Nursing Interventions

Improving Nutrition

• Assess current timing and content of meals.
• Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one food group and eliminate another are generally not recommended.
• Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patient's actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters.
• Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life.
• Explain the importance of exercise in maintaining/reducing body weight.
  • Caloric expenditure for energy in exercise
  • Carryover of enhanced metabolic rate and efficient food utilization
• Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them.
• Strategize with patient to address the potential social pitfalls of weight reduction.

Teaching About Insulin

• Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulin injection, conveying a sense of empathy, and identifying supportive coping techniques.
• Demonstrate and explain thoroughly the procedure for insulin self-injection 
• Help patient to master technique by taking a step-by-step approach.
  • Allow patient time to handle insulin and syringe to become familiar with the equipment.
  • Teach self-injection first to alleviate fear of pain from injection.
  • Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure.
• Review dosage and time of injections in relation to meals, activity, and bedtime based on patient's individualized insulin regimen.

Preventing Injury Secondary to Hypoglycemia

• Closely monitor blood glucose levels to detect hypoglycemia.
• Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia.
• Assess patient for the signs and symptoms of hypoglycemia.
  • Adrenergic (early symptoms)sweating, tremor, pallor, tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly
  • Neurologic (later symptoms)light-headedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls
• Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates.
  • Half cup (4 oz) juice, 1 cup skim milk, three glucose tablets, four sugar cubes, five to six pieces of hard candy may be taken orally.
  • Nutrition bar specially designed for diabetics- supplies glucose from sucrose, starch, and protein sources with some fat to delay gastric emptying and prolong effect; may prevent relapse. Used after hypoglycemia treated with fact-acting carbohydrate.
  • Glucagon 1 mg (subcutaneously or I.M.) is given if the patient cannot ingest a sugar treatment. Family member or staff must administer injection.
  • I.V. bolus of 50 mL of 50% dextrose solution can be given if the patient fails to respond to glucagon within 15 minutes.
• Encourage patient to carry a portable treatment for hypoglycemia at all times.
• Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin.
• Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia.
• Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency.

Improving Activity Tolerance

• Advise patient to assess blood glucose level before and after strenuous exercise.
• Instruct patient to plan exercises on a regular basis each day.
• Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia.
• Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.
• Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. Patient should contact health care provider if levels remain elevated.
• Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.

Providing Information About Oral Antidiabetic Agents

• Identify barriers to learning, such as visual or hearing impairments, low literacy, distractive environment.
• Encourage active participation of the patient and family in the educational process.
• Teach the action, use, and adverse effects of oral antidiabetic agents.
• Sulfonylurea compounds promote the increased secretion of insulin by the pancreas and partially normalize both receptor and postreceptor defects. Many drug interactions exist, so patient should alert all health care providers of use. Potential adverse reactions include hypoglycemia, photosensitivity, GI upset, allergic reaction, reaction to alcohol, cholestatic jaundice, and blood dyscrasias.
• Metformin (Glucophage), a biguanide compound, appears to diminish insulin resistance. It decreases hepatic glucose production and intestinal reabsorption of glucose and increases insulin reception and glucose transport in cells. Many drug interactions exist, so patient should alert all health care providers of its use. Metformin must be used cautiously in renal insufficiency, conditions that may cause dehydration, and hepatic impairment. Potential adverse reactions include GI disturbances, metallic taste, and lactic acidosis (rare).
• Alpha-glucosidase inhibitors (acarbose [Precose] and miglitol [Glyset]) delay the digestion and absorption of complex carbohydrates (including sucrose or table sugar) into simple sugars, such as glucose and fructose, thereby lowering postprandial and fasting glucose levels.
• Thiazolidinedione derivatives (rosiglitazone [Avandia] and pioglitazone [Actos]) primarily decrease resistance to insulin in skeletal muscle and adipose tissue without increasing insulin secretion. Secondarily, they reduce hepatic glucose production. They should be used cautiously in liver disease and heart failure. Liver function tests should be monitored periodically. Ovulation may occur in anovulatory premenopausal women. Adverse reactions include edema, weight gain, anemia, and elevation in serum transaminases.

Maintaining Skin Integrity

• Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes.
  • Use a monofilament to test sensation of the feet and detect early signs of peripheral neuropathy (see Figure 25-2).
    
    
    

• • Test vibratory sense over interphalangeal joints of the feet using a low-frequency tuning fork. Vibratory sense is typically lost before tactile sensation.
• Maintain skin integrity by protecting feet from breakdown.
  • Use heel protectors, special mattresses, foot cradles for patients on bed rest.
  • Avoid applying drying agents to skin (eg, alcohol).
  • Apply skin moisturizers to maintain suppleness and prevent cracking and fissures.
• Instruct patient in foot care guidelines
• Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow. Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program.

Improving Coping Strategies

• Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life, occupation.
• Explore previous coping strategies and skills that have had positive effects.
• Encourage patient and family participation in diabetes self-care regimen to foster confidence.
• Identify available support groups to assist in lifestyle adaptation.
• Assist family in providing emotional support.