NURSING NR 228 Nutrition- Week 7 edapt Nutrition and Diabetes - Chamberlain College of Nursing

Nutrition and Diabetes Nutrition is an essential component and critically important in preventing diabetes, managing existing diabetes, and at least slowing, the rate of development of diabetes complications. Diabetes is a group of diseases in which the body lacks insulin production or defects within the insulin receptors.

As you complete the activities in this lesson, you will gain the knowledge and skills needed to:  Differentiate the types of diabetes  Explain the characteristics and presentation of both types of diabetes  Compare and contrast current and traditional nutritional approaches  Identify appropriate nutritional interventions based on client needs

Cases of Diabetes by Age Group (2017-2018) Incidence Estimates, 2017–2018 Age in Years

Rate per 1,000 (95% CI)

Total

6.9 (5.8–8.3)

18-44

4.3 (3.2–5.9)

45-64

9.9 (7.6–12.8)

65 and older

8.8 (6.5–11.9)

According to the Center for Disease Control (2020) in 2017-2018 which age group has the highest rate of diabetes?

18-44 45-64 65 and older Although diabetes is growing in those above the age of 20 years old, the greatest number of cases is for those individuals that are 45-64 years and older.

Your response is correct!

Goals of Nutrition Therapy One of the goals in the management of nutritional therapy is to decrease the risk of diabetes and cardiovascular disease (CVD) by promoting healthy food choices and physical activity. Which activities below, if expressed by the client, would indicate understanding of recommended exercise methods for weight loss? Select all that apply.

Walking briskly Jogging Swimming Ballet Frequent leg movements while sitting Standing at work to use computer Boating The American Diabetes Association recommends aerobic exercise and strength training for optimal physical fitness.

Aerobic exercise (think anything that raises your heart rate) can be achieved through activities such as walking, running, swimming, dancing, tennis, basketball, and more. Boating would not be applicable unless strenuous paddling was occurring. Frequent leg movements while sitting are helpful, as are standing to work, but neither are aerobic activities.

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Client Teaching A client has a new diagnosis of type 2 diabetes and asks what she can do to control her disease. What is the best response from the healthcare provider? Select all that apply.

"You can decrease your physical activity to conserve insulin for exercise.”

“It is important to adopt an active lifestyle to help with this disease.”

“Changing your diet can be very impactful with diabetes management.”

“Injections of a medication called insulin can control your diabetes.”

When focusing on controlling your type 2 diabetes, it is important to recognize that this condition can be controlled by diet and physical

activity. Insulin is used for the primary treatment of type 1 diabetes, and not type 2.

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Types of Diabetes Diabetes is a group of disorders and is classified into two types: type 1 and type 2 diabetes mellitus. Explore each one in further detail below.

Diabetes Management The primary goal of diabetes management is control of blood glucose in an attempt to achieve normal or near-normal levels. Diet and exercise play an immense and critical role in the regulation of blood glucose levels.

Development of an active lifestyle works well in conjunction with selection of a healthy diet. Several nutrition interventions are often implemented to achieve this control.

Nutritional Recommendations

M any healthcare providers often select a specific caloric level for clients with diabetes. However, the American Diabetes Association (ADA) does not endorse any type of caloric level or percentage of carbohydrates, proteins, and fats. Instead, the ADA recommends that the dietary needs for each client be individualized (Grodner, et. al., 2020). Specifically, the focus is no longer on a “diet” but nutrition therapy. Each client requires different nutrition needs to achieve treatment goals.

Diabetes self-management education is the focus; teaching the client to manage blood sugar levels based on current influences. In order to complete nutrition therapy, the client undergoes several steps: 1. Comprehensive nutritional assessment 2. Self-care treatment plan development 3. Evaluation of client’s health status, learning ability, readiness to change, and current lifestyle 4. Tailored meal planning approach to fit the client’s lifestyle and needs, designed to meet treatment goals

Total fat, saturated fat, cholesterol, fiber, vitamins, and minerals should be the same as those recommended for the general population (Grodner, 2020). The only variance is in carbohydrate consumption, which will be discussed in detail in the following slides.

Clients with diabetes should also use caution with alcohol intake and not omit foods. Alcoholic beverages should be consumed with food to prevent hypoglycemia. Moderate alcohol does not negatively impact clients with well-controlled glucose levels.

