Nursing Care Plan Sample: Type 2 Diabetes Mellitus

Model Answer

Patient Scenario

Mrs J, a 58-year-old woman, was admitted to an acute medical ward following three days of increasing thirst, polyuria, lethargy and blurred vision. She has a nine-year history of Type 2 diabetes mellitus, previously managed with metformin and gliclazide, alongside hypertension treated with amlodipine. On admission her capillary blood glucose was 21.4 mmol/L, HbA1c 89 mmol/mol, blood pressure 148/92 mmHg, pulse 96 beats per minute, respiratory rate 18 breaths per minute, temperature 37.1°C and oxygen saturation 97% on room air. She reports poor adherence to her prescribed diet over recent months, self-reported medication non-concordance during a period of bereavement, and a healing ulcer on her left heel. Mrs J lives alone, is independently mobile with a stick, and expresses anxiety about “becoming a burden” to her adult children.

A collateral history obtained from Mrs J and her daughter, who accompanied her to the department, indicated that the deterioration had been gradual over approximately three weeks, coinciding with the anniversary of her husband’s death. She admitted to skipping evening doses of gliclazide on several occasions because she “didn’t feel like eating properly” and had been drinking sweetened squash rather than water because of persistent thirst, unaware this was worsening her glucose control. She has no known allergies, does not smoke, and drinks alcohol rarely. Her most recent diabetic review, six months prior, had already flagged suboptimal control and referred her to the community diabetes specialist nurse, an appointment she had not attended. This context is important for care planning, as it points to a psychosocial driver of the acute presentation rather than a purely physiological one, and shapes the education and support strand of the plan below.

Mrs J’s regular medication chart on admission listed metformin 1g twice daily, gliclazide 80mg twice daily, amlodipine 5mg once daily and atorvastatin 20mg at night. She has no known drug allergies. On examination, her abdomen was soft and non-tender, bowel sounds were present, and there was no evidence of ketotic breath or Kussmaul breathing, making diabetic ketoacidosis unlikely, consistent with her Type 2 (rather than Type 1) diabetes status. Peripheral pulses were palpable bilaterally, though reduced compared with expected strength, and both feet were warm with intact capillary refill, reassuring against acute critical limb ischaemia. This baseline picture was essential in distinguishing a manageable hyperglycaemic presentation from a medical emergency, and in directing the subsequent nursing diagnoses toward glycaemic control, tissue viability and education rather than emergency stabilisation alone.

Assessment

Assessment followed the ADPIE nursing process, beginning with a structured Airway, Breathing, Circulation, Disability, Exposure (A–E) review to exclude immediate life-threatening deterioration, followed by a focused systems assessment (Roper, Logan and Tierney, 2000; NMC, 2018).

Airway/Breathing: patent airway, respiratory rate within normal limits, no respiratory distress, oxygen saturation 97%. Circulation: tachycardic at 96 bpm, blood pressure elevated at 148/92 mmHg, capillary refill under two seconds, mild dehydration evident from dry mucous membranes and reduced skin turgor. Disability: alert and orientated, Glasgow Coma Scale 15/15, blood glucose grossly elevated, no ketones detected on urinalysis. Exposure: a 2 cm superficial ulcer on the left heel, dry with no signs of infection but reduced sensation to light touch on monofilament testing, consistent with peripheral neuropathy.

Further assessment covered diet and fluid intake (reduced appetite, high intake of sugary drinks whilst thirsty), elimination (polyuria, no dysuria), mobility (independent with a walking stick, reports fatigue), and psychological state (low mood, anxiety about independence, some evidence of diabetes-related distress). Baseline observations were recorded on a National Early Warning Score (NEWS2) chart, giving a score of 3, prompting increased monitoring frequency in line with local escalation policy (Royal College of Physicians, 2017).

A blood-borne infection screen and urinalysis were also completed to rule out an infective trigger for the hyperglycaemia, both returning negative, supporting the working impression that non-concordance and dietary intake were the primary drivers of this admission rather than sepsis. A cognitive screen was not indicated, as Mrs J remained fully orientated to time, place and person throughout assessment. Her weight and height were recorded to calculate body mass index (31.4 kg/m²), and a Malnutrition Universal Screening Tool (MUST) score of 0 was documented, indicating no immediate nutritional risk despite her reduced appetite. A falls risk assessment scored her as low risk, reflecting her normal independent mobility, though this was flagged for review given her reported fatigue and the possibility of postural hypotension secondary to dehydration. Pressure area assessment using the Waterlow tool identified her at moderate risk owing to reduced mobility during the acute phase of illness and pre-existing skin compromise at the heel, prompting proactive pressure-area care alongside the wound-specific interventions detailed below.

