Chapter 46: Assessment and Management of Patients With Diabetes

The meal plan created for a diabetic must consider the patient's: 1) 2) 3) 4)

1) Food preferences 2) Lifestyle 3) Usual eating times 4) Ethnic and cultural background

Foods high in carbs, such as sucrose (concentrated sweets) are not totally eliminated from the diet, but should be eaten in moderation (up to _____% of total calories).

10%

The ADA, recommends that for all levels of caloric intake, ______-______% of calories should be derived from proteins.

10-20%

The ADA, recommends that for all levels of caloric intake, ______-______% of calories should be derived from fat.

20-30%

At least ______ g of fiber should be ingested daily.

28g

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what? A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." B) "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." C) "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea." D) "I will call the doctor if my blood sugar is over 300 mg/dL or if I have ketones in my urine."

A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." Feedback: The nurse must explanation the "sick day rules" again to the patient who plans to stop taking insulin when sick. The nurse should emphasize that the patient should take insulin agents as usual and test one's blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the patient should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A) Always carry a form of fast-acting sugar. B) Perform exercise prior to eating whenever possible. C) Eat a meal or snack every 8 hours. D) Check blood sugar at least every 24 hours.

A) Always carry a form of fast-acting sugar. Feedback: The following teaching points should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.

A diabetes nurse educator is teaching a group of patients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic patient? A) Do not eliminate insulin when nauseated and vomiting. B) Report elevated glucose levels greater than 150 mg/dL. C) Eat three substantial meals a day, if possible. D) Reduce food intake and insulin doses in times of illness.

A) Do not eliminate insulin when nauseated and vomiting. Feedback: The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

In terms of DKA, patients are instructed to have what for potential "sick days"/in their sick day kits? SATA A) Foods available for use B) Supply of urine test strips (for ketone testing) C) Blood glucose strips D) Must know how to contact provider 24 hrs/day. E) BP cuff

A) Foods available for use B) Supply of urine test strips (for ketone testing) C) Blood glucose strips D) Must know how to contact provider 24 hrs/day.

A patient has been brought to the emergency department by paramedics after being found unconscious. The patient's Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaCl

A) IV administration of 50% dextrose in water Feedback: In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patient's condition.

For patients who have obesity and diabetes but don't take insulin or an oral anti-diabetic medication: SATA A) Meals shouldn't be skipped B) Pace food intake throughout day (decreases demands on pancreas) C) Meals should be big and hearty, and limited to 3 a day.

A) Meals shouldn't be skipped B) Pace food intake throughout day (decreases demands on pancreas)

Calorie controlled diets are planned by first calculating a person's energy needs and caloric requirement based on ____________, ____________, ____________, and ____________.

Age, gender, height, weight

Guidelines to follow during periods of illness ("Sick Day Rules") include: SATA A) Take insulin/oral anti-diabetic agents as usual B) Test blood glucose levels as specified or urine ketones to your primary provider C) Take supplemental doses of regular insulin every 3-4 hours if needed, if you take insulin D) Substitutes soft foods (1/3 cup regular gelatin, 1 cup cream soup, 1/2 cup custard) 6-8x a day if you can't follow usual meal plan E) Take liquids (1/2 cup regular cola/OJ, 1/2 cup broth, 1 cup sports drink (Gatorade) every 1/2 hr-1hour to prevent dehydration and to provide calories, if vomiting/diarrhea persists. F) Report nausea, vomiting, diarrhea to PP, b/c extreme fluid loss can be dangerous G) Be aware that if you're unable to retain oral fluids, you may require hospitalization to avoid diabetic ketoacidosis and possibly coma. H) Test BP regularly and report abnormally high levels

A) Take insulin/oral anti-diabetic agents as usual B) Test blood glucose levels as specified or urine ketones to your primary provider C) Take supplemental doses of regular insulin every 3-4 hours if needed, if you take insulin D) Substitutes soft foods (1/3 cup regular gelatin, 1 cup cream soup, 1/2 cup custard) 6-8x a day if you can't follow usual meal plan E) Take liquids (1/2 cup regular cola/OJ, 1/2 cup broth, 1 cup sports drink (Gatorade) every 1/2 hr-1hour to prevent dehydration and to provide calories, if vomiting/diarrhea persists. F) Report nausea, vomiting, diarrhea to PP, b/c extreme fluid loss can be dangerous G) Be aware that if you're unable to retain oral fluids, you may require hospitalization to avoid diabetic ketoacidosis and possibly coma.