Another important factor to consider is the client's lipid and cholesterol levels. Protein can be 15-20% of daily kilocalories from animal and vegetable protein sources, which is important for clients to remember when selecting foods.

References Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications: A nursing approach (7th ed.). Elsevier.

Carbohydrates Carbohydrates are a major component in diabetes management. Current nutritional recommendations for the management of diabetes includes a diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk.

Carbohydrate counting to try and control postprandial glucose levels is successful in most clients. However, research has shown that lowcarbohydrate diets are an important source of energy, fiber, vitamins, and minerals and are important in dietary palatability (Grodner, et. al., 2020).

Therefore, these foods are important components of the diet for individuals with diabetes.

The purpose of carbohydrate counting is to establish an appropriate balance between the amount of carbohydrates eaten and insulin to regulate the blood glucose level. A registered dietitian (RD) is an essential part of the multidisciplinary team to help determine when and how much a client can eat. It is a flexible meal planning strategy that helps the client

understand how food choices affect blood glucose levels. The carb’s rating on the glycemic index determines the amount of insulin needed to balance the blood glucose.

Transcript Link References Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications: A nursing approach (7th ed.). Elsevier.

Glycemic Index The glycemic index classifies carbohydrate-containing foods according to their potential to raise your blood sugar levels. Foods with a high glycemic index value tend to raise your blood sugar higher and faster than do foods with a lower value.

Foods with low glycemic indexes include:          

Oats Barley Beans Legumes Pasta Pumpernickel (coarse rye) bread Apples Oranges Milk Lettuce

Foods with high glycemic indexes include:     

Potatoes White bread Pizza Cereals with sugar Corn

Fiber Fiber is an important component in the control of blood sugar. People with diabetes are encouraged to choose a variety of fiber-containing foods such as legumes, fiber-rich cereals (≥5 g fiber/serving), fruits, vegetables, and whole grain products because they provide vitamins, minerals, and other substances important for good health (ADA, 2008) Whole grain–containing foods have been associated with improved insulin sensitivity, independent of body weight, and dietary fiber has been associated with improved insulin sensitivity and improved ability to secrete insulin adequately to overcome insulin resistance.

Carbohydrate Teaching A client reads about carbohydrates and the impact that they have on diabetes. The client expresses concern about the consumption of carbohydrates in her diet. What is the best response from the healthcare provider?

"Carbohydrates are a source of energy, fiber, vitamins and minerals.”

“All carbohydrate intake should be restricted.”

"You should only eat carbohydrates after 7 pm.”

"Your diet should be made up of only carbohydrates.”

Carbohydrates are a good source of energy, fiber, vitamins, and minerals and should not be eliminated from or increased in a diabetic diet. Instead, carbs should be balanced along with protein and fats.

Your response is correct!

Source of Carbohydrates A health care provider is teaching a client about the importance of carbohydrates in the control of type II diabetes. Which choices of carbohydrates are the best options? Select all that apply.

Vegetables Whole grains Fruits Legumes High-fat milk Carbohydrates are a major component in diabetes management. Current nutritional recommendations for the management of diabetes includes a diet that includes carbohydrates, fats, and proteins in balanced amounts.

Carbohydrates should come from fruits, vegetables, whole grains, legumes, and low-fat milk.

Your response is correct!

Hypoglycemia Hypoglycemia is a condition that occurs when one's blood sugar is lower than normal, usually less than 70 mg/dL (Mayo Clinic, 2019).

Signs include:       

Hunger Nervousness Shakiness Perspiration Dizziness or light-headedness Sleepiness Confusion

If left untreated, hypoglycemia may lead to unconsciousness.

Hypoglycemia is treated by consuming a carbohydrate-rich food such as a glucose tablet, juice or honey. It may also be treated with an injection of glucagon if the person is unconscious or unable to swallow.

References

Glycemic Index A client with diabetes is finding it difficult to follow the glycemic index.

Even though the client is reading the packages on foods, it has been challenging to identify the glycemic index of the chosen foods. The client asks the healthcare provider for recommendations of foods that have a low glycemic index. Which are appropriate to recommend?

