A patient with type 2 diabetes mellitus presents with worsening fatigue, nocturia, blurry vision, and tingling in the feet. Recent tests reveal an HbA1c of 8.5%, elevated LDL cholesterol at 140 mg/dL, and signs of diabetic retinopathy and nephropathy. Which intervention should the nurse prioritize in the care plan to address these complications and reduce future risks?

A) Initiate a GLP-1 receptor agonist to improve glycemic control and reduce cardiovascular risk.

B) Recommend increased dietary protein to support kidney function.

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

D) Suggest decreasing fluid intake to manage nocturia.

A patient with poorly controlled type 2 diabetes mellitus presents with new complications including diabetic retinopathy, microalbuminuria, and elevated LDL cholesterol. Which intervention should the nurse prioritize to address these complications?

A) Initiating a GLP-1 receptor agonist to improve glycemic control and provide renal benefits

B) Counseling the patient on increasing physical activity to improve cardiovascular health

C) Scheduling regular ophthalmology appointments to monitor diabetic retinopathy progression

D) Educating the patient on dietary changes to reduce LDL cholesterol levels

A patient with type 2 diabetes is on a treatment regimen that includes a GLP-1 receptor agonist. During a follow-up visit, the patient reports improvements in energy levels and glycemic control, but persistent tingling and burning sensations in the feet. What should be the nurse's priority action in addressing the patient's current symptoms?

A) Educate the patient on the importance of foot care and inspect feet for any signs of injury.

B) Increase the dosage of the GLP-1 receptor agonist to enhance glycemic control.

C) Suggest the addition of a neuropathic pain medication to the treatment plan.

D) Recommend a higher intensity exercise program to improve circulation.

A patient with type 2 diabetes is experiencing persistent tingling and burning sensations in his feet despite improvements in blood glucose levels and blood pressure. Which nursing intervention should be prioritized to address this ongoing symptom?

A) Educate the patient on the importance of regular foot inspections to prevent injury.

B) Advise the patient to increase protein intake to support nerve health.

C) Reinforce the importance of adherence to the current medication regimen.

D) Recommend the use of a daily foot bath with Epsom salts to alleviate symptoms.

A patient with a history of type 2 diabetes presents with worsening peripheral neuropathy and stage 3 chronic kidney disease. The healthcare team plans to initiate an ACE inhibitor to manage his renal condition. Which nursing intervention is most important to prioritize when initiating this medication?

A) Monitor blood pressure closely for hypotension.

B) Increase the patient's fluid intake to support kidney function.

C) Advise the patient to discontinue all non-prescription medications.

D) Educate the patient about the signs of hyperkalemia.

A patient with type 2 diabetes mellitus presents with symptoms indicative of diabetic neuropathy and stage 3 chronic kidney disease. Which intervention should the nurse prioritize to address both complications effectively?

B) Reinforce the importance of tight glycemic control through medication adherence

A) Encourage increased protein intake to support kidney function

B) Reinforce the importance of tight glycemic control through medication adherence

C) Suggest the use of over-the-counter pain relievers for neuropathic pain

D) Recommend daily foot checks to monitor for potential injuries

A patient with diabetes and early-stage heart failure has been started on a beta-blocker and had their diuretic therapy adjusted. Which nursing intervention is most important to prioritize during the initial phase of this treatment adjustment?

C) Assess the patient's respiratory status and lung sounds regularly

A) Monitor blood glucose levels closely

B) Educate the patient on the importance of daily weight monitoring

C) Assess the patient's respiratory status and lung sounds regularly

D) Encourage increased fluid intake to prevent dehydration

A patient with diabetes and early signs of heart failure with reduced ejection fraction (HFrEF) is being managed with a beta-blocker and diuretic therapy. Which of the following nursing interventions is most important to prevent further complications in this patient?

B) Educate the patient on the importance of daily weight monitoring and reporting sudden weight gain.

A) Encourage the patient to increase their fluid intake to prevent dehydration.

B) Educate the patient on the importance of daily weight monitoring and reporting sudden weight gain.

C) Advise the patient to reduce potassium-rich foods to prevent hyperkalemia.

D) Instruct the patient to limit physical activity to avoid fatigue.

A patient with a history of heart failure and diabetes reports occasional dizziness when standing up quickly. Which nursing intervention is most appropriate to address the patient's symptoms and prevent potential complications?

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

A) Encourage the patient to increase fluid intake to maintain hydration

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

C) Advise the patient to take an additional dose of diuretic when experiencing dizziness

D) Recommend the patient reduce physical activity to prevent dizziness

A patient with a history of heart failure and diabetes reports improvement in symptoms but experiences occasional dizziness when standing quickly. Considering his current medication regimen and health status, which nursing intervention is most appropriate to address this issue?

