Question

A 50 year old male patient presented to the emergency department at 2AM with vomiting and abdominal pain. He had a 2 week history of polyuria and polydipsia, accompanied by a 20 pound weight loss and blurred vision. His medical history was unremarkable, except for being treated with hypertension with lisinopril 40 mg daily, which provided good control. His blood pressure on admission was 135/80. He is a smoker and smokes ½ pack of cigarettes per day. Results of hospital laboratory studies revealed that the patient’s initial blood glucose level was 1192 mg/dL and clinical presentation and laboratory findings were consistent with a diagnosis of diabetic ketoacidosis (DKA). The patient reported no family history of diabetes. His father died at age 35 of renal failure. The patient was treated successfully for DKA and discharged from the hospital 3 days later on an insulin regimen consisting of 30 units of NPH/regular human insulin 70/30 mixture before breakfast, 15 units of regular human insulin before diner, and 20 units of NPH insulin at bedtime. On discharge, he was instructed to perform blood glucose measurements four times a day. 1. What are the priority nursing diagnoses for this patient (list at least 2-4)? 2. What discharge teaching will you provide the patient? 3. How can smoking and poor self-management of diabetes increase the risk of long term complications?

Answer 1

1. What are the priority nursing diagnoses for this patient (list at least 2-4)?

• Risk for Unstable Blood Glucose related to inadequate glucose monitoring and poor health management

• Risk for Ineffective Therapeutic Regimen Management related to new-onset diabetes, lack of knowledge about diabetes and its management and complex medical regimen.

• Risk for Infection related to high glucose levels, decreased leukocyte function and alterations in circulation

2. What discharge teaching will you provide the patient?

DKA happens when your body does not have enough insulin to move glucose into your cells, and your body begins to burn fat for energy. The burning of fats causes a build-up of dangerous levels of ketones in the blood. At the same time, sugar also builds up in the blood. DKA is an emergency that must be treated right away. If it is not treated right away, it can cause coma or death. DKA can be delayed or even prevented by taking care of yourself and maintaining good blood sugar control.

The discharge teachings are as follows:

• Consume enough fluids to keep your urine light yellow in color, unless you are told to limit fluids.
• Limit the amount of alcohol you drink. It can cause low blood sugar as well as worsen nervous system problems caused by diabetes.
• Keep a healthy weight and reduce weight if needed
• Exercise as your provider recommends.
• check your blood sugars more often, when you increase your activity. Avoid hypoglycemia.
• Quit smoking.
• Teach when and how to test your blood sugar. Keep a log of your blood sugar measurements.
• It is important to try to prevent infection. People who have diabetes are at risk for infection. If you are diabetic and have an infection, your blood sugar often rises above your usual levels.
• Learn how to do proper skin and foot care every day.
  • Look for injuries on the skin of your feet and lower legs daily.
  • Wear comfortable, well-fitting shoes to help prevent foot injury.
  • Break in new shoes gradually.
  • Ask your provider about how to trim your toenails properly.
• Carry an ID card or bracelet that says you have diabetes, in case of an emergency.
• It's good for your family to also learn about diabetes. Make sure your family members know what to do if your sugar is too high or too low.
• Find ways to make your life less stressful.
• Having diabetes or complications of diabetes can be scary or depressing. You may wish to talk with a therapist about your feelings.
• Managing therapeutic regimen is very important.
• Know your medicines. Know what they look like, how much you should take each time, how often you should take them, and why you take each one.

• • Take your medicines exactly as your provider tells you to.
  • Carry a list of your medicines in your wallet or purse. Include any nonprescription medicines and supplements on the list.
• Ask your healthcare provider about the symptoms and causes of low blood sugar and what to do when you have low blood sugar. Carry some form of sugar at all times, so you can treat low blood sugar quickly.

3. How can smoking and poor self-management of diabetes increase the risk of long term complications?

Smoking can make diabetes significantly and increasingly troublesome. Smoking may make your body progressively resistant to insulin, which can prompt higher glucose levels. Uncontrolled glucose can prompt genuine inconveniences from diabetes, incorporating issues with your kidneys, heart, and veins.

Poor self management is another factor which may cause the blood sugar levels to rise high and high affecting the major organs adversely.

The more you have diabetes — and the less controlled your glucose — the higher the danger of intricacies. In the end, diabetes intricacies might be crippling or life threatening.

Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you're more likely to have heart disease or stroke.
Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in your legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. This is called Neuropathy.

Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can develop serious infections, which often heal poorly. These infections may ultimately require toe, foot or leg amputation.
Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.
The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system (diabetic nephropathy). Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant.
Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
Hearing problems are more common in people with diabetes.
Type 2 diabetes may increase the risk of dementia, such as Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears to be. Although there are theories as to how these disorders might be connected, none has yet been proved.
Depression symptoms are common in people with type 1 and type 2 diabetes. Depression can affect diabetes management.