A nurse is developing a care plan for a patient with poorly controlled type 2 diabetes, peripheral neuropathy, and retinopathy. Which intervention should be prioritized to address the patient's risk of further microvascular complications?

B) Increasing the frequency of blood glucose monitoring to adjust the treatment plan effectively.

A) Educating the patient on the importance of daily foot inspections to prevent injury.

B) Increasing the frequency of blood glucose monitoring to adjust the treatment plan effectively.

C) Referring the patient to an ophthalmologist for regular eye examinations.

D) Encouraging the patient to engage in a low-impact exercise program to improve cardiovascular health.

A nurse is developing a care plan for a patient with type 2 diabetes who presents with peripheral neuropathy, retinopathy, and early nephropathy. Which nursing intervention should be prioritized to address the patient's microvascular complications?

B) Educate the patient on the importance of maintaining blood pressure below 130/80 mmHg.

A) Schedule the patient for regular podiatry visits to prevent foot ulcers.

B) Educate the patient on the importance of maintaining blood pressure below 130/80 mmHg.

C) Recommend an annual comprehensive metabolic panel to monitor blood glucose levels.

D) Advise the patient to attend bi-weekly support groups for diabetes management.

A patient with type 2 diabetes, hypertension, and elevated LDL cholesterol is being managed with metformin, a statin, and an ACE inhibitor. Despite these interventions, the patient reports increased thirst and more frequent urination. Which of the following actions should the nurse prioritize to address these symptoms and optimize the patient's management plan?

C) Consult with the healthcare team about initiating an SGLT2 inhibitor to improve glycemic control and provide renal protection.

A) Assess the patient's current blood glucose levels and consider increasing the dose of metformin.

B) Educate the patient on the importance of adhering to a low-sodium diet to manage hypertension.

C) Consult with the healthcare team about initiating an SGLT2 inhibitor to improve glycemic control and provide renal protection.

D) Encourage the patient to increase physical activity to help reduce blood pressure and blood glucose levels.

A patient with type 2 diabetes is experiencing increased thirst and frequent urination despite adherence to her current medication regimen, including metformin and a recently added statin. Her hemoglobin A1c is 8.0%, and her urine microalbumin levels are elevated. Which intervention should the nurse anticipate as the next step to address her symptoms and improve her glycemic control?

B) Initiate an SGLT2 inhibitor in addition to her current medications.

A) Discontinue metformin and switch to insulin therapy.

B) Initiate an SGLT2 inhibitor in addition to her current medications.

C) Increase the dose of her current statin medication.

D) Recommend a high-protein diet to manage blood glucose levels.

A nurse is evaluating a patient with diabetes who is experiencing persistent fatigue, numbness, and tingling in her feet. Her blood pressure is averaging 140/88 mmHg, and recent lab results show an increase in urine microalbumin levels and an elevated hemoglobin A1c of 8.2%. Which intervention should the nurse prioritize to address the patient's current condition and prevent further complications?

B) Educate the patient on the importance of tight glycemic control and consider initiating an SGLT2 inhibitor.

A) Increase the dose of the patient's ACE inhibitor to improve blood pressure control.

B) Educate the patient on the importance of tight glycemic control and consider initiating an SGLT2 inhibitor.

C) Refer the patient to a neurologist for further evaluation of neuropathic symptoms.

D) Adjust the patient's statin therapy to further decrease LDL cholesterol levels.

A patient with type 2 diabetes and hypertension has been started on an ACE inhibitor and a statin. She presents with persistent fatigue, worsening numbness and tingling in her feet, increased urine microalbumin levels, and an elevated hemoglobin A1c of 8.2%. The healthcare team is considering adding an SGLT2 inhibitor to her regimen. Which nursing intervention should take priority to address the patient's current condition?

A) Educate the patient on the importance of consistent foot care to prevent complications from peripheral neuropathy.

B) Reinforce adherence to the prescribed antihypertensive regimen to maintain blood pressure control.

C) Discuss the benefits of SGLT2 inhibitors in managing both blood sugar levels and renal protection with the patient.

