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

Assess for signs of
hyperglycemia.
Assess blood glucose level before Non-intensive care patients
meals and at bedtime.
Monitor patient’s HbA1c-
glycosylated hemoglobin.
Hyperglycemia results when
there is an inadequate
amount of insulin to
glucose. Excess glucose in
the blood creates an
osmotic effect that results in
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.
should be maintained at
pre-meal levels <140
mg/dL.
This is a measure of blood
glucose over the previous 2

Assess for anxiety, tremors, and
slurring of speech. Treat
hypoglycemia with 50%
dextrose.
Assess feet for temperature,
pulses, color, and sensation.
Assess the patient’s current
knowledge and understanding
about the prescribed diet.
Assess the pattern of physical
activity.
Monitor for signs of
hypoglycemia.
Administer basal and prandial
insulin.
to 3 months. A level of
6.5% to 7% is desirable.
These are signs of
hypoglycemia and D50 is
treatment for it.
To monitor peripheral
perfusion and neuropathy.
Nonadherence to dietary
guidelines can result in
hyperglycemia. An
individualized diet plan is
recommended.
Physical activity helps lower
blood glucose levels.
Regular exercise is a core
part of diabetes
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
individual. The signs are
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.
Keeping glucose in the
normal range slows
progression of microvascular
disease.

Teach patient how to perform
home glucose monitoring.
Report BP of more than 160 mm Control of BP
Hg (systolic). Administer
hypertensive as prescribed.
Instruct patient to avoid heating
pads and always to wear shoes
when walking.
Monitor urine albumin to serum
creatinine for renal failure.
Instruct patient to take oral hypoglycemic medications as
directed: 
Sulfonylureas: glipizide
(Glucotrol), glyburide
(DiaBeta), glimepiride (Amaryl).
Meglitinides: repaglinide
(Prandin)
Biguanides: metformin
(Glucophage)
Phenylalanine derivatives: nategli secretion to reduce the
nide (Starlix)
Alpha-glucosidase
inhibitors: acarbose
(Precose), miglitol (Glyset).
Thiazolidinediones: pioglitazone
Blood glucose is monitored
before meals and at
bedtime. Glucose values are
used to adjust insulin doses.
Hypertension is commonly
associated with diabetes.
prevents coronary
artery disease, stroke,
retinopathy, and
nephropathy.
Patients have decreased
sensation in the extremities
due to peripheral
neuropathy.
Renal failure causes
creatinine >1.5 mg/dL.
Microalbuminuria is the first
sign of diabetic
nephropathy.
Stimulates insulin secretion
by the pancreas. They also
enhance cell receptor
sensitivity to insulin and
decrease the liver synthesis
of glucose from amino acids
and stored glycogen.
Stimulates insulin secretion
by the pancreas.
These drugs decrease the
amount of glucose produced
by the liver and improve
insulin sensitivity. They
enhance muscle cell
receptor sensitivity to
insulin.
Stimulates rapid insulin
increases in blood glucose
that occur soon after eating.
Delays the absorption of
glucose into the blood from
the intestine.
Drugs decrease insulin

