A patient with poorly controlled diabetes presents with signs of peripheral neuropathy and early diabetic retinopathy. Laboratory tests reveal an HbA1c of 9.2% and elevated LDL cholesterol despite atorvastatin therapy. Which nursing intervention is most appropriate to address these findings and prevent further complications?

C) Recommend immediate insulin therapy adjustment to improve glycemic control.

A) Educate the patient about the importance of daily foot inspections to prevent injury.

B) Suggest an increase in atorvastatin dosage to better manage cholesterol levels.

C) Recommend immediate insulin therapy adjustment to improve glycemic control.

D) Advise the patient to monitor blood pressure at home to manage hypertension.

A patient with poorly controlled diabetes presents with decreased sensation in the lower extremities and blurred vision. Laboratory tests indicate elevated HbA1c and dyslipidemia. What is the priority nursing intervention to prevent further complications?

A) Educate the patient on the importance of daily blood glucose monitoring and adherence to the prescribed insulin regimen.

B) Advise the patient to increase physical activity to at least 150 minutes per week to improve cardiovascular health.

C) Recommend the patient start a low-sodium diet to manage hypertension and prevent kidney damage.

D) Encourage the patient to reduce carbohydrate intake drastically to lower HbA1c levels quickly.

A patient with type 2 diabetes has been started on a GLP-1 receptor agonist along with insulin therapy to improve glycemic control. The patient now presents with new-onset palpitations and an ECG confirms atrial fibrillation. Which nursing intervention is most important to prioritize in this scenario?

B) Administer anticoagulation therapy as prescribed to prevent thromboembolic events.

A) Educate the patient on the importance of regular blood glucose monitoring.

B) Administer anticoagulation therapy as prescribed to prevent thromboembolic events.

C) Encourage the patient to maintain a low-sodium diet to manage blood pressure.

D) Monitor the patient for signs of diabetic neuropathy progression.

A patient with type 2 diabetes has been newly diagnosed with atrial fibrillation and started on anticoagulation therapy. Which nursing intervention is the priority to prevent complications associated with the patient's condition?

B) Monitor the patient’s INR levels regularly to ensure therapeutic anticoagulation.

A) Educate the patient about the signs and symptoms of hypoglycemia and how to manage them.

B) Monitor the patient’s INR levels regularly to ensure therapeutic anticoagulation.

C) Advise the patient to avoid foods high in vitamin K to enhance anticoagulation effectiveness.

D) Encourage the patient to engage in regular physical activity to improve cardiovascular health.

A patient with long-standing hypertension and diabetes on anticoagulation therapy presents with occasional dizziness, mild lower extremity swelling, and a decline in renal function. Given these symptoms and findings, which nursing intervention is most appropriate to address the potential complications related to the patient's condition?

A) Initiate a low-sodium diet to manage hypertension and reduce fluid retention.

B) Encourage increased fluid intake to improve renal perfusion and function.

C) Suggest the use of compression stockings to alleviate lower extremity swelling.

D) Recommend cessation of anticoagulation therapy to prevent further renal decline.

A patient with a history of hypertension and diabetes is being managed with anticoagulation therapy and rate control. The patient now presents with mild renal impairment and left ventricular hypertrophy. Which nursing intervention is most appropriate to address the patient's renal issues while maintaining cardiovascular stability?

B) Reinforce the importance of adhering to prescribed antihypertensive medications.

A) Encourage the patient to increase protein intake to support kidney function.

B) Reinforce the importance of adhering to prescribed antihypertensive medications.

C) Advise the patient to decrease physical activity until renal function improves.

D) Suggest reducing fluid intake to prevent swelling in the lower extremities.

A patient with a history of hypertension and recent orthostatic hypotension presents with dizziness upon standing and mild pitting edema. After adjusting the patient's diuretic dosage, which of the following interventions should the nurse prioritize to prevent further complications?

C) Educate the patient on the importance of slow positional changes to manage orthostatic hypotension.

A) Encourage the patient to increase salt intake to address hyponatremia.

B) Teach the patient to perform leg exercises to reduce lower extremity swelling.

C) Educate the patient on the importance of slow positional changes to manage orthostatic hypotension.

D) Advise the patient to restrict fluid intake to avoid fluid overload.

A patient with a history of hypertension and recent adjustments to their antihypertensive and diuretic therapy presents with dizziness upon standing and lower extremity edema. The nurse is monitoring the patient's response to the new treatment plan. Which nursing intervention is the most appropriate to address the patient's symptoms of orthostatic hypotension and hyponatremia?

B) Advise the patient to rise slowly from sitting or lying positions.

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

B) Advise the patient to rise slowly from sitting or lying positions.

C) Restrict the patient's fluid intake to prevent further edema.

D) Discontinue all antihypertensive medications immediately.

A patient with a history of diabetes and hypertension is experiencing increased fatigue and muscle cramps after a recent adjustment in their diuretic medication. Laboratory results indicate a slight increase in serum creatinine levels. Which nursing intervention is most appropriate to address these findings?

B) Educate the patient on the importance of consuming potassium-rich foods such as bananas and oranges.

