{ "name": "Diabetes Mellitus (Type 1 & 2)", "slug": "diabetes-mellitus", "url": "https://nursingplex.com/care-plans/diabetes-mellitus", "category": "Endocrine & Metabolic", "summary": "Chronic hyperglycemia care: glucose monitoring, insulin/oral agents, diet, foot care and complication prevention.", "nursing_diagnoses": [ "Risk for unstable blood glucose", "Deficient knowledge", "Risk for impaired skin integrity", "Ineffective peripheral tissue perfusion" ], "overview": [ "Diabetes mellitus is a group of metabolic disorders defined by chronic hyperglycemia from defective insulin secretion, defective insulin action, or both. In type 1, autoimmune destruction of pancreatic beta cells leaves an absolute insulin deficiency, so exogenous insulin is required for life and ketoacidosis is the classic acute crisis. In type 2, insulin resistance in muscle, liver and fat combines with a progressive secretory defect; insulin is present but ineffective, and the classic acute crisis is a hyperosmolar hyperglycemic state without significant ketones.", "Without insulin, glucose cannot enter cells. The cells starve while the blood is sugar-rich, glucose spills into the urine past the renal threshold and drags water with it — producing the classic triad of polyuria, polydipsia and polyphagia along with weight loss, blurred vision, fatigue and slow wound healing. In insulin deficiency the body burns fat for fuel, generating ketones and metabolic acidosis with Kussmaul respirations and fruity breath.", "The long-term damage is vascular. Microvascular disease produces retinopathy, nephropathy and neuropathy; macrovascular disease produces coronary artery disease, stroke and peripheral arterial disease. Neuropathy plus poor perfusion plus impaired immunity is why a small foot wound becomes an amputation. Nursing care therefore has two horizons at once: keep today's glucose in range, and prevent the complications that arrive in a decade." ], "key_facts": [ { "label": "Diagnostic thresholds", "text": "Fasting glucose 126 mg/dL or higher, A1C 6.5 percent or higher, 2-hour OGTT 200 mg/dL or higher, or a random glucose of 200 with classic symptoms." }, { "label": "A1C", "text": "Reflects average glucose over roughly the previous 2–3 months; general target under 7 percent, individualized in older adults." }, { "label": "Hypoglycemia", "text": "Under 70 mg/dL. Rule of 15: 15 g fast-acting carbohydrate, recheck in 15 minutes, repeat as needed, then a protein-containing snack if the next meal is over an hour away." }, { "label": "Hypo vs hyper onset", "text": "Hypoglycemia is sudden — cold, clammy, shaky, confused. Hyperglycemia is gradual — hot, dry, thirsty, deep breathing." }, { "label": "Insulin peaks", "text": "Rapid-acting peaks about 1 hour, regular about 2–3 hours, NPH about 4–12 hours; the peak is when hypoglycemia is most likely. Long-acting basal insulin is peakless and is never mixed." }, { "label": "Mixing order", "text": "Clear before cloudy — draw regular insulin before NPH." } ], "nursing_priorities": [ "Stabilize blood glucose and treat hypoglycemia or hyperglycemic crisis immediately.", "Restore fluid and electrolyte balance, especially potassium during insulin therapy.", "Prevent, detect and treat infection and skin breakdown.", "Protect the feet, eyes and kidneys from long-term complications.", "Build the patient's day-to-day self-management skill and confidence.", "Address the emotional load of a lifelong condition and support adherence." ], "assessment": { "subjective": [ "Excessive thirst, frequent urination, constant hunger despite eating", "Unexplained weight loss or, in type 2, difficulty losing weight", "Fatigue, weakness, irritability, difficulty concentrating", "Blurred vision, numbness, burning or tingling in the feet or hands", "Slow-healing sores, recurrent yeast, skin or urinary infections", "Fear of injections, frustration with the regimen, or cost concerns limiting supplies" ], "objective": [ "Elevated capillary and serum glucose, elevated A1C, glucosuria and ketonuria", "Signs of dehydration: dry mucous membranes, poor skin turgor, sunken eyes, tachycardia, hypotension", "Kussmaul respirations and acetone breath in ketoacidosis; profound dehydration with normal or minimal ketones in hyperosmolar state", "Diminished pedal pulses, hair loss on the lower legs, thick discolored nails, cool feet", "Reduced monofilament sensation, absent ankle reflexes, foot deformity, calluses or ulcers", "Poor wound healing, cellulitis, fungal infection between toes", "Retinal changes, proteinuria or rising creatinine, elevated blood pressure and lipids" ], "related_factors": [ "Absolute insulin deficiency from beta cell destruction, or insulin resistance with relative deficiency", "Inadequate glucose monitoring, insulin or medication error, missed or mistimed meals", "Acute illness, infection, surgery, corticosteroids or emotional stress raising glucose demand", "Peripheral neuropathy with loss of protective sensation and impaired peripheral perfusion", "Insufficient knowledge of diet, exercise, sick-day rules and medication action" ] }, "goals": [ "The client will maintain blood glucose within the individualized target range with no severe hypoglycemic episodes.", "The client will demonstrate correct self-monitoring of blood glucose, insulin preparation and injection or pump use with return demonstration.", "The client will maintain adequate hydration and electrolyte balance with stable vital signs and urine output.", "The client will maintain intact skin, particularly on the feet, and will describe the daily foot inspection routine.", "The client will state the signs of hypoglycemia and hyperglycemia and the exact action to take for each.", "The client will describe sick-day management and when to seek care." ], "interventions": [ { "title": "1. Monitoring and stabilizing blood glucose", "points": [ "Check capillary glucose at the ordered times — usually before meals and at bedtime, and