Diabetes mellitus is a chronic disease characterized by high blood glucose levels resulting from insufficient insulin production or utilization. It manifests as two primary types: type 1 autoimmune disease destroying pancreatic beta cells and type 2 metabolic disease caused by insulin resistance. Complications include microvascular and macrovascular diseases, diabetic ketoacidosis, hyperosmolar hyperglycemic syndrome, and chronic renal failure. Nursing care focuses on stabilizing glucose levels, educating patients on self-care, and optimizing therapeutic regimen management through addressing potential barriers.

1. Diabetes mellitus
Diabetes mellitus (DM) is a chronic disease that causes high blood glucose
levels. It results from insulin nonproduction, insufficient insulin production, or
inadequate insulin utilization. DM causes carbohydrate, protein, and fat
metabolism disturbances in two primary forms: autoimmune disease that destroys
islets of Langerhans pancreatic beta cells, which produce insulin, and metabolic
disease caused by insulin resistance, with a resulting defect in compensatory
insulin production.
Pathophysiology
Insulin allows cells to use glucose as energy or to store it as glycogen. It also
stimulates protein synthesis and free fatty acid storage in adipose tissues. A
deficiency compromises body tissues' access to essential nutrients for fuel and
storage.
Complications
■ Microvascular disease (including retinopathy, nephropathy, and neuropathy)
■ Dyslipidemia
■ Macrovascular disease (including coronary, peripheral, and cerebral artery
disease)
■ Diabetic ketoacidosis
■ Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
■ Excessive weight gain
■ Skin ulcerations
■ Chronic renal failure
Assessment (only potential abnormalities listed)
NURSING HISTORY BY FUNCTIONAL HEALTH PATTERN
Health perception and management
Type 1
■ Family history of diabetes
■ Age younger than 30
■ Flulike syndrome with acute symptom onset
Type 2
■ Family history of diabetes
■ Age older than 45

2. ■ Gradual symptom onset
Nutrition and metabolism
Type 1
■ Increased thirst (polydipsia)
■ Increased appetite (polyphagia)
■ Weight loss
■ Ketosis
■ Nausea (occasionally)
Type 2
■ Polydipsia
■ Polyphagia
■ History of high−refined carbohydrate, high-calorie diet
■ Excess weight (possible recent weight gain)
Elimination
Type 1
■ Polyuria
■ Constipation
■ Diarrhea
Type 2
■ Nocturia
■ Polyuria
■ Constipation
■ Diarrhea
■ Diuretics (taken for another condition)
■ Acute or recurrent urinary tract infections (UTIs)
Activity and exercise
Type 1
■ Sudden weakness
■ Increased fatigue
■ Sleepiness
Type 2
■ Weakness and fatigability (gradually increasing)
■ Lack of regular exercise
Cognition and perception
Type 1
■ Dizziness

3. ■ Orthostatic hypotension
■ Abdominal pain
Type 2
■ Pruritus
■ Poorly healing skin infections
■ Myopia
■ Blurred vision
■ Muscle cramping
■ Abdominal pain
■ Extremity numbness, pain, or tingling
■ Irritability
Sleep and rest
Type 1
■ Sleep disturbance (due to nocturia)
Type 2
■ Sleep disturbance
■ Drowsiness after meals
Sexuality and reproduction
Type 2
■ Loss of sex drive
■ Erectile dysfunction
■ Recurrent vaginitis or vaginal infections
Roles and relationships
Types 1 and 2
■ Role strain
■ Workplace disruption due to treatment responsibilities or complications
Coping and stress management
Types 1 and 2
■ Noncompliance due to denial
PHYSICAL EXAMINATION
Integumentary
■ Poorly healing skin wounds, especially on feet
■ Skin infections
■ Warm, flushed, dry skin (in diabetic ketoacidosis [DKA])
Respiratory
■ Deep, rapid (Kussmaul's) respirations
■ Fruity breath odor (in DKA)

