Objective cues:

Increased Urine Output

Weight Loss
Dry skin
Exhaustion
Elevated Temp
Dehydrated
Sweating of the skin
Sudden Vision changes
Extreme Hunger
Numbness in the hands and feet

Nursing Diagnosis:

Risk for Unstable Blood Glucose

Deficient Knowledge
Risk for Infection
Risk for Disturbed Sensory Perception
Risk for Deficient Fluid Volume
Risk for Impaired Skin Integrity

Nursing Interventions Rationale

Hyperglycemia results when
there is an inadequate
amount of insulin to
glucose. Excess glucose in
the blood creates an
Assess for signs of osmotic effect that results in
hyperglycemia. increased thirst, hunger,
and increased urination. The
patient may also report
nonspecific symptoms
of fatigue and
blurred vision.
Blood glucose should be
between 140 to 180 mg/dL.
Assess blood glucose level before Non-intensive care patients
meals and at bedtime. should be maintained at
pre-meal levels <140
mg/dL.
Monitor patient’s HbA1c- This is a measure of blood
glycosylated hemoglobin. glucose over the previous 2
 to 3 months. A level of
6.5% to 7% is desirable.
Assess for anxiety, tremors, and
These are signs of
slurring of speech. Treat
hypoglycemia and D50 is
hypoglycemia with 50%
treatment for it.
dextrose.
Assess feet for temperature, To monitor peripheral
pulses, color, and sensation. perfusion and neuropathy.
Nonadherence to dietary
Assess the patient’s current guidelines can result in
knowledge and understanding hyperglycemia. An
about the prescribed diet. individualized diet plan is
recommended.
Physical activity helps lower
blood glucose levels.
Regular exercise is a core
Assess the pattern of physical
part of diabetes
activity.
management and reduces
risk for cardiovascular
complications.
A patient with type 2 DM
who uses insulin as part of
the treatment plan is at
increased risk for
hypoglycemia.
Manifestations of
hypoglycemia may vary
among individuals but are
consistent in the same
Monitor for signs of
individual. The signs are
hypoglycemia.
the result of both increased
adrenergic activity and
decreased
glucose delivery to the
brain, therefore, the patient
may experienced
tachycardia, diaphoresis,
dizziness, headache, fatigue,
and visual changes.
Adherence to the
therapeutic regimen
promotes tissue perfusion.
Administer basal and prandial
Keeping glucose in the
insulin.
normal range slows
progression of microvascular
disease.
 Blood glucose is monitored
Teach patient how to perform before meals and at
home glucose monitoring. bedtime. Glucose values are
used to adjust insulin doses.
Hypertension is commonly
associated with diabetes.
Report BP of more than 160 mm Control of BP
Hg (systolic). Administer prevents coronary
hypertensive as prescribed. artery disease, stroke,
retinopathy, and
nephropathy.
Patients have decreased
Instruct patient to avoid heating
sensation in the extremities
pads and always to wear shoes
due to peripheral
when walking.
neuropathy.
Renal failure causes
creatinine >1.5 mg/dL.
Monitor urine albumin to serum
Microalbuminuria is the first
creatinine for renal failure.
sign of diabetic
nephropathy.
Instruct patient to take oral hypoglycemic medications as
directed: 
Stimulates insulin secretion
by the pancreas. They also
Sulfonylureas: glipizide enhance cell receptor
(Glucotrol), glyburide sensitivity to insulin and
(DiaBeta), glimepiride (Amaryl). decrease the liver synthesis
of glucose from amino acids
and stored glycogen.
Meglitinides: repaglinide Stimulates insulin secretion
(Prandin) by the pancreas.
These drugs decrease the
amount of glucose produced
by the liver and improve
Biguanides: metformin
insulin sensitivity. They
(Glucophage)
enhance muscle cell
receptor sensitivity to
insulin.
Stimulates rapid insulin
Phenylalanine derivatives: nategli secretion to reduce the
nide (Starlix) increases in blood glucose
that occur soon after eating.
Alpha-glucosidase Delays the absorption of
inhibitors: acarbose glucose into the blood from
(Precose), miglitol (Glyset). the intestine.
Thiazolidinediones: pioglitazone Drugs decrease insulin
 resistance in peripheral
(Actos), rosiglitazone (Avandia)
tissues.
Increases insulin secretion
Incretin modifier: sitagliptin and
phosphate (Januvia) decreases glucagon secretio
n.
Instruct patient to take insulin as directed
Have an onset of action
within 15 minutes of
Rapid-acting insulin
administration. The duration
analogs: lispro insulin (Humalog),
of action is 2 to 3 hours for
insulin aspart
Humalog and 3 to 5 hours
for aspart.
Has an onset of action
within 30 minutes of
Short-acting insulin: regular
administration; duration of
action is 4 to 8 hours.
Onset of action for the
Intermediate-acting
intermediate-acting is one
insulin: neutral protamine
hour after administration;
Hagedorn (NPH), insulin zinc
duration of action is 18 to
suspension (Lente)
26 hours.
Premixed concentration has
an onset of action similar to
Intermediate and rapid: 70% that of rapid-acting insulin
NPH/30% regular. and a duration of action
similar to that of
intermediate-acting insulin.
Have an onset of one hour
after administration.
Long-acting insulin: Ultralente, Duration of action is 36
insulin glargine (Lantus) hours for Ultralente is 36
hours and for glargine is at
least 24 hours.
Instruct the patient on the proper preparation and
administration of insulin.
Injection procedures. Absorption of insulin is more
consistent when insulin is
always injected in the same
anatomical site. Absorption
if fastest in the abdomen,
followed by the arms,
thighs, and buttocks. It is
recommended by the
American Diabetes
Association to administer
 insulin into the
subcutaneous tissue of the
abdomen.
Injection of insulin in the
same site over time will
Rotation of injection within one
result in lipoatrophy and
anatomical site.
lipohypertrophy with
reduced insulin absorption.
Insulin should be
refrigerated at 2º to 8º C
(36º to 46º F). Unopened
vials may be stored until
their expiration date. To
Storage of insulin. prevent irritation from “cold
insulin,” vials may be stored
at temperatures of 15º to
30ºC (59º to 86ºF) for 1
month. Opened vials are to
be discarded after that time.

