A patient with diabetes presents with diminished sensation in the feet, a small ulcer on the left foot, elevated hemoglobin A1c, and early signs of nephropathy. Which nursing action is most appropriate to address the patient’s risk for further complications?

B) Educate the patient on daily foot inspection and proper foot care techniques.

A) Encourage the patient to increase physical activity to improve circulation.

B) Educate the patient on daily foot inspection and proper foot care techniques.

C) Increase the patient's dose of atorvastatin to lower LDL cholesterol levels.

D) Recommend an increased protein intake to promote healing of the foot ulcer.

A nurse is developing a care plan for a patient with diabetes who exhibits peripheral neuropathy and an elevated Hemoglobin A1c level. Which nursing intervention is most appropriate to address the risk of foot complications in this patient?

C) Teach the patient to inspect her feet daily using a mirror to identify any injuries or changes.

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

B) Advise the patient to soak her feet daily in warm water to maintain skin hydration.

C) Teach the patient to inspect her feet daily using a mirror to identify any injuries or changes.

D) Recommend the patient wear tight-fitting shoes to provide better foot support.

A patient with diabetes presents with a foot ulcer that is not healing well and new symptoms of intermittent claudication. What is the most appropriate nursing intervention to address the underlying cause of these symptoms?

B) Educate the patient on smoking cessation to reduce vascular risk.

A) Encourage increased physical activity to improve circulation.

B) Educate the patient on smoking cessation to reduce vascular risk.

C) Recommend a high-protein diet to promote wound healing.

D) Advise the patient to apply heat to the affected area to improve blood flow.

During a follow-up visit, a patient with diabetes reports symptoms of intermittent claudication and has a small foot ulcer with signs of potential infection. Which nursing intervention is most appropriate to address the current complications?

C) Refer the patient to a vascular specialist for further evaluation and potential revascularization procedures.

A) Recommend increasing daily physical activity to improve circulation.

B) Educate the patient on the importance of strict dietary adherence to manage blood glucose levels.

C) Refer the patient to a vascular specialist for further evaluation and potential revascularization procedures.

D) Apply a more potent topical antibiotic to the ulcer to promote faster healing.

A patient with diabetes and recent diagnosis of peripheral artery disease presents with increased blood pressure, elevated LDL levels, and frequent claudication. What is the nurse's priority intervention to address the patient's cardiovascular risk factors?

D) Recommend intensification of statin therapy.

A) Increase the dosage of the patient's ACE inhibitor.

B) Initiate a supervised exercise program for the patient.

C) Adjust the patient's insulin regimen to improve glycemic control.

D) Recommend intensification of statin therapy.

A patient with diabetes, hypertension, and peripheral artery disease is experiencing increased blood pressure and has an LDL level of 130 mg/dL. The nurse notes intermittent claudication and a foot ulcer with Staphylococcus aureus infection. Which of the following nursing interventions is the highest priority to prevent further complications?

D) Collaborate with the healthcare team to optimize antibiotic therapy for the foot ulcer.

A) Initiate a supervised exercise program to improve circulation and reduce claudication symptoms.

B) Adjust the patient's ACE inhibitor dosage to better control blood pressure.

C) Educate the patient on dietary changes to lower LDL levels and improve overall cardiovascular health.

D) Collaborate with the healthcare team to optimize antibiotic therapy for the foot ulcer.

A patient with peripheral artery disease (PAD) presents with severe intermittent claudication, a reduced ankle-brachial index, and a non-healing foot ulcer despite targeted antibiotic therapy and an exercise program. The nurse notes persistent fatigue and dizziness upon standing following an increased ACE inhibitor dosage. Which intervention should the nurse prioritize to address the patient's current condition?

B) Suggest initiating aggressive surgical revascularization to improve blood flow.

A) Recommend adjusting the ACE inhibitor dosage to reduce the risk of orthostatic hypotension.

B) Suggest initiating aggressive surgical revascularization to improve blood flow.

C) Focus on enhancing glycemic control to prevent further ulcer deterioration.

D) Encourage the patient to increase physical activity to improve circulation.

A patient with peripheral artery disease (PAD) and hypertension is experiencing persistent fatigue and dizziness upon standing after an increase in her ACE inhibitor dosage. Her ankle-brachial index has decreased to 0.58, and her foot ulcer shows minimal healing. What should be the nurse's priority action in managing this patient's care?

B) Collaborate with the healthcare provider to reassess the patient's medication regimen for potential adjustment.

A) Encourage the patient to increase her fluid intake to address potential dehydration.

B) Collaborate with the healthcare provider to reassess the patient's medication regimen for potential adjustment.

C) Advise the patient to rest and elevate her affected limb to reduce fatigue.

D) Increase the frequency of blood pressure monitoring to assess for fluctuations.

A patient with Type 2 Diabetes Mellitus presents with escalating fatigue, dizziness, and a recent increase in HbA1c to 9.2%. The patient is inconsistently taking her insulin due to fear of hypoglycemia. Which of the following nursing interventions is most appropriate to address the patient's concerns and improve glycemic control?