4. Cardiovascular
■ Tachycardia
■ Orthostatic hypotension
■ Hypertension
■ Cool extremities
■ Decreased pulses
Gastrointestinal
■ Abdominal distention
■ Decreased bowel sounds
■ Abdominal tenderness
Neurologic
■ Drowsiness
■ Confusion
■ Coma (in DKA)
■ Altered reflexes
Renal and urinary
■ Vaginal discharge
■ Perineal irritation
DIAGNOSTIC STUDIES
■ Random serum glucose test reveals a level greater than or equal to 200 mg/dl.
■ Fasting serum glucose test reveals a level greater than or equal to 126 mg/dl
(confirms DM).
■ Urinalysis reveals glycosuria and, in type 1, ketonuria. (Urine microalbumin is
the earliest indication of diabetic renal disease.)
■ Glucose tolerance test reveals a level greater than or equal to 200 mg/dl in the
2-hour sample.
■ Blood insulin level is absent or minimal in type 1, and low, normal, or high in
type 2.
■ Glycosylated hemoglobin test detects elevations or wide fluctuations in blood
glucose over time; greater than 8% indicates poor glucose control in either type
1 or type 2.
■ Arterial blood gas studies can reveal metabolic acidosis, particularly common
in type 1, with compensatory respiratory alkalosis.
■ Electrolyte panel (needed to establish baseline) may be normal or reveals
hyponatremia or hyperkalemia associated with dehydration or DKA (type 1).

5. ■ Blood urea nitrogen (BUN) levels (needed to establish baseline) may be normal
or elevated in DKA or HHNS.
■ BUN and creatinine levels (needed to establish baseline) may be normal or
elevated in the presence of renal involvement.
Nursing care plan
Nursing diagnosis
Nursing priorities
Risk for unstable glucose level related to inadequate ■ Prevent or minimize complications when
endogenous insulin (type 1 DM) or inadequate
establishing treatment regimen to control altered
endogenous insulin and insulin resistance (type 2
glucose metabolism.
DM)
Deficient knowledge (self-care) related to newly
■ Establish a diabetes control regimen,
diagnosed complex chronic disease
emphasizing self-care.
Ineffective therapeutic regimen management related ■ Optimize management of personal therapeutic
to lack of material resources, lack of support, or
regimen.
ineffective coping
Other potential nursing diagnoses: Ineffective coping related to denial ■ Risk for imbalanced fluid volume
related to physiologic manifestations of disease process ■ Risk prone health behavior related to inability to
modify lifestyle with change in health status
Risk for unstable glucose level related to inadequate
endogenous insulin (type 1 DM) or inadequate
endogenous insulin and insulin resistance (type 2 DM)
EXPECTED OUTCOME
The patient will maintain a stable blood glucose level.
Suggested NOC Outcomes
Neurological status: Consciousness
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Collaborative
Administer insulin or oral
antidiabetic medications, as
ordered.
Collaborative
Monitor fingerstick blood glucose
levels according to facility
protocol, clinical status, and
before giving antidiabetic
medications. Follow established
Insulin increases cellular
glucose uptake and decreases
gluconeogenesis. Exogenous
insulin is essential for
controlling type 1 DM and may
also be used in type 2 DM.
Oral agents stimulate beta
cells to secrete insulin, block
glucose absorption in the small
intestine, increase insulin
sensitivity in peripheral tissue,
or reduce glucose production
in the liver.
Assessment of glucose levels
is essential for monitoring the
patient's response and
adjusting treatment. Checking
the glucose level and

