The Client with Alterations in Metabolic Function

CHAPTER 8


The Client with Alterations in Metabolic Function



DIABETES MELLITUS


Diabetes mellitus is a chronic multisystem disease characterized by alterations in carbohydrate, fat, and protein metabolism resulting from abnormal insulin production, impaired insulin utilization, or both. The hallmark of this metabolic disorder is hyperglycemia.


Diabetes* is often complicated by structural and functional abnormalities in the blood vessels and nerves. The atherosclerotic changes that frequently occur in the large vessels (macroangiopathy) affect the cardiac, cerebral, and peripheral circulation. Thickening of the basement membrane of the capillaries (microangiopathy) can also occur and is especially significant when it involves the vessels in the eyes and kidneys. The neurological involvement can be manifested in a wide variety of ways and is referred to as diabetic neuropathy. Several different mechanisms are thought to contribute to the development of diabetic neuropathy. These include reduced blood flow to the nerves as a result of angiopathies and a metabolic defect in the polyol pathway resulting in accumulation of sorbitol in the nerves, which subsequently alters nerve function. The most common neuropathy is peripheral sensorimotor polyneuropathy, which has a gradual onset of sensory manifestations such as numbness and tingling, burning or shooting pain sensations, and/or hyperesthesia. Neuropathy of the autonomic nervous system is also common.


Parasympathetic involvement often occurs earlier and is more profound than sympathetic nervous system involvement, and manifestations vary depending on the system involved.


The two major types of diabetes are type 1 and type 2. Individuals with type 1 diabetes have an absolute insulin deficiency and are dependent on insulin replacement. The insulin deficiency is usually due to an immune-mediated destruction of the pancreatic beta-cells in a person with a genetic predisposition and a triggering environmental insult (e.g., viral infection). Individuals with type 2 diabetes have a relative deficiency of insulin caused by decreased tissue responsiveness to insulin (insulin resistance), a defect in insulin secretion, and inappropriate hepatic glucose production. Heredity plays a role in development of type 2 diabetes. Additional risk factors for type 2 diabetes include a history of gestational diabetes mellitus or impaired glucose tolerance, increasing age, obesity, and a sedentary lifestyle.


A sequence of pathophysiological events occurs in diabetes. When an insulin deficiency exists, glucose cannot be transported into the cells for energy metabolism. As a result, glucose accumulates in the blood and starts to spill into the urine once the level exceeds the renal threshold (>180 mg/dL). The high blood glucose acts as an osmotic diuretic, which leads to excessive diuresis and subsequent deficient fluid volume. Because the glucose cannot be used as an energy source by many cells, fat and protein are broken down to provide a source of energy for the starving cells. The free fatty acids that are mobilized from adipose tissue are converted by the liver to ketones to be used as an energy source. The ketones are strong acids and eventually deplete the body’s buffer system and respiratory compensatory ability, leading to a state of metabolic acidosis. The simultaneous increase in glucagon and epinephrine release that occurs with an insulin deficiency exacerbates the hyperglycemia and ketogenesis. Continuation of these metabolic derangements leads to life-threatening imbalances.


This care plan focuses on the adult client who has had diabetes for many years and is being hospitalized because of difficulty stabilizing blood glucose levels. Many of the long-term vascular and neurological complications have been included in this care plan and should be individualized based on the client’s current status. Much of the information in this care plan is applicable to clients receiving follow-up care in an extended care facility or home setting.


This care plan should be used in conjunction with the care plans on Heart Failure, Myocardial Infarction, Cerebrovascular Accident, Hypertension, and/or Chronic Renal Failure if the client is also being treated for one of these vascular complications of diabetes.



OUTCOME/DISCHARGE CRITERIA


The client will:



1. Have blood glucose stabilized within a desired range


2. Have signs and symptoms of vascular and neurological complications at a manageable level


3. Verbalize a basic understanding of diabetes mellitus


4. Verbalize an understanding of medications ordered and demonstrate the ability to correctly draw up and administer insulin if prescribed


5. Verbalize an understanding of the principles of dietary management and be able to calculate and plan meals within the prescribed caloric distribution


6. Demonstrate the ability to perform blood glucose and urine tests correctly and interpret results accurately


7. Verbalize an understanding of the role of exercise in the management of diabetes


8. Identify health care and hygiene practices that should be integrated into lifestyle


9. Identify appropriate safety measures to follow because of the diagnosis of diabetes


10. State signs and symptoms of hypoglycemia and ketoacidosis and appropriate actions for prevention and treatment


11. State signs and symptoms to report to the health care provider


12. Share feelings and concerns about diabetes and its effect on lifestyle


13. Identify resources that can assist in the adjustment to and management of diabetes


14. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider and for laboratory studies.



Collaborative Diagnosis RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL NDx


Definition: Risk for variation of blood glucose/sugar levels from the normal range


Related to:











NURSING ASSESSMENT



















  RATIONALE
Assess blood glucose levels before meals and at bedtime. Monitoring the client’s blood glucose levels determines effectiveness of glucose control and allows for prompt treatment as needed.
Assess for increased blood pressure (B/P). Hypertension is frequently associated with diabetes. Control of B/P is associated with decreased incidence of or limited development of heart disease, stroke, retinopathy, and nephropathy.
Assess for capillary refill, temperature, peripheral pulses, and color. Monitors adequate peripheral vascular perfusion and aids in detection of peripheral vascular disease
Assess for increased or decreased urine output and excessive complaints of thirst and hunger. Indicators that the individual may be experiencing increased blood glucose levels




Nursing Diagnosis IMPAIRED COMFORT NDx (BURNING, ACHING, CRAMPING, HYPERESTHESIA, NUMBNESS, AND/OR TINGLING [PARTICULARLY IN LOWER EXTREMITIES])


Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and social dimensions


Related to:







Nursing Diagnosis RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY NDx


Definition: Risk for increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system


Related to: Delayed emptying of the stomach associated with autonomic neuropathy involving the gastrointestinal tract






Nursing Diagnosis DISTURBED SENSORY PERCEPTION NDx (VISUAL)


Definition: Change in amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli


Related to:







Collaborative Diagnosis RISK FOR DIABETIC KETOACIDOSIS (DKA)


Definition: A life-threatening complication of diabetes in which there is inadequate insulin, resulting in increased blood glucose levels, acidosis, and ketone bodies


Related to: Hyperglycemia and accelerated ketogenesis associated with the combined effect of severe insulin deficiency and excess secretion of counterregulatory hormones such as glucagon and epinephrine










Collaborative Diagnosis RISK FOR HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (SYNDROME)


Definition: A life-threatening complication of diabetes characterized by hyperglycemia, hyperosmolarity, and dehydration


Related to: Coma related to severe dehydration associated with sustained osmotic diuresis resulting from uncontrolled hyperglycemia






Nursing Diagnosis INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx


Definition: Pattern of regulating and integrating into family processes a program for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals












Nursing Diagnosis DEFICIENT KNOWLEDGE NDx OR INEFFECTIVE SELF HEALTH MANAGEMENT* NDx


Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/treatment/lifestyle changes; pattern of regulating and integrating into daily living a therapeutic regime for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals












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Feb 11, 2017 | Posted by in NURSING | Comments Off on The Client with Alterations in Metabolic Function

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