and a decreased estimated glomerular filtration rate (eGFR) of 58 mL/min/1.73 m^2, raising concerns about the early stages of diabetic nephropathy. These results emphasize the importance of comprehensive management strategies and prompt the healthcare team to consider intensifying treatment to prevent further complications.

The patient's current status necessitates a multidisciplinary approach, encompassing adjustments to his pharmacotherapy, enhanced lifestyle modifications, and regular monitoring. The nurse collaborates with the healthcare team to develop a care plan focusing on improving glycemic control, managing cardiovascular risk factors, and preventing the progression of diabetic complications. This includes considering the addition of a GLP-1 receptor agonist or SGLT2 inhibitor to his regimen, which could aid in achieving better glucose management while offering cardiovascular and renal protection. The patient is educated on the importance of adhering to his treatment plan, recognizing early signs of complications, and maintaining regular follow-ups to optimize his health outcomes. This stage of the patient's journey underscores the necessity for vigilant monitoring and timely intervention to mitigate the impact of diabetes-related complications.

Section 2

Several weeks into the revised care plan, the patient returns for a follow-up appointment. The nurse begins with a thorough assessment to evaluate the response to the newly implemented interventions. Notably, the patient reports a slight improvement in his energy levels and a reduction in the frequency of blurred vision episodes. However, he mentions persisting numbness in his feet and occasional tingling in his hands, which suggests that peripheral neuropathy remains a challenge despite recent adjustments.

Vital signs are checked, revealing a blood pressure of 150/90 mmHg, which is higher than the target range, highlighting the need for optimized antihypertensive therapy. The patient's weight has decreased by 3 pounds, an encouraging sign of his efforts in lifestyle modification. A repeat HbA1c test shows a modest improvement, now at 8.6%, indicating better glycemic control, though still above the recommended target. The lipid panel shows a slight reduction in LDL cholesterol to 150 mg/dL, but further work is needed to reach optimal levels.

During the visit, the nurse also conducts a comprehensive foot examination and emphasizes the importance of foot care given the ongoing neuropathy. There is a small, non-healing ulcer on the left foot, which raises concerns for potential infection and necessitates immediate attention. The patient is referred to a podiatrist for specialized wound care and to prevent further complications. The healthcare team discusses the possibility of adding an SGLT2 inhibitor to further aid in glucose management and offer renal protection, considering the patient's renal function status. The nurse reinforces the importance of medication adherence, regular blood sugar monitoring, and timely recognition of any new symptoms, setting the stage for ongoing management and prevention of further diabetic complications.

Section 3

Several weeks after the follow-up appointment, the patient contacts the clinic reporting new symptoms of increased fatigue and occasional shortness of breath. Concerned about these developments, the healthcare team schedules an urgent appointment. Upon arrival, the nurse performs a detailed assessment, noting the patient's vital signs: blood pressure has risen to 160/95 mmHg and heart rate is slightly elevated at 98 bpm. Additionally, the patient appears pale and has mild edema in the lower extremities. These findings prompt the nurse to consider potential cardiovascular implications and fluid retention as complications of poorly controlled diabetes and hypertension.

The nurse orders a series of diagnostic tests to further evaluate the patient's condition. The results reveal a slight decrease in glomerular filtration rate (GFR) to 55 mL/min/1.73 m², suggesting a decline in renal function. An electrolyte panel shows a mild imbalance, with sodium at the lower end of normal and potassium slightly elevated. A chest X-ray is performed due to the patient's shortness of breath, revealing mild pulmonary congestion, which raises suspicion of early heart failure. These findings necessitate a re-evaluation of the patient's current treatment regimen, particularly concerning cardiovascular and renal health.

