A patient with type 2 diabetes mellitus presents with a hemoglobin A1c of 8.2%, elevated LDL cholesterol, and an elevated serum creatinine level. Which nursing intervention is most important to prioritize in the patient's care plan to address these findings?

B) Collaborate with the dietitian to develop a heart-healthy, low-sodium diet plan.

A) Initiate patient education on the importance of daily blood glucose monitoring and maintaining a log.

B) Collaborate with the dietitian to develop a heart-healthy, low-sodium diet plan.

C) Schedule an ophthalmology consultation to evaluate for potential diabetic retinopathy.

D) Encourage the patient to begin a low-impact exercise program to improve cardiovascular health.

A patient with type 2 diabetes presents with a blood glucose level of 210 mg/dL, a hemoglobin A1c of 8.2%, and symptoms suggestive of diabetic neuropathy and retinopathy. Given these findings, which nursing action is the most appropriate to prioritize for this patient?

C) Assess the patient's understanding and adherence to the current medication regimen.

A) Educate the patient on the importance of regular eye examinations.

B) Discuss the potential benefits of intensifying lifestyle modifications.

C) Assess the patient's understanding and adherence to the current medication regimen.

D) Initiate a referral to a nephrologist for early diabetic nephropathy management.

A patient with type 2 diabetes mellitus is being treated with an SGLT2 inhibitor and a GLP-1 receptor agonist. Despite these interventions, the patient reports fatigue and dizziness, with fasting blood glucose levels fluctuating between 180-210 mg/dL. Which of the following nursing interventions should be prioritized to help stabilize the patient's blood glucose levels?

B) Advise the patient to monitor blood glucose levels more frequently and adjust dietary intake accordingly.

A) Encourage increased physical activity to improve insulin sensitivity.

B) Advise the patient to monitor blood glucose levels more frequently and adjust dietary intake accordingly.

C) Suggest the patient increase their fluid intake to prevent dehydration associated with SGLT2 inhibitors.

D) Refer the patient to a diabetes education program for comprehensive management education.

A patient with type 2 diabetes is experiencing variability in fasting blood glucose levels despite adhering to an SGLT2 inhibitor and dietary recommendations. The healthcare team has recently added a GLP-1 receptor agonist to the patient's treatment regimen. Which nursing intervention is most appropriate to prioritize during the follow-up appointment to enhance the patient's self-management of diabetes?

B) Review the patient's technique for self-monitoring blood glucose to ensure accurate readings.

A) Educate the patient on the importance of regular foot care to prevent complications.

B) Review the patient's technique for self-monitoring blood glucose to ensure accurate readings.

C) Discuss strategies to increase physical activity levels safely.

D) Emphasize the importance of medication adherence, including timing and dosing of the new GLP-1 receptor agonist.

A patient with type 2 diabetes presents with improved glycemic control but persistent peripheral neuropathy symptoms. Which nursing intervention is most appropriate to address the patient's neuropathy symptoms while considering his current treatment plan?

B) Educate the patient about foot care to prevent complications associated with peripheral neuropathy.

A) Increase the dosage of his GLP-1 receptor agonist to improve neuropathy symptoms.

B) Educate the patient about foot care to prevent complications associated with peripheral neuropathy.

C) Encourage the patient to increase physical activity to reduce neuropathy symptoms.

D) Advise the patient to reduce carbohydrate intake further to manage neuropathy symptoms.

A patient with type 2 diabetes mellitus presents with improved glycemic control and weight loss but continues to experience peripheral neuropathy and elevated blood pressure. Which intervention should the nurse prioritize to address the patient's current health status?

B) Educate the patient on the importance of adhering to lifestyle changes for blood pressure control.

A) Initiate gabapentin therapy for peripheral neuropathy management.

B) Educate the patient on the importance of adhering to lifestyle changes for blood pressure control.

C) Discuss the potential initiation of statin therapy to manage elevated LDL cholesterol.

D) Reinforce the need for consistent monitoring and follow-up to evaluate the effectiveness of the current treatment plan.