Appropriate Recommendations beans oats apples

The glycemic index classifies carbohydrate-containing foods according to their potential to raise your blood sugar levels. Foods with a high glycemic index value tend to raise your blood sugar higher and faster than do foods with a lower value.

Foods with low glycemic indexes include: oats, beans, and apples.

Potatoes, white bread, and corn are high glycemic indexes.

Your response is correct!

Artificial Sweeteners Artificial sweeteners can be used to reduce both calorie and carbohydrate intake. Sugar substitutes also can help curb those cravings individuals have for something sweet. The FDA has approved these 5 non-nutritive artificial sweeteners for use in the U.S (Grodner, et. al., 2020). These are:     

Acesulfame potassium Aspartame Neotame Saccharin Sucralose

Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public and more specifically, those individuals with diabetes.

Steviocide (Stevia) is a low-calorie sweetener that has both antioxidant and antidiabetic properties. Unlike artificial sweeteners and sugar, stevia

can suppress your plasma glucose levels and significantly increase glucose tolerance. Steviocide is derived from a South American shrub, presents a sweet taste but cannot be marketed or sold as a sweetener in the United States. It is a natural herb.

Incorporating Fiber What are the appropriate choices to suggest for including fiber in the diet?

Match all that apply.

Appropriate Choices whole grains fruit vegetables beans

Fiber is an important component in the control of blood sugar. People with diabetes are encouraged to choose a variety of fiber-containing foods such as legumes, fiber-rich cereals (≥5 g fiber/serving), fruits, vegetables, and whole grain products because they provide vitamins, minerals, and other substances important for good health. Lower glycemic index foods have low fiber content and elevate the blood glucose levels, such as milk and pasta.

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Special Considerations Special considerations consist of illness, eating disorders, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Review each of these below for more information.

Illness Eating Disorders DKA HHNS

Review of Nutrition Therapy for Clients with Diabetes When working with a client to develop nutrition therapy to control diabetes, a healthcare provider must complete an individualized assessment of:  Current eating patterns  Food preferences  Metabolic goals.

Consider personal preferences (e.g., tradition, culture, religion, health beliefs, and socioeconomics) as well as metabolic goals when working with individuals to determine the best eating pattern for them. An individualized eating pattern considers the individual’s health status, skills, resources, food preferences, and health goals.

Referral to a registered dietitian nutritionist (RD/RDN) is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan. The meal plan will also align with the overall treatment plan, including physical activity and medication use.

Type 1 Diabetes A client with type 1 diabetes is transported to the emergency department with a family member stating that the client “is not acting right.“ The family member indicates that the client seems confused, reported being dizzy and shaky. Currently, the client is drowsy. Based on these symptoms, what does the healthcare provider think is occurring?

Hyperglycemia Hypoglycemia

Metabolic syndrome Gestational diabetes Hypoglycemia is classified as a blood sugar that is below normal and usually less than 70 mg/dL. The signs and symptoms of hypoglycemia include shakiness, dizziness or light-headedness, sleepiness and confusion. Diabetic patients with hypoglycemia often have an increased appetite and increased perspiration.

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Assessment - Recognize and Analyze Cues A high school student is staring off into space, and the teacher asks for the student’s blood sugar reading. The monitor registers “HIGH.” What is the appropriate intervention by the teacher? Select all that apply.

Encourage the client to drink a bottle of water Administer the emergency glucagon injection Placing a glucose tablet in the student’s mouth Call the school nurse for insulin injection Having the student drink fruit juice Have the client walk to the restroom to check for ketones If left untreated, hyperglycemia may lead to coma. Hypoglycemia, or low blood sugar, is treated by consuming a carbohydrate-rich food such as a glucose tablet, juice or honey. If the client is drowsy, do not put anything in the client’s mouth to potentially cause choking. In this case, the client has hyperglycemia or extremely high blood sugar. Most monitors only register HIGH if the level is over 500mg/dL. This client needs to drink water until the nurse arrives with the insulin injection. This client also needs to be transported to the hospital for evaluation.

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Nutritional Therapy Considerations – Generate Solutions A client who has been newly diagnosed with type 2 diabetes needs medical nutrition therapy to properly manage the condition. Which factors should be taken into consideration when developing the client’s plan?

Select all that apply.

