What should a diabetes care plan include?

Diabetes mellitus (DM) is a chronic condition defined by insufficient pancreatic insulin synthesis or the body’s inability to use the insulin it produces adequately. This results in an elevated glucose concentration in the circulation (hyperglycemia). It is characterized by abnormalities in the metabolism of carbohydrates, proteins, and fats. Sustained hyperglycemia has been found to hurt nearly every tissue in the body. It has been linked to severe issues in various organ systems, including the eyes, nerves, kidneys, and blood vessels.


Diabetes mellitus is classified as follows:

  • The apoptosis of pancreatic beta cells defines type 1 diabetes.

  • Diabetes type 2 is characterized by insulin resistance and reduced insulin secretion.

  • Gestational diabetes mellitus occurs when a pregnant woman has some level of glucose resistance during pregnancy.

  • Diabetes mellitus related to other disorders occurs when certain types of diabetes develop due to other conditions (e.g., pancreatic diseases, hormonal abnormalities, medications).

  • Prediabetes (impaired glucose tolerance or impaired fasting glucose) is a novel type of diabetes that refers to a metabolic stage between normal glucose homeostasis and diabetes.

Diabetic care planning is a procedure that tries to give patients more control over their condition’s management.

Diabetes is a complicated disease that impairs the performance of multiple physiological systems. As such, diabetic patients must have regular visits with a multidisciplinary team of physicians and health experts to ensure that their condition is managed optimally.

Because diabetes affects individuals differently, these health professionals collaborate with patients to develop and adhere to a diabetic care plan tailored to their unique needs. Diabetes care plans are a critical component of long-term diabetes management success.

The following are critical components of a diabetes treatment plan:

  • Plan for diet and exercise

  • Taking prescription drugs as directed

  • Appointments with health care experts (podiatrists, dieticians, diabetes educators)

  • Individual health objectives

  • Regular care plan sessions allow the patient to discuss predetermined goals, experiences, concerns, and the results of diabetic checks.

  • Diabetes, by its very nature, necessitates a multitude of lifestyle and dietary modifications to avoid complications.

  • Patients must regularly monitor their blood glucose levels, engage in physical activity, take prescribed medications, and maintain a nutritious diet. Diabetes care plans assist patients in adhering to this routine and giving them a greater sense of control over their self-care

What purpose do they serve?

  1. Diabetes management care plans are used by health professionals, primarily primary care physicians, to aid patients in establishing clinical goals and reminding them of diabetes care responsibilities.

  2. Additionally, care plans detail patient referrals to allied health specialists for more specialized self-management support services.

  3. By including individuals in their care, care plans can benefit health providers. Implementing evidence-based targets can help patients better understand their health conditions and motivate them to change unhealthy behaviors.

  4. Care plans are also beneficial for reminding patients about the continuous therapy and monitoring required.

  5. Nursing and allied health professionals can use care plans to assist them in treating patients.

  6. This is typically more individualized patient information, such as specific hurdles to reaching evidence-based goals, that allied health providers can use to assist with the patient’s treatment plan.

Why is it critical to have diabetic care plans?

Diabetes is a disease that affects each body system uniquely. Diabetes pathogenesis is complex, involving hormonal and metabolic mechanisms that vary significantly between individuals.

Individuals’ behavior and preferences also vary, and the interaction of biological processes and various human behaviors result in an endless range of diabetes responses.

This is essentially why diabetes management strategies are customized for each patient.

There is mounting evidence that people with chronic diseases benefit from increased control over their condition.

Diabetes that is not adequately treated can result in more severe problems such as renal disease, amputations, blindness, strokes, and heart attacks. Individualized care plans have been shown to assist in lowering the risk of such problems.

How are they created and maintained?

Numerous factors are considered when creating an individualized diabetes care plan. The following are some of the primary tasks of health providers when developing a diabetic care plan:

They are educating patients about their involvement in controlling their disease optimally.

They are educating patients on the importance of dietary adjustments. If a patient has heart issues, they may be encouraged to follow a Mediterranean diet. A dietitian may advise patients to lose 5-10% of their body weight if they are overweight. These weight-loss targets must be re-evaluated every six months.

The patient’s primary care physician should do routine biological examinations to monitor changes in critical parameters. These include the following:

  • Cholesterol levels—blood test (LDL-C less than 2.0, HDL-C greater than 1.0)

  • BP-to a national target that is acceptable (130)

  • HbA1c-blood test every three months; recommended levels are less than 53mmol/mol.

  • Healthy blood glucose levels are between 6-8mmol/L fasting.

  • Medication should be monitored per the patient’s biomedical test findings. These medications should be designed to maximize benefits while minimizing adverse effects.

  • If a health professional detects diabetes problems, the patient should be sent to specialized health specialists who can assist in managing and controlling these complications.

Nurses’ critical role in diabetes management

Nurses are critical in assisting patients in primary and tertiary healthcare settings in managing their conditions. Nurses’ primary responsibilities include the following:

Assess diabetic patients initially and execute individualized diabetes care regimens

Evaluate tools and procedures for diabetes patient assessment. Blood glucose monitoring, pathology, and monofilaments are examples of these tools.

Recognize patients with metabolic syndrome, pre-diabetes, or difficulty maintaining their glucose levels, and then establish a suitable nursing care plan to prevent future problems.

Determine the effect of lifestyle factors on a patient’s condition and design patient education techniques

Nurses’ responsibilities include administering insulin to patients via intravenous infusion and closely monitoring essential factors such as blood pressure, temperature, and vision.

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