Nursing Diagnosis: Type 1 Diabetes & Hypertension Case Study

Introduction

In this paper I intend to present on the case of Mr. Douglas, admitted to the unit with confusion, and disorientation. History revealed Type 1 diabetes and hypertension. The diabetes was managed with Insulin and Perindopril managed the hypertension. The low blood sugar level was successfully managed with simple carbohydrates and the BSL started resuming normal level (4.7mmol/L). (Sinclair, 2006, p. 231).The client is now fully conscious with a GCS of 15. In this paper, I would like to present on various nursing diagnosis for Mr. Douglas, with the priority ones such as Risk for high blood sugar, Risk for unstable blood glucose and risk for falls, and the related nursing interventions with the rational (Boyle, Zrebiec, & John, 2007).

Nursing Diagnosis

The nursing diagnosis based on the identified and primary problems are, “Risk for injury related to hypoglycemia, ‘Risk for Unstable blood glucose level (hypoglycemia) related to lack of adequate management of hypoglycemia evidenced by decreased blood glucose level’, ‘Risk for injury related to hypoglycemia, impaired mobility and hypotension evidenced by decreased blood glucose level and blood pressure’. “Risk for imbalanced nutrition, less than body requirement related to inadequate intake of nutrient”, impaired mobility and hypertension evidenced by decreased blood glucose level and blood pressure’ ‘Fatigue related to decreased blood glucose level and poor nutritional intake evidenced by complaints of weakness’, ‘Fear and anxiety related to hospitalization and development of complications evidenced by the verbal statements of the client. (Farrell, & Dempsey, 2011).

Nursing Interventions for the Primary Problems

‘Risk for Unstable blood glucose level (hypoglycemia) related to lack of adequate management of hypoglycemia and decreased oral intake, evidenced by decreased blood glucose level’. The goal of the nurse is to maintain normalcy in blood glucose level. To achieve this, nurse should maintain a safe and effective glycemic control, and implement nursing care based on evidence (Sanchez & Cruz, 2011, p. 56-89) to achieve glucose control (Judy et al. 2010, p. 98-106). Be alert to monitor for early signs of hypoglycemia (Mayerson, & Inzucchi, 2002, p. 13-28) that can be both neurogenic and Neuroglycopenic symptoms (Briscoe & Davis, 2006, p. 78-95). Review the hisotry and other data such as medications intake to find for clues that may cause persistent hypoglycemia (Cryer et al, 2009, p. 92-124). Perform continuous monitoring of blood sugar to ensure that the patient does not relapse back into hypoglycemia (Klonoff et al. 2011, p. 45-50 & Sanches & Cruz, 2011, p. 57-90). Administer 10% dextrose if the patient’s blood sugar lowers again and the patient is at a risk of falling back into hypoglycemia (Nehme & Cudini, 2009, p. 114-127). Fruit juice or honey could also be used if the patient develops hypoglycemia as these are simple forms of carbohydrates and can be absorbed easily and raise the blood sugar (Gorecki, 2009, p. 34-37). Plan for meal timings and provide required amount of carbohydrates (Day, Paul & Williams, 2009, p. 25-29). If the next scheduled meal is not ready, provide the patient with a combination of carbohydrates and protein, such as ½ cup milk, 1 ounce of cheese, and three saltine crackers. These will keep the blood sugar raised as the meal is in preparation (Smart, Vliet & Waldron, 2009, p. 44-47). Provide foods containing naturally occurring resistant starch (cornstarch) or foods modified to contain more resistant starch (high amylose cornstarch) that can prevent hypoglycemia. Be alert to monitor for hyperglycemia that result from over treatment of hypoglycemia (Shomali, 2011). The effectiveness of the above interventions implemented can be assessed by checking the patient’s blood sugar level regularly and ensuring that it is maintained at a normal level thus successfully preventing the client from hypoglycemia and by maintaining normal blood glucose level (Martorella, 2011, p. 8).

‘Risk for unstable blood glucose level (hyperglycemia) related to continued use of carbohydrate rich foods and fluids for the management of the hypoglycemia is the second priority nursing diagnoses. The evidence is found after testing the patient’s blood sugar level and finding out he has elevated blood sugar level to above normal levels (Bhasin et al, (2009). his could have been brought about by the carbohydrate intake by the patient that was aimed at eliminating the hypoglycemia since the patient has diabetes type 1, his body did not produce adequate insulin thus he was not able to control the sugar level. The goal of the nurse is to prevent hyperglycemia and to maintain a normal blood glucose level so as to maintain a safe and effective glycemic control (Sanches & Cruz, 2011, p. 38-41). To achieve glucose control the nurse should be alert at all times and monitor early signs of hyperglycemia (Judy, Paige, Barnachea, Dawn, Locke, Christy, Backhaus, Brenda & Shannon, 2010, p. 59-62). The nurse should perform continuous monitoring of blood sugar and administer insulin if the blood sugar rises above normal level (Klonoff et al. 2011, p. 58 & Sanches & Cruz, 2011, p. 77). The patient’s history should be consulted to find out the amount of insulin that had been earlier prescribed. The nurse should inform the patient the signs of hyperglycemia and closely monitor him for early signs (Kedia, 2011, p. 55-70). The patient should be assessed continuously to check on signs of ketoacidosis since the patient has diabetes type 1. In the event that the patients blood sugar raises above normal and insulin is administered, an IV set up should be arranged with fluids to hydrate the patient; high blood sugar may cause thirst. Even after administering insulin, the patient should be closely monitored to ensure that hypoglycemia does not recur due to overcorrection of the hyperglycemia (Cryer et al. 2009, p. 67).