(Actos), rosiglitazone (Avandia)
Incretin modifier: sitagliptin
phosphate (Januvia)
Instruct patient to take insulin as directed
Rapid-acting insulin
analogs: lispro insulin (Humalog),
insulin aspart
Short-acting insulin: regular
Intermediate-acting
insulin: neutral protamine
Hagedorn (NPH), insulin zinc
suspension (Lente)
Intermediate and rapid: 70%
NPH/30% regular.
Long-acting insulin: Ultralente,
insulin glargine (Lantus)
Instruct the patient on the proper preparation and
administration of insulin.
Injection procedures.
resistance in peripheral
tissues.
Increases insulin secretion
and
decreases glucagon secretio
n.
Have an onset of action
within 15 minutes of
administration. The duration
of action is 2 to 3 hours for
Humalog and 3 to 5 hours
for aspart.
Has an onset of action
within 30 minutes of
administration; duration of
action is 4 to 8 hours.
Onset of action for the
intermediate-acting is one
hour after administration;
duration of action is 18 to
26 hours.
Premixed concentration has
an onset of action similar to
that of rapid-acting insulin
and a duration of action
similar to that of
intermediate-acting insulin.
Have an onset of one hour
after administration.
Duration of action is 36
hours for Ultralente is 36
hours and for glargine is at
least 24 hours.
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
Provide meticulous skin care:
gently massage bony areas,
keep skin dry. Keep linens dry
and wrinkle-free.
Auscultate breath sounds.
Place in semi-Fowler’s position.
Reposition and encourage
coughing or deep breathing if
patient is alert and
cooperative. Otherwise,
suction airway using sterile
technique as needed.
Provide tissues and trash bag
in a convenient location for
sputum and other secretions.
Instruct patient in proper
handling of secretions.
Encourage and assist with oral Reduces risk of oral/gum
hygiene.
Encourage adequate dietary
and fluid intake (approximately maintaining urine pH/acidity,
3000 mL/day if not
contraindicated by cardiac or
renal dysfunction), including 8 system. Note: Use of cranberry
oz of cranberry juice per day
as appropriate.
Administer antibiotics as
appropriate.
Rationale
yeast infections.
Peripheral circulation may be
ineffective or impaired, placing
the patient at increased risk
for skin breakdown and
infection.
Rhonchi may indicate
accumulation of secretions
possibly related
to pneumonia or bronchitis.
Crackles may results from
pulmonary congestion or
edema from rapid fluid
replacement or heart failure.
Facilitates lung expansion;
reduces risk of aspiration.
Aids in ventilating all lung
areas and mobilizing
secretions. Prevents stasis of
secretions with increased risk
of infection.
To minimizes spread of
infection.
disease.
Decreases susceptibility to
infection. Increased urinary
flow prevents stasis and aids in
reducing bacteria growth and
flushing organisms out of
juice can help prevent bacteria
from adhering to
the bladder wall, reducing the
risk of recurrent UTI.
Early treatment may help
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
Assist patient with ambulation
or position changes.
Monitor laboratory values:
blood glucose, serum
osmolality, Hb/Hct, BUN/Cr.
Carry out prescribed regimen
for correcting DKA as
indicated.
Nursing Interventions
Assess patient’s history related
to duration or intensity of
symptoms such as vomiting,
excessive urination.
Monitor vital signs: 
Note orthostatic BP changes.
Respiratory pattern:
Rationale
Promotes patient safety,
especially when sense of
balance is affected.
Imbalances can impair
mentation. Note: If fluid is
replaced too quickly, excess
water may enter brain cells
and cause alteration in the
level of consciousness (water
intoxication).
Alteration in thought processes
or potential for seizure activity
is usually alleviated once
hyperosmolar state is
corrected.
Rationale
Assists in estimation of total
volume depletion. Symptoms
may have been present for
varying amounts of time
(hours to days). Presence of
infectious process results in
fever and hypermetabolic
state, increasing insensible
fluid losses.
Hypovolemia may be
manifested
by hypotension and
tachycardia. Estimates of
severity of hypovolemia may
be made when patient’s
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.
Lungs remove carbonic acid
Nursing Interventions
Kussmaul’s respirations,
acetone breath.
Respiratory rate and quality,
use of accessory muscles,
periods of apnea, and
appearance of cyanosis.
Temperature, skin color,
moisture, and turgor.
Assess peripheral pulses,
capillary refill, and mucous
membranes.
Monitor I&O and note urine
specific gravity.
Weigh daily.
Maintain fluid intake of at least
2500 mL/day within cardiac
tolerance when oral intake is
resumed.
Promote comfortable
environment. Cover patient
with light sheets.
Investigate changes in
mentation and LOC.
Rationale
through respirations,
producing a compensatory
respiratory alkalosis for
ketoacidosis. Acetone breath is
due to breakdown of
acetoacetic acid and should
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
respirations, and presence of
cyanosis may indicate
respiratory fatigue and/or that
patient is losing ability to
compensate for acidosis.
Although fever, chills, and
diaphoresis are common with
infectious process, fever with
flushed, dry skin and
decreased skin turgor may
reflect dehydration.
Indicators of level of
hydration, adequacy of
circulating volume.
Provides ongoing estimate of
volume replacement
needs, kidney function, and
effectiveness of therapy.
Provides the best assessment
of current fluid status and
adequacy of fluid replacement.
Maintains hydration and
circulating volume.
Avoids overheating, which
could promote further fluid
loss.
Changes in mentation can be
due to abnormally high or low
glucose, electrolyte
Nursing Interventions
Insert and maintain indwelling
urinary catheter.
Nursing Interventions
Assess integrity of the skin.
Assess knee and deep tendon
reflexes and proprioception.
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
immersing feet in the water.
Inspect feet daily for
erythema or trauma.
Change socks or stockings
daily. Encourage the patient
to wear white cotton socks.
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
neurogenic bladder (urinary
retention/overflow incontinenc
e). May be removed when
patient is stable to reduce risk
of infection.
Rationale
These are assessments for
neuropathy. Skin on lower
extremity pressure points is at
great risk for ulceration.
the risk for burns.
These are signs that the skin
needs preventive care.
To prevent infection from
moisture. White fabric enables
easy visualization of blood or
exudates.

Use gentle moisturizers on
the feet.
Cut toenails straight across
after softening toenails with a toenails, which could cause
bath.
The patient should not walk
barefoot.
Moisturizers soften and
lubricate dry skin, preventing
skin cracking.
This action prevents ingrown
infection.
This is a high risk for trauma
and may result in ulceration
and infection.