more often during illness, insulin adjustment or continuous insulin infusion.", "Correlate glucose readings with meals, activity, stress and medication timing so patterns rather than single values guide adjustment.", "Administer insulin or oral agents on schedule and match rapid-acting insulin to food actually being eaten; giving it and then withholding the tray causes hypoglycemia.", "Rotate injection sites within one anatomic region to keep absorption predictable and prevent lipohypertrophy, which slows absorption unpredictably.", "Know the onset, peak and duration of every insulin the patient uses, and plan snacks and monitoring around peaks.", "Monitor A1C to evaluate long-term control and to open a non-judgmental conversation about barriers." ] }, { "title": "2. Treating hypoglycemia and hyperglycemic crises", "points": [ "For a conscious patient with glucose under 70, give 15 g of fast-acting carbohydrate — glucose tablets, 4 oz juice or regular soda — recheck in 15 minutes and repeat until above 70, then give a longer-acting snack.", "For an unconscious or unsafe-to-swallow patient, give IM or subcutaneous glucagon or IV dextrose per protocol, then reassess and protect the airway.", "Never give oral carbohydrate to a patient who cannot protect their airway, and never assume symptoms are behavioral — check the glucose.", "In diabetic ketoacidosis, expect isotonic IV fluid first, then a regular insulin infusion, and follow potassium closely: insulin drives potassium into cells and a normal-looking initial potassium can crash quickly.", "Add dextrose to the fluids when glucose falls to about 250 mg/dL while the insulin infusion continues, so ketosis clears without hypoglycemia.", "In hyperosmolar hyperglycemic state, expect much larger fluid deficits, higher glucose, minimal ketones and a slower, careful correction of osmolality to avoid cerebral edema.", "Monitor neurologic status throughout; a change in level of consciousness is the most important sign in either crisis." ] }, { "title": "3. Nutrition and activity", "points": [ "Coordinate with a dietitian on an individualized plan built around consistent carbohydrate intake, portion control and the patient's actual food culture and budget.", "Teach carbohydrate counting and label reading; carbohydrate quantity affects glucose more than sugar alone does.", "Emphasize regular meal timing, especially with insulin or sulfonylureas, and never skipping meals.", "Encourage at least 150 minutes of moderate activity weekly, checking glucose before and after exercise and carrying fast-acting carbohydrate.", "Teach that exercise lowers glucose for hours afterward, and that exercising with glucose above about 250 with ketones present can worsen ketosis.", "Support gradual, realistic weight loss in type 2 diabetes; even 5–7 percent improves insulin sensitivity measurably." ] }, { "title": "4. Preventing infection and protecting skin", "points": [ "Inspect skin, skin folds and injection sites daily, and treat minor breaks promptly; hyperglycemia impairs leukocyte function.", "Assess for fever, dysuria, cough, wound drainage and vaginal or oral candidiasis, remembering that infection also drives glucose up.", "Use meticulous aseptic technique for any invasive procedure and remove unnecessary lines and catheters early.", "Encourage annual influenza vaccination and recommended pneumococcal and other vaccines." ] }, { "title": "5. Foot care and neurovascular protection", "points": [ "Inspect the feet every shift in the hospital, including between the toes and the soles, using a mirror if needed at home.", "Test protective sensation with a monofilament and check pedal pulses, capillary refill, temperature and hair distribution.", "Wash feet daily in lukewarm water, dry thoroughly between the toes, and apply lotion to the tops and bottoms but never between the toes.", "Cut nails straight across, or refer to podiatry for thick nails, calluses and corns; the patient should never use over-the-counter corn removers or cut their own calluses.", "Insist on well-fitting closed shoes and clean socks at all times, and never walking barefoot even indoors.", "Teach that a painless wound is still an emergency — loss of sensation means damage is discovered late." ] }, { "title": "6. Monitoring long-term complications", "points": [ "Track blood pressure and lipids at each visit and support blood pressure control, which protects kidneys and heart as much as glucose control does.", "Monitor urine albumin and serum creatinine annually for early nephropathy; ACE inhibitors or ARBs are often prescribed for renal protection.", "Arrange annual dilated eye examinations; retinopathy is silent until vision is already lost.", "Screen for neuropathy symptoms, gastroparesis, erectile dysfunction and orthostatic hypotension, which are commonly unreported unless asked directly.", "Screen for depression and diabetes distress, which strongly predict poor self-management." ] } ], "patient_teaching": [ "Check glucose as prescribed, record results, and bring the log or meter to every appointment.", "Carry fast-acting sugar at all times and wear medical identification.", "Learn the difference: hypoglycemia comes on fast with shakiness, sweating, hunger and confusion; hyperglycemia builds slowly with thirst, urination and fatigue.", "Sick-day rules: never stop insulin when ill, check glucose every 3–4 hours, check ketones if type 1, drink sugar-free fluids, and call the provider for vomiting, persistent ketones or glucose that will not come down.", "Inspect your feet every single day and report any cut, blister, redness or color change immediately, even if it does not hurt.", "Keep insulin in use at room temperature per manufacturer guidance and extra supply refrigerated; never use cloudy or clumped clear insulin.", "Do not share pens, lancets or meters with anyone.", "Keep annual eye, kidney, foot and dental checks, and stop smoking, which multiplies vascular damage." ] }