A patient with a history of hypertension and dyslipidemia presents with occasional shortness of breath during physical activity, despite improvements in other symptoms with current treatment. The nurse should prioritize which intervention to address this new symptom?

B) Educate the patient on monitoring their heart rate and symptoms during exercise.

A) Encourage the patient to increase the intensity of their exercise regimen.

B) Educate the patient on monitoring their heart rate and symptoms during exercise.

C) Advise the patient to discontinue gabapentin until further evaluation.

D) Suggest the patient increase their fluid intake to manage potential dehydration.

A patient with a history of hypertension and dyslipidemia reports new-onset shortness of breath during physical activity. Which of the following nursing actions is most appropriate for addressing this symptom and preventing potential complications?

B) Educate the patient on the signs of heart failure and instruct to report them immediately.

A) Increase the frequency of blood pressure monitoring to detect any acute changes.

B) Educate the patient on the signs of heart failure and instruct to report them immediately.

C) Advise the patient to reduce physical activity until symptoms resolve.

D) Suggest increasing dietary fiber intake to help with weight management.

A nurse is assessing a patient with a history of hypertension and recent findings of exertional angina. The patient is on low-dose aspirin therapy and has been advised to follow lifestyle modifications. Which nursing intervention is most important to prioritize to prevent further cardiovascular complications?

B) Educate the patient about the importance of maintaining consistent blood pressure monitoring.

A) Encourage the patient to engage in high-intensity exercise daily.

B) Educate the patient about the importance of maintaining consistent blood pressure monitoring.

C) Advise the patient to increase sodium intake to manage exercise-related fatigue.

D) Suggest the patient consume a high-protein diet to support cardiovascular health.

A patient with hypertension and a recent diagnosis of exertional angina is being managed with lifestyle modifications and low-dose aspirin therapy. The nurse is collaborating with the patient to improve his dietary habits and exercise routines. Which of the following interventions should the nurse prioritize to effectively support the patient's cardiovascular health?

B) Suggest the patient increase dietary fiber intake by incorporating more whole grains, fruits, and vegetables into meals.

A) Encourage the patient to participate in a high-intensity interval training program to rapidly enhance cardiovascular endurance.

B) Suggest the patient increase dietary fiber intake by incorporating more whole grains, fruits, and vegetables into meals.

C) Advise the patient to monitor blood pressure daily and adjust antihypertensive medication accordingly.

D) Recommend the patient avoid all social gatherings to prevent dietary lapses.

Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance occurs when cells in muscles, fat, and liver do not respond effectively to insulin, leading to impaired glucose uptake and increased blood glucose levels. This is often associated with obesity and a sedentary lifestyle.

• Secondary mechanism: Pancreatic beta-cell dysfunction results in inadequate insulin secretion. Over time, the pancreas cannot compensate for insulin resistance, exacerbating hyperglycemia and contributing to the progression of diabetes.

• Key complication: Chronic hyperglycemia damages blood vessels and nerves, leading to complications such as cardiovascular disease, neuropathy, and retinopathy, which significantly impact patient health and quality of life.

Patient Profile

Demographics:

57-year-old male, accountant

History:

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

• Current medications: Metformin 1000 mg BID, Lisinopril 10 mg daily, Atorvastatin 20 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and tingling in feet

• Key symptoms: Polyuria, polydipsia, blurred vision, numbness in lower extremities

• Vital signs: Blood pressure 148/92 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose 210 mg/dL

Section 1

During the initial assessment, the nurse notes several concerning findings that warrant further investigation. The patient's blood glucose level of 210 mg/dL indicates poor glycemic control, despite being on Metformin. The patient's blood pressure is elevated at 148/92 mmHg, which, combined with his history of hypertension and hyperlipidemia, increases his risk for cardiovascular complications. The tingling and numbness reported in the patient's feet, coupled with the polyuria and polydipsia, suggest the development of diabetic neuropathy, a common complication of chronic hyperglycemia. Additionally, the blurred vision may indicate the beginning stages of diabetic retinopathy, necessitating an ophthalmological evaluation.