Metabolic goals Eating patterns Food Preferences Childhood weight When working with a client to develop a medical nutrition therapy to control their diabetes, a healthcare provider must complete an individualized assessment of current eating patterns, preferences, and metabolic goals. Consider personal preferences (e.g., tradition, culture, religion, health beliefs, and economics) as well as metabolic goals when working with individuals to determine the best eating pattern for them. An individualized eating pattern considers the individual’s health status, skills, resources, food preferences, and health goals. Referral to a registered dietitian nutritionist (RD/RDN) is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan that coordinates and aligns with the overall treatment plan, including physical activity and medication use.

Your response is correct!

Nutrition Referral – Generate Solutions A teenage client has elevated A1C levels and blood glucose levels and is referred to a registered dietitian nutritionist (RD/RDN). The client is angry and asks why this is necessary. What is the appropriate response by the healthcare provider? Select all that apply.

“It is important that you lose weight and decrease your activity and the dietitian can help with those things.“ "The nutritionist assess the overall nutritional status of client and will help you manage your diabetes and glucose levels.”

“This is to work with you to create a personalized meal plan that you like and also meet the treatment plan for diabetes.”

“If you see the nutritionist now, you might not ever have to take insulin again or worry about what you eat in the future.”

Referral to a registered dietitian nutritionist (RD/RDN) is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan that coordinates and aligns with the overall treatment plan. The client might need to lose weight, but not decrease activity. That is not going to improve the activity level. The other response gives false information and false hope, dismissing the seriousness and reality of the diagnosis.

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Nutritional Assessment – Recognize Cues When the teenager and parent arrive at the nutritionist office, they are asked to complete a questionnaire to gain personal traditions, culture, religion, health beliefs, and economics. The client is irritated and is

resistant to complete the form. What is the best response by the healthcare provider? Select all that apply.

"I understand it is a lot, but this form is irrelevant and not necessary.”

"Personal preferences are important, but you do not have to complete the form and we’ll skip them.“ "This form is extremely important because it helps determine the best eating pattern for you.”

"This information allows me to get to know you a little better.”

When developing a medical nutrition therapy, it is important to consider personal preferences (e.g., tradition, culture, religion, health beliefs, and economics) as well as metabolic goals when working with individuals to determine the best eating pattern for them.

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Artificial Sweeteners As an experienced diabetic, a client attempts to limit the use of sugar. A family member performs an internet search about artificial sweetener and reports that all of them are the same. What is the best response by the client?

“All things artificial should be avoided when you are diabetic and already struggle with sugar.“ “Artificial sweeteners can help curb cravings for sweet foods but should be used sparingly.“ “This research is correct, and any of them can be used to reduce both calorie and carbohydrate intake.“ “Artificial sweeteners are only used for individuals with type I diabetes and gestational diabetes.”

Artificial sweeteners can be used to reduce both calorie and carbohydrate intake. Sugar substitutes also can help curb those cravings individuals have for something sweet. The Federal Drug Administration (FDA) has approved five non-nutritive sweeteners for use in the United States. These are acesulfame potassium, aspartame, neotame, saccharin, and sucralose.

Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public and more specifically, those individuals with diabetes.

Your response is correct!

At-Risk - Generate Solutions A client is injured and reports to the occupational health clinic. During assessment, it is found that the client has diabetes and has 4-5 alcoholic drinks per day. What is the best response for this client?

“With your diabetes, drinking alcohol is strictly avoided.“ “It is recommended that you have no more than three drinks per day.“ “There is no limit on the amount of alcohol you can drink daily.”

“You can have 1-2 alcoholic beverages per day.“ Mild consumption of alcohol (one to two drinks per day) has been associated with a decreased risk of type 2 diabetes, coronary heart disease and stroke. Heavy consumption of alcohol (three drinks or more per day), may be associated with increased incidence of diabetes. The recommended consumption of alcohol is one drink per day for women and two drinks per day for men.

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Diabetes – Recognize and Analyze Cues A freshman student who plays football and runs track starts to lose weight without trying and is continually thirsty and hungry. Based on this information, what does the healthcare provider suspect that the client might have?

Type 1 diabetes Type 2 diabetes Diabetes insipidus Gestational diabetes Type 1 diabetes is considered an auto-immune condition. Auto-immune means that a person’s body develops an antibody that attacks normal tissue. No one quite knows why this occurs, or what triggers it. Once these antibodies attack the pancreas and complete their destruction, the pancreas is no longer able to make insulin.