C) Refer the patient to a diabetes educator for comprehensive insulin management and lifestyle modification support.

A) Encourage the patient to stop insulin and manage diabetes with oral medications only.

B) Educate the patient on recognizing early signs of hypoglycemia and adjusting insulin dosage accordingly.

C) Refer the patient to a diabetes educator for comprehensive insulin management and lifestyle modification support.

D) Increase the patient's insulin dosage to rapidly lower HbA1c levels without addressing current concerns.

A nurse is reviewing the case of a patient with uncontrolled diabetes, elevated HbA1c, and increasing serum creatinine levels. The patient reports fatigue and dizziness and has been inconsistently taking prescribed insulin. Which of the following interventions should the nurse prioritize to address the patient's current health status and prevent further complications?

B) Educate the patient on the importance of consistent insulin administration and establish a routine monitoring schedule for blood glucose levels.

A) Increase the patient's insulin dosage and schedule more frequent follow-up appointments.

B) Educate the patient on the importance of consistent insulin administration and establish a routine monitoring schedule for blood glucose levels.

C) Refer the patient to a nephrologist for immediate evaluation and potential treatment of renal impairment.

D) Initiate a high-protein diet to improve energy levels and support renal function.

Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance leads to impaired glucose uptake by cells, causing elevated blood glucose levels. In type 1 diabetes, autoimmune destruction of pancreatic beta cells results in minimal or no insulin production. In type 2 diabetes, tissues develop resistance to insulin, and beta cells may fail to compensate with increased insulin production.

• Secondary mechanism: Chronic hyperglycemia leads to glycation of proteins and lipids, forming advanced glycation end products (AGEs). AGEs contribute to vascular damage by promoting inflammation and oxidative stress, which are central to diabetes complications.

• Key complication: Persistent high blood glucose levels and AGEs cause microvascular damage, leading to complications such as diabetic neuropathy, retinopathy, and nephropathy, significantly impacting patient quality of life and increasing healthcare needs.

Patient Profile

Demographics:

56-year-old female, accountant

History:

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

• 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 numbness and tingling in feet

• Key symptoms: Fatigue, blurred vision, frequent urination, slow healing of minor cuts

• Vital signs: Blood pressure 148/92 mmHg, Heart rate 88 bpm, Respiratory rate 18 breaths per minute, Temperature 98.6°F, Blood glucose 190 mg/dL (fasting)

Section 1

Initial Assessment Findings:

During the initial assessment, the nurse conducts a thorough examination to evaluate the extent of the patient's symptoms and potential complications arising from her diabetes. The nurse notes that the patient's feet exhibit diminished sensation to light touch and vibration, consistent with peripheral neuropathy. There is also evidence of decreased ankle reflexes bilaterally. The patient reports difficulty in recognizing temperature changes in her feet, indicating possible sensory nerve involvement. A visual inspection of the feet reveals dry skin and a small, slow-healing ulcer on the lateral aspect of the left foot, which the patient was previously unaware of, highlighting the risk for further complications such as infections or ulcers due to neuropathy and impaired wound healing.

In addition to the focused physical examination, the nurse reviews recent laboratory results. Hemoglobin A1c is elevated at 8.5%, indicating suboptimal long-term blood glucose control. Kidney function tests reveal a slight increase in creatinine levels at 1.4 mg/dL and the presence of microalbuminuria, suggesting early nephropathy. These findings are concerning as they reflect ongoing microvascular damage associated with chronic hyperglycemia. Lipid panel results show elevated LDL cholesterol at 145 mg/dL, despite atorvastatin therapy, posing an increased risk for cardiovascular complications.

The comprehensive assessment findings emphasize the need for enhanced management strategies to prevent progression of diabetic complications. The nurse collaborates with the healthcare team to develop a more aggressive treatment plan, which may include intensifying glycemic control measures, optimizing antihypertensive therapy, and reinforcing patient education on foot care and lifestyle modifications. The patient's case is discussed at the next interdisciplinary team meeting to ensure a coordinated approach to her care, setting the stage for potential adjustments in her management plan and monitoring her response to new interventions.

Section 2

The patient's management plan is adjusted to address the multifaceted complications of her diabetes. Three months into the revised treatment plan, which includes intensified insulin therapy and dietary modifications focused on glycemic control, the patient returns for a follow-up visit. The nurse conducts a thorough reassessment to evaluate the efficacy of the interventions and identify any new developments.

During this visit, the patient's hemoglobin A1c has decreased to 7.8%, indicating some improvement in blood glucose control. However, she reports new symptoms of intermittent claudication, characterized by pain in the calves during walking, which subsides with rest. This symptom suggests peripheral artery disease (PAD), a common macrovascular complication of diabetes. A Doppler ultrasound confirms decreased blood flow in the popliteal and posterior tibial arteries, underscoring the need for further vascular assessment and management.