6. protocol for withholding the dose
based on normal values.
Collaborative
Collaborative
Collaborative
Collaborative
Note differences in peak action
and duration of action for various
antidiabetic medications.
■ Rapid-acting insulins (insulin
aspart) peak between 1 and 2
hours.
■ Short-acting insulins (regular,
Humulin R), peak within 2 and 4
hours.
■ Intermediate-acting insulins
(NPH, lente) peak between 6 and
12 hours.
■ Long-acting insulins
(Ultralente, insulin glargine) peak
between 10 and 30 hours.
■ Oral antidiabetic drugs with a
24-hour duration peak on the
average between 3 and 4 hours.
Establish and maintain an I.V. fluid
infusion, as ordered. Monitor for
dry mucous membranes, poor skin
turgor, cracked lips, abdominal
pain, elevated urine specific
gravity, elevated hematocrit, and
other signs or symptoms of
dehydration. Keep an accurate
intake and output record.
Document daily weight.
Observe for signs and symptoms
of medication-induced
hypoglycemia. Reactions are most
likely to coincide with peak insulin
effect or late or missed meals,
depending on the type of insulin
and the patient's response. If a
reaction occurs, notify the
physician, measure blood glucose
level, and treat immediately with
oral glucose, I.V. glucose, or
glucagon, depending on protocol
and the patient's responsiveness.
Recheck blood glucose in 10
minutes. Feed the patient a small
snack of carbohydrate and protein
if his next meal is more than 1
hour away.
Make sure the patient is served
the prescribed therapeutic diet at
consistent times.
withholding the dose if the
level is acceptable prevents
medication-induced
hypoglycemia. Protocols for
withholding doses vary
depending on the antidiabetic
medication ordered and the
patient's status.
Awareness of these
characteristics helps the nurse
correlate onset and duration of
signs and symptoms with
peaks and troughs in serum
drug levels.
Accurate intake and output
documentation and daily
weights are essential for
assessing fluid status and for
early detection of inadequate
renal function. Daily weight is a
gross indicator of general fluid
and nutritional status.
Insulin reactions can occur
with relative suddenness. Oral
glucose is used for mild to
moderate hypoglycemia when
the patient can swallow;
parenteral glucagon or glucose
is used when the person is
unconscious or can't swallow.
The patient with DM—
especially type 1 DM—needs
diet guidelines tailored to meet
his specific needs. Consistent
carbohydrate intake distributed
throughout the day is
fundamental to all types of

7. Collaborative
Collaborative
Observe for signs and symptoms
of DKA (in type 1 DM only):
■ Early: nausea; fatigue;
polyuria; dry, flushed skin; dry
mucous membranes; thirst; and
tachycardia.
■ Late: vomiting, poor skin
turgor, lethargy, Kussmaul's
respirations, acetone breath,
hypotension, and abdominal pain.
If the patient's condition suggests
DKA, notify the physician
immediately.
Observe for signs and symptoms
of HHNS (in type 2 DM), including
lethargy or stupor, fatigue,
drowsiness, confusion, coma,
seizures, intense thirst, and very
dry mucous membranes. If the
patient's condition suggests
HHNS, notify the physician
immediately.
[Additional individualized
interventions]
medical nutrition therapy for
DM because it helps stabilize
blood glucose levels.
Insulin and oral antidiabetic
drugs are prescribed to fit the
normal diet schedule; a missed
or delayed meal can lead to
hypoglycemia.
Rapid identification of DKA
allows for prompt treatment
and prevents more serious
complications.
Rapid identification of HHNS
allows for prompt treatment
and prevents more serious
complications.
Suggested NIC Interventions
Hyperglycemia management: Intravenous (IV) therapy; Laboratory data
interpretation; Neurologic monitoring
Deficient knowledge (self-care) related to newly
diagnosed complex chronic disease
EXPECTED OUTCOME
The patient will demonstrate proficiency in injection technique and produce
evidence of site rotation documentation (if insulin is ordered); discuss disease
management in relation to medication, diet, exercise, and stress; demonstrate
proper foot care; discuss hypoglycemia and hyperglycemia and their appropriate
treatments; initiate diet planning with dietitian and plan adequate diet for 3-day
period; and perform and interpret blood glucose tests accurately.
Suggested NOC Outcomes
Knowledge: Disease process; Knowledge: Health behavior; Knowledge:
Treatment regimen

8. NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Independent
Provide information regarding
disease process, treatment
regimen, and reduction of risk
factors to improve health status.
Independent
Teach the significance of insulin or
oral antidiabetic medications for
disease control. Demonstrate
injection techniques, and observe
the patient's performance.
Independent
Involve the patient, his family, and
dietitian in planning a therapeutic
diet. Reinforce nutritional
guidelines. Encourage supervised
weight loss if the patient is
overweight. Ensure that the
patient has been given written diet
guidelines before discharge.
Provide referral for further
questions and special situations
(such as "sick day" management,
pregnancy, dining out, exercise,
use of alcohol, or complications).
Teach blood glucose testing
methods for home use. Observe
patient demonstrations for
accuracy of testing, interpretation
of results, calibration, and
documentation. Provide target
glucose ranges. Encourage the
patient to keep a daily record of
glucose monitoring.
Emphasize the importance of
regular activity and exercise and
of maintaining the same level of
activity from day to day. Teach the
patient to check his blood glucose
level before exercise and
consume a carbohydrate snack if
blood glucose is lower than 100
mg/dl.
Providing information may help
the patient comply with the
treatment plan and adjust his
lifestyle appropriately to reduce
risk factors.
Patient understanding is
essential for home
management of DM.
Observing the patient's
injection technique and
providing opportunities for
supervised practice help
ensure accuracy.
Involving the patient and his
family with dietary planning
helps ensure compliance at
home. Written materials help
minimize misunderstanding.
Referral ensures an ongoing
source of dietary information.
Independent
Independent
Independent
Tell the patient to be aware of
increased susceptibility to
infections; discuss ways to avoid
exposure. Review signs of
infection, such as redness,
Successful home management
of DM requires that the patient
perform self-monitoring to
ensure that the prescribed
regimen of medication, diet,
and exercise remains
appropriate to needs.
Exercise stimulates
carbohydrate metabolism,
lowers blood pressure, aids in
weight control, and may help
avert or minimize circulatory
complications by increasing
levels of high-density
lipoproteins. Exercise induces
blood glucose fluctuations, and
increases or decreases in
activity may require dietary or
medication changes. Checking
his blood glucose level before
exercising and eating a
carbohydrate snack, if
indicated, minimizes the
patient's hypoglycemia risk.
Awareness of signs of infection
may help ensure prompt
treatment.

