Diabetes mellitus in itself is considered an endocrine issue. When determining the priority diagnoses for an admitted patient, however, it is important to consider taking an all-encompassing perspective with regards to the pathophysiology of each patient and address each issue accordingly. The priorities in the selected aggregate for diabetes mellitus are as follows:
Firstly, there is the situation of unbalanced nutrition often evidenced by increased urinary output (or dilute urine), recent weight loss and a decrease in muscle tone, disinterest in eating, diarrhea and an increase in ketosis. Some of the pathophysiological factors that may have led up to these symptoms include insulin deficiency (due to the decreased uptake and utilization of glucose within tissue and subsequent increase of protein and fat metabolism), a decreased oral intake of food possibly due to gastric fullness or abdominal pain, and a hypermetabolic state due to the release of epinephrine, cortisol and growth hormone. Secondly, the situation of disturbed sensory perception or impaired skin integrity may occur due to an imbalance in endogenous electrolytes or glucose and insulin. Decreased circulation often correlates with decreased levels of activity and mobilization. Thirdly, there will be an overall fluid volume deficit. Often occurring in conjunction with unbalanced nutritional uptake, polyuria occurs due to “glucose-induced osmotic diuresis” (Spira, 1997) especially within patients who suffer from hyperglycemia (again, due to insulin deficiency). Dry mucosal membranes, poor skin turgor and delayed capillary refill times are also indicators of a fluid volume deficit. Finally, a diabetic patient will often exhibit overwhelmingly low levels of energy and noticeably impaired abilities to concentrate and maintain regular daily routines. This occurs due to a lack of metabolic energy production – resulting in a hypermetabolic state or infection.
Strategies to Address Diagnoses
The MAP-IT framework that utilizes the steps of Mobilizing, Assessing, Planning, Implementing and Tracking can be used to form intervention strategies to combat the previously listed diagnoses. During the Assessment step, it is particularly important to take the social determinants of health into account while providing service; although the aggregate is a geographically centered population, the needs of the patients will not be entirely uniform. Additionally, during the Tracking portion, regular evaluations of the listed strategies (checking for data validity and reliability) are advisable in order to continue providing the highest level of service.
Unbalanced Nutrition:
Weigh the patient daily. Measuring a patient’s weight allows for a preliminary assessment of the patient’s nutritional uptake.
Auscultate bowl sounds and make note of abdominal pain, bloating, reports of nausea or vomiting undigested food. Hyperglycemia and electrolyte imbalance can affect gastric function (distention of the ileus). Repeated difficulties with lowered gastric emptying time or poor intestinal motility may indicate autonomic neuropathies that will need to be addressed with sympathetic treatment.
Transitioning from fluid nutrients to solid food as tolerated.
Cultural food preferences and the inclusion of family members in meal planning will increase the likelihood of following dietary requirements after discharge as well as facilitating a sense of involvement for family members
Looking for signs of hypoglycemia through changes in the LOC, headaches, rapid heart rate, lightheadedness or skin temperature. Hypoglycemia can potentially occur once carbohydrate metabolism has resumed, glucose levels are reduced and insulin is being provided.
Perform fingerstick glucose testing; bedside analyses of serum glucose levels are much more accurate than merely monitoring sugar levels within urine. Urine sugar levels do not provide accurate indication of serum levels and can be affected by patient’s urine retention.
Disturbed Sensory Perception / Impaired Skin Integrity
Evaluate visual acuity since retinal edema, temporary paralysis of extraocular muscles, hemorrhaging, or the presence of cataracts can impair vision and will require corrective treatment.
Make note of pain sensation or lack thereof, hyperesthesia or sensory loss in the limbs. The occurrence of peripheral neuropathies and any lack of tactile sensation can impair balance and increase risk of injury.
Monitor lab test values for blood glucose, Hb/Hct, BUN/Cr and serum osmolality since imbalances will have an effect on mentation. Be aware of the chance for water intoxication.