Additionally, the small ulcer on the lateral aspect of the left foot shows minimal improvement, and there is a surrounding area of erythema and warmth, raising concern for potential infection. The nurse notes that despite diligent foot care and topical antibiotic application, the ulcer's slow healing may indicate compromised local circulation, likely exacerbated by the newly identified PAD. These findings necessitate a multidisciplinary approach to prevent further deterioration. The healthcare team considers the addition of a vascular specialist for possible revascularization procedures and continues to emphasize the importance of strict glycemic control and lipid management to mitigate the progression of both microvascular and macrovascular complications.

Section 3

In the following weeks, the patient's condition evolves, revealing new challenges in her diabetes management. During a routine check-up, the nurse observes that the patient's blood pressure has increased to 148/92 mmHg, a notable rise from her previous readings. This hypertension, coupled with her recent diagnosis of peripheral artery disease, raises concerns about a heightened risk for cardiovascular events. The nurse reviews the patient's medication regimen and notes that while she is on an ACE inhibitor, the current dosage may require adjustment. Additionally, lipid profile results show an LDL level of 130 mg/dL, higher than the recommended target for individuals with diabetes, prompting consideration of statin therapy intensification.

The patient's complaints of intermittent claudication have become more frequent and severe, limiting her ability to engage in physical activity, which is crucial for managing both her diabetes and cardiovascular health. A subsequent ankle-brachial index test confirms significant peripheral artery disease, with a reading of 0.6 in the affected limb, suggesting moderate arterial obstruction. The healthcare team discusses the introduction of a supervised exercise program to improve circulation and suggests initiating cilostazol to alleviate claudication symptoms, pending clearance from her cardiologist due to potential interactions with her existing medications.

In conjunction with these developments, the ulcer on the patient's left foot has become more problematic. A repeat culture indicates the presence of Staphylococcus aureus, prompting a change in antibiotic therapy to better target the pathogen. The vascular specialist is consulted, and plans for a potential angioplasty are discussed to improve blood flow to the area, aiming to facilitate ulcer healing. The interdisciplinary team emphasizes the importance of continued glycemic control, and the patient's insulin regimen is adjusted to address postprandial glucose spikes more effectively. The nurse reinforces education on lifestyle modifications, stressing the role of diet, exercise, and regular monitoring in preventing further complications.

Section 4

In the subsequent weeks, the patient returns for a follow-up appointment, where the nurse conducts a thorough initial assessment to evaluate the response to recent interventions and monitor for any new complications. During the assessment, the nurse notes that the patient's blood pressure has slightly improved, now reading 142/88 mmHg, following an increase in her ACE inhibitor dosage. However, the patient reports persistent fatigue and a recent episode of dizziness upon standing, which prompts the nurse to consider the possibility of orthostatic hypotension, a potential side effect of her adjusted medication regimen.

Further laboratory tests reveal a modest improvement in the patient's lipid profile, with her LDL level reduced to 115 mg/dL, suggesting a positive response to the intensified statin therapy. Despite this progress, the patient continues to experience severe intermittent claudication, which has not significantly improved with the introduction of cilostazol and the supervised exercise program. The nurse documents a slight decrease in the patient's ankle-brachial index, now at 0.58, indicating worsening peripheral artery disease in the affected limb.

The ulcer on the patient's left foot remains a significant concern. While the targeted antibiotic therapy has reduced signs of local infection, the ulcer shows minimal healing progress, and the surrounding tissue appears increasingly ischemic. The vascular specialist's team is now considering more aggressive interventions, such as surgical revascularization, to enhance blood flow and promote healing. The nurse collaborates with the interdisciplinary team to prioritize the patient's glycemic control, adjusting her insulin regimen further and reinforcing the critical need for adherence to lifestyle modifications. The team also emphasizes the importance of regular foot care and monitoring for any signs of deterioration, as the patient's complex condition requires vigilant management to prevent further complications.

Section 5

The patient returns for another follow-up appointment two weeks later, and the nurse conducts a comprehensive assessment. During this visit, the patient reports increased difficulty in managing her daily activities due to escalating fatigue and frequent episodes of dizziness, particularly in the mornings. A careful review of her medication regimen reveals that the patient has been inconsistently taking her prescribed insulin, citing concerns about hypoglycemic episodes. This insight prompts the nurse to discuss the importance of maintaining a consistent insulin schedule and to consider potential adjustments to minimize adverse effects.

New laboratory results indicate a concerning rise in the patient's HbA1c level to 9.2%, reflecting poor glycemic control over the past few months. Concurrently, serum creatinine levels have increased to 1.8 mg/dL, suggesting a decline in renal function, possibly exacerbated by suboptimal blood pressure control and the patient's ongoing vascular issues. The nurse recognizes the significance of these findings and collaborates with the healthcare team to implement a revised diabetes management plan. This includes a more personalized insulin regimen, increased frequency of blood glucose monitoring, and a referral to a diabetes educator for additional support in lifestyle modifications.

The patient's condition necessitates a more integrated approach to care, as the risk of further complications remains high. The nurse emphasizes the need for stringent adherence to medication, dietary adjustments, and foot care protocols to prevent the progression of peripheral artery disease and potential renal complications. This focused intervention strategy aims to stabilize the patient's condition and prevent the emergence of new complications, guiding the next steps in her treatment journey.