Learning Outcome

• Identify appropriate nursing diagnoses for patients with type 2 diabetes mellitus
• Describe medical management of type 2 diabetes mellitus
• Discuss nursing management of type 2 diabetes mellitus

Introduction

Diabetes mellitus is an increasingly prevalent condition.[1][2] This condition is characterized by hyperglycemia. The two main types of diabetes are type 1 diabetes mellitus and type 2 diabetes mellitus, with type 2 diabetes accounting for 90% of all cases. Other types of diabetes mellitus include gestational diabetes, drug-induced diabetes, and monogenic diabetes. Complications of diabetes mellitus affect all body systems and can include lethal consequences. The purpose of this article is to review nursing diagnoses, causes, risk factors, assessment, evaluation, medical management, nursing management, and other aspects of importance to nurses.

Nursing Diagnosis

Some nursing diagnoses which might be appropriate for patients with a medical diagnosis of diabetes mellitus include impaired skin integrity if a superficial rash is present, impaired tissue integrity if a wound is present, deficient knowledge, imbalanced nutrition, and ineffective health maintenance. If the disease is not properly managed, this can result in hospitalization, fluid volume deficit with extreme hyperglycemia such s diabetic ketoacidosis, risk for falls in the presence of dizziness, peripheral neuropathy, or vision alterations (i.e., blurred vision or diabetic retinopathy), risk for infection with chronic hyperglycemia especially in the presence of an open wound, risk for injury if there is nerve damage such as peripheral neuropathy, and risk for unstable blood glucose if the blood glucose fluctuates significantly from hyperglycemia to hypoglycemia within a short time frame.

Causes

Type 1 diabetes mellitus involves an autoimmune process whereby the body destroys the islets of Langerhans, which are pancreatic cells responsible for producing insulin; therefore, the body lacks the ability to produce insulin altogether. In type 2 diabetes mellitus, the body cannot properly utilize insulin, commonly referred to as “insulin resistance.” Insulin production can eventually decrease. Drug-induced diabetes can occur in patients who receive corticosteroids. Sometimes the patient’s diabetes resolves once the corticosteroids are discontinued; however, sometimes, the patient’s diabetes persists despite discontinuation of the corticosteroids.

Risk Factors

Multiple factors increase the risk of developing diabetes mellitus. Risk factors for type 2 diabetes mellitus include belonging to a certain ethnic group (Native American, African American, Hispanic, Asian American, Pacific Islander), being increased in age, being overweight or obese, family history of diabetes, history of heart disease, or hypertension, hyperlipidemia, and history of gestational diabetes.

Assessment

Various tools designed to assess the risk of cardiac disease are available for categorizing risk.[3] A patient’s history will include an assessment for risk factors such as a family history of diabetes, ethnicity, and increased age (>40 years old). A physical assessment will involve calculating the body mass index and possibly a visual inspection for acanthosis nigricans in pediatric patients.[4][5][6] A medical history combined with physical assessment findings (such as having a body mass index >25 kg/m2) may trigger the healthcare provider to screen the patient for diabetes mellitus with laboratory testing.

For patients already diagnosed with type 2 diabetes mellitus, a physical assessment may involve inspecting the skin for wounds, examining the eyes with an ophthalmoscope to determine retinal damage, and performing microfilament testing to determine the presence of peripheral neuropathy.

Evaluation

Any patient who is at least 40 years old, has a body mass index greater than 25 kg/m2, or has multiple risk factors for diabetes will be screened with laboratory testing. A fasting blood glucose level is a common component of routine laboratory testing. A level of 126 mg/dL or greater is diagnostic of diabetes mellitus. Glycosylated hemoglobin or “hemoglobin A1c” is the standard laboratory test used for screening, diagnosing, and evaluating treatment regimens because it provides the average blood glucose over the past 3 months. A result of 5.7 to 6.4% indicates prediabetes, while a result of 6.5% or higher is diagnostic of diabetes.[7]

Medical Management

When lifestyle modification fails to achieve the targeted blood glucose levels, the first-line medication prescribed is metformin.[7] Various types of oral anti-diabetic agents are available as adjunct therapy. Insulin is a major treatment for diabetes mellitus.[8] Insulin can be categorized as rapid-acting, short-acting, intermediate-acting, and long-acting. Furthermore, if the patient with diabetes mellitus has developed complications, medications might also be prescribed to ameliorate those conditions.

Nursing Management

Hypoglycemia is the most common life-threatening condition which requires immediate nursing management.[7] Extreme hyperglycemia is less common but another possibility. Therefore, nurses must recognize the clinical manifestations of altered blood glucose levels in patients and integrate blood glucose monitoring into the plan of care. Nursing management also includes assessing the patient for complications of type 2 diabetes mellitus and providing patient education relating to the plan of care as well as healthy dietary intake, activity recommendations, and the prescribed medication regimen as needed.

