A 58-year-old patient with type 2 diabetes presents with diminished sensation in the feet, blurred vision, and frequent urination. Laboratory results reveal a hemoglobin A1c of 9.2% and elevated creatinine levels. Which nursing intervention is the most appropriate to address his current symptoms and prevent further complications?

D) Instruct the patient to perform regular foot inspections and wear protective footwear to prevent injury.

A) Recommend the patient start a high-protein diet to improve renal function.

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

C) Suggest the patient engage in daily weight-bearing exercises to enhance peripheral circulation.

D) Instruct the patient to perform regular foot inspections and wear protective footwear to prevent injury.

A patient with type 2 diabetes mellitus presents with diminished sensation in the feet, blurred vision, and reports frequent urination and polydipsia. Laboratory tests reveal a hemoglobin A1c of 9.2% and a slight increase in creatinine level with a decreased eGFR. Which of the following nursing interventions is the highest priority to address the patient's current condition?

C) Collaborate with the healthcare team to adjust the patient’s diabetes medication regimen.

A) Educate the patient on the importance of foot care to prevent injury and infection.

B) Schedule an appointment for the patient with an ophthalmologist to evaluate for diabetic retinopathy.

C) Collaborate with the healthcare team to adjust the patient’s diabetes medication regimen.

D) Provide dietary counseling to help the patient lower his blood glucose levels.

A patient with type 2 diabetes and peripheral neuropathy presents with a small ulcer on the lateral aspect of the left foot, surrounded by erythema. Which nursing intervention is the most appropriate to prioritize during this visit?

C) Reinforce proper foot care techniques and assess the ulcer daily.

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

B) Initiate a referral to a dietitian for nutritional counseling.

C) Reinforce proper foot care techniques and assess the ulcer daily.

D) Discuss the addition of an SGLT2 inhibitor with the healthcare provider.

A patient with type 2 diabetes presents with a small ulcer on the lateral aspect of his left foot, along with surrounding erythema, indicating possible infection. His laboratory tests reveal a hemoglobin A1c of 8.8%, fasting glucose of 175 mg/dL, and microalbuminuria. Which of the following nursing interventions is most appropriate to address the patient's current condition?

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

B) Encourage the patient to increase carbohydrate intake to manage glucose levels.

C) Advise the patient to decrease physical activity to prevent foot injury.

D) Suggest reducing fluid intake to address microalbuminuria.

A patient with type 2 diabetes presents with swelling and a dull ache in the lower legs, mild bilateral pitting edema, and elevated liver enzymes after starting new medications. Which nursing intervention should the nurse prioritize to address these findings?

D) Collaborate with the healthcare provider to evaluate the need for adjusting the medication regimen.

A) Elevate the patient's legs and apply compression stockings to manage edema.

B) Educate the patient on dietary modifications to reduce sodium intake.

C) Instruct the patient to monitor for signs of hypoglycemia due to medication changes.

D) Collaborate with the healthcare provider to evaluate the need for adjusting the medication regimen.

A patient with type 2 diabetes presents with mild bilateral pitting edema and elevated liver enzymes following the introduction of an SGLT2 inhibitor and ACE inhibitor. Which nursing intervention is the priority to address potential complications given the current clinical findings?

A) Monitor daily weight and educate the patient on signs of fluid overload.

B) Instruct the patient to increase fluid intake to flush out toxins.

C) Encourage the patient to perform vigorous exercise to reduce edema.

D) Discontinue all medications and consult the healthcare provider.

A patient with a new diagnosis of early-stage heart failure and diabetic cardiomyopathy is being managed with a low-dose loop diuretic and an ACE inhibitor. Which nursing intervention is most important to implement to prevent potential complications related to the new treatment regimen?

B) Monitor the patient's blood pressure and renal function regularly.

A) Encourage the patient to increase dietary potassium intake.

B) Monitor the patient's blood pressure and renal function regularly.

C) Advise the patient to limit fluid intake to 1 liter per day.

D) Schedule the patient for weekly liver function tests.

A patient with newly diagnosed early-stage heart failure secondary to diabetic cardiomyopathy is on a treatment regimen that includes a low-dose loop diuretic and an ACE inhibitor. Which nursing intervention is most important to prioritize given the patient's current condition?

A) Monitor the patient's blood pressure closely to ensure it remains within a safe range.

B) Educate the patient about the signs of hyperkalemia, such as muscle weakness and fatigue.

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

D) Advise the patient to avoid all physical activities to reduce cardiac workload.

A patient with CHF and diabetes is experiencing minor weight gain over a few days, slightly elevated blood pressure, and mildly elevated liver transaminases. The healthcare team has adjusted the loop diuretic dosage to manage fluid retention. As a nurse, which of the following interventions is most appropriate to ensure the patient's safety and effective management of his condition?

B) Monitor daily weights and report any weight gain of more than 2 pounds in 24 hours.

A) Encourage the patient to increase fluid intake to flush out excess sodium.

B) Monitor daily weights and report any weight gain of more than 2 pounds in 24 hours.

C) Advise the patient to reduce physical activity to prevent fatigue.

