A patient with poorly controlled diabetes presents with diminished sensation in the feet, a poorly healing foot ulcer, and early signs of diabetic retinopathy. The healthcare team has decided to increase the dosage of Metformin and consider adding a GLP-1 receptor agonist. Which nursing intervention is most important to prioritize in this patient's care plan to prevent further complications?

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

B) Encourage the patient to increase fluid intake to prevent dehydration.

C) Recommend the use of over-the-counter analgesics for foot pain management.

D) Instruct the patient to avoid weight-bearing activities until the ulcer heals.

A patient with poorly controlled type 2 diabetes presents with peripheral neuropathy, a non-healing foot ulcer, and early signs of diabetic retinopathy. Laboratory results show an elevated HbA1c of 9.2%. Which of the following interventions should the nurse prioritize to address the patient's complications and improve their overall condition?

A) Educate the patient on the importance of daily foot inspections and proper footwear.

B) Increase the frequency of blood glucose monitoring and record keeping.

C) Refer the patient to a dietitian for a personalized meal plan to manage hyperglycemia.

D) Emphasize the importance of attending regular ophthalmology appointments for retinopathy monitoring.

A patient with type 2 diabetes mellitus and a recent finding of moderate anemia reports intermittent dizziness and occasional palpitations. Which nursing intervention is most appropriate to prioritize during this follow-up visit to address these symptoms?

B) Monitor the patient's blood pressure and heart rate while assessing for signs of orthostatic hypotension.

A) Educate the patient on the importance of adhering to the prescribed iron supplements to address anemia.

B) Monitor the patient's blood pressure and heart rate while assessing for signs of orthostatic hypotension.

C) Recommend increasing the patient's fluid intake to manage potential dehydration contributing to symptoms.

D) Advise the patient to rest and avoid strenuous activities until further evaluated by a cardiologist.

A patient with type 2 diabetes mellitus returns for a follow-up visit after the implementation of lifestyle modifications and the addition of a GLP-1 receptor agonist. She reports improved energy and modest weight loss but experiences intermittent dizziness and palpitations. Her blood pressure is 135/85 mmHg, heart rate is 92 bpm, HbA1c is 8.4%, and moderate anemia is noted with a hemoglobin level of 10.5 g/dL. Which nursing intervention is most appropriate to address her dizziness and cardiovascular risk?

D) Recommend consulting with a cardiologist and consider adding an SGLT2 inhibitor for better cardiovascular outcomes.

A) Educate the patient on increasing dietary iron intake and monitor blood pressure regularly.

B) Encourage increased physical activity to assist in lowering LDL cholesterol and triglycerides.

C) Advise the patient to drink more fluids to manage dizziness and improve circulation.

D) Recommend consulting with a cardiologist and consider adding an SGLT2 inhibitor for better cardiovascular outcomes.

A 58-year-old female patient with a history of diabetes mellitus and recent iron deficiency anemia is being discharged with oral iron supplements and an SGLT2 inhibitor. The nurse is providing discharge education. Which statement by the patient indicates a need for further teaching?

C) 'I can expect my urine output to decrease with the use of an SGLT2 inhibitor.'

A) 'I will take my iron supplements with a glass of orange juice to improve absorption.'

B) 'I should monitor my blood sugar levels closely due to the change in my diabetes medication.'

C) 'I can expect my urine output to decrease with the use of an SGLT2 inhibitor.'

D) 'I will notify my healthcare provider if I experience significant gastrointestinal discomfort from the iron supplements.'

A patient with type 2 diabetes mellitus is experiencing increased thirst, frequent urination, fatigue, and mild headaches. Her laboratory tests indicate mild hyponatremia and hypokalemia. Given the patient's current symptoms and lab results, which intervention should the nurse prioritize to address the underlying cause of her electrolyte imbalance?

C) Recommend dietary potassium intake to address hypokalemia and review medication regimen.

A) Increase the patient's fluid intake to correct dehydration.

B) Educate the patient on reducing sodium intake to prevent hypertension complications.

C) Recommend dietary potassium intake to address hypokalemia and review medication regimen.

D) Initiate insulin therapy to improve glycemic control and reduce osmotic diuresis.

A patient with type 2 diabetes is experiencing increased thirst, frequent urination, fatigue, and mild headaches, with lab results showing mild hyponatremia and hypokalemia. Which nursing intervention is most appropriate to prioritize in addressing her current symptoms?

B) Educate the patient on consuming potassium-rich foods to correct hypokalemia.

A) Increase the patient's fluid intake to alleviate thirst.

B) Educate the patient on consuming potassium-rich foods to correct hypokalemia.

C) Adjust the patient's SGLT2 inhibitor dosage to reduce osmotic diuresis.

D) Collaborate with the healthcare team to review and modify antihypertensive therapy.

A patient with type 2 diabetes and early nephropathy is experiencing orthostatic hypotension and hypokalemia. Which nursing intervention is the highest priority to address these clinical findings?

C) Monitor blood pressure and heart rate closely during position changes.

A) Encourage the patient to increase fluid intake to address orthostatic hypotension.