The third priority nursing diagnosis is, ‘Risk for injury related to hypoglycemia, impaired mobility and hypertension evidenced by decreased blood glucose level and blood pressure’. (Allemann et al. 2009, p. 13). he expected outcome is that client’s safety will be maintained and is prevented from falls and other injuries. This diagnosis should be prioritized since Hyperglycemia can increase the risk of impaired cognition, and falls in the elderly (Blair et al., 2010, p. 103 & Schwartz et al., 2008, p. 28-29 & Akhuemokhan et al., 2009, p. 88-92).

The appropriate nursing interventions to be implemented are to appropriately maintain blood glucose levels, to provide continuous blood glucose and blood pressure monitoring, and to provide appropriate assistance while mobilizing the client, such as taking him to the bathroom and other daily activities of living (Gray-Micelli, 2008, p. 59). Put up the side rails when the client is in bed (Day, Paul & Williams, 2009, p. 108-109), to avoid injuries. Use standard environmental checklists for other risk factors and keep evaluating the patient’s safety (Gray-Micelli, 2008, p. 66). The nurse should evaluate the effectiveness of above intervention by inspecting the patient to make sure that he has no injuries. The nurse should stay close to the patient to assist him incase he wants to move about and advice him to ask for help (Beacham et al. 2008, p. 425).

References

Akhuemokhan, Eregie, A., & Edo, A. (2009). Hypocalcaemia unawareness and falls in older adults with type 2 diabetes. African Journal of Diabetes Medicine, 14 (55), 22- 24. Web.

Allemann, S., Houriet, C., Diem, P & Stettler, C. (2009). Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis. Curr Med Res Opin, 25(12), 2903-13. Web.

Beacham et al. (2008). Insulin Management: A Guide for the Home Health Nurse. Home Healthcare Nurse, 26 (7), 421 – 428. Web.

Bhasin, Cryer, E., & Vigersky. (2009). Patient Guide on the Diagnosis and Management of Hypoglycemic Disorders (Low Blood Sugar) in Adults. The Journal of Clinical Endocrinology & Metabolism, 94 (3). Web.

Blair., Angela., Hazelwood & Kristen. (2010). Hypoglycemia, diabetes and increased risk of falls, (focus: Aged care). Australian Nursing Journal, 17 (9). Web.

Boyle., Zrebiec, J & John. (2007). Management of diabetes-related hypoglycemia (Review Article). Southern Medical Journal. Web.

Briscoe, J & Davis, N. (2006). Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management. Clinical Diabetes, 24 (3), 115-121. Web.

Cryer, E., Axelrod, Grossman, B., Heller, R., Montori, M. Seaquist, R & John Service. (2009). Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (3), 709-728.

Day, A., Paul & Williams. (2009). Brunnar and Suddarth’s textbook of Canadian medical-surgical nursing (2^nd Edi). Lippincott Williams & Wilkins: Philadelphia. Diabetic hypoglycemia. (2010). Web.

Farrell, M and Dempsey, J., (2011), Smeltzer & Bares Textbook of Medical- Surgical Nursing, 2nd Edition, Lippincott Williams & Wilkins.

Gorecki, 2009. Chapter 12: Hypoglycemia. University of Toronto. Web.

Gray-Micelli, D. (2008). ‘Nursing Standard of Practice Protocol: Fall Prevention’. Hartford Institute for Geriatric Nursing, New York University. Web.

Judy, A., Paige, K., Barnachea, Dawn, F., Locke, Christy, L., Backhaus, Brenda R & Shannon, K. (2010). Cultivating quality: an evidence-based protocol for managing hypoglycemia. American Journal of Nursing, 110(7), 40-45. Web.

Kedia, N. (2011). Treatment of severe diabetic hypoglycemia with glucagon: an underutilized therapeutic approach. Dovepress Journal, Volume 4, 337 – 346.

Klonoff, D C., Buckingham, B., Christiansen, JS., Montori, VM., Tamborlane, WV., Vigersky, RA & Wolpert, H.(2011). Continuous glucose monitoring: an endocrine society clinical practice guideline. Journal of Clinical Endocrinology Metabolism, 96(10), 2968-79. Web.

Martorella, AJ.(2011). Iatrogenic hypoglycemia in patients with type 2 diabetes: comparison of insulin analog premixes and human insulin premixes. PostgradMed, 123(4), 7-16. Web.

Mayerson, A, B. & Inzucchi, S, E., (2002). Type 2 diabetes therapy: A pathophysiologically based approach, Post grad Med 111 (3):83-87.

Nehme & Cudini. (2009). A review of the efficacy of 10% dextrose as an alternative to high concentration glucose in the treatment of out-of-hospital hypoglycemia. Journal of Emergency Primary Health Care, 7 (3).

Sanches, P & Cruz, I. (2011). Management of Hypoglycemia: Systematic Literature Review. Journal of Specialized Nursing Care, 4 (1). Web.

Shomali. (2011). Hypoglycemia in the hospital. Journal of Community Hospital Internal Medicine Perspectives, 1(2), 7217.

Schwartz, et al. (2008). Diabetes-Related Complications, Glycemic Control, and fall in Older Adults. Diabetes Care, 31, 391. Web.

Sinclair, J. (2006). Special Considerations in Older Adults with Diabetes: Meeting the Challenge. Diabetes Spectrum, 19 (4), 229-233.

Smart C., Vliet, E & Waldron, S. (2009). Nutritional management in children and adolescents with diabetes. Pediatric Diabetes, 10 (Suppl. 12), 100–117. Web.