9. Independent
swelling, exudate, and fever.
Emphasize the importance of
prompt, appropriate treatment of
even minor injuries to avoid
serious complications.
Discuss ways to prevent the
vascular complications of DM,
such as proper leg and foot care.
Emphasize the need to use
protective footwear. Teach the
patient about potential eye
complications, symptoms of UTI,
and renal impairment. Help the
patient understand the
significance of careful disease
control.
DM is characterized by
degenerative vascular changes
that predispose the patient to
infections, ulcerations, and
gangrene, particularly of the
legs and feet. Proper foot care
and protective footwear reduce
the risk of complications from
altered peripheral perfusion.
Careful disease control can
help minimize the
complications caused by DM.
[Additional individualized
interventions]
Suggested NIC Interventions
Teaching: Disease process; Teaching: Foot care; Teaching: Individual; Teaching:
Prescribed activity/exercise; Teaching: Prescribed diet; Teaching: Prescribed
medication; Teaching: Procedure/treatment
Ineffective therapeutic regimen management related to
lack of material resources, lack of support, or ineffective
coping
EXPECTED OUTCOME
The patient will verbalize an understanding of the need for lifestyle changes, ask
appropriate questions, verbalize feelings about diagnosis, participate actively in
disease control planning, have resource deficits resolved or appropriate referrals
completed, and have a home visit or outpatient follow-up appointment scheduled.
Suggested NOC Outcomes
Compliance behavior; Knowledge: Diet; Knowledge: Treatment regimen;
Participation in health care decisions; Treatment behavior: Illness or injury
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Independent
Assess the patient's resources,
including financial status, physical
abilities, and family support
system.
Involve the patient's family in all
teaching and planning.
Financial status, physical
disabilities, and lack of support
can interfere with successful
home treatment.
Family members may help
reinforce teaching and
encourage compliance.
Home visits allow assessment
of environmental factors that
may contribute to
noncompliance.
Independent
Independent
Arrange appropriate follow-up
home health visits.

10. Independent
Independent
Refer the patient and his family to
community resources and mutual
support groups.
Encourage verbalization of
feelings, and support healthy
coping behaviors.
Community or mutual support
groups can offer ongoing
education and support.
Expression of feelings is a
necessary prelude to
acceptance of the disease and
active, responsible
management. Supporting
healthy coping behaviors helps
maintain the patient's
independence and sense of
self-control—both essential for
compliance.
[Additional individualized
interventions]
Suggested NIC Interventions
Behavior modification; Decision-making support; Health system guidance;
Mutual goal-setting; Patient contracting; Self-modification assistance; Selfresponsibility facilitation
Teaching checklist
■ Disease and its implications
■ Medication regimen (purpose, dosage, administration schedule, and adverse
effects)
■ Signs and symptoms requiring urgent medical treatment
■ Blood glucose testing procedure and results
■ Dietary changes
■ Signs and symptoms, prevention, and treatment of hypoglycemia and
hyperglycemia
■ Exercise regimen
■ Foot care
■ Signs and symptoms of complications, the need to report them, and appropriate
treatment
■ Community resources and support
■ Ways to obtain emergency medical treatment
■ Follow-up care