Laboratory results reveal a hemoglobin A1c level of 8.2%, confirming suboptimal long-term glucose control. The lipid profile shows elevated LDL cholesterol at 140 mg/dL and low HDL cholesterol at 35 mg/dL, both of which are concerning given his cardiovascular risk profile. Renal function tests indicate an elevated serum creatinine of 1.4 mg/dL and a decreased eGFR of 58 mL/min/1.73m², suggesting early diabetic nephropathy. These findings highlight the need for a comprehensive management plan to address the multifactorial nature of his diabetes and its complications, focusing on optimizing glycemic control, managing blood pressure and lipid levels, and preventing further progression of organ damage.

Clinically, these developments prompt the healthcare team to initiate a collaborative approach. The patient's medication regimen may need adjustment, potentially introducing additional antihyperglycemic agents like an SGLT2 inhibitor or GLP-1 receptor agonist to improve glucose control and offer cardiovascular benefits. The patient would benefit from dietary counseling, emphasizing a heart-healthy and diabetic-friendly diet, along with an exercise plan tailored to his capabilities. Regular follow-ups for monitoring blood pressure, renal function, and lipid levels will be crucial, alongside patient education on recognizing and managing symptoms of hypoglycemia or other complications. This integrated approach aims to mitigate the current complications and prevent further deterioration of the patient's health.

Section 2

In the weeks following the initial assessment, the patient returns for a follow-up appointment. Despite the introduction of an SGLT2 inhibitor to his regimen, his fasting blood glucose levels remain variable, with readings fluctuating between 180-210 mg/dL. The patient reports adherence to the prescribed medication and dietary recommendations, yet he still experiences frequent episodes of fatigue and occasional dizziness. Upon examination, his blood pressure is slightly improved at 142/88 mmHg, but still not at target levels. Weight assessment shows a modest reduction of 3 pounds, suggesting some positive lifestyle changes, but not significant enough to impact metabolic parameters substantially.

New laboratory results show a slight improvement in hemoglobin A1c, now at 7.9%, indicating some progress in glycemic control. However, lipid panel results remain concerning, with LDL cholesterol at 135 mg/dL and HDL cholesterol unchanged at 35 mg/dL. The patient is also beginning to experience more pronounced symptoms of peripheral neuropathy, with increased tingling and numbness extending up to his calves. Additionally, a recent microalbuminuria test reveals a slightly elevated albumin-to-creatinine ratio, at 35 mg/g, signaling a potential worsening of renal function despite stable serum creatinine and eGFR.

These findings highlight the need for further intervention. The healthcare team decides to intensify the patient's treatment plan by introducing a GLP-1 receptor agonist, aiming to improve glycemic control and provide additional cardiovascular protection. A referral to a nephrologist is also made to address the early signs of nephropathy more aggressively. The patient is advised to continue dietary modifications with an increased focus on reducing saturated fats and incorporating more omega-3 fatty acids to address dyslipidemia. The nurse schedules a follow-up appointment in one month to closely monitor the effects of these interventions and to reassess the management strategy, emphasizing the importance of patient education in managing and understanding the progression of diabetic complications.

Section 3

At the one-month follow-up appointment, the patient presents with some notable changes in his clinical status. He reports a slight improvement in his energy levels and a reduction in dizziness episodes, which he attributes to the recent adjustments in his treatment regimen. Upon examination, his fasting blood glucose levels have shown more stability, now consistently ranging between 150-180 mg/dL. This improvement aligns with a further decrease in hemoglobin A1c to 7.5%, suggesting that the addition of the GLP-1 receptor agonist is having a positive effect on his glycemic control. His weight has decreased by an additional 5 pounds, indicating continued adherence to lifestyle changes. However, his blood pressure remains suboptimal at 140/85 mmHg, necessitating ongoing monitoring and possible future adjustment of antihypertensive therapy.