When To Seek Help

Hypoglycemia is the most common emergency requiring the nurse to intervene and consult healthcare team members. If, upon assessment, the nurse finds a patient with diabetes who has signs and symptoms of hypoglycemia (such as diminished level of consciousness), the nurse should assess for additional clinical manifestations of hypoglycemia such as cool, clammy (moist) skin and perform blood glucose testing. Most in-patient clinical facilities provide automatically generated treatment protocols for hypoglycemia. These protocols might include providing orange juice for conscious patients with the ability to swallow. Otherwise, if the patient is lethargic and providing oral intake would pose an aspiration risk, the protocol might include intravenous administration of dextrose 50% or a glucagon injection followed by retesting the blood glucose in 10 to 15 minutes and notifying the healthcare provider so that the patient’s medication regimen can be adjusted appropriately.[8] Another emergency in patients with diabetes is extreme hyperglycemia. If the patient with diabetes is experiencing tachypnea and extreme hyperglycemia (such as a blood glucose level greater than 600 mg/dL), the nurse should notify the healthcare provider immediately. Anticipated orders might include transferring the patient to an intensive care unit, administering insulin intravenously, administering potassium intravenously, and infusing intravenous fluids.[9] Additionally, the nurse should seek help from the respiratory therapist who might obtain blood sampling for arterial blood gases.

Outcome Identification

Expected outcomes for patients with diabetes depend on the patient’s admitting medical diagnosis. For example, for patients with diabetes experiencing the complication of myocardial infarction, the expected outcomes are that the patient will have no reports of chest pain, demonstrate stable vital signs, and maintain a stable cardiac rhythm on telemetry. On the other hand, for patients with diabetes experiencing the complication of osteomyelitis, the expected outcomes are that the patient will exhibit wound healing (absence of purulent drainage, presence of granulation tissue, normal white blood cell count) and maintain stable vital signs remaining afebrile.  

Monitoring

Performing blood glucose testing is a routine component of nursing care for patients with diabetes mellitus. Individuals with diabetes mellitus perform routine self-monitoring of blood glucose as outpatients.

Coordination of Care

Collaboration among healthcare team members has demonstrated improved outcomes for patients with type 2 diabetes mellitus.[10] Besides the healthcare providers and nurses, other interdisciplinary team members who might be involved in the plan of care for patients with diabetes include pharmacists, endocrinologists, nurses with specialty training and certification in wound care, registered dieticians, and diabetes educators. Diabetes educators are an invaluable resource since they are equipped with the knowledge to provide teaching on various aspects of diabetes care and management. Depending on which complications of diabetes are present, neurologists, cardiologists, pulmonologists, nephrologists, infectious disease specialists, and podiatrists might also serve on the team. Physical therapists, occupational therapists, and speech therapists can assist when patients experience certain complications of diabetes (i.e., cerebrovascular accident, foot amputation). Social workers and case managers can address psychosocial or financial issues along with needs for special equipment. On an outpatient basis, ophthalmologists play an important role in screening and maintaining eye health.

Health Teaching and Health Promotion

Equipping patients with the proper knowledge to mitigate their risk of developing diabetes mellitus or the associated complications is critical.[11][12] Nurses should assess the patient’s knowledge related to diabetes care and provide education regarding dietary intake (such as limiting carbohydrate intake), exercise, and medications since these factors influence blood glucose levels. While providing patient education, the nurse should also assess for any potential barriers such as limited access to healthy foods in the community, limited income, or language barriers. Nurses are also responsible for teaching certain skills such as conducting self-monitoring of blood glucose and how to administer insulin injections. Since pneumonia and influenza pose a higher risk of mortality to patients with diabetes, nurses should encourage patients to remain up-to-date with pneumonia and influenza vaccinations. Furthermore, the nurse should encourage self-monitoring of blood glucose, daily foot inspections, and regular eye exams. Smoking cessation is another key lifestyle modification to prevent complications.

Risk Management

Providing for patient safety is critical. When providing patient teaching, it is imperative that the nurse considers obstacles that have the potential to lead to unsafe patient outcomes. For example, teaching a patient who has diabetes mellitus and a severe vision impairment how to self-inject insulin has the potential for lethal results and poses significant liability risk.

Discharge Planning

As with all patients, it is essential to review the prescribed medication regimen for each patient with diabetes upon discharge. Additionally, the nurse should provide patient education encompassing health promotion and review when to follow-up with the healthcare provider after discharge.

Evidence-Based Issues

Implementation of lifestyle modification programs that improve outcomes among patients diagnosed with type 2 diabetes mellitus is supported by research.[11][12][11][13][14][15][16] Many programs to improve the outcomes of patients with type 2 diabetes mellitus involve patient education.[11][12][11][17] Since one of the responsibilities of nurses is to provide patient education, the nurse plays a central role in teaching those diagnosed with type 2 diabetes mellitus.

Pearls and Other issues

• Diabetes mellitus can be type 1, type 2, gestational, or medication-induced.
• Risk factors for developing type 2 diabetes mellitus include being of certain ethnicities, increased age, obesity, sedentary lifestyle, and family history of the disease.
• The main diagnostic test for diabetes mellitus is glycosylated hemoglobin or hemoglobin A1c.
• Medical management for type 2 diabetes mellitus usually involves oral anti-diabetic agents and/or insulin administration.
• Lifestyle modification plays a key role in blood glucose control.
• Patients should consult with their healthcare provider to determine how often to perform self-monitoring of blood glucose as outpatients.
• Eating only sugar-free foods will not control blood glucose since carbohydrate intake influences blood glucose.