With diabetes type 2, the body does not absorb insulin as well. This is called insulin resistance. As this begins, the pancreas produces more insulin to address the higher level of glucose that is not able to get into the muscle due to the body’s resistance to insulin. Over time, the pancreas starts to break down and is not able to produce as much insulin as is needed to escort the glucose into the cell. As this occurs, patients start to notice symptoms of diabetes.

Gestational diabetes only occurs in pregnant females, and gender is not specified in this scenario. Diabetes insipidus is a hormonal abnormality and is not related to blood glucose.

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Type 1 vs Type 2 Diabetes

Identify the appropriate characteristics of each type of diabetes.

Characteristics

Type 1 Diabetes

Type 2 Diabetes

Genetic influenced Destruction of pancreatic beta cells Occurs in children under 14

Insulin resistance Can be developed throughout the lifespan Often called adult-onset diabetes

Type 1 diabetes is caused by destruction of pancreatic beta cells, is genetically influenced, and occurs in pediatrics. Type 2 diabetes is a result of insulin resistance, can be developed throughout the lifespan, and is often called adult-onset diabetes.

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Nursing Application: Nutrition and Diabetes Diabetes has become an increasingly serious, global health issue with the number of people living with diabetes rising significantly over the last 35 years. According to the International Diabetes Federation, in 2017, approximately 425 million adults (20–79 years) were living with diabetes, and by 2045 this will rise to 629 million. With the increase in cases worldwide, nurses must have a strong foundation to provide appropriate nutritional treatment to effectively teach and care for clients at risk for and with diabetes.

As you complete these activities, you will gain the knowledge and skills needed to:  Utilize prior knowledge of theories and principles of nutrition and diabetes  Implement the nursing process to provide nutritional care for clients with diabetes

 Demonstrate clinical decision making as it pertains to the concept

Blood Glucose Levels – Recognizing Cues The nurse is caring for a client with a new diagnosis of Type 1 diabetes.

The client asks the nurse what the blood sugar levels should be after eating. Select all that apply.

"Two hours after meals, your blood sugar should be less than 180 mg/dL.“ "Before meals, your blood sugar should be 70 to 130 mg/dL.” "90 to 150 mg/dL is a good level for you at bedtime.”

"At bedtime, your blood sugar should be 190 to 250 mg/dL

Self-monitoring is useful for evaluating effectiveness of meal plans in meeting goals of nutrition therapy. It is important to monitor your glucose levels to determine food, insulin, and exercise needs.

Blood sugar levels should be:  Before meals: 70 to 130 mg/dL  Two hours after meals: less than 180 mg/dL (expect a 30- to 50-point rise from premeal glucose)  Bedtime: 90 to 150 mg/dL

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Nutritional Goals for Management of Diabetes A client with a new diagnosis of type 1 diabetes is questioning the importance of nutrition in the management of the disease. Select the appropriate responses from the nurse. Select all that apply.

"Proper nutritional control of type 1 diabetes helps maintain as nearnormal blood glucose levels as possible, by integrating insulin therapy into each individual's diet and physical activity patterns.”

"There is no benefit to proper nutritional control of type 1 diabetes.”

“Practicing good nutrition provides the proper number of calories to achieve and maintain a reasonable body weight.”

“Adequate nutrition and activity will assist in the control of your diabetes, maintain good blood pressure and normal lipid levels.”

The nutritional goals for people with type 1 diabetes are to:  Maintain as near-normal blood glucose levels as possible, by integrating insulin therapy into everyone's diet and physical activity patterns.

 Achieve optimal blood pressure and lipid levels.  Provide adequate calories for achieving and maintaining a reasonable body weight, normal growth, and development.

The nutritional goals for people with type 1 diabetes are to:  Maintain as near-normal blood glucose levels as possible, by integrating insulin therapy into everyone's diet and physical activity patterns.  Achieve optimal blood pressure and lipid levels.  Provide adequate calories for achieving and maintaining a reasonable body weight, normal growth, and development.

Blood Glucose Testing The nurse is caring for a client who is using insulin to control type 2 diabetes. What is the recommended frequency of blood glucose monitoring for this client?