D) Instruct the patient to stop the diuretic if experiencing dizziness or lightheadedness.

A patient with a history of heart failure and diabetes is experiencing slight improvement in shortness of breath and leg swelling after starting a new treatment regimen. However, there is a trend of gradual weight gain and mildly elevated liver enzymes. Given these findings and the recent increase in the loop diuretic dosage, which nursing intervention should be prioritized?

B) Monitor the patient for signs of electrolyte imbalance and dehydration.

A) Educate the patient on the importance of adhering to a low-sodium diet.

B) Monitor the patient for signs of electrolyte imbalance and dehydration.

C) Encourage the patient to increase their daily physical activity level.

D) Suggest the patient takes over-the-counter potassium supplements.

diabetes mellitus type 2 - Nursing Case Study

Pathophysiology

• Primary mechanism: Insulin resistance occurs when cells in muscles, fat, and the liver do not respond well to insulin, leading to reduced glucose uptake and increased blood sugar levels. This resistance is often linked to obesity and sedentary lifestyles.

• Secondary mechanism: Beta-cell dysfunction in the pancreas results in inadequate insulin secretion. Over time, the pancreas fails to keep up with the increased demand for insulin, exacerbating hyperglycemia.

• Key complication: Chronic hyperglycemia can lead to microvascular complications such as diabetic retinopathy, nephropathy, and neuropathy, as well as macrovascular complications like cardiovascular disease, emphasizing the importance of early intervention and management.

Patient Profile

Demographics:

56-year-old male, office manager

History:

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

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

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased fatigue and tingling sensation in feet

• Key symptoms: Blurred vision, frequent urination, unintentional weight loss, polydipsia

• Vital signs: Blood pressure 148/92 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, BMI 31 kg/m²

Section 1

During the initial assessment, the patient's physical examination reveals diminished sensation in the feet, consistent with peripheral neuropathy, a common complication of diabetes mellitus. The patient reports that the tingling sensation has gradually transitioned to numbness over the past few months, making it difficult to discern the texture of surfaces when walking barefoot. This symptomatology is often indicative of nerve damage due to prolonged hyperglycemia. Additionally, the blurred vision suggests possible diabetic retinopathy, which warrants further evaluation by an ophthalmologist. The patient's frequent urination and polydipsia align with signs of poor glycemic control, necessitating immediate attention to his current diabetes management plan.

Laboratory tests are ordered to further assess the patient’s condition. The results show a hemoglobin A1c of 9.2%, indicating suboptimal long-term glucose control. His fasting blood glucose level is elevated at 182 mg/dL, and a random glucose test comes back at 210 mg/dL. Renal function tests show a slight increase in creatinine levels at 1.4 mg/dL, with a decreased estimated glomerular filtration rate (eGFR) of 58 mL/min/1.73 m², hinting at early diabetic nephropathy. These findings, coupled with his elevated blood pressure and cholesterol levels, place him at increased risk for both microvascular and macrovascular complications. The healthcare team recognizes the need for a comprehensive approach to manage his diabetes, hypertension, and dyslipidemia to prevent further deterioration of his condition.

The patient is advised to enhance his lifestyle modifications, including a balanced diet and increased physical activity, tailored to his sedentary lifestyle as an office manager. The clinical team considers intensifying his pharmacological regimen, possibly by adding a newer class of antidiabetic medication such as an SGLT2 inhibitor or GLP-1 receptor agonist, which have cardiovascular and renal benefits. The patient is counseled on the importance of regular follow-up appointments to monitor his blood glucose levels, renal function, and blood pressure, as well as the necessity of annual eye exams to screen for retinopathy. The case underscores the critical need for a multidisciplinary approach to effectively manage type 2 diabetes and its complications, ensuring a holistic path forward in the patient's care journey.

Section 2

Three months after the initial assessment, the patient returns for a follow-up appointment. During this visit, the patient reports persistent numbness in his feet, and he mentions noticing a small ulcer on the lateral aspect of his left foot. He recalls a minor scrape from a shoe that didn't heal properly, which is concerning given the context of his existing peripheral neuropathy. On examination, the ulcer appears superficial but with some surrounding erythema, indicating possible infection. The patient's vital signs reveal a blood pressure of 148/92 mmHg and a heart rate of 88 beats per minute, suggesting suboptimal blood pressure management. His weight remains unchanged, indicating that lifestyle modifications have not yet led to significant weight loss.

Laboratory tests are repeated, revealing a hemoglobin A1c of 8.8%, a slight improvement but still above target levels. His fasting glucose level reads 175 mg/dL, and creatinine has increased slightly to 1.5 mg/dL, with an eGFR now at 55 mL/min/1.73 m². Lipid panel results show LDL cholesterol at 130 mg/dL, still above the recommended target, necessitating more aggressive lipid management. The patient's urinalysis reveals microalbuminuria, further substantiating the diagnosis of diabetic nephropathy. These results suggest that while there has been some improvement, the patient's diabetes and associated conditions require more intensive management.