A) Encourage the patient to increase their fluid intake to at least 3 liters per day.

B) Educate the patient on the importance of consuming potassium-rich foods such as bananas and oranges.

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

D) Recommend the patient to reduce their salt intake to prevent further fluid retention.

A patient with a history of hypertension and diabetes presents with increased fatigue and muscle cramps following a change in diuretic dosage. The laboratory results show a slight improvement in serum sodium levels but a mild elevation in serum creatinine. Which intervention should the nurse prioritize to address the patient's symptoms and laboratory findings while considering potential renal impairment?

C) Recommend the patient to eat potassium-rich foods to alleviate muscle cramps.

A) Encourage the patient to increase fluid intake to dilute serum sodium levels.

B) Advise the patient to reduce potassium intake to prevent hyperkalemia.

C) Recommend the patient to eat potassium-rich foods to alleviate muscle cramps.

D) Suggest the patient to restrict protein intake to protect kidney function.

Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency/resistance - In Type 1 diabetes, autoimmune destruction of pancreatic beta cells leads to insufficient insulin production. In Type 2 diabetes, cells exhibit reduced sensitivity to insulin, impairing glucose uptake and leading to hyperglycemia.

• Secondary mechanism: Hyperglycemia-induced damage - Persistent high blood sugar levels cause glycation of proteins and lipids, leading to endothelial damage, altered blood flow, and increased risk of vascular complications, such as neuropathy and retinopathy.

• Key complication: Diabetic ketoacidosis (DKA) - Particularly in Type 1 diabetes, severe insulin deficiency triggers lipolysis and ketogenesis, resulting in the accumulation of ketones, metabolic acidosis, and potential life-threatening electrolyte imbalances.

Patient Profile

Demographics:

55-year-old male, office worker

History:

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

• Current medications: Metformin 1000 mg twice daily, Lisinopril 20 mg once daily, Atorvastatin 40 mg once daily, Aspirin 81 mg once daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and numbness in feet

• Key symptoms: Polyuria, polydipsia, blurred vision, tingling sensation in feet, occasional dizziness

• Vital signs: Blood pressure 150/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose level 210 mg/dL

Section 1

As the healthcare team conducts a thorough assessment of the patient, several new findings emerge that require immediate attention. The patient’s physical examination reveals decreased sensation to light touch and pinprick in the bilateral lower extremities, suggestive of peripheral neuropathy—a common complication of poorly controlled diabetes. Additionally, a fundoscopic examination uncovers microaneurysms and cotton wool spots, indicating the early stages of diabetic retinopathy. These findings correlate with the patient's reported symptoms of blurred vision and tingling in the feet, underscoring the impact of chronic hyperglycemia on microvascular health.

Laboratory tests reveal additional concerns. The patient's HbA1c level is reported at 9.2%, confirming poor long-term glycemic control. Lipid profile results show elevated LDL cholesterol at 145 mg/dL and triglycerides at 220 mg/dL, despite ongoing atorvastatin therapy. These results highlight the increased cardiovascular risks associated with metabolic syndrome, accentuated by the patient's existing hypertension and dyslipidemia. Kidney function tests reveal a slightly elevated serum creatinine of 1.4 mg/dL and trace amounts of albumin in the urine, raising concerns about possible diabetic nephropathy.

Given the new diagnostic results, the healthcare team considers adjustments to the patient's management plan. Enhanced glycemic control strategies, such as intensifying insulin therapy or introducing a GLP-1 receptor agonist, are considered to mitigate further microvascular and macrovascular damage. Additionally, a referral to an ophthalmologist for further evaluation and potential intervention for retinopathy is deemed necessary. These steps aim to address the current complications and prevent further deterioration of the patient’s condition, setting the stage for ongoing monitoring and adjustment of the therapeutic approach.

Section 2

As the healthcare team implements changes to the patient’s management plan, the focus shifts to enhancing glycemic control and addressing the emerging complications. The patient is started on a GLP-1 receptor agonist to complement the current insulin regimen, with the aim of achieving better blood glucose regulation. Over the following weeks, the patient attends regular follow-up appointments, where the healthcare team closely monitors blood glucose levels and HbA1c trends. Encouragingly, the patient's HbA1c shows a gradual decrease, now measuring at 8.5%, indicating an initial positive response to the intensified treatment.

Despite the improvements in glycemic control, new developments in the patient’s condition prompt further evaluation. The patient reports experiencing new-onset palpitations and increased fatigue, which are concerning given the background of cardiovascular risk factors. A thorough cardiac assessment is conducted, revealing an irregular heartbeat and a blood pressure reading of 150/95 mmHg, suggesting possible atrial fibrillation. An electrocardiogram (ECG) confirms the presence of atrial fibrillation, a complication that necessitates immediate intervention to prevent thromboembolic events. The healthcare team initiates anticoagulation therapy and considers rate control management to stabilize the patient’s cardiac rhythm.

These developments underscore the complexity of managing diabetes and its associated complications. The healthcare team is now tasked with integrating the management of atrial fibrillation into the patient’s existing treatment plan, while continuing to monitor and address the ongoing challenges posed by diabetic neuropathy and retinopathy. The next steps involve coordinating care with a cardiologist to optimize cardiac management and prevent long-term complications, while maintaining a multidisciplinary approach to address the multifaceted nature of diabetes.