Once a week at varying times of the day and evening Once or twice a week with meals and exercise At least two times per day at different times each day At least once per day at the same time each day Frequency of blood glucose monitoring depends on the type of diabetes and the type of therapy. With Type 2 diabetes test once or twice a week with meals and exercise; with an oral hypoglycemic agent, test at least once per day. If control is good, then test one or two times per week. If insulin is used, then test at least two times per day, at different times each day.

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Assessment and Health History

As with all nursing care, assessment of the client with diabetes is completed in a logical sequence by a nurse using the nursing process and clinical decision-making to identify actual and potential health risks and provide interventions that promote health. You begin this assessment with recognizing and analyzing cues within the clinical situation.

Cultural, genetic, developmental, and lifestyle influences influence the client with diabetes and should also be included in screening (Grodner, et. al., 2020). As you prioritize hypothesis and generate solutions (having awareness of potential complications too) you will identify priorities of care, take action, and provide health education. You will then evaluate outcomes with what was expected for your client. Overall, this promotes optimal health for each client.

Assessment should include both health history and physical assessment.

Health History           

Family history of diabetes, hypertension, or cardiovascular problems Dizziness, numbness, or tingling in hands and feet Change in vision Speech abnormalities Pain with ambulation Frequent urination Change in weight, appetite, thirst Recent infections, delayed healing Gastrointestinal (GI) or urinary functional changes Altered sexual function Diet © 2022 Chamberlain University LLC. All rights reserved.

Physical Assessment Here are some physical cues the nurse can look for in monitoring diabetes:  Height and weight  Vital signs  Serum glucose levels  Normal  Before meals: 70 to 130 mg/dL

   

 Two hours after meals: less than 180 mg/dL (expect a 30to 50-point rise from pre-meal glucose)  Bedtime: 90 to 150 mg/dL Visual acuity and cranial nerve evaluation Sensory abilities in extremities Peripheral pulses and capillary refill Skin and mucous membrane changes (hair loss, appearance, lesions, rash, itching, vaginal discharge)

Glucose Levels Two hours after meals you would expect the client’s blood sugar to be less than 180 mg/dL (expect a 30- to 50-point rise from pre-meal glucose). Less than 70 is considered hypoglycemic. 70-130 is expected before meals.

200-250 would be hyperglycemic.

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Diabetes Management The goal of dietary influence in the client with diabetes is to stabilize the blood sugar levels in order to maintain function, prevent complications, and teach the client to manage personal care of the disease. The most common nursing diagnoses that are associated with nutritional needs related to diabetes include:  Knowledge deficit related to dietary management of diabetes  Risk for unstable blood glucose due to poor dietary habits  Risk for ineffective therapeutic regimen management due to lack of knowledge or acceptance of disease  Imbalanced nutrition: less than body requirements due to poor dietary habits  Risk for deficient fluid volume due to poor dietary habits  Risk for impaired skin integrity due to poor dietary habits and decreased cardiovascular perfusion  Risk for infection due to poor dietary habits and decreased cardiovascular perfusion  Risk for injury due to poor dietary habits and lack of sensation  Ineffective coping due to recent diagnosis, denial, and lack of nutritional knowledge

Nursing Planning and Interventions

D ietary and Activity Plan            

Nutritional evaluation Nutritional counseling and education Development of client appropriate diet Decrease weight, blood pressure, and lipid levels as appropriate Demonstrate understanding of nutritional categories and appropriate food selection for each Provide adequate calories for achieving and maintaining a reasonable body weight, normal growth, and development Teach client how exercise controls diabetes Activity assessment and determination of appropriate aerobic goals, step count, or exercises for bedridden clients Avoiding exercise when insulin level is at its peak and choose ideal level of 100 to 200 mg/dL, 30 to 60 minutes after meals Avoid exercise when blood glucose level is greater than 250 ml/dL and ketones are present in urine Ingest added carbohydrate if glucose level is less than 100 mg/dL Monitor blood glucose levels before and after exercise and learn to adjust food and insulin amounts

 Consume added carbohydrate as needed to avoid hypoglycemia; keep carbohydrate-based foods available during and after exercise

Client Monitoring and Medication Administration  Demonstrates appropriate blood glucose monitoring based on type of diabetes and age of client  Explains and return demonstrates proper foot care and inspection  Describe strategies to reduce risk of injury and infection  Explains and demonstrates appropriate administration of prescribed medications

Dietary Options A client researches different diets that can help control diabetes and prevent complications. The client asks the nurse what the Mediterranean and vegan diets include for nutrients. What is the appropriate response?