Given these findings, the healthcare team decides to adjust the patient's treatment plan. An SGLT2 inhibitor is added to his regimen to harness its renal and cardiovascular protective effects, along with an ACE inhibitor to better manage his blood pressure and mitigate nephropathy progression. The patient is educated on foot care to prevent further complications and is referred to a podiatrist for ulcer management. Additionally, the importance of adherence to dietary recommendations and regular physical activity is reinforced. These interventions aim to halt the progression of his complications and highlight the need for ongoing, comprehensive management of type 2 diabetes. The patient's case continues to evolve, underscoring the importance of a proactive approach to chronic disease management.

Section 3

Three months following the adjustment of his treatment plan, the patient returns for another follow-up, presenting with a notable change in his status. He reports a marked reduction in the numbness of his feet, which he attributes to more vigilant foot care and consistent use of the prescribed medications. However, he expresses concern about swelling and a dull ache in his lower legs, which have been worsening over the past few weeks. On examination, there is mild bilateral pitting edema, and the erythema around the ulcer on his left foot has resolved, indicating that the infection is under control. His blood pressure is slightly improved at 142/88 mmHg, and his heart rate is steady at 85 beats per minute.

The laboratory tests reveal a hemoglobin A1c of 8.2%, showing further improvement but still above the target goal. Fasting glucose levels have decreased to 160 mg/dL. Notably, his creatinine level has stabilized at 1.4 mg/dL, and the eGFR has slightly improved to 60 mL/min/1.73 m², suggesting a positive response to the addition of an SGLT2 inhibitor and ACE inhibitor. His lipid panel now shows LDL cholesterol at 120 mg/dL, indicating modest progress in lipid management. However, new laboratory findings indicate elevated liver enzymes, with an ALT of 65 U/L and an AST of 70 U/L, suggesting a possible adverse effect of the medication or underlying hepatic issues.

Given these findings, the healthcare team considers the possibility of medication-induced liver dysfunction and decides to monitor liver function closely while evaluating the need for further adjustments in his medication regimen. The patient is also educated on the signs and symptoms of potential liver issues to ensure early detection and intervention. The persistence of lower extremity edema prompts further investigation into possible heart failure or diabetic cardiomyopathy, considering the patient's history and current presentation. This new development in the patient's journey underscores the complexity of managing type 2 diabetes and its systemic implications, highlighting the need for vigilant monitoring and a multidisciplinary approach to care.

Section 4

In the weeks following the last visit, the patient's condition evolves with new complications that demand attention. The swelling in his lower legs has not only persisted but has also become more pronounced, accompanied by increased shortness of breath during minimal exertion. Recognizing these as potential indicators of heart failure, the healthcare team initiates a series of diagnostic tests. An echocardiogram reveals a reduced ejection fraction of 45%, confirming a diagnosis of early-stage heart failure, likely exacerbated by diabetic cardiomyopathy. Additionally, a chest X-ray shows mild pulmonary congestion, correlating with the patient's respiratory symptoms.

In response to these developments, the medical team adjusts the patient's treatment regimen to include a low-dose loop diuretic to manage the edema and improve cardiac function. His ACE inhibitor dosage is carefully titrated to provide additional cardiovascular protection without compromising renal function, given his stable creatinine levels. The team also emphasizes the importance of dietary sodium restriction and regular physical activity tailored to his tolerance level, aiming to enhance fluid management and overall cardiac health.

As the patient embarks on this updated treatment path, he is encouraged to monitor his weight daily, track any changes in symptoms, and maintain regular follow-up appointments. The team remains vigilant about the liver enzyme elevation, opting to reassess his medication regimen if liver function tests do not stabilize. This phase of the patient's journey highlights the interconnected nature of diabetes-related complications, calling for a nuanced, integrated approach to manage both existing and emerging health challenges effectively.

Section 5

As the patient continues on the updated treatment regimen, the healthcare team pays close attention to his response to the interventions. During a follow-up appointment two weeks later, the patient reports a slight improvement in his shortness of breath and a reduction in the swelling of his lower legs. He adheres to the recommended dietary sodium restriction and has started a low-impact walking routine. However, his daily weight log indicates minor fluctuations, with a concerning trend of gradual weight gain over the past few days.

Vital signs during the visit reveal a blood pressure of 145/90 mmHg, which is slightly elevated from the previous readings, and a heart rate of 92 beats per minute. His respiratory rate is 22 breaths per minute with an oxygen saturation of 94% on room air, reflecting a modest improvement. Lab results show a stable creatinine level, but the liver function tests continue to show mildly elevated transaminases, raising concerns about potential medication-induced liver stress or ongoing hepatic involvement related to diabetes.

Recognizing the subtle yet significant changes in the patient's status, the healthcare team decides to adjust the therapeutic plan further. The loop diuretic dosage is slightly increased to enhance fluid management, while the team closely monitors for any signs of electrolyte imbalance. Moreover, the patient is referred for a consultation with a dietitian to optimize his nutritional intake, focusing on managing both his cardiovascular and hepatic health. The plan includes more frequent follow-up appointments to reassess symptoms, weight trends, and laboratory values, ensuring a proactive approach to mitigate any emerging complications and maintain his overall well-being.