Nursing Interventions Rationale

Explain that long-acting
Long-acting insulin does not have a
insulin (Lantus) only
peak of action. Insulin glargine is
need to be injected
effective over 24 hours.
once or twice daily.
Explain that regular
prandial insulins
(Humulin) should be
Dosage may be adjusted based on the
injected 30 mins before
actual amount of food ingested
meals.
because rapid acting insulins can be
Rapid acting insulins
given after a meal.
(Novolog, Humalog)
may be injected before
or after eating.
Insulin dosage should be reduced
Explain that insulin when fasting for surgery, when not
dosages may need to eating, or when hypoglycemia occurs.
be adjusted. Illness or infection may increase
insulin requirements.
Teach patient to rotate Multiple injections in the same site
insulin injection sites. may cause fat deposits.
Explain the importance
of inserting the needle This ensures deep subcutaneous
perpendicular to the administration of insulin.
skin.
Verify that the patient
understands and Monitoring provides data on the
demonstrates the degree of glucose control and
technique and timing of identifies the need for changes in the
home monitoring of insulin dosage.
glucose.
A diet low in fat and high in fiber
helps to control cholesterol and
Teach patient to follow
triglycerides. Three daily meals and an
a diet that is low in
evening snack is recommended.
simple sugars, low in
Refined and simple sugars should be
fat, and high in fiber
reduced, and complex carbohydrates,
and whole grains.
such as cereals, rice, should be
increased.
Teach patient that
These are indicators of hypoglycemia,
anxiety, tremors, and
which causes seizures, coma, and
slurred speech are
death.
signs of hypoglycemia.
Teach patient to treat Hypoglycemia should be treated with
hypoglycemia with a carbohydrate snack. If the patient is
crackers, a snack, or unconscious, glucagon should be
glucagon injection. given IM by a caregiver.