B) Advise the patient to change positions slowly to reduce episodes of dizziness.

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

B) Advise the patient to change positions slowly to reduce episodes of dizziness.

C) Suggest reducing physical activity to prevent dizziness related to exertion.

D) Increase the dosage of diuretics to manage potential fluid overload.

Diabeties - 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 become resistant to insulin's effects, impairing glucose uptake and leading to elevated blood glucose levels.

• Secondary mechanism: Hyperglycemia-induced damage - Persistent high blood glucose causes damage to blood vessels and nerves, contributing to complications such as retinopathy, nephropathy, and neuropathy, which impact vision, kidney function, and nerve signaling.

• Key complication: Cardiovascular disease - Chronic hyperglycemia and insulin resistance increase the risk of atherosclerosis, hypertension, and heart disease, highlighting the importance of blood glucose and cardiovascular risk management in diabetic patients.

Patient Profile

Demographics:

62-year-old male, retired school teacher

History:

• Type 2 diabetes diagnosed 10 years ago, hypertension, hyperlipidemia

• Metformin, Lisinopril, Atorvastatin, Aspirin

• No known drug allergies

Current Presentation:

• Chief complaint: Increasing fatigue and occasional blurry vision

• Key symptoms: Polyuria, polydipsia, tingling sensation in feet, mild chest discomfort

• Vital signs: Blood pressure 148/92 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, blood glucose level 210 mg/dL

Section 1

New Complications:

During a follow-up visit, the patient reports worsening fatigue and increased frequency of blurry vision episodes. He also mentions experiencing nocturia and persistent tingling in his feet, now accompanied by occasional burning pain. A comprehensive assessment reveals that his blood pressure has increased to 152/94 mmHg, and his heart rate remains stable at 90 bpm. A recent HbA1c test shows a level of 8.5%, indicating poor long-term glycemic control. Additionally, a lipid panel reveals elevated LDL cholesterol levels at 140 mg/dL, further complicating his cardiovascular risk profile.

The patient undergoes an eye examination, which reveals signs of diabetic retinopathy, including microaneurysms and hemorrhages in the retinal blood vessels. These findings confirm the impact of chronic hyperglycemia on his vision. Concurrently, a microalbuminuria test shows a slight increase in albumin levels in the urine, suggesting early diabetic nephropathy. Given these developments, the healthcare team emphasizes the need for tighter blood glucose, blood pressure, and lipid control to prevent further progression of complications.

To address these new challenges, the team considers adjusting the patient's medication regimen. They discuss potentially adding a GLP-1 receptor agonist or an SGLT2 inhibitor to improve glycemic control and offer renal protective benefits. The patient is also counseled on lifestyle modifications, including dietary changes and increased physical activity, to manage his diabetes and cardiovascular risk factors more effectively. These interventions aim to stabilize his condition and prevent further deterioration, setting the stage for the next phase of his management plan.

Section 2

Response to Interventions:

After implementing the adjusted treatment plan, the patient returns for a follow-up visit. He reports some improvement in his energy levels and a reduction in the frequency of blurry vision episodes. However, the tingling and burning sensations in his feet persist, albeit with a slight decrease in intensity. The updated medication regimen, which now includes a GLP-1 receptor agonist, appears to be contributing to better glycemic control, as evidenced by his recent HbA1c level dropping to 7.8%. This improvement, though modest, suggests that the intervention is positively impacting his blood sugar management.

The patient's blood pressure has also shown some progress, with his latest reading at 138/88 mmHg. This reduction is a step in the right direction, indicating that lifestyle modifications and medication adjustments are beginning to address his hypertension. Despite these improvements, the lipid panel remains a concern, as LDL levels have only slightly decreased to 130 mg/dL. The healthcare team decides to continue monitoring his lipid profile closely and reinforces the importance of dietary changes and regular exercise as part of his ongoing management.

Throughout the follow-up, the patient expresses commitment to adhering to the treatment plan and acknowledges the importance of sustained lifestyle changes. The healthcare team encourages him to maintain regular eye exams and kidney function tests to detect any further complications early. As the patient continues on this path, the focus remains on optimizing his treatment regimen and lifestyle modifications to achieve better control of his diabetes and reduce the risk of future complications. The next phase will involve assessing whether more aggressive interventions might be necessary if current measures do not yield significant improvements in all areas.