In light of these developments, the healthcare team discusses the need to adjust the patient's antihypertensive therapy, considering the addition of an ACE inhibitor or angiotensin receptor blocker (ARB) to address both hypertension and renal protection. The nurse emphasizes the importance of fluid management and dietary modifications, such as reducing sodium intake, to help alleviate the symptoms of fluid overload. Education on recognizing signs of worsening heart failure is provided, ensuring the patient is equipped to seek timely medical intervention. This comprehensive approach aims to stabilize the patient's condition and prevent further progression of complications, setting the stage for continuous monitoring and tailored treatment adjustments.

Section 4

In the weeks following the adjustment of the patient's treatment regimen, including the initiation of an ACE inhibitor and the implementation of dietary modifications, the patient initially reports feeling a slight improvement in overall energy levels and a reduction in lower extremity edema. However, during a routine follow-up visit, the nurse notes that the patient appears more fatigued than during previous encounters, and upon auscultation, there are new crackles in the lung bases, suggesting worsening pulmonary congestion. The patient's blood pressure remains elevated at 158/92 mmHg, and the heart rate has increased to 105 bpm. These findings prompt a reevaluation of the patient's response to the prescribed interventions and raise concerns about the adequacy of the current management plan.

A repeat set of laboratory tests is ordered to gain further insight into the patient's condition. The results reveal a further decline in renal function with a GFR now at 48 mL/min/1.73 m², indicating a progressive deterioration. The electrolyte panel shows persistent mild hyponatremia at 133 mEq/L and hyperkalemia has worsened with a potassium level of 5.8 mEq/L. These abnormalities suggest that the renal function decline may be impacting the patient's electrolyte balance more significantly, and the ACE inhibitor may need to be reconsidered or adjusted. The patient's hemoglobin A1c remains elevated at 8.5%, indicating that glycemic control is still suboptimal and further contributing to the complications.

In light of these findings, the healthcare team decides to temporarily discontinue the ACE inhibitor and initiate a loop diuretic to manage the fluid overload and pulmonary congestion more effectively. The nephrologist is consulted to provide input on optimizing renal protection while balancing cardiovascular needs. The patient is educated on the importance of adhering to the revised medication regimen and the role of frequent monitoring to prevent further renal decline and manage electrolyte imbalances. This adjustment aims to stabilize the patient's condition and prevent the onset of more severe complications, setting the stage for close monitoring and potential further adjustments in treatment as the patient's clinical status evolves.

Section 5

Several days after the adjustment in the patient's treatment plan, including the discontinuation of the ACE inhibitor and the introduction of a loop diuretic, the patient returns for a follow-up visit. During this appointment, the nurse conducts a thorough assessment to evaluate the patient's response to the interventions. The patient reports a noticeable reduction in shortness of breath and states that the swelling in the legs has decreased. However, the patient also mentions experiencing muscle weakness and occasional palpitations, raising concerns about potential electrolyte imbalances.

Vital signs reveal a blood pressure of 142/88 mmHg and a heart rate of 98 bpm, indicating some improvement but still not optimal control. The follow-up laboratory tests show a slight improvement in renal function, with a GFR now at 52 mL/min/1.73 m². Electrolyte levels reveal a reduction in potassium to 5.3 mEq/L, but sodium remains low at 134 mEq/L, suggesting that while hyperkalemia is improving, hyponatremia persists. These findings prompt the healthcare team to consider additional adjustments to the patient's medication regimen, aiming to balance electrolyte levels without compromising renal function or cardiovascular stability.

The healthcare team decides to continue monitoring the patient's response closely, emphasizing the importance of maintaining hydration and dietary modifications to support electrolyte balance. The patient's glycemic control remains a critical focus, with a plan to intensify diabetes management strategies, potentially incorporating additional glucose-lowering medications or insulin therapy. This approach aims to prevent further complications related to uncontrolled diabetes, such as neuropathy or worsening nephropathy, while maintaining vigilance for any new signs of deterioration that may require immediate attention. The patient is scheduled for another follow-up visit in one week to reassess their clinical status and ensure that the treatment adjustments are achieving the desired outcomes.