Nursing Interventions Rationale

Patients with DM may be
Observe for the signs of
admitted with infection, which
infection and
could have precipitated the
inflammation: fever, flushed
ketoacidotic state. They may
appearance, wound drainage,
also develop nosocomial
purulent sputum, cloudy urine.
infection.
Teach and promote good hand Reduces risk of cross-
hygiene. contamination.
Maintain asepsis during IV
insertion, administration of Increased glucose in the blood
medications, and providing creates an excellent medium
wound or site care. Rotate IV for bacteria to thrive.
sites as indicated.
Provide catheter or perineal Minimizes risk of UTI.
care. Teach female patients to Comatose patient may be at
clean from front to back after particular risk if urinary
elimination. retention occurred before
hospitalization.
Note: Elderly female diabetic
patients are especially prone to
urinary tract and/or vaginal
Nursing Interventions Rationale
yeast infections.
Peripheral circulation may be
Provide meticulous skin care:
ineffective or impaired, placing
gently massage bony areas,
the patient at increased risk
keep skin dry. Keep linens dry
for skin breakdown and
and wrinkle-free.
infection.
Rhonchi may indicate
accumulation of secretions
possibly related
to pneumonia or bronchitis.
Auscultate breath sounds.
Crackles may results from
pulmonary congestion or
edema from rapid fluid
replacement or heart failure.
Facilitates lung expansion;
Place in semi-Fowler’s position.
reduces risk of aspiration.
Reposition and encourage
Aids in ventilating all lung
coughing or deep breathing if
areas and mobilizing
patient is alert and
secretions. Prevents stasis of
cooperative. Otherwise,
secretions with increased risk
suction airway using sterile
of infection.
technique as needed.
Provide tissues and trash bag
in a convenient location for
To minimizes spread of
sputum and other secretions.
infection.
Instruct patient in proper
handling of secretions.
Encourage and assist with oral Reduces risk of oral/gum
hygiene. disease.
Decreases susceptibility to
infection. Increased urinary
Encourage adequate dietary flow prevents stasis and aids in
and fluid intake (approximately maintaining urine pH/acidity,
3000 mL/day if not reducing bacteria growth and
contraindicated by cardiac or flushing organisms out of
renal dysfunction), including 8 system. Note: Use of cranberry
oz of cranberry juice per day juice can help prevent bacteria
as appropriate. from adhering to
the bladder wall, reducing the
risk of recurrent UTI.
Administer antibiotics as Early treatment may help
appropriate. prevent sepsis.
Nursing Interventions Rationale
To provide baseline from
Monitor vital signs and mental
which to compare abnormal
status.
findings.
Call the patient by name,
reorient as needed to place,
Decreases confusion and helps
person, and time. Give short
maintain contact with reality.
explanations, speak slowly and
enunciate clearly.
To provide uninterrupted rest
Schedule and cluster nursing periods and promote
time and interventions. restful sleep, minimize fatigue
and improve cognition.
Keep patient’s routine as
consistent as possible. Helps keep patient in touch
Encourage participation in with reality and maintain
activities of daily living (ADLs) orientation to the environment.
as able.
Disoriented patients are prone
Protect patient from injury by to injury, especially at night,
avoiding or limiting the use of and precautions need to be
restraints as necessary when taken as
LOC is impaired. Place bed in indicated. Seizure precautions
low position and pad bed rails need to be taken as
if patient is prone to seizures. appropriate to prevent physical
injury, aspiration, and falls.
Retinal edema or detachment,
hemorrhage, presence
of cataracts or temporary
Evaluate visual acuity as
paralysis of extraocular
indicated.
muscles may impair vision,
requiring corrective therapy
and/or supportive care.
Observe and investigate
Peripheral neuropathies may
reports of hyperesthesia, pain,
result in severe discomfort,
or sensory loss in the feet or
lack of or distortion of tactile
legs. Investigate and look for
sensation, potentiating risk of
ulcers, reddened areas,
dermal injury and impaired
pressure points, loss of pedal
balance.
pulses.
Provide bed cradle. Keep
hands and feet warm, avoiding
Reduces discomfort and
exposure to cool drafts and/or
potential for dermal injury.
hot water or use of heating
pad.
Nursing Interventions Rationale
Promotes patient safety,
Assist patient with ambulation
especially when sense of
or position changes.
balance is affected.
Imbalances can impair
mentation. Note: If fluid is
Monitor laboratory values: replaced too quickly, excess
blood glucose, serum water may enter brain cells
osmolality, Hb/Hct, BUN/Cr. and cause alteration in the
level of consciousness (water
intoxication).
Alteration in thought processes
Carry out prescribed regimen or potential for seizure activity
for correcting DKA as is usually alleviated once
indicated. hyperosmolar state is
corrected.