Plant sources High carbohydrate foods High fat foods Animal sources Mediterranean diets and vegan diets primarily receive their nutrition from plant sources. Both are high in antioxidant nutrients and have been proven to lower HbA1c, lower other cardiovascular risk factors, including weight, blood pressure, and lipids.

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Plant Source Diets

After speaking with the nurse about the Mediterranean and vegan diet, the client questions the nurse whether their change in diet would be beneficial. What would be the appropriate response about the positive effects of the diets? Select all that apply.

increase blood pressure lower hemoglobin A1c (HbA1c) lower cardiovascular risk factors increase cholesterol reduce weight Mediterranean diets and vegan diets primarily receive their nutrition from plant sources. Both are high in antioxidant nutrients and have been proven to lower HbA1c, lower other cardiovascular risk factors, including weight, blood pressure, and lipids. Increasing blood pressure and cholesterol increases risk for cardiovascular disease.

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Exercise and Diet The client chooses to proceed with the Mediterranean diet and the nurse provides appropriate resources. When the client returns for follow up, the client also decided to walk daily. The nurse is excited for the client but cautions about proper management of glucose levels when exercising.

The nurse would instruct the client to consume carbohydrates

if glucose level is less than 100 mg/dL when preparing to exercise.

If a client has a glucose level less than 100 mg/dL, the nurse would instruct the client to ingest carbohydrates prior to exercising. Sucrose is a sugar, glycogen is a diabetic medication and protein does not provide the necessary energy required for exercise.

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Nursing Evaluation

W hen clients return for evaluation and follow-up visits, it is imperative that nurses continue the education from the previous visit, evaluate current nutritional needs related to diabetes, provide appropriate resources, and consult the healthcare provider as appropriate.

Clients should also be monitored for additional complications such as:    

Neuropathy Renal insufficiency/failure Sexual dysfunction Vision loss due to uncontrolled glucose levels (retinopathy).

Neuropathy and retinopathy are very common complication for those with a diagnosis of diabetes. Recent studies have shown that a combination of a vegan diet and exercise may help in treating neuropathy.

The nurse should encourage exercise and proper nutrition.

Renal insufficiency and failure are also common complications from diabetes. Urine output, color, and renal function should be evaluated using urinalysis and renal function labs.

Sexual dysfunction can also be present in both males and females. Males struggle with erectile dysfunction, and females experience decreased desire and vaginal lubrication. This difficult subject may not be shared openly by the client, so it is important to evaluate and provide education and resources as appropriate.

Vision loss can be a problem with clients who are diabetic. Routine eye examinations should be encouraged for clients with diabetes.

Reducing Cardiac Complications A nurse is providing instruction to a client regarding dietary changes to reduce the risk of cardiac complications. What would the nurse include in teaching? Select all that apply.

Move frequently to promote peripheral circulation Reduce blood pressure with aerobic exercise Increase oil with cooking red meat Select low fat meats to lower lipid concentrations Macrovascular complications include coronary artery disease, peripheral vascular disease, cerebrovascular disease. Neuropathy is a condition of microvascular disease. Managing dietary choices to reduce fat helps lower lipids to reduce circulating fats. Reducing blood pressure helps with cardiovascular health. Increasing oils and red meat will increase the cholesterol and lipid levels, adding risk for cardiovascular involvement.

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Blood Glucose and Exercise A client taking regular insulin and NPH insulin at 7 am to help control type 1 diabetes. Peak NPH insulin occurs at 4 pm. The client is at the ideal body weight and has had good glycemic control for many months. The client begins a 45-minute walk before dinner each day. You estimate the expenditure to be an additional 200 kilocalories (kcal). The client reports feeling tired and shaky halfway through the walk and cuts it short after 25 minutes. What does the nurse suspect is occurring?

Hyperglycemia Hypoglycemia Hypertension Urinary tract infection The client might be experiencing hypoglycemia because the NPH insulin is peaking at the same time as exercise occurs. The other options do not apply.