B) Educate the patient on consuming potassium-rich foods to correct hypokalemia.

C) Monitor blood pressure and heart rate closely during position changes.

D) Schedule an immediate follow-up with the dietitian to modify dietary intake.

A patient with type 2 diabetes is experiencing hypokalemia and orthostatic hypotension. Her current medications include an SGLT2 inhibitor. Which intervention should the nurse prioritize to address these findings?

D) Discuss with the healthcare provider about adjusting or discontinuing the SGLT2 inhibitor.

A) Encourage increased fluid intake to prevent dehydration.

B) Educate the patient on incorporating potassium-rich foods into her diet.

C) Instruct the patient to change positions slowly to prevent dizziness.

D) Discuss with the healthcare provider about adjusting or discontinuing the SGLT2 inhibitor.

Diabetes - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance - In Type 1 Diabetes, the immune system attacks pancreatic beta cells, reducing insulin production. In Type 2 Diabetes, cells become resistant to insulin, impairing glucose uptake despite normal or elevated insulin levels.

• Secondary mechanism: Hyperglycemia - Insufficient insulin action leads to elevated blood glucose levels, as glucose cannot efficiently enter cells for energy production, resulting in chronic high blood sugar.

• Key complication: Vascular damage - Persistent hyperglycemia causes glycation of proteins and lipids, damaging blood vessels and increasing the risk of cardiovascular diseases, neuropathy, nephropathy, and retinopathy, necessitating ongoing monitoring and management.

Patient Profile

Demographics:

56-year-old female, office manager

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: Increased fatigue and numbness in feet

• Key symptoms: Blurred vision, frequent urination, slow-healing foot ulcer, tingling in hands and feet

• Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose 210 mg/dL

Section 1

Following the initial assessment, the healthcare team conducted a thorough evaluation to better understand the extent of the patient's complications. The physical examination revealed diminished sensation in the feet, consistent with peripheral neuropathy, and a small ulcer on the plantar surface of the right foot that appeared to be healing poorly. Monofilament testing confirmed reduced tactile sensation, indicating significant nerve damage likely related to chronic hyperglycemia. Additionally, the fundoscopic exam showed early signs of diabetic retinopathy, characterized by microaneurysms and cotton wool spots, explaining the patient's blurred vision.

To further evaluate the patient's condition, laboratory tests were ordered. The patient's HbA1c was elevated at 9.2%, indicating poor long-term glycemic control. A lipid panel revealed elevated LDL cholesterol at 145 mg/dL and triglycerides at 220 mg/dL, despite ongoing statin therapy. Urine microalbumin levels were slightly elevated, suggesting early nephropathy. These findings emphasize the need for tighter glucose control and potential adjustments to her medication regimen to prevent further vascular complications.

Given these results, the healthcare team decided to adjust the patient's treatment plan. They increased the dosage of Metformin to improve glycemic control and considered adding a GLP-1 receptor agonist to address both glucose levels and weight management. The team also recommended consulting with a podiatrist for specialized care of the foot ulcer and an ophthalmologist for regular eye examinations to monitor retinopathy progression. Patient education focused on lifestyle modifications, including dietary changes and increased physical activity, to enhance overall cardiovascular health and prevent further complications. These steps aim to stabilize the patient's condition and prevent further decline, highlighting the importance of comprehensive management in patients with complex diabetes complications.

Section 2

Following the adjustments in her treatment plan, the patient returned for a follow-up appointment after three months. The clinical team was eager to assess the response to the intensified interventions. During this visit, the patient reported improved energy levels and a modest weight loss of five pounds, suggesting positive adherence to lifestyle modifications. However, she expressed concerns about intermittent episodes of dizziness and occasional palpitations. Vital signs revealed a blood pressure of 135/85 mmHg, which was slightly elevated compared to previous readings, and a heart rate of 92 beats per minute.

Repeat laboratory tests showed a reduction in HbA1c to 8.4%, indicating some progress in glycemic control, though still above the target range. Lipid panel results were mixed, with LDL cholesterol reduced to 130 mg/dL but triglycerides slightly increased to 230 mg/dL. Of particular note was a new finding of moderate anemia, with a hemoglobin level of 10.5 g/dL, which may contribute to her reported symptoms of dizziness. The foot ulcer showed signs of improvement under podiatric care, though it remained a concern due to the persistent neuropathy.

Given these findings, the healthcare team decided to further refine the treatment plan. The introduction of the GLP-1 receptor agonist appeared beneficial, but additional adjustments were necessary to address the patient's cardiovascular risk and new symptoms. They recommended a consultation with a cardiologist to evaluate her palpitations and anemia. Additionally, they considered adding an SGLT2 inhibitor to further improve cardiovascular outcomes and glycemic control, while also advising continued vigilance in foot care and regular ophthalmologic assessments. This nuanced approach illustrates the complexity of managing diabetes with multiple complications, emphasizing the importance of ongoing assessment and tailored interventions to prevent further deterioration of the patient's health.