Section 3

In the weeks following the initiation of anticoagulation therapy and rate control management, the patient returns for another scheduled follow-up. During this visit, the healthcare team conducts a comprehensive assessment to evaluate the patient's response to the interventions and to monitor for any new complications. The patient reports feeling less fatigued, and the palpitations have become less frequent, indicating a positive response to the cardiac management plan. Vital signs reveal a blood pressure of 140/88 mmHg and a heart rate of 78 beats per minute, suggesting improved cardiovascular stability. However, the patient mentions experiencing occasional dizziness and mild swelling in the lower extremities, which prompts further investigation.

To explore these new symptoms, the healthcare team orders a series of diagnostic tests, including renal function tests and an echocardiogram. The results indicate a slight decline in renal function, with an estimated glomerular filtration rate (eGFR) of 55 mL/min/1.73 m², down from previous readings. The echocardiogram reveals mild left ventricular hypertrophy, a finding consistent with long-standing hypertension and diabetes. These results highlight the ongoing challenge of managing the patient's complex condition, as they suggest the emergence of diabetic nephropathy alongside the existing cardiovascular issues.

In response to these findings, the healthcare team adjusts the patient's treatment plan to address the renal concerns while maintaining focus on cardiovascular and glycemic control. The patient is referred to a nephrologist for further evaluation and management of kidney function. Additionally, the team initiates lifestyle interventions, emphasizing the importance of dietary modifications and regular physical activity to support overall cardiovascular health and renal preservation. As the patient embarks on this adjusted treatment path, the healthcare team remains vigilant in monitoring for any further complications, ensuring a coordinated approach to the multifaceted management of diabetes and its systemic effects.

Section 4

During a subsequent follow-up visit, the patient reports experiencing increased episodes of dizziness, particularly upon standing, along with persistent mild swelling in the lower extremities. These symptoms raise concerns about the potential exacerbation of orthostatic hypotension, possibly linked to the antihypertensive medications and diuretic therapy prescribed to manage the patient's blood pressure and fluid retention. The healthcare team conducts a thorough physical examination and notes a significant postural drop in blood pressure, with readings of 135/85 mmHg while seated and 110/70 mmHg upon standing. Additionally, the patient exhibits pitting edema in the ankles, graded at +2.

To better understand the underlying causes of these symptoms, the team orders additional laboratory tests, including serum electrolytes and a complete blood count. The results reveal hyponatremia, with a serum sodium level of 130 mmol/L, suggesting a possible side effect of the diuretics or an inappropriate antidiuretic hormone response. The complete blood count remains within normal limits, which helps rule out other potential causes of the dizziness, such as anemia. Given these findings, the healthcare team considers adjusting the patient's medication regimen, focusing on optimizing blood pressure control while minimizing the risk of orthostatic changes and electrolyte imbalances.

In response to the current challenges, the healthcare team decides to reduce the dosage of the diuretic and closely monitor the patient's blood pressure and electrolyte levels. They also educate the patient on strategies to manage orthostatic hypotension, such as rising slowly from seated or lying positions and increasing fluid intake to counteract potential dehydration. As the patient navigates these adjustments, the team emphasizes the importance of regular follow-up appointments to assess the efficacy of the modified treatment plan and to detect any emerging complications promptly. This ongoing monitoring and holistic approach aim to support the patient's cardiovascular stability while safeguarding renal function and overall well-being.

Section 5

Several weeks into the adjusted treatment plan, the patient returns for another follow-up appointment. The healthcare team conducts a thorough examination and notes that while the dizziness has decreased in frequency, the patient continues to experience it occasionally when rising too quickly. The patient's blood pressure readings have stabilized somewhat, showing 130/80 mmHg while seated and a less dramatic drop to 115/75 mmHg upon standing. However, the patient now reports increased fatigue and occasional muscle cramps, prompting further investigation.

Given these new symptoms, the healthcare team orders a repeat serum electrolyte panel alongside a renal function test to assess the effects of the adjusted diuretic dosage. The laboratory results indicate a slight improvement in serum sodium levels to 135 mmol/L, suggesting some resolution of the hyponatremia. However, the results also show a mild elevation in serum creatinine at 1.4 mg/dL, up from a previous level of 1.1 mg/dL. This change raises concerns about potential renal impairment, possibly linked to the ongoing diuretic therapy or underlying diabetic nephropathy, warranting further evaluation.

In response to these findings, the healthcare team decides to further adjust the patient's medication regimen by exploring alternative antihypertensive options that are renal-protective. They initiate a referral to a nephrologist for specialized input on managing the patient's kidney health. Additionally, the team advises dietary modifications to include potassium-rich foods to address the muscle cramps and continues to emphasize the importance of maintaining adequate hydration. The patient is scheduled for more frequent follow-up visits to closely monitor kidney function, electrolyte balance, and overall health, underscoring the need for a collaborative, multidisciplinary approach in managing the complex interplay of diabetes and its complications.