Section 3

Several months have passed, and the patient returns for another follow-up visit. During the consultation, he reports persistent issues with his feet, describing the tingling and burning sensations as more pronounced, particularly at night. Concerned about the potential development of diabetic neuropathy, the healthcare team conducts a thorough neurological assessment. Monofilament testing reveals diminished sensation in both feet, and the patient struggles with balance during a Romberg test. These findings suggest a progression in peripheral neuropathy, necessitating a reassessment of his pain management and glycemic control strategies.

Additionally, the patient's recent laboratory results indicate a further decline in renal function. His estimated glomerular filtration rate (eGFR) has decreased to 58 mL/min/1.73m², pointing to stage 3 chronic kidney disease. Urinalysis also reveals microalbuminuria, indicating increased pressure on the kidneys. This development prompts the healthcare team to initiate a more robust nephroprotective strategy, which includes adjusting his antihypertensive therapy to incorporate an ACE inhibitor, hoping to slow the progression of kidney damage.

In light of these changes, the patient expresses concern about the progression of his diabetes complications. The healthcare team emphasizes the importance of maintaining strict blood glucose control and reinforces the need for continued lifestyle modifications, including dietary adjustments and consistent physical activity. They also discuss the potential need for future adjustments in his medication regimen, possibly integrating an SGLT2 inhibitor to address both his glycemic control and renal protection. As the patient leaves, he is scheduled for more frequent follow-ups to closely monitor these evolving complications, ensuring that any further interventions are timely and effective.

Section 4

A few months later, the patient returns for a follow-up appointment, and the healthcare team observes a change in his clinical status. He reports new symptoms of fatigue and shortness of breath, particularly during physical activity, which he attributes to his daily walks. His blood pressure is slightly elevated at 145/90 mmHg, and his heart rate is 85 beats per minute. Upon examination, there are subtle signs of fluid retention, including mild bilateral ankle edema and a slight increase in abdominal girth. These findings suggest the possibility of early heart failure, a common complication in patients with diabetes, particularly those with deteriorating renal function.

Further diagnostic work-up is initiated to assess the extent of these cardiac concerns. An echocardiogram reveals mild left ventricular hypertrophy and a reduced ejection fraction of 45%, indicating compromised cardiac function. Blood tests show elevated B-type natriuretic peptide (BNP) levels, further supporting a diagnosis of heart failure with reduced ejection fraction (HFrEF). These results necessitate an adjustment in the patient's treatment plan, focusing on optimizing his cardiovascular health while considering his existing renal challenges.

In response to these findings, the healthcare team decides to introduce a beta-blocker to manage his heart failure symptoms and improve cardiac function. They also carefully reassess his diuretic therapy to effectively manage fluid overload without exacerbating his kidney issues. The patient is educated on recognizing early signs of worsening heart failure and the importance of daily weight monitoring. As part of a comprehensive approach, the team emphasizes the need for continued lifestyle modifications and adherence to his modified medication regimen, aiming to prevent further complications and improve his overall quality of life. Regular follow-up appointments are scheduled to monitor his response to these interventions and to adjust the treatment strategy as needed.

Section 5

Several weeks after the adjustments to his treatment plan, the patient returns for a scheduled follow-up appointment. During the visit, he reports some improvement in his symptoms, noting that his shortness of breath during daily activities has diminished, and he feels less fatigued overall. However, he mentions experiencing occasional dizziness, particularly when standing up quickly, which could be indicative of changes in his blood pressure or a side effect of his new medication regimen. On physical examination, his vital signs reveal a heart rate of 78 beats per minute and a blood pressure of 130/85 mmHg, suggesting effective management of his cardiovascular status. His ankle edema has decreased, and his abdominal girth appears stable, indicating better control of fluid retention.

Laboratory results offer additional insights into his current health status. His renal function, as measured by serum creatinine and estimated glomerular filtration rate (eGFR), has remained stable, alleviating concerns of further renal compromise due to the adjusted diuretic therapy. However, his hemoglobin A1c remains slightly elevated at 7.8%, highlighting the need for continued attention to his diabetes management. Additionally, a repeat BNP level, though still elevated, shows a slight decrease from previous measurements, suggesting a positive response to the heart failure treatment.

The healthcare team discusses the importance of ongoing lifestyle modifications, emphasizing dietary adjustments and consistent exercise within tolerated limits to support both his cardiovascular and diabetes management. They also reinforce the need for vigilance in monitoring his blood pressure and blood glucose levels to prevent potential complications. The patient's treatment plan is adjusted with a focus on fine-tuning his medication dosages to minimize side effects while maintaining therapeutic efficacy. Plans for the next follow-up are scheduled, ensuring that the patient's progress is closely monitored, and any emerging issues can be promptly addressed, guiding him towards improved health outcomes.