Nursing Diagnoses

Three prioritised nursing diagnoses were identified, ranked by immediacy of risk to life, limb and wellbeing:

1. Hyperglycaemia related to inadequate glycaemic control and treatment non-concordance, evidenced by capillary blood glucose of 21.4 mmol/L and HbA1c of 89 mmol/mol (actual problem, high priority).

2. Risk of impaired skin integrity related to peripheral neuropathy and reduced sensation, evidenced by an existing heel ulcer and diminished monofilament response (risk problem, high priority).

3. Deficient knowledge of diabetes self-management related to psychosocial stressors, evidenced by reported non-adherence during bereavement and expressed anxiety about independence (actual problem, medium priority).

Prioritisation followed a physiological-before-psychosocial logic broadly consistent with Maslow’s hierarchy of needs as applied to nursing practice, addressing the immediate metabolic and tissue-viability risks before the longer-term educational need, while recognising that all three problems are interlinked: unresolved psychosocial distress is a plausible driver of the non-concordance that produced the acute hyperglycaemia, so the educational diagnosis, though ranked third for immediacy, is treated as central to preventing recurrence rather than as an afterthought (NMC, 2018; Roper, Logan and Tierney, 2000).

The Care Plan

The following table translates each prioritised nursing diagnosis into a Specific, Measurable, Achievable, Realistic and Time-bound (SMART) goal, with interventions drawn from current national guidance and an explicit evidence-based rationale for each. Evaluation criteria are stated in observable, measurable terms so that any member of the multidisciplinary team can objectively judge progress at handover, rather than relying on subjective impression alone. This structure is intended to demonstrate accountable, evidence-based decision-making consistent with the NMC Code’s requirement to practise in line with the best available evidence and to keep clear, accurate records (NMC, 2018).

Evaluation and Review

Evaluation was planned for 48 hours post-admission and at each nursing handover, using the NEWS2 score, capillary blood glucose trend and wound assessment as objective markers of progress, alongside Mrs J’s own account of her symptoms and confidence. Where goals were only partially met, for example if glucose remained labile, the plan specified escalation to the diabetes specialist team and reassessment of the insulin regimen rather than repetition of an ineffective approach. Discharge planning was initiated early, involving the multidisciplinary team, the community diabetes nursing service and, with Mrs J’s consent, her daughter, to support safe transition home and reduce the risk of readmission (NMC, 2018).

By 48 hours, Mrs J’s capillary blood glucose readings had stabilised within the 7–9 mmol/L range on four occasions consecutively, her heel ulcer showed early granulation with no signs of infection, and she was able to correctly demonstrate insulin pen technique and glucose self-monitoring using the teach-back method, indicating that all three goals had been substantively met. Her fluid balance chart showed a positive balance over the final 24 hours, and repeat urea and electrolytes were within normal limits, confirming resolution of the dehydration risk. A formal multidisciplinary discharge planning meeting was held on day three, attended by the ward nurse, the diabetes specialist nurse, the tissue viability link nurse and Mrs J herself, at which a structured follow-up pathway was agreed: a community diabetes nurse visit within 48 hours of discharge, a podiatry review for the heel ulcer within one week, and a telephone check-in from the ward at day seven. Mrs J was also offered a referral to a bereavement support service, which she accepted, reflecting a person-centred approach that addressed the underlying psychosocial contributor to her admission rather than the biomedical presentation alone. This evaluation illustrates the cyclical, iterative nature of the nursing process: assessment findings informed diagnoses, diagnoses informed goals and interventions, and evaluation against those goals in turn reshaped the ongoing plan and the discharge pathway, consistent with the ADPIE model (Roper, Logan and Tierney, 2000; NMC, 2018).

Reflection on this case also highlights a broader lesson for nursing practice: episodes of acute deterioration in long-term conditions such as Type 2 diabetes are rarely purely biomedical events. Mrs J’s admission arose from a convergence of a stressful life event, a missed community follow-up appointment and a gradual drift away from her usual self-management routine, none of which would have been captured by glucose readings alone. A care plan that addressed only the physiological derangement, without exploring why concordance had broken down, would have carried a high risk of early readmission. Building the psychosocial assessment into the plan from the outset, rather than treating it as an afterthought once the medical emergency had passed, is consistent with a person-centred model of nursing and with the NMC’s expectation that registered nurses treat people as individuals, upholding their dignity and taking into account their individual needs, values and preferences at every stage of care (NMC, 2018).

References

Diabetes UK (2021) Diabetes Self-Management Education Guidance. London: Diabetes UK.
National Institute for Health and Care Excellence (2019) Diabetic Foot Problems: Prevention and Management (NG19). London: NICE.
National Institute for Health and Care Excellence (2022) Type 2 Diabetes in Adults: Management (NG28). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Roper, N., Logan, W.W. and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.
Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. London: RCP.