The patient should never walk barefoot as all pressure points on the lower extremities have a high risk for ulceration, trauma and infection. The feet of a patient should be checked daily for erythema or trauma since these are immediate signs that the skin needs preventative care. Gentle moisturizers should be used to soften the skin and prevent cracking.
All water temperatures for bathing should be double checked due to a decreased sensation and higher risk for burns.
Overall Fluid Volume Deficit
Report for signs of dry mucous membranes, decreased skin turgor, a weak rapid pulse, a sudden weight loss of 2% or more, low blood pressure and elevated levels of Hct or BUN
Control diarrhea through the prescription of antidiarrheal agents and antimicrobial therapy
Maintain intravenous fluid therapy as ordered and take whatever actions are required to reduce nausea and vomiting
Orthostatic blood pressure levels should be monitored since hypovolemia occurs through hypotension and tachycardia.
Recording respiratory patterns and noting the presence of acetone breath. Acetone breath occurs due to the breakdown of acetoacetic acid and is a side product of ketosis. Correcting hyperglycemia and acidosis will incur the normalization of the respiratory rate.
Fatigue:
Pulse, respiratory rate and blood pressure fluctuations before and after activities should be noted in order to determine physiological levels of tolerance.
Discussing the importance of continuing to move and stay active helps to motivate patient to continue despite initial levels of fatigue.
Creating a personalized plan for the patient which alternates period of activity with periods of uninterrupted sleep will prevent excessive levels of fatigue and motivate them to continue moving
Providing adequate ventilation and the administration of oxygen as required will allow for improved breathing and relaxation in the patient.
Disaster Plan and Disaster Pack Approach
The aggregate in question consists of the African American population within Ft. Pierce, Florida. Florida is a coastal state commonly witness to severe tropical storms and flooding, hurricanes and tornadoes. There have also been periodic reports of district fires. Ft. Pierce, specifically, has over 1.3 miles of shore line with a humid subtropical climate. A large aspect of geoenvironmental diabetology (Cook, 2011) has to do with how geophysical phenomena impact a diabetic patient, especially during a classified disaster situation.
In geographical areas prone to disaster situations, it is imperative that there is an emergency strategy in place to prevent fatality or dangerous complications for individuals with medical disorders. For example, diabetic patients or families in which a member is a diabetic patient, specialized diet (with measured amounts of glucose) are required at all times for the affected individual and are integral to their daily lives. A disaster kit should be created in advance with extra instructions for a non-healthcare provider to use if they are the first responder. A basic disaster kit for diabetic patients should include materials for both hyperglycaemic and hypoglycaemic situations. The kit should include supplemental insulin doses, ketone strips, a ketone meter (with instructions), glucose tablets, glucose tubes, fruit juices or other quick-acting glucose products. Extra batteries for detection meters and a flashlight, as well as several bottles of water should be included. Alcohol swabs, extra copies of prescriptions a bottle to dispose of sharp objects such as lancets and syringes are also advisable. General first-aid kit materials such as bandages, adhesives, gauze pads, scissors and tweezers and ice pack would also ideally be included as some diabetic patients may have greater complications. Non-perishable foods such as nuts, granola bars, dry cereals, dried fruits, and electrolyte drink and juice boxes for a period of at least 3 days are excellent additions to disaster packs. Patients should also consider having a medical alert bracelet for situations where the individual can no longer speak for themselves. Identification and extra copies of prescription lists should be placed in wallets or purses. Copies of emergency telephone numbers, local poison control and personal physician contact information should be placed somewhere within the kit.
References
Spira, A., Gowrishankar, M., & Halperin, M.L. (1997). Factors contributing to the degree of polyuria in a patient with poorly controlled diabetes mellitus. American Journal of Kidney Diseases 30(6), 829-835. Retrieved February 8, 2016.
Cook, C. B., Wellik, K. E., & Fowke, M. (2011). Geoenvironmental Diabetology. Journal of Diabetes Science and Technology, 5(4), 834-842. Retrieved February 8, 2016.