D) Coordinate a referral to a neurologist for further evaluation of the patient's neuropathy symptoms.

A patient on an SGLT2 inhibitor reports increased urinary frequency and thirst. Given the patient's history of diabetes and recent lab results indicating an increased urine microalbumin level, what is the most appropriate nursing intervention?

B) Educate the patient about the signs of dehydration and the importance of maintaining hydration.

A) Advise the patient to increase fluid intake to manage thirst.

B) Educate the patient about the signs of dehydration and the importance of maintaining hydration.

C) Suggest the patient reduces the dosage of the SGLT2 inhibitor.

D) Recommend the patient discontinue the use of the SGLT2 inhibitor until further evaluation.

A patient with type 2 diabetes mellitus is being treated with an SGLT2 inhibitor and reports increased urinary frequency and thirst. The nurse notes a rise in urine microalbumin levels to 140 mg/L during a follow-up visit. Which of the following actions should the nurse prioritize to address these findings?

B) Monitor the patient's renal function and electrolytes more frequently.

A) Advise the patient to decrease fluid intake to reduce urinary frequency.

B) Monitor the patient's renal function and electrolytes more frequently.

C) Increase the dosage of the patient's antihypertensive medication.

D) Discontinue the SGLT2 inhibitor immediately to prevent further renal damage.

A patient with hypertension and type 2 diabetes is experiencing increased fatigue, dizziness upon standing, and muscle cramps. Her lab results show mild hyponatremia and hypokalemia. Which nursing intervention is most appropriate to address these symptoms and prevent further complications?

C) Educate the patient on increasing dietary potassium intake and monitor fluid status.

A) Increase the dosage of her SGLT2 inhibitor to enhance glycemic control.

B) Advise the patient to reduce her physical activity to prevent fatigue.

C) Educate the patient on increasing dietary potassium intake and monitor fluid status.

D) Encourage the patient to decrease fluid intake to prevent further electrolyte imbalances.

A patient with a history of hypertension and type 2 diabetes is experiencing increased fatigue, dizziness upon standing, and muscle cramps. Laboratory results show sodium at 132 mEq/L and potassium at 3.4 mEq/L. Which nursing intervention is most appropriate to address the patient's current symptoms and laboratory findings?

A) Encourage the patient to increase fluid intake, particularly water, to manage dehydration.

B) Suggest the patient reduce salt intake to manage hypertension.

C) Advise the patient to increase dietary potassium and monitor for signs of hyperkalemia.

D) Recommend the patient decrease physical activity to reduce fatigue.

Diabetes mellitus - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin deficiency or resistance - In Type 1 Diabetes, autoimmune destruction of pancreatic beta cells leads to insufficient insulin production. In Type 2 Diabetes, insulin resistance occurs when cells fail to respond to insulin, often due to obesity and sedentary lifestyle, resulting in elevated blood glucose levels.

• Secondary mechanism: Impaired glucose uptake - With inadequate insulin action, glucose cannot efficiently enter cells, causing hyperglycemia. This persistent high blood sugar damages blood vessels and tissues over time.

• Key complication: Microvascular damage - Chronic hyperglycemia leads to complications such as retinopathy, nephropathy, and neuropathy, stemming from damage to small blood vessels, significantly impacting a patient's quality of life and increasing healthcare needs.

Patient Profile

Demographics:

57-year-old female, accountant

History:

• Key past medical history: Diagnosed with type 2 diabetes mellitus 8 years ago, hypertension, hyperlipidemia

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

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased fatigue and numbness in feet

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

• Vital signs: Blood pressure 150/95 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 the patient's increased fatigue and reports of numbness in her feet, indicative of potential neuropathy associated with poorly controlled type 2 diabetes. Upon further examination, the nurse observes diminished sensation in the patient's feet using a monofilament test, suggesting peripheral neuropathy. The patient also exhibits signs of retinopathy, such as blurred vision and occasional dizziness, which may be linked to chronic hyperglycemia and hypertension. The blood pressure remains elevated at 150/95 mmHg, despite the patient's current antihypertensive regimen. Given these findings, the nurse suspects worsening microvascular complications due to prolonged elevated blood glucose levels.