Nursing Interventions Rationale

Assists in estimation of total
volume depletion. Symptoms
may have been present for
Assess patient’s history related
varying amounts of time
to duration or intensity of
(hours to days). Presence of
symptoms such as vomiting,
infectious process results in
excessive urination.
fever and hypermetabolic
state, increasing insensible
fluid losses.
Monitor vital signs: 
Hypovolemia may be
manifested
by hypotension and
tachycardia. Estimates of
severity of hypovolemia may
be made when patient’s
Note orthostatic BP changes. systolic BP drops more than 10
mmHg from a recumbent to a
sitting then a standing
position. Note: Cardiac
neuropathy may block reflexes
that normally increase heart
rate.
Respiratory pattern: Lungs remove carbonic acid
Nursing Interventions Rationale
through respirations,
producing a compensatory
respiratory alkalosis for
ketoacidosis. Acetone breath is
due to breakdown of
Kussmaul’s respirations,
acetoacetic acid and should
acetone breath.
diminish as ketosis is
corrected. Correction of
hyperglycemia and acidosis will
cause the respiratory rate and
pattern to approach normal.
In contrast, increased work of
breathing, shallow, rapid
Respiratory rate and quality,
respirations, and presence of
use of accessory muscles,
cyanosis may indicate
periods of apnea, and
respiratory fatigue and/or that
appearance of cyanosis.
patient is losing ability to
compensate for acidosis.
Although fever, chills, and
diaphoresis are common with
Temperature, skin color, infectious process, fever with
moisture, and turgor. flushed, dry skin and
decreased skin turgor may
reflect dehydration.
Assess peripheral pulses, Indicators of level of
capillary refill, and mucous hydration, adequacy of
membranes. circulating volume.
Provides ongoing estimate of
Monitor I&O and note urine volume replacement
specific gravity. needs, kidney function, and
effectiveness of therapy.
Provides the best assessment
Weigh daily. of current fluid status and
adequacy of fluid replacement.
Maintain fluid intake of at least
2500 mL/day within cardiac Maintains hydration and
tolerance when oral intake is circulating volume.
resumed.
Promote comfortable Avoids overheating, which
environment. Cover patient could promote further fluid
with light sheets. loss.
Investigate changes in Changes in mentation can be
mentation and LOC. due to abnormally high or low
glucose, electrolyte
Nursing Interventions Rationale
abnormalities, acidosis,
decreased cerebral perfusion,
or developing hypoxia.
Regardless of the cause,
impaired consciousness can
predispose patient to
aspiration.
Provides for accurate ongoing
measurement of urinary
output, especially if autonomic
neuropathies result in
Insert and maintain indwelling
neurogenic bladder (urinary
urinary catheter.
retention/overflow incontinenc
e). May be removed when
patient is stable to reduce risk
of infection.

Nursing Interventions Rationale

These are assessments for
Assess integrity of the skin.
neuropathy. Skin on lower
Assess knee and deep tendon
extremity pressure points is at
reflexes and proprioception.
great risk for ulceration.
Use foot cradle on the bed.
Use space boots on ulcerated To prevent pressure on
heels, elbow protectors, and pressure-sensitive points.
pressure-relief mattresses.
Wash feet daily with mild
soap and warm water. Check Decreased sensation increases
water temperature before the risk for burns.
immersing feet in the water.
Inspect feet daily for These are signs that the skin
erythema or trauma. needs preventive care.
To prevent infection from
Change socks or stockings
moisture. White fabric enables
daily. Encourage the patient
easy visualization of blood or
to wear white cotton socks.
exudates.
 Moisturizers soften and
Use gentle moisturizers on
lubricate dry skin, preventing
the feet.
skin cracking.
Cut toenails straight across This action prevents ingrown
after softening toenails with a toenails, which could cause
bath. infection.
This is a high risk for trauma
The patient should not walk
and may result in ulceration
barefoot.
and infection.