Section 3

Following the consultation with the cardiologist, the patient underwent a series of diagnostic tests, including an electrocardiogram (ECG) and echocardiogram, to investigate her palpitations and assess cardiac function. The ECG revealed occasional premature ventricular contractions (PVCs), which were deemed benign yet likely contributing to her palpitations. The echocardiogram showed normal cardiac structure and function, ruling out any significant cardiomyopathy. Concurrently, further evaluation of her anemia included iron studies and a peripheral blood smear. Results revealed microcytic hypochromic anemia, indicating iron deficiency as the underlying cause, likely exacerbated by poor dietary intake and possible gastrointestinal absorption issues.

In response to these findings, the healthcare team initiated oral iron supplementation and dietary counseling to address the anemia. They also educated the patient on potential side effects of iron therapy, such as gastrointestinal discomfort, and emphasized the importance of adherence to the supplementation regimen. Meanwhile, the addition of the SGLT2 inhibitor was noted to have a positive impact on the patient's glycemic control, as evidenced by a slight reduction in fasting blood glucose levels upon subsequent monitoring. The patient's blood pressure remained stable, though slightly elevated, prompting discussions about potential antihypertensive therapy adjustments to further mitigate cardiovascular risk.

Despite the progress made, the patient began to report new symptoms of increased thirst and nocturia, raising concerns about potential osmotic diuresis related to the intensified diabetes management. The clinical team opted to closely monitor her renal function and electrolyte balance, remaining vigilant for signs of dehydration or electrolyte disturbances. This multidimensional approach underscores the ongoing challenge of managing diabetes with coexisting complications, requiring careful balancing of treatments to optimize overall health outcomes. As the patient continues her journey, the team remains committed to providing comprehensive care and anticipates further evaluating her response to the current interventions in upcoming follow-up appointments.

Section 4

As the follow-up appointment approached, the patient reported persistent symptoms of increased thirst and frequent urination, coupled with the emergence of fatigue and mild headaches. These symptoms prompted the healthcare team to conduct a thorough reassessment of her current condition. Upon examination, her vital signs revealed a blood pressure of 148/92 mmHg, a heart rate of 78 beats per minute, and a temperature of 98.6°F. Notably, her fasting blood glucose had improved to 145 mg/dL, yet her hemoglobin A1c remained at 8.2%, indicating suboptimal long-term glycemic control. Laboratory tests further indicated a serum sodium level of 134 mmol/L and a potassium level of 3.3 mmol/L, suggesting mild hyponatremia and hypokalemia.

The recent diagnostic tests raised concerns about potential complications related to the intensified diabetes management. The patient's ongoing increased thirst and nocturia, in conjunction with her lab findings, suggested possible osmotic diuresis and subsequent electrolyte imbalance. This hypothesis was further supported by the mild hypokalemia, which could be exacerbated by her current treatment regimen, including the SGLT2 inhibitor. The clinical team recognized the need for a delicate balance between achieving glycemic control and maintaining electrolyte homeostasis.

In response to these findings, the healthcare team decided to adjust the patient's treatment plan. A consultation with a nephrologist was recommended to explore potential renal implications and ensure appropriate management of her electrolyte disturbances. Additionally, her antihypertensive therapy was reviewed, considering the possibility of modifying her diuretic use to prevent further electrolyte shifts. The patient was advised to increase her dietary intake of potassium-rich foods and continue monitoring her fluid intake to address her persistent thirst. The team emphasized the importance of frequent follow-up appointments to closely track her progress and adapt her treatment plan as needed, underscoring their commitment to providing comprehensive, patient-centered care.

Section 5

Several weeks after the adjustments to her treatment plan, the patient returned for a follow-up appointment. She reported some improvement in her symptoms; her thirst had slightly decreased, and she was experiencing fewer episodes of nocturia. However, she continued to feel fatigued and occasionally experienced dizziness upon standing. The clinical team conducted a thorough assessment to evaluate her current status and the effectiveness of the interventions.

Upon examination, her vital signs showed a blood pressure of 142/90 mmHg and a heart rate of 82 beats per minute. Notably, her orthostatic blood pressure readings revealed a significant drop when moving from a sitting to a standing position, suggesting orthostatic hypotension. Her fasting blood glucose had further improved to 130 mg/dL, but the hemoglobin A1c remained relatively unchanged at 8.0%. Updated laboratory tests indicated a slight improvement in her serum sodium level at 136 mmol/L, while her potassium level had decreased further to 3.0 mmol/L, raising concerns about worsening hypokalemia.

The nephrologist's assessment revealed early signs of nephropathy, evidenced by microalbuminuria in her urine analysis. These findings prompted the clinical team to revisit her medication regimen once more. They decided to initiate potassium supplementation to address the persistent hypokalemia and considered switching her SGLT2 inhibitor to another class of glucose-lowering medication to mitigate any renal implications. The team scheduled more frequent follow-ups to closely monitor her electrolyte levels, blood pressure, and renal function, reiterating the importance of a multidisciplinary approach in managing her diabetes and its complications. This comprehensive strategy aimed to stabilize her condition and prevent further deterioration, highlighting the need for continuous adaptation of her care plan.