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Preventing Hypoglycemia The nurse determined that the client is experiencing hypoglycemia when completing the evening walk. Select the appropriate actions to teach the client. Select all that apply.

Use a lower dose of insulin Eat a snack before the walk Walk at a different time of day Take a higher dose of insulin

To prevent the risk of hypoglycemia to occur, the client can eat a snack before walking, use a lower dose of insulin, or walk at a different time of day. You would not recommend that a higher dose be taken.

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Glaucoma and Diet A client realizes that ophthalmic complications that can occur when one has a diagnosis of diabetes. At an eye examination, the client is diagnosed with glaucoma. What should be included in client teaching to prevent additional progression of the disease?

"Eat foods that contain low amounts of sucrose and high natural sugars” “Increase the number of dairy products like cheese, yogurt, and eggs.”

“Food high in sugar and complex carbohydrates can be beneficial.”

“Choose vegetables containing higher amounts of vitamin A.” Research shows that diabetes and nutrition related to glaucoma have suggested that individuals can lower their risk for advancing glaucoma by eating higher amounts of vitamin A-containing vegetables. Sugar and dairy products have not been proven beneficial to glaucoma.

Your response is correct!

Neuropathy The client with glaucoma begins stumbling when walking to the mailbox.

The healthcare provider diagnoses neuropathy, and the client voices frustration, stating that weight, A1C, blood glucose levels are normal as well as regular exercise occurs daily. What is the best response by the nurse?

"Increase your consumption of fast food since healthy choices have resulted in this."

"A combination of a gluten free diet and exercise may help in treating neuropathy."

"Continue with your current diet and exercise to prevent additional damage."

“A combination of a vegan diet and exercise may help in treating neuropathy."

Effects of Diet The client demonstrates an understanding of the benefit of a balanced, diabetic diet when verbalizing that the purpose of a diabetic diet. Which is the appropriate response from the client? Select all that apply.

Increases circulating blood glucose levels Boosts weight to promote stored levels of nutrients Monitors carbohydrates, proteins, and fats Maximizes nutritional benefits for disease management A type 1 diabetes diet is designed to provide maximum nutrition, while also monitoring intake of carbohydrates, protein, and fat. The healthy diet for clients with diabetes decreases circulating glucose levels and decreases weight.

Your response is correct!

Processed Foods A client is seeking guidance on how to modify the current dietary choices.

What is the best response to explain that processed foods are unhealthy and should not be selected?

“Processed foods offer minimal nutrients and are high in fat, sugar, and salt.”

“These types of foods can be used for replacing other foods in the diet.”

"Processed foods are considered part of the diabetic diet.”

"You can eat processed foods for one meal a week.”

Processed foods should be avoided since they are high in fat, sugar, and salt. The preservatives that allow for convenience and low cost offer minimal nutrients. They are not appropriate for clients with diabetes.

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Mediterranean Diet When following a healthy diet, there are foods that can be consumed on a daily, weekly and monthly basis. Match the recommended consumption of the foods on an appropriate diet for a diabetic client, such as the Mediterranean diet.

Foods

Daily

Weekly

Monthly

Fruit Beans Olive oil Vegetables

Dairy Poultry Eggs Fish

Sweets Red meat

The core concept behind this healthy diet is to eat like the people who live in the Mediterranean region by filling your plate with fresh fruits and vegetables, healthy fats, whole grains, oil and legumes. Fish and other lean protein can be eaten weekly, but they still contain cholesterol. Sugars and red meat increase the glucose and lipid levels, increasing risk for complications.

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Priority Intervention A client with diabetes wants to encourage their family members to make lifestyle changes to decrease their disease risk. Which is the highest priority recommendation?

Walk for 20 minutes 3-times per week Increase dietary fiber intake Move to a vegetarian diet Decrease intake of refined sugar Increasing activity is a primary risk reduction technique to lower disease risk. Increasing fiber is appropriate if they do not have adequate intake, but fiber alone does not prevent diabetes. Decreasing intake of refined sugar is helpful, but not the priority. Moving to a strict vegetarian diet can be impactful, but such a radical change is not often maintained. Small changes first make big impacts. Additional changes can be added later.

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