Nutrition management of diabetes includes the following goals: SATA A) To achieve/maintain: blood glucose levels in the normal range/as close to normal as is safely possible. As well as a lipid/lipoprotein profile that reduces the risk for vascular disease. BP levels in a normal range/as close to normal as safely possible B) To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrition/lifestyle. C) To address the individual nutrition needs, taking into account personal and cultural preferences and willingness to change. D) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence. E) To reduce HR to normal range or as close to normal as possible

A) To achieve/maintain: blood glucose levels in the normal range/as close to normal as is safely possible. As well as a lipid/lipoprotein profile that reduces the risk for vascular disease. BP levels in a normal range/as close to normal as safely possible B) To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrition/lifestyle. C) To address the individual nutrition needs, taking into account personal and cultural preferences and willingness to change. D) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.

A diabetic patient calls the clinic complaining of having a "flu bug." The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) "Make sure to stick to your normal diet." B) "Try to eat small amounts of carbs, if possible." C) "Ensure that you check your blood glucose every hour." D) "For now, check your urine for ketones every 8 hours."

B) "Try to eat small amounts of carbs, if possible." Feedback: For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

36. A diabetes nurse is assessing a patient's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient's knowledge of nutritional therapy in diabetes? A) Ask the patient to describe an optimally healthy meal. B) Ask the patient to keep a food diary and review it with the nurse. C) Ask the patient's family what he typically eats. D) Ask the patient to describe a typical day's food intake.

B) Ask the patient to keep a food diary and review it with the nurse. Feedback: Reviewing the patient's actual food intake is the most accurate method of gauging the patient's diet.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patient's fluid balance C) Assessing the patient's level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

B) Maintaining and monitoring the patient's fluid balance Feedback: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA's recommendations include? A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.

A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what? A) "I read that a pancreas transplant will provide a cure for my diabetes." B) "I will take my oral antidiabetic agents when my morning blood sugar is high." C) "I will make sure to follow the weight loss plan designed by the dietitian." D) "I will make sure I call the diabetes educator when I have questions about my insulin."

C) "I will make sure to follow the weight loss plan designed by the dietitian." Feedback: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body's need for insulin? A) Adequate sleep B) Low stimulation C) Exercise D) Low-fat diet

C) Exercise Feedback: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low fat intake and low levels of stimulation do not reduce a patient's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class? A) Low fat generally indicates low sugar. B) Protein should constitute 30% to 40% of caloric intake. C) Most calories should be derived from carbohydrates. D) Animal fats should be eliminated from the diet.

C) Most calories should be derived from carbohydrates. Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

For patients who have obesity and diabetes but don't take insulin or an oral anti-diabetic medication, consistent meal content/timing is important but not as critical. Rather, decreasing the overall ____________ intake is of greater importance.

Caloric

A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurse's priority action? A) Ensure that the patient understands the basic pathophysiology of diabetes. B) Identify the patient's body mass index. C) Teach the patient "survival skills" for diabetes. D) Assess the patient's readiness to learn.

D) Assess the patient's readiness to learn. Feedback: Before initiating diabetes education, the nurse assesses the patient's (and family's) readiness to learn. This must precede other physiologic assessments (such as BMI) and providing health education.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

D) Fluid and electrolyte replacement Feedback: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual's risk for developing diabetes? A) Have blood glucose levels checked annually. B) Stop using tobacco in any form. C) Undergo eye examinations regularly. D) Lose weight, if obese.

D) Lose weight, if obese. Feedback: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent the diabetes.

The meal plan may include the use of some nonanimal sources of protein such as: __________ or _______ _________, to help reduce saturated fat and cholesterol intake.

Legumes, whole grains

For prevention of DKA related to illness, "_______ ________ rules" for managing diabetes when ill should be reviewed with patients. The most important concept in this is to NEVER ____________ insulin doses when nausea and vomiting occur. Instead, the patient should _______ the usual insulin dose and then attempt to consume frequent small portions of carbs- including foods usually avoided- juices, regular sodas, gelatin.

Sick day Eliminate Take

The majority of the selections for carb should come from _____.

Whole grains

The first step in preparing a meal plan is a thorough review of the patient's __________ history and ____________ and cultural eating patterns. This includes a thorough assessment of the patient's need for weight loss, gain, or maintenance. Type 2=weight reduction.

diet, lifestyle