The patient also reports persistent peripheral neuropathy symptoms, with tingling and numbness now occasionally affecting his hands. This progression highlights the need for vigilant management of neuropathic pain, prompting the healthcare team to consider introducing gabapentin or pregabalin for symptom relief. Additionally, the nephrologist's initial evaluation has confirmed early-stage diabetic nephropathy, with a recommendation to start an ACE inhibitor to further protect renal function and potentially assist in blood pressure control.

The lipid panel remains a concern, with LDL cholesterol still elevated at 130 mg/dL and HDL unchanged. The patient is encouraged to intensify dietary modifications and increase physical activity, aiming to improve his lipid profile. The healthcare team also considers the potential need for statin therapy if lifestyle changes are insufficient. The nurse emphasizes the importance of these interventions and schedules another follow-up in two months to re-evaluate the patient's progress. Continuous patient education remains a priority, empowering the patient to actively participate in managing his diabetes and associated complications.

Section 4

Two months later, the patient returns for his follow-up appointment, eager to discuss his progress. He notes that the tingling and numbness in his hands have become less frequent since starting gabapentin, although he still experiences occasional discomfort. His energy levels have improved, and he reports feeling more motivated to continue his exercise regimen, now walking briskly for 30 minutes most days of the week. Despite these positive changes, the patient expresses concern about occasional shortness of breath during physical activity, which is a new symptom for him.

Upon examination, his blood pressure has improved slightly to 135/80 mmHg, thanks to the addition of the ACE inhibitor. However, the patient's weight has plateaued, and his BMI remains slightly above the target range. The nurse reviews his dietary habits and encourages further refinement of his meal plans to enhance weight management efforts and improve his lipid profile. The latest lipid panel shows a slight reduction in LDL cholesterol to 125 mg/dL, yet it remains above the optimal level. The decision is made to initiate statin therapy to address this persistent dyslipidemia more aggressively.

The nephrologist's follow-up indicates stable renal function with a slight reduction in albuminuria, suggesting the ACE inhibitor is providing renal protection. However, given the patient's report of shortness of breath, the healthcare team orders a series of cardiac evaluations, including an echocardiogram and a stress test, to rule out any underlying cardiac issues, particularly given the patient's history of hypertension and dyslipidemia. The nurse educates the patient on recognizing signs of cardiovascular complications, reinforcing the importance of prompt reporting of any new or worsening symptoms. The patient leaves the appointment with a renewed sense of vigilance, understanding the critical role of comprehensive management in preventing further complications.

Section 5

Two weeks later, the patient returns to the clinic for a review of his recent cardiac evaluations. The echocardiogram reveals mild left ventricular hypertrophy, a finding consistent with his history of hypertension, but no significant valvular abnormalities. The stress test, however, indicates the presence of exertional angina, with the patient experiencing chest discomfort and shortness of breath at moderate levels of exertion. These findings suggest the possibility of underlying coronary artery disease. Given these results, the healthcare team decides to initiate low-dose aspirin therapy to reduce the risk of cardiovascular events and schedules a consultation with a cardiologist for further evaluation and potential intervention.

During this visit, the nurse conducts a thorough assessment and notes a slight increase in the patient's weight, with a current reading of 210 pounds and a BMI of 31. The patient admits to occasional lapses in his dietary regimen, particularly during social gatherings, which may have contributed to this weight fluctuation. His blood pressure remains stable at 130/78 mmHg, and his fasting blood glucose level is 150 mg/dL, indicating suboptimal glycemic control. The nurse emphasizes the importance of adhering to his prescribed lifestyle modifications and medication regimen, highlighting the interconnected nature of his conditions and the potential for further complications if not managed effectively.

To address these concerns, the nurse collaborates with the patient to set realistic dietary and exercise goals, aiming for gradual weight loss to alleviate cardiovascular stress. The patient is encouraged to keep a daily log of his food intake and physical activity, which will be reviewed at subsequent visits. The nurse also provides educational materials on managing stress and recognizing signs of angina, empowering the patient to take an active role in his health management. As the patient leaves the clinic, he expresses a commitment to making necessary changes, understanding the critical importance of proactive measures in preventing the progression of his condition.