New diagnostic results reveal a hemoglobin A1c level of 8.3%, indicating suboptimal glycemic control over the past three months. Additionally, a lipid panel shows elevated LDL cholesterol at 150 mg/dL, and a urine microalbumin test is positive, suggesting early nephropathy. These results confirm the nurse's concerns about progressive microvascular damage and underscore the need for a comprehensive management plan to address these complications. The healthcare team discusses potential adjustments to the patient's treatment regimen, including optimizing her diabetes and hypertension management, possibly through medication adjustments or lifestyle interventions.

The patient's journey now focuses on enhancing her understanding of diabetes self-management and adhering to a more rigorous monitoring schedule. The healthcare team emphasizes the importance of regular follow-ups to monitor her blood pressure, glucose levels, and kidney function. They also discuss the necessity of annual eye exams to assess for retinopathy progression. The patient is encouraged to work with a dietitian to optimize her nutrition and consider a referral to a diabetes educator to reinforce lifestyle modifications. This approach aims to mitigate further complications and improve her overall quality of life.

Section 2

As the healthcare team implements adjustments to the patient's treatment regimen, including increasing her dosage of metformin and adding a statin to address her elevated LDL cholesterol, they also emphasize the importance of lifestyle modifications. The patient commits to attending a diabetes education class and begins working closely with a dietitian to better understand how her diet can impact her blood glucose levels. During a follow-up visit, the nurse notes that the patient has made some progress in adhering to dietary recommendations, such as reducing carbohydrate intake and incorporating more fiber into her meals. However, the patient reports continued difficulty with maintaining a consistent exercise routine due to persistent fatigue and numbness in her feet.

The patient's blood pressure remains a concern, with readings averaging 148/92 mmHg despite adherence to her antihypertensive medications. Recognizing the need for a more aggressive approach, the healthcare team decides to add an ACE inhibitor to her regimen, given its renal protective benefits and potential to further reduce her blood pressure. Meanwhile, her recent laboratory results show a slight improvement in her hemoglobin A1c, now at 8.0%, indicating a positive response to the increased focus on glycemic control. Nevertheless, the nurse is vigilant about monitoring her renal function, as the patient's urine microalbumin levels remain elevated, warranting close observation for any signs of worsening nephropathy.

Despite these interventions, the patient begins to exhibit new symptoms, including increased thirst and more frequent urination, which could suggest further complications or a need for additional adjustments to her management plan. The nurse considers the possibility of osmotic diuresis due to persistent hyperglycemia and discusses with the healthcare team whether additional medications, such as a SGLT2 inhibitor, might be beneficial to enhance her glycemic control and provide further renal protection. This ongoing assessment and adjustment of the patient's treatment plan underscore the importance of a dynamic, patient-centered approach to managing chronic conditions like diabetes, aiming to prevent further complications and improve her quality of life.

Section 3

In the weeks following the addition of the ACE inhibitor and ongoing adjustments to her treatment plan, the patient returns for another follow-up visit. During this visit, the nurse conducts a comprehensive assessment and notes some significant changes in the patient's condition. The patient's blood pressure has improved slightly, now averaging 140/88 mmHg, suggesting a partial response to the antihypertensive regimen. However, she continues to report persistent fatigue, and the numbness in her feet has worsened, now accompanied by tingling sensations. These symptoms raise concerns about the progression of peripheral neuropathy, a common complication of diabetes requiring further evaluation and management.

Moreover, the nurse reviews the patient's most recent laboratory results, which reveal an increase in urine microalbumin levels, now at 120 mg/L, indicating a potential progression of nephropathy despite the introduction of renal-protective measures. The patient's hemoglobin A1c remains elevated at 8.2%, suggesting that her glycemic control is still suboptimal, possibly contributing to the exacerbation of her symptoms. Additionally, the patient's lipid profile shows a slight decrease in LDL cholesterol to 125 mg/dL, demonstrating some benefit from the statin therapy, yet still requiring ongoing monitoring and lifestyle interventions.

These findings prompt the healthcare team to consider further adjustments to the patient's management plan. The nurse discusses with the team the potential benefits of adding an SGLT2 inhibitor, which could aid in enhancing glycemic control, addressing the osmotic diuresis symptoms, and offering additional renal protection. The team also emphasizes the need for the patient to adhere closely to her diabetes education plan, focusing on consistent lifestyle modifications, while considering a referral to a neurologist for further assessment of her neuropathic symptoms. This dynamic approach aims to address the current complications while preventing further deterioration of the patient's overall health and quality of life.

Section 4

In the weeks following the introduction of the SGLT2 inhibitor, the patient returns to the clinic for another follow-up visit. During this visit, the nurse conducts a thorough assessment and notes some encouraging changes, as well as new concerns that require attention. The patient's blood pressure has continued to improve, now averaging 132/84 mmHg, indicating a more favorable response to the combination of antihypertensive treatments. The patient reports a slight reduction in fatigue, suggesting some benefit from the enhanced glycemic control provided by the SGLT2 inhibitor. However, the numbness and tingling sensations in her feet remain persistent, highlighting the need for ongoing management of her peripheral neuropathy.

The nurse reviews the latest laboratory results, which reveal a slight improvement in the patient's hemoglobin A1c, now at 7.8%, reflecting better, though still suboptimal, glycemic control. Despite this progress, the patient's urine microalbumin levels have increased to 140 mg/L, raising further concerns about the progression of nephropathy. The lipid profile shows a further decrease in LDL cholesterol to 118 mg/dL, suggesting continued benefits from the statin therapy. However, the patient mentions experiencing increased urinary frequency and thirst, symptoms that could be linked to the osmotic diuresis effect of the SGLT2 inhibitor, warranting careful monitoring of her hydration status and renal function.

Given these findings, the healthcare team decides to maintain the current pharmacological regimen while emphasizing the importance of regular monitoring of renal function and electrolytes, considering the potential impact of the SGLT2 inhibitor. The team also reiterates the need for the patient to adhere closely to dietary recommendations and engage in regular physical activity to support further improvements in glycemic control and overall cardiovascular health. To address the persistent neuropathic symptoms, the team considers adjusting the patient's pain management plan and reinforcing the need for protective foot care practices to prevent complications such as foot ulcers. This comprehensive approach aims to stabilize the patient's condition, mitigate the risk of further complications, and enhance her quality of life.

Section 5

During a subsequent follow-up visit, the patient presents with new concerns that warrant immediate attention. The nurse observes that the patient's blood pressure has increased slightly, now averaging 138/86 mmHg. While still within an acceptable range, this change prompts a review of her adherence to antihypertensive medications and lifestyle modifications. The patient reports a noticeable increase in fatigue and a sense of dizziness upon standing, which raises suspicion of orthostatic hypotension, possibly exacerbated by the SGLT2 inhibitor leading to volume depletion. Additionally, the patient notes the onset of more pronounced muscle cramps during the night, suggesting potential electrolyte imbalances.

The laboratory results reveal a concerning electrolyte profile, with a sodium level of 132 mEq/L and potassium at 3.4 mEq/L, indicating mild hyponatremia and hypokalemia. This finding, coupled with the patient's symptoms, reinforces the necessity for careful monitoring and perhaps modification of her diuretic therapy. Fortunately, her hemoglobin A1c has further decreased to 7.5%, indicating continued improvement in glycemic control. However, the elevated urine microalbumin levels persist, now at 160 mg/L, underscoring the urgency of addressing her renal function deterioration proactively.

In response to these developments, the healthcare team decides to adjust the patient's diuretic dosage and closely monitor her fluid and electrolyte balance, while also reinforcing dietary strategies to address these imbalances. They recommend increasing dietary potassium intake through foods like bananas and spinach, and ensuring adequate fluid consumption to prevent dehydration. The team also considers the addition of a mineralocorticoid receptor antagonist to better manage her blood pressure and protect renal function. Through these targeted interventions, the goal is to stabilize the patient's condition, prevent